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[ { "category": "Nursing/other", "chartdate": "2142-11-02 00:00:00.000", "description": "Report", "row_id": 1869896, "text": "Admission Note\nOb-\ndelivering Ob-\nPedi-Dr. in -Wellesly\n\nBaby boy is the 2455 gram product of a 34 week gestation (EDC ) born to a 36 yo G4 P1 mom with PNS blood type AB positive, antibody negative, RPR NR, Rubella Immune, Hep B negative, GBS unknown. Pregnancy complicated by preterm labor at 33 weeks. Mom was treated with betamethasone at that time. Mom had a repeat occurance of preterm labor with a resulant delivery.\n\nSocial-The FOB, , is a hepatology fellow at .\nFH-mom has to penacillin\n\nThis infant was born by vaginal delivery with Apgar scores 8 (1 min) 9 (5 min). He was dried, bulb suctioned and BBO2 briefly given.\n\nHe was taken to the NICU for further evaluation.\n\nExam Gen active screaming infant in no obvious distress\nweight 2455 grams (75%) HC 33 cm (75%) Length 48 cm (90%)\nTemp 99.4 HR 170 RR oxygen saturation 95% in room air D stick 62\nHEENT slight molding of head ant font open flat palate intact red reflex present bilaterally\nneck supple\nthorax symmetric\nLungs clear\nCV RRR no murmur femoral pulses normal bilaterally\nAbd soft with active bowel sounds no masses\nGU normal preterm male testes palpable\nSpine midline no sacral dimple\nAnus patent\nHips stable\nClavicles intact\nExt cap refill brisk\nNeuro normal tone good suck\n\nImp-34 week preterm infant in stable condition born because of unstoppable preterm labor.\n\nResp-stable in room air. He was betamethasone complete at delivery.\nCV-stable without issues. Will monitor for spells and bradycardia\nFEN-will keep NPO for now. Will begin IVF at 80 ml/kg/day\nID-Only sepsis risk factor is preterm delivery. Will draw cbc and blood culture. Will begin antibiotics if cbc is shifted or there is other clinical concern\nSocial-will update the family of the plan and clinical situation\n" }, { "category": "Nursing/other", "chartdate": "2142-11-03 00:00:00.000", "description": "Report", "row_id": 1869897, "text": "NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, RRR, no murmur, normal perfusion, abd soft, +bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-03 00:00:00.000", "description": "Report", "row_id": 1869898, "text": "NICU Nursing Admission Note O: Baby boy was born vaginally at 34 3/7 weeks gestation. See Neonatology Note for maternal history. Infant was dried, given stim and BBO2 briefly in the DR, with apgars of 8 and 9. VS upon admission to the NICU were temp 99.4 rectal, HR 170, RR 50, sat 95% in roomair and B/P 67/39 mean 49 - see flow sheet for further vital signs. Infant is breathing comfortably in RA, with O2sats 97-100%, lungs sounds clear and equal, resp rates 30s-70s with with occasional mild retractions. Skin is pink/ruddy and warm. HR regular, no murmur heard, b/p remains stable. BW = 2455g. Peripheral IV is infusing with D10W at 80cc/k/day. D-sticks have been 62 and 68. Abd is soft, + BS, no loops. Voiding minimal amts, no stool. CBC and blood cultures drawn and sent - CBC results WNL. Temp has been warm on open wamrer and have weaned the temp setting. Small skin tag noted just below infant's left nipple. Infant is active with cares, irritable at times and will settle with sucking on his pacifier. Erythromycin eye ointment and Vitamin K given. were in to visit a couple of times and brought in several extended family members. asked appr. questions and were updated at the bedside. A: 34 week premature infant, stable in roomair, R/O sepsis. P: Moniter I&Os closely - ?begin feeds today. Provide support for .\n" }, { "category": "Nursing/other", "chartdate": "2142-11-03 00:00:00.000", "description": "Report", "row_id": 1869899, "text": "Neonatology\nDoing well. Remains in RA. No spells. COmfortable appearing. No murmur.\n\nNPO at prersent. Will begin feeds as tolerated this am.\nAbdomen benign.\n\njaundice not currentyl an issue.\nClinically stable No abx.\n\nContinue a sat present.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-04 00:00:00.000", "description": "Report", "row_id": 1869905, "text": "Nursing Progress Note\n\n1 Infant with Potential Sepsis\n\n#1 O: blood cx neg to date P: resolve problem\n#2 O: temp staying stable double wrapped on warmer. \nw/cares but falls asleep quickly. pacifier intermittently.\nA: AGA P: cont to assess and support developmentally\n#3 O: Min 60cc/k/d BM20/PE20 =25cc q4h. just taking that\nwith encouragement. poor latch on at breast, mom's milk not\nyet in. abd benign, vdg and stooling. IV dc'd at 1600. A:\nslow po feeds tho improved over yesterday. P: offer bottle,\nassist w/breastfeeding. may need feeding tube again if gets\ntired. check bili tonight w/PKU\n#4 O: mom having very hard day-crying, upset over not being\nable to do enough for baby, wants him to nurse, feeling\nguilty. Much support and encouragement given to family. IN\nto visit w/grandparents and sibling. A: loving family w/NICU\nadmission P: cont to update and support.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-05 00:00:00.000", "description": "Report", "row_id": 1869906, "text": "NPN 1900-0700\n\n\nDEV: Received infant on an off warmer. Infant moved to an\noac at 0300. Infant swaddled, temps stable. and active\nwith cares, starting to wake for feeds. Brings hands to face\nfor comfort, enjoys pacifier. PKU sent. , . A: AGA P:\nContinue to support development.\n\nFEN: CW 2295g (-160g,discussed w/ ) Infant on a min\nof 60cc/k/d of BM/PE20 (25cc q4hrs) Infant current all po's.\nBottling well, taking 25-55cc w/each bottle. Mom also\nattempt to BF infant at each feed, infant not yet\ninterested, briefly latches/sucks. Lactation consult planned\nfor tuesday. Infants Abdomen soft with active bowel sounds,\nno loops, no spits, girth stable. Voiding w/each diaper\nchange, Multiple sm-med green stools tonight. A: tolerating\ncurrent feeding regimen. P: Continue per nutritional plan\n\n: Mom in for each care tonight. Very independent,\nasking appropriate questions, updated at the bedside by this\nRN. She is very loving toward infant. Mom in being\ndischarged later today. A: Involved, loving, appropriately\nconcerned.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-05 00:00:00.000", "description": "Report", "row_id": 1869907, "text": "Neonatology Attending\n\nDOL 3 PMA 34 6/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 60/38 mean 42\n\nOn min 60 ml/kg/d BM/PE 20. Just taking minimum. Voiding. Stooling. Wt 2295 grams (down 160).\n\nBili 9.9/0.4\n\nPKU sent.\n\nTemp stable in crib.\n\n in and up to date. Mother being discharged today.\n\nA: Stable. No spells. All po thus far. Hyperbili not yet requiring phototherapy.\n\nP: Monitor\n Encourage pos\n Increase minimum to 80 ml/kg/d\n Follow bili\n Hep B vaccine\n Family meeting today\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-05 00:00:00.000", "description": "Report", "row_id": 1869908, "text": "Case Management Note\nChart has been reviewed and events noted. EIP & VNA options in record. I will be following for any d'c planning needs along with team & family\n" }, { "category": "Nursing/other", "chartdate": "2142-11-06 00:00:00.000", "description": "Report", "row_id": 1869911, "text": "Nursing\n\n\n#2O: Temp stable in crib, placed in isolette on servo for\nphototherapy. Waking for feeds. Loves pacifier and being\nswaddled. Hep B vaccine given.\n#3O: Wt. down 45g, taking in 93cc/kg, . Bottling well\nof Pe 20, q 4 hrs., but did have a desat to the 70's at the\nbeginning of 1 feed, self-resolved when bottle removed.\nBelly soft, voiding and stooling, D-s 74.\n#4O: Dad called and was updated. Mom will be in to visit\nin the am.\n#5O: Bili 12.5/0.3. Neoblue phototherapy started and eyes\ncovered. Color is jaundiced.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-06 00:00:00.000", "description": "Report", "row_id": 1869912, "text": "Neonatology Attending\n\nDOL 4 PMA 35 weeks\n\nStable in RA. 1 desat to 73% with bottling. No A/B.\n\nNo murmur. BP 72/40 mean 53.\n\nFeeding ad lib on BM/PE 20 with min 80 ml/kg/d. Took 93 ml/kg + BF x 2 yesterday. Voiding. Stooling (heme neg). DS 74 Wt 2255 grams (down 45).\n\nBili 12.5/0.3. Phototherapy started.\n\nHep B vaccine given.\n\n in and up to date. Mother went home yesterday. We had a family meeting yesterday.\n\nA: Stable. No spells. Feeding well. Hyperbili being treated.\n\nP: Monitor\n Encourage pos\n Min 100 ml/kg/d\n Lactation consult today\n Continue phototherapy\n Follow bili\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-06 00:00:00.000", "description": "Report", "row_id": 1869913, "text": "SOCIAL WORK\nFamily meetin held yesterday with , , neonatology attending, nursing and social work. Infant's current status reviewed, care plan and criteria for d/c discussed. asked several appropraite questions. Mum slightly as she anticiaptes seperation from newborn with her d/c today. Husband quite supportive of her. They have good understanding of info offered to them. Overall coping well and adjusting to premature delivery which requires NICU stay. Will remain available to during their son's admission. Please call should concerns arise. Thank you.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-06 00:00:00.000", "description": "Report", "row_id": 1869914, "text": "Lactation Progress Note\nAsked to help mom with breastfeeding. Baby is now 35 weeks PMA. He is awake and for this feed showing feeding cues. Baby went to breast latching intermittently. He latched well with use of the small nipple shield with sustained sucking and audible swallows. Reviewed positioning and assessment of latch. Mom is pumping. Reviewed need to pump a minimum of 8 times per day to establish supply. Would recommend mopm get a larger phlange for pumping. A message was left for the baby carriage to contact mom to assess needed size. Mom is using both an ameda and medula pump depending on where she is. Mom has a hospital grade pump. Encouraged mom to keep a breastfeeding diary. Discussed possibility of putting baby to breast each time mom is here for feeding. Support and encouraged offered. Encouraged mom to call with any questions or concerns.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-06 00:00:00.000", "description": "Report", "row_id": 1869915, "text": "Neonatology NP Note\nPE: well developed preterm infant neslted in isolette\nPink, jaundiced, well perfused RA.\nAFOF sutures approximated, eyes clear, nares patent, MMMP\nChest is clear, equal , comfortbale resp pattern\nCV: RRR, no murmur, pulses=2=\nAbd: soft, active bs, NTND, cord dry\nGU: Testes in scrotum\nEXTR: MAE,WWP\nNeuro: symmetric tone and relfexes.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-03 00:00:00.000", "description": "Report", "row_id": 1869900, "text": "Nursing Progress NOte\n\n\n#1 O: no growth to date blood cx, not on antibiotics. P:\nmonitor labs.\n#2 O: on servo warmer, swaddled and dressed at 1300 to see\nif can maintain temp on own, so far so good, tho borderline\nand may need isolette. pacifier vigorously tho no interest\nin po/bf. A: acting a little premature P: support\ndevelopmentally\n#3 O: IV D10W infusing PIV, attempted to BF at 1300 but no\nreal latch on. PO feed not much better w/PE20, no real\ninterest. abd benign, vdg per flow sheet and no stool so\nfar. DS 68. A: prmature feeding pattern P: offer po, in\nneeded use pg feeds.\n#4 O: family in at 1300, mom to BF but baby not\ninterested,no real latch on. FAllng asleep while holding\nbaby, RN attempted to po. Dad here, asking many\nquestions. A: loving family P: cont to update and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-03 00:00:00.000", "description": "Report", "row_id": 1869901, "text": "Nursing addendum\nO: still not interested in po feeds- NGT placed at 1700 and in good position. Tol feed well over 40mins w/some gagging initially. IV now at 40cc/k/d, feeds at 40cc/k/d and will adv by 15cc/k/ as tol.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-04 00:00:00.000", "description": "Report", "row_id": 1869902, "text": "NICU NPN 1900-0700\n\n\nDEV O: Temps are stable, swaddled warmer off. Baby is \nand active with cares, waking for feeds. Sleeps well in\nbetween cares. Fontanells are soft and flat. Takes pacifier\nfor comfort.\n\nFEN O: Weight 2455g, no change. Tolerating advancing feeds\nof pe/bm 20 well. Abdominal exam benign, voiding andf\nstooling, no spits, minimal ngt aspirates. Bottled both\nfeeds thus far this shift, attempted breastfeed x1. IVF of\nd10 infusing through piv well, d sticks stable.\n\nParenting O: Mom and dad in for evening cares, asking\nappropriate questions, loving towards baby.\n\nBili 6.2/0.3. Color pink, slightly jaundiced.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-04 00:00:00.000", "description": "Report", "row_id": 1869903, "text": "NNP PHysical EXam\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy wOb, no murmur, abd soft, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-04 00:00:00.000", "description": "Report", "row_id": 1869904, "text": "Neonatology Attending\n\nDay 2 PMA 34 wks\n\nRemains in RA. Clear breath sounds. RR 30-50s. No murmur. Pink. Bilirubin 6.2/0.3. HR 120-140s. BP mean 50s. Weight 2455 gms (unchanged). TF at 80 cc/kg/d. IV dextrose at 25 cc/kg/d. Enteral feeds at 55 cc/kg/d. Blood glucose 60s. Mother having pain possibly related to spinal anesthesia. Father is GI fellow.\n\nDoing well overall. Adequate breathing control. Monitoring for apnea. Will establish minimum po goal of 60 cc/kg/d. continue to require gavage supplementation. Will check bilirubin with newborn screen.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-05 00:00:00.000", "description": "Report", "row_id": 1869909, "text": "NPN 7a-7p\n\n\n#2: Temp is stable while swaddled in an open crib. Infant\nis /active with cares. MAE. Fonts soft/flat. Brings\nhands to face. Sucks on pacifier intermittently. A: AGA\nP:Cont to support dev needs.\n\n#3: TF: ^'ed to min80cc/k/d. Conts bottling Bm20/PE20,\ntaking 30-45cc q4hrs. Bottling with good coordination.\nBreastfed very well this am. Latched and sucked\nintermittently on each side for over 15mins. Bottled 30cc\nafter. This afternoon infant was too sleepy and irritable.\nDid not latch. No spits. Abd soft, +, no loops. AG\nstable. Voiding qs. Stooled x1 heme negative. A: working\non PO feeding skills P:Cont with current feeding plan.\nFollow wt and exam. Assist with breastfeeding as needed.\n\n#4: in for several visits, both updated. Plan to\nhave family meeting at 1600. Mom in for cares and\nparticipated. Tried to have LC meet with Mom, but there\nwasn't anyone available. Mom does have LC appt scheduled\nfor tomorrow at 1300. Mom signed consent for NB state\nscreen. Will give her written info on HepB and when she is\nready have her sign consent. Mom informed that Team feels\ninfant is stable enough to have circ. Mom now to call OB\nand arrange. Potentially would like to have a Bris. Mom\nbeing d/c'ed home today. Bag of BM supplies given to Mom. A:\nInvolved, loving family P:Cont to support and educate.\nFamily meeting at 1600.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-05 00:00:00.000", "description": "Report", "row_id": 1869910, "text": "Neonatology NP NOTE\nPE: well appearing preterm infant nestled in open crib.\nPink, jaundiced, well perfused in RA.\nAFOF eyes clear, nares patent, MMMP\nChest is clear, eqaul bs, comfortbale breathing pattern\nCV: RRR, no murmur, pulses+2=\nAbd: soft,active bs, NTND, cord dry\nGU: testes in scrotum\nEXT: MAE,WWP\nNeuro: symmetric tone and reflexes\n\nFamily meeting held today with , Dr and SW.\nDiscussed course to date. Mother and expressing concern for infant ability to po feed better with bottle that at breast. Reinforced that this is preamture infant behavior and encouraged her BF efforts. Will have mom meet with lactation as well. Discussed possible need for ng feeds if fedings o not keep pace with vlume increase and will reassess daily.\nReveiwed criteria of discharge inluding temp stability, feeding ability, matuation of breathing pattern, resolution of bilirubin and possible phototherapy. desire circ, briss if possible. Also revaiewed creenings incluidng NB screen, hearing CST. Immunizations, pedi appointment.\nQuestions encouraged and answered.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-08 00:00:00.000", "description": "Report", "row_id": 1869921, "text": "Nursing Progress Note\n\n\n#2 Dev: is swaddled in OAC, temps stable.\n/active, wakes for feeds q3.5-4hrs. Brings hands to\nface, mae, fontanels soft/flat. AGA .Cont. to support dev.\nneeds. #3 F/N: wt 2285 (^5 grams). Fluid min 120cc/kg of\nBM/PE20. Pt took in 115cc/kg plus BF. Abd soft, no loops,\nactive bs, voiding, stooling. No spits. PO feeds well\ncoordinated. Stable. Cont. to monitor. #4 Parenting: mom/dad\nin for 2100 cares. Dad w/ temp/diaper, handling baby.\n BF baby for 15 minutes. D/c teaching started. I told\n to bring car seat in tomorrow. Cont.to\nupdate/support. #5 Bili: slightly jaundiced, will draw bili\nw/ next care. See flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-08 00:00:00.000", "description": "Report", "row_id": 1869922, "text": "Neonatology Attending\n\nDay 6 PMA 35 wks\n\nRemains in RA. RR 30-40s. Clear breath sounds. No murmur. BP mean 54. Bilirubin 7.5/0.3 rebound (unchanged). Weight 2285 gms (+5). Took 115 cc/kg and breast fed. On BM/PE 20. Passing heme negative stool. Stable temperature in crib. Passed hearing screen.\n\nDoing well overall. Mature breathing control. Doing well with feeds. Needs car seat study. Ready for discharge. Follow up visit to be arranged in next 2-3 days. Discharge summary pending.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-08 00:00:00.000", "description": "Report", "row_id": 1869923, "text": "NPN Days\nAddendum: Pt passed carseat test. Pt to be DC home with parePt DC'd home with this evening.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-08 00:00:00.000", "description": "Report", "row_id": 1869924, "text": "NPN Days\nAddendum: Pt passed carseat test. Pt to be DC home with parePt DC'd home with this evening.\n" }, { "category": "Nursing/other", "chartdate": "2142-11-08 00:00:00.000", "description": "Report", "row_id": 1869925, "text": "NPN Days\n\n\n#2 G&D- Temp stable in open crib. and active with\ncares. waking for feeds. sucking on pacifier. DC teaching\ncompleted. to bring in carseat later this shift and\npt to be DC home.\n#3 Pt ad lib min 120cc/kg/d. BM or PE 20. Pt taking\nadequate amount from bottle. Mom BF when here and pt awake.\nPt voiding and stooling. no spits. P- Will send pt home BF\nand supp with E20.\n#4 Parenting- visiting this shift. updates given.\nMom upset r/t missing pt awake and feeding. Pt waking\nq2-4hrs. Mom pumping. DC teaching completed with both\n. asking approp ques. pedi apt made for tomorrow @\n1400. Pt to be DC home after carseat test.\n#5 hyperbili- Pt rebound bili this am 7.5/0.3. Bili\nresolved.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-06 00:00:00.000", "description": "Report", "row_id": 1869916, "text": "NPN 7a-7p\n\n\n#2: Temps stable in servo isolette. Infant is /active\nwith cares. Waking on own for some feeding. Fonts\nsoft/flat. Brings hands to face. Sucks on pacifier. A: AGA\nP:Cont to support dev needs.\n\n#3: TF: ^'ed to min100cc/k/d. Conts on q4hr schedule,\nbottling 28-42cc. Bottling with good coordination. No\ndesats with bottling thus far. Breastfed x2. At 2nd\nbreastfeeding infant did very well. He fed for over 15mins\nwith more consistent latch and suck. Mom used shield\nfor feeding. No spits. Abd soft, +, no loops. Voiding\nqs. Stooled x2- heme negative. A: Improved PO feeding\nskills P:Cont with current feeding plan. Follow wt and\nexam.\n\n#4: Mom and grandmother in for cares. Dad in x1 for brief\nvisit. updated. Mom with cares. Worked with\nLC on breastfeeding. Mom's BM supply is improving. A:\nInvolved, loving P:Cont to support and educate.\n\n#5: Ruddy. TF's ^'ed. Tol'ing feeds. Voiding and\nstooling. Conts under Neoblue bank. A: hyperbili P:Cont\nwith phototherapy as ordered and check bili level in the am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-07 00:00:00.000", "description": "Report", "row_id": 1869917, "text": "NPN 11p-7a\n\n\n#2 Temps stable in isolette. Waking in between care times.\nRooting eagerly for feeds. Settling with ease after fed.\nEnjoys pacifier. Nested within boundaries. A:AGA P: support\ndevelopmental needs\n\n#3 TF's 100cc/k. Fed 41cc of BM20 at 0100 fairly well and\nthen was up again ~ 0345 with feeding seeking behaviors. Fed\nfull volume again. Abdominal exam unremarkable. No spits.\nVoiding and passing heme neg, green stool. Took in 102cc/k +\nBF yest. Weight ^ 25g. A: fed q 3-4hrs P: Support FEN needs\n\n#4 No parental contact thus far overnoc.\n\n#5 Remains under neoblue bank. Am bili sent-pending. On full\nfeeds. Passing medium green stools. A: ^ Bili P:Follow\nlevels\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-07 00:00:00.000", "description": "Report", "row_id": 1869918, "text": "Neonatology Attending\n\nDOL 5 PMA 35 1/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 68/50 mean 56\n\nOn 100 ml/kg/d min BM/PE 20. Took 102 ml/kg + BF yesterday. Voiding. Stooling. Wt 2280 grams (up 30).\n\nOn phototherapy. Bili 7.5/0.2.\n\n visiting and up to date.\n\nA: Doing well. No spells. Feeding all po. Hyperbili responding to phototherapy.\n\nP: Monitor\n Increase to 120 ml/kg/d\n D/C phototherapy\n Check rebound bili\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-07 00:00:00.000", "description": "Report", "row_id": 1869919, "text": "NPN days\n\n\n#2 G&D- Temp stable in open crib. and active with\ncarses. waking for feeds. sucking on pacifier. Passed\nhearing screen this shift, Mom aware. P- Will cont to\nmonitor G&D.\n#3 FEN- TF=min 120cc/kg/d of BM or PE 20. abd benign.\nvoiding and stooling. no spits. all po feeds. po 50-53cc.\nTaking min requirement. P- Will cont to monitor FEN.\n#4 Parenting- visiting this shift. updates given.\nExplained to pt getting ready to be DC home\npossibley tomorrow or Friday. Mom expressed her anxiety. RN\nexplained to Mom about making pedi apt for Monday. DC\nteaching started. P- Will cont to update and support\n.\n#5 Pt received under high intensity phototherapy.\nBili lights DC'd this am. P- Will obtain rebound bili in am.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-11-07 00:00:00.000", "description": "Report", "row_id": 1869920, "text": " PHysical Exam\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with easy wOB, no murmur, abd soft, + bowel sounds, active with good tone.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2113-05-31 00:00:00.000", "description": "Report", "row_id": 1279101, "text": "MICU NURSING NOTE 3P-7P\n\nPT 2, PLEASENTLY CONFUSED, EASILY REORIENTED. HR 90-110 NSR. NO ECTOPY. 02 SATS 99-100% 2L NC. LS CLEAR. ABDOMEN SOFT, NO BM. PT DENIES ANY PAIN OR N/V. FOLEY PATENT DRAINING CLEAR YELLOW URINE. 4TH UNIT PRBC'S HUNG AT 1600. 1800 HCT 28.9. PT DUE FOR HCT POST TRANSFUSION AT 2200. PT REMAINS FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2113-06-01 00:00:00.000", "description": "Report", "row_id": 1279102, "text": "Nursing Progress Note\nNeuro: Awake, alert, oriented x2. Picking at lines, bed linens most of night, legs over side rails. Soft restraints on both wrists for safety\nResp: BS clear bilat Sats > 96% on 2l NP\nCV: Stable, SR 80's\nGI: Incont mod amt black soft OB pos stool x1 NPO overnight\nHeme: Hct only 26.8 after 4u PRBC, transfused with additional 2u PRBC, AM labs pending\nGU: Adequate U/O via FC\nSocial: Full code Anticipate call out to med floor if Hct stable this AM\n" }, { "category": "Nursing/other", "chartdate": "2113-05-31 00:00:00.000", "description": "Report", "row_id": 1279100, "text": "MICU NSG Admission Note:\n For HPI, PMH, meds please refer to ICU course section of care-vue. In brief, pt is a 82 y/o male admitted this morning with UGIB (HCT down from 45 to 21). He was admitted to MICU for scope/hemodynamic monitoring/blood products. NKDA.\n Neuro: Pt is A + O X 2, he reorients easily to time. He moves all extremities strongly and to command. At times he will get confused and try to get oob--reorients easily, bilat soft wrist restraints applied for safety. Pt sedated during scope with 25 mcg fentanyl and 1.5 mg versed--with these doses, pt sleeping comfortably but aroused easily during procedure.\n CV: Afebrile. #3 of 4 u PRBC infusing now. HCT after 2nd unit up to 25. To recheck hct after 4th unit. No N/V/wretching/diarrhea or other signs of active bleed. Pt was orthostatic by BP and c/o dizziness on admission to unit. Access = 2 #16g PIV. During scope pt did vagal and drop HR to 40's--0.5 mg IV atropine administered and subsequent HR Increased to 150's (pt had beeen simultaneously given epi with encoscopy). After procedure, HR gradually decreased to low 100's. IVF on hold during transfusion as pts HR has returned to baseline.\n Pulm: Lungs CTA on admission. No hx of failure. Will reeval pulm status after blood. Pt on 2 L NC with sp02 100%. RR 16-18.\n GI: Endoscopy found ulcer with exposed vessle--injected with epi and (?) successfully cauterized. Abd benign, soft, NT. Will f/u closely for s/sx more bleeding.\n GU: foley in place. UOP picking up to 80-100 cc/hr. Clear yellow.\n Labs: Lytes WNL. First 2 CPK's/troponin negative. Hct bumped to 25 after first 2 units.\n Family: Wife takes care of pt at home. She is at home and her contact # is in the chart.\n" }, { "category": "ECG", "chartdate": "2113-06-01 00:00:00.000", "description": "Report", "row_id": 314205, "text": "Sinus rhythm\nEarly R wave progression\nSince previous tracing, heart rate decreased\n\n" }, { "category": "ECG", "chartdate": "2113-05-31 00:00:00.000", "description": "Report", "row_id": 314206, "text": "Sinus tachycardia, rate 105. Since the previous tracing of the heart\nrate is faster. No other changes have occurred.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-02-16 00:00:00.000", "description": "CAROTID/CEREBRAL BILAT", "row_id": 1182558, "text": " 8:44 AM\n CAROT/CEREB Clip # \n Reason: 47 year old woman with R ICA occlusion and L sylvian fissure\n Admitting Diagnosis: AVM ? BLEED\n Contrast: OPTIRAY Amt: 204\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 * CAROTID/CERVICAL UNILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with R ICA occlusion presented with HA and R visual\n disturbances and L sylvian fissure vessel abnormality, possible AVM.\n REASON FOR THIS EXAMINATION:\n 47 year old woman with R ICA occlusion and L sylvian fissure vessel\n abnormality, possible AVM.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE:?????? DIAGNOSTIC?????? CEREBRAL?????? ANGIOGRAPHY\n\n ATTENDING:?????? Dr.?????? ,?????? who?????? was?????? present?????? for?????? the?????? entire procedure.\n\n ASSISTANT?????? :?????? , NP.\n\n\n CLINICAL??????HISTORY:?????? 47 year old woman with R ICA occlusion presented with HA\n and R visual disturbances and L sylvian fissure vessel abnormality, possible\n AVM.\n\n TECHNIQUE:?????? The?????? patient?????? was?????? brought?????? to?????? the neurointerventional?????? suite??????\n and?????? IVCS was??????initiated. The?????? patient?????? was?????? prepped?????? and?????? draped?????? in?????? the??????\n usual?????? sterile?????? fashion. The?????? 4 French?????? ?????? catheter?????? was?????? coaxially??????\n advanced?????? through?????? the introducer?????? sheath??????into?????? the?????? aortic?????? arch?????? selecting??????\n the?????? right?????? common carotid?????? artery?????? followed?????? by?????? an?????? angiographic?????? run?????? of??????\n the?????? neck and head.?????? Using road mapping techniques the catheter was advanced\n into he right external carotid artery, left internal carotid artery, left\n external acrotid artery, and left vertebral artery and angiogram in the\n friontal and lateral planes was performed. In addition, 3D angiogram from the\n left internal carotid artery and left vertebral artery was performed with\n reconstruction on dedicated workstation. The right common femoral artery\n roadmap was performed, thereafter the Angioseal of the puncture site was\n performed. The??????patient??????tolerated??????the??????entire\n procedure??????without??????any??????apparent??????complications.\n\n TASKS:\n\n Catheterization?????? of?????? the?????? right?????? common?????? femoral?????? artery.\n Selective?????? catheterization?????? of?????? the?????? right?????? common?????? carotid?????? artery.\n Selective?????? catheterization?????? of?????? the?????? right?????? external carotid artery.\n (Over)\n\n 8:44 AM\n CAROT/CEREB Clip # \n Reason: 47 year old woman with R ICA occlusion and L sylvian fissure\n Admitting Diagnosis: AVM ? BLEED\n Contrast: OPTIRAY Amt: 204\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Selective catheterization of the left internal carotid artery.\n Selective?????? catheterization?????? of?????? the?????? left?????? external?????? carotid?????? artery.\n Selective catheterization of the left vertebral artery.\n 3D angiogram from the left internal carotid artery and left vertebral artery\n was performed with reconstruction on dedicated workstation.\n\n ANESTHESIA:??????IVCS for 1 hour. .\n\n CONTRAST:?????? Ultravist?????? 190\n FLUOROSCOPY?????? TIME:?????? 8?????? minutes.\n\n FINDINGS:\n\n RIGHT?????? COMMON??????AND EXTERNAL CAROTID?????? ARTERY:?????? The?????? right?????? common??????and external\n carotid?????? artery injection?????? demonstrated severe stenosis of the right cervical\n ICA after the carotid bulb. Slow flow into the distal and intracranial ICA was\n noted. Faint opacification of the was noted with mild opacification of\n the MCA. The injection of the RECA demonstrated filling?????? of?????? external?????? carotid\n arterial?????? branches?????? with?????? normal?????? distal?????? runoff.??????\n\n LEFT?????? INTERNAL AND EXTERNAL CAROTID?????? ARTERY:?????? The?????? left?????? internal and external\n carotid?????? artery injection?????? demonstrated?????? brisk?????? filling?????? of?????? the?????? anterior??????\n and?????? middle cerebral?????? arterial?????? candelabras?????? and?????? external?????? carotid?????? arterial\n branches?????? with?????? normal?????? distal?????? runoff.?????? Cross filling of the right sided\n circulation was noted via the AcoM artery. The proximal MCA artery showed a\n \"corkscrew\" like apperance suggestive of an underlying vasculopathy. The\n capillary?????? and?????? venous?????? phases?????? were?????? otherwise?????? unremarkable.\n\n LEFT VERTEBRAL ARTERY: Selective injection of the left vertebral artery\n demonstrated good filling of the posterior circulation and distal runoff. Good\n sized right PcoM artery noted supplying the right sided circulation. 3D images\n demonstrated a broad based 3 mm right MCA bifurcation aneurysm. The capillary\n and venous phases were otherwise unremarkable.\n\n\n Impression:\n 1. Severe stenosis of the distal to the carotid bulb, likely due to a\n dissection.\n 2. Left MCA vasculopathy.\n 3. R MCA bifurcation aneurysm.\n 4. Good filling of the right sided cerebral circulation via Acom and right\n PcoM arteries.\n (Over)\n\n 8:44 AM\n CAROT/CEREB Clip # \n Reason: 47 year old woman with R ICA occlusion and L sylvian fissure\n Admitting Diagnosis: AVM ? BLEED\n Contrast: OPTIRAY Amt: 204\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-02-16 00:00:00.000", "description": "CT BRAIN PERFUSION", "row_id": 1182622, "text": " 1:37 PM\n CT BRAIN PERFUSION Clip # \n Reason: Please obtain a CT perfusion study of the head\n Admitting Diagnosis: AVM ? BLEED\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with R MCA aneurysm\n REASON FOR THIS EXAMINATION:\n Please obtain a CT perfusion study of the head\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:25 PM\n PFI:\n 1. No evidence of acute infarction. Note that MRI is more sensitive for\n small infarction.\n 2. Delayed transit time in the right MCA and watershed territory.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old woman with right ICA occlusion.\n\n COMPARISON: MRA from an outside institution , cerebral\n angiography .\n\n TECHNIQUE: Contiguous MDCT data were acquired to the brain without contrast.\n An axial perfusion CT was performed during the infusion of Omnipaque\n intravenous contrast. Images were processed on a separate workstation with\n display of mean transit time, relative cerebral volume and cerebral\n flow maps.\n\n FINDINGS:\n\n HEAD CT: There is no hemorrhage, large territorial infarction, mass, or shift\n of normally midline structures. The ventricles and sulci are normal in size\n and appearance. Osseous structures are grossly unremarkable. The visualized\n paranasal sinuses and mastoid air cells are well-pneumatized.\n\n CT PERFUSION: Mean transit time is delayed in the right MCA territory and\n watershed areas. volume is normal throughout the brain parenchyma.\n\n IMPRESSION:\n 1. No evidence of acute infarction. Note that MRI is more sensitive for\n small infarction.\n 2. Delayed transit time in the right MCA and watershed territory.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-16 00:00:00.000", "description": "CT BRAIN PERFUSION", "row_id": 1182623, "text": ", M. NSURG SICU-B 1:37 PM\n CT BRAIN PERFUSION Clip # \n Reason: Please obtain a CT perfusion study of the head\n Admitting Diagnosis: AVM ? BLEED\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with R MCA aneurysm\n REASON FOR THIS EXAMINATION:\n Please obtain a CT perfusion study of the head\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No evidence of acute infarction. Note that MRI is more sensitive for\n small infarction.\n 2. Delayed transit time in the right MCA and watershed territory.\n\n\n" }, { "category": "ECG", "chartdate": "2164-02-16 00:00:00.000", "description": "Report", "row_id": 257960, "text": "Sinus bradycardia with minor non-diagnostic repolarization abnormalities. No\nprevious tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2194-03-25 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 816972, "text": " 8:22 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: MITRAL VALVE REGURGITATION\n Admitting Diagnosis: MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p MVR now with recurrent mitral regurgitation.\n REASON FOR THIS EXAMINATION:\n Pre-op for re-do MVR.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mitral valve repair.\n\n PA/LATERAL CHEST: Compared with , there are no new acute changes.\n There are persistent calcifications of the costochondral cartilage and\n trachea. The mitral valve prosthesis is present as well as median sternotomy\n wires. No focal infiltrates, pleural effusions, or vascular congestion. The\n cardiac silhouette is unchanged.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2194-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 817216, "text": " 1:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p redo sternotomy/ repair prosthetic paravalvular leak\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post reoperation, sternotomy and repair of prosthetic\n _____ valvular leak. First postoperative chest examination.\n\n FINDINGS: AP single view of patient in supine position demonstrate an ETT in\n place terminating in the trachea some 5 cm above the carina. An NG tube is\n present which reaches far below the diaphragm. There is no evidence of\n pneumothorax. The film is analyzed in direct comparison with the next\n previous chest examination of . Changes in number and\n position of sternal wires indicate cardiac redo operation during recent\n interval. A right internal jugular vein approach central venous line with\n sheath, carrying a Swan-Ganz catheter the tip of which reaches barely the area\n of the main PA. A left-sided chest tube is in place with tip reversing into\n posterior pleural sinus position. A mediastinal drainage and a right medially\n located pleural drainage is seen. The lungs remain well expanded. The right\n pleural sinus is free, however, there is some blunting on the left pleural\n sinus obliterating also the cardiac contour. Obliteration of the left\n diaphragmatic contour suggest partial atelectasis in the left lower lobe. The\n metallic components of a St. type mitral valve are noted with same\n appearance and position as on the previous examination.\n\n Comparison suggest some increased perivascular haze in the pulmonary\n circulation and mild postoperative mediastinal widening. No other major\n abnormalities are identified. It is recommended to advance the Swan-Ganz\n catheter a few cm so to assure stable position.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-03-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 817460, "text": " 2:29 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pneumo\n Admitting Diagnosis: MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p MV repair s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status-post mitral valve repair. Chest tube removal.\n\n CHEST, 2 VIEWS.\n\n Status-post sternotomy, with mitral valve. Compared with , ETT tube, NG\n tube, Swan-Ganz catheter and left-sided chest tubes have been removed. There\n is increased retrocardiac density with air bronchograms, consistent with left\n lower lobe collapse and/or consolidation, unchanged. There is blunting of the\n left greater than right costophrenic angles, consistent with pleural fluid\n and/or thickening. There is also pleural thickening along the right lung apex,\n with surgical clips adjacent to the right superior mediastinum. No CHF is\n identified. No pneumothorax is detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-04-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 817834, "text": " 10:46 AM\n CHEST (PA & LAT) Clip # \n Reason: ? effusion\n Admitting Diagnosis: MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p MV repair\n REASON FOR THIS EXAMINATION:\n ? effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n INDICATION: Status post mitral valve repair.\n\n Comparison is made with the prior chest x-ray on .\n\n PA AND LATERAL CHEST: There is stable cardiomegaly with the presence of\n sternal wires and aortic valve replacement. There are again demonstrated\n small bilateral pleural effusions which appear slightly improved. There are\n again demonstrated chronic interstitial changes. There is also minor\n atelectasis at the left base. Incidental note is made of a high-riding right\n humeral head.\n\n IMPRESSION: Small bilateral pleural effusions appearing slightly improved.\n\n" }, { "category": "ECG", "chartdate": "2194-03-27 00:00:00.000", "description": "Report", "row_id": 165669, "text": "Atrial fibrillation\nNondiagnostic septal+lateral ST-T changes\nRepolarization changes may be partly due to rhythm\nSince previous tracing, ST-T wave changes are more pronounced - ? ischemia\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2194-03-25 00:00:00.000", "description": "Report", "row_id": 165670, "text": "Atrial fibrillation with moderate ventricular response\nPossible anterior infarct - age undetermined\nLateral ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2194-03-27 00:00:00.000", "description": "Report", "row_id": 1407096, "text": "Admission\n72 y.o. female admitted to CSRU today after a redo sternotomy and repair of the mitral valve paravalvular leak. Some oozing in the OR, received 5u PRBC, 5u FFP, and 2u Plts. Cross clamp and bypass time WNL. No other issues in the OR.\n\nHX: Chronic afib, HTN, CHF, ?hepatitis possibly from hysterectomy, cholecystectomy, MVR in 9/00, irritable bowel syndrome, lymphoma, right lunch resection . Has been SOB with DOE recently. Cath showed paravalvular leak.\n\nCV: Afib, rate 90-110s. V-pacing wires only, tested but they did not sense or capture. Pacer turned off. Afebrile. Arrived on Ntg and epi gtts. Weaning epi to off. Ntg being used for HTN. CO >2, using CCO swan.\n\nPULM: Weaned and extubated without difficulty. Currently on 4L/NC, sats 96-97%. Lungs clear. Attempted to use IS, still too much pain. Strong cough though. CTs draining sanginous fluid, no airleak. SVO2 >60%.\n\nNEURO: Sleeping when undisturbed. Pt c/o pain but very quickly falls back asleep. Morphine given for pain relief. Husband and children in to visit. Husband is spokesperson.\n\nGU: Foley, good UOP, beginning to slow.\n\nGI: No bowel sounds yet, OG tube d/c'd with extubation. NPO.\n\nENDO: Insulin gtt started per new protocol today.\n\nPLAN: Medicate for pain then retry IS. Wean Ntg gtt as BP tolerates. Turn epi off, monitor SVO2 and CO.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-27 00:00:00.000", "description": "Report", "row_id": 1407097, "text": "Respiratory Care\nPt admitted to unit s/p cardiac surgery. Weaned quickly and extubated first to face tent, then nasal cannula. Vent pulled by end of shift. RRT\n" }, { "category": "Nursing/other", "chartdate": "2194-03-28 00:00:00.000", "description": "Report", "row_id": 1407098, "text": "NEURO:ASLEEP WHEN UNDISTURBED, EASILY AROUSABLE TO VERBAL STIMULI. ANSWERS /'S APPROPRIATELY, OBEYS COMMANDS.\n\nCV:AFIB W/ RARE PVC'S, HR 80-90'S, SBP 100'S-120'S. NITRO WEANED TO 0.6. PACER WIRS IN SENSED AT 0.8 AND CAPTURED AT MA 25, CURRENTLY OFF.\n\nRESP: O2 SAT 96-98% ON 4L NC, NO C/O SOB OR DIFFICULTY BREATHING. I.S. ATTEMPTED BUT UNSUCCESSFUL, ABLE TO C&DB APPROPRIATELY. CT DRG SANG 15-15CC/HR.\n\nGI/GU:ABD SOFT HYPOACTIVE BS, ND. FOLEY PATENT DRG CONC URINE. UOP POOR 1L LR GIVEN FOR UOP 16 W/ LITTLE AFFECT, UOP NOW20-25CC DR. AWARE.\n\nENDO:INSULIN GTT OFF, COVERED SC PER PROTOCOL.\n\nSOCIAL: HUSBAND CALLED WILL CALL AGAIN IN AM. DTR IN TO VISIT.\n\nPLAN: WEAN NITRO TO OFF. CONT TO MONTIOR HEMODYNAMICS, RESP, ENDO & GU STATUS. POSSIBLE D/C TO FLOOR IN AM IF REMAINS STABLE\n" } ]

[ { "category": "Radiology", "chartdate": "2180-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1175104, "text": " 5:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: New onset pulmonary edema\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with decreased saturation s/p blood transfusion\n REASON FOR THIS EXAMINATION:\n New onset pulmonary edema\n ______________________________________________________________________________\n WET READ: JKSd WED 6:47 PM\n worsening pulmonary edema and new moderate bilateral pleural effusions.\n cardiomegaly. right IJ line ends in SVC, NGT courses through stomach although\n tip excluded from view.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:40 P.M. \n\n HISTORY: Decreased saturation after blood transfusion. New pulmonary edema.\n\n IMPRESSION: AP chest compared to :\n\n Small bilateral pleural effusions right greater than left and mild pulmonary\n edema worse in the lower lobes in the presence of a moderate cardiomegaly,\n probably due to worsening cardiac decompensation. No pneumothorax. Pneumonia\n could be missed in the lower lungs.\n\n Right internal jugular line ends in the right atrium. Nasogastric tube is\n looped widely in the stomach and tip in the fundus.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-03-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1174809, "text": " 4:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? PTX\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with new CVL R IJ\n REASON FOR THIS EXAMINATION:\n ? PTX\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPSc MON 5:59 PM\n ET tube, NG tube, right IJ inserted in expected positions without\n complication. Persistent left lung disease could be asymmetric edema or\n pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New right internal jugular central venous catheter.\n\n STUDY: AP portable chest x-ray.\n\n FINDINGS:\n\n Compared to , the patient has been intubated and the endotracheal tube\n is roughly 5 cm above the carina. Right internal jugular central venous\n catheter has its tip in the upper right atrium. NG tube has its tip in the\n body or fundus of the stomach.\n\n No pneumothorax. The lung volumes are slightly lower with resultant increase\n in atelectasis. There is persistent left lower and mid lung opacities that\n could represent asymmetric pulmonary edema or early pneumonia. Small left\n pleural effusion is again noted. Borderline cardiomegaly is unchanged.\n\n Extensive degenerative changes are seen in bilateral shoulders.\n\n" }, { "category": "Radiology", "chartdate": "2180-03-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1174810, "text": ", J. TSICU 4:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? PTX\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with new CVL R IJ\n REASON FOR THIS EXAMINATION:\n ? PTX\n ______________________________________________________________________________\n PFI REPORT\n ET tube, NG tube, right IJ inserted in expected positions without\n complication. Persistent left lung disease could be asymmetric edema or\n pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2180-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1175508, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pulmonary edema\n REASON FOR THIS EXAMINATION:\n Evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:53 A.M. \n\n HISTORY: Pulmonary edema, evaluate interval change.\n\n IMPRESSION: AP chest compared to through :\n\n Mild pulmonary edema which developed between and ,\n subsequently improved, is minimal, unchanged since . Bilateral\n infrahilar consolidation is probably atelectasis. Moderate cardiomegaly is\n stable. Pleural effusion is small on the left if any. No pneumothorax.\n Nasogastric tube ends in the stomach. Right jugular line in the upper right\n atrium. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-03-13 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1174713, "text": " 9:43 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for acute pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with fever, abdominal pain, diarrhea\n REASON FOR THIS EXAMINATION:\n eval for acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MON 11:02 AM\n Non-specific wall thickening of distal descending colon through distal sigmoid\n colon is consistent with colitis. There is no associated fat stranding,\n pneumatosis, or pneumoperitoneum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, abdominal pain, and diarrhea.\n\n TECHNIQUE: MDCT axial images were acquired from the lung bases through the\n proximal femurs without administration of intravenous contrast. Multiplanar\n reformations were performed.\n\n COMPARISON: CT abdomen/pelvis from .\n\n ABDOMINAL CT: Bibasilar atelectasis or vascular crowding due to low lung\n volumes is seen. There is an unchanged calcified granuloma in the right lower\n lobe of the lung. Relative hypodensity of blood in the cardiac \n indicates anemia. Surgical clips from a prior CABG are noted.\n\n The liver is normal in appearance. The patient is status post cholecystectomy\n and surgical clips are seen in the gallbladder fossa. There is an unchanged\n 13 x 16 mm hypodensity in the spleen. The pancreas, adrenal glands, and\n kidneys are normal appearing. The stomach and small bowel are unremarkable.\n There are no pathologically enlarged lymph nodes in the abdomen. Diffuse\n vascular calcifications of the aorta, splenic artery, celiac axis, and iliac\n arteries are seen. There is no free fluid or free air in the abdomen.\n\n PELVIC CT: There is a segment of bowel wall thickening involving the distal\n descending colon through the distal sigmoid colon. Detailed evaluation is\n limited by poor underdistention and lack of IV contrast. There is no\n pneumatosis or significant pericolonic fat stranding. The transverse colon\n and proximal descending colon are distended with gas, though not frankly\n dilated. There are no pathologically enlarged lymph nodes in the abdomen.\n\n BONE WINDOW: Multiple degenerative changes of the thoracic and lumbar spine\n are seen. Severe disc space narrowing is present at T8-9 and L4-5.\n Multilevel small anterior osteophytes are noted. There is an old fracture of\n the eleventh right posterior rib. A left hip gamma nail and intramedullary\n femoral rod are seen.\n\n IMPRESSION:\n 1. Bowel wall thicking involveing the descending and sigmoid colon without\n pneumatosis or significant fat stranding. This appearance may be seen with\n (Over)\n\n 9:43 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for acute pathology\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n infectious vs ischemic colitis.\n\n 2. Extensive atherosclerosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1175545, "text": " 12:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Evaluate NGT placement\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with replaced NGT\n REASON FOR THIS EXAMINATION:\n Evaluate NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:34 P.M., \n\n HISTORY: NG tube replaced.\n\n IMPRESSION: AP chest compared to through 5:\n\n Nasogastric tube passes to the mid stomach and out of view. Minimal\n interstitial edema, unchanged. Mild cardiomegaly, stable. Small left pleural\n effusion is presumed. Right jugular line ends in the upper right atrium. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1175139, "text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate lungs\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pulmonary edema\n REASON FOR THIS EXAMINATION:\n Evaluate lungs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old woman with pulmonary edema, evaluate lungs.\n\n TECHNIQUE: Semi-erect portable AP chest radiograph compared to multiple prior\n studies most recent dated .\n\n FINDINGS: Small bilateral pleural effusions have improved slightly compared\n to the prior study. There is persistent bilateral pulmonary edema, possibly\n slightly improved. Left lower lobe atelectasis. No focal consolidation\n suggestive of pneumonia. No pneumothorax seen. An NG tube is seen within the\n stomach. The right internal jugular catheter lies with its tip in the\n mid-to-distal SVC, unchanged in position.\n\n IMPRESSION:\n Mild interval improvement in the pulmonary edema. Slight decrease in the\n bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2180-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174696, "text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension, evaluate for infiltrate.\n\n COMPARISON: Chest radiographs from .\n\n FINDINGS: In the setting of low lung volumes, bibasilar opacities could be\n due to bronchovascular crowding or atelectasis, less likely pneumonia. The\n remainder of the lungs are clear. There are no pleural abnormalities. Mild\n to moderate cardiomegaly is unchanged. Sternotomy wires and surgical clips\n overlie the thorax. Additional surgical clips are seen in the right upper\n quadrant of the abdomen.\n\n IMPRESSION: Bibasilar bronchovascular opacities likely due to bronchovascular\n crowding and atelectasis. Cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2180-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1175318, "text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval edema\n Admitting Diagnosis: BOWEL ISCHEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pulm edema\n REASON FOR THIS EXAMINATION:\n eval edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:13 A.M. \n\n HISTORY: Pulmonary edema.\n\n IMPRESSION: AP chest compared to through :\n\n Mild pulmonary edema is essentially unchanged since , but previous\n small right pleural effusion has substantially decreased. Heart size is top\n normal. Nasogastric tube is looped in the stomach. Right internal jugular\n line ends no less than 3 cm below the estimated location of the superior\n cavoatrial junction. No pneumothorax. Small left pleural effusion, probably\n unchanged.\n\n\n" }, { "category": "ECG", "chartdate": "2180-03-13 00:00:00.000", "description": "Report", "row_id": 314149, "text": "Baseline artifact. Irregularly irregular rhythm with considerable artifact may\nbe atrial fibrillation with controlled ventricular response. ST-T wave\nabnormalities are less prominent and QRS voltage is diminished. Clinical\ncorrelation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2180-03-13 00:00:00.000", "description": "Report", "row_id": 314150, "text": "Sinus rhythm. Leftward axis. ST-T wave abnormalities. Since the previous\ntracing of the rate is faster. The Q-T interval is shorter. Early\nprecordial and lateral limb lead T wave inversions are new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2192-04-20 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 955698, "text": " 3:55 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please evaluate abd pathology in patient found down. please\n Admitting Diagnosis: C1-C2 FRACTURE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with unstable C spine fx after being found down.\n REASON FOR THIS EXAMINATION:\n please evaluate abd pathology in patient found down. please perform recon\n images of L and S spine\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST.\n\n INDICATION: 81-year-old woman with unstable C-spine fracture, evaluate for\n abdominal pathology.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained following\n administration of 130 cc of Optiray intravenously. Coronal and sagittal\n reformatted images were obtained.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is partial left lower lobe\n collapse. There are small pleural effusions, right great than left.\n\n The liver, spleen, adrenal glands, pancreas, stomach, abdominal loops of large\n and small bowel are unremarkable. Kidneys enhance equally and excrete\n contrast normally. There is no free abdominal fluid, and no pathologically\n enlarged mesenteric or retroperitoneal lymphatic nodes.\n\n Extensive calcifications of the abdominal aorta, without aneurysmal\n dilatation, extending into common iliac arteries bilaterally.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: There is a Foley catheter in the urinary\n bladder. Rectum, sigmoid colon are unremarkable. There is no free pelvic\n fluid, and no pathologically enlarged pelvic or inguinal lymphatic nodes.\n There is a nonobstructing lower ventral hernia.\n\n BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic lesions. There\n are multiple bilateral old rib fracture deformities of unknown chronicity;\n however, were not present on . There is an old compression\n fracture of L1, unchanged.\n\n IMPRESSION:\n\n 1. Multiple rib deformities, of uncertain acuity, new from . Old\n L1 compression fracture.\n\n 2. Left lower lobe partial collapse.\n\n (Over)\n\n 3:55 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please evaluate abd pathology in patient found down. please\n Admitting Diagnosis: C1-C2 FRACTURE\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Small pleural effusions, right greater than left.\n\n Preliminary report was discussed with Dr. by Dr. on , .\n\n" }, { "category": "Radiology", "chartdate": "2192-04-20 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 955693, "text": " 2:09 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? brain injury\n Admitting Diagnosis: C1-C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall / cardiac arrest / not move UE / c1 & c2 fx\n REASON FOR THIS EXAMINATION:\n ? brain injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman found down. Status post C1-2 fracture.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through\n the brain with diffusion-weighted imaging.\n\n FINDINGS: There is no slow diffusion to indicate an acute infarct. The dens\n fracture noted on the CT scan is again identified. There has\n been significant posterior displacement of the superior fracture fragments and\n occiput relative to the vertebral body. There is cord compression at\n this level with increased T2 signal within the cord. Dr. was contact\n with these findings at the time of dictation and is uncertain whether there is\n increased T2 signal within the spinal cord as the axial FLAIR images only\n cover two sections of the cervical spinal cord. Within those two sections,\n there is a suggestion of cord edema.\n\n There are periventricular and subcortical T2 white matter hyperintensities,\n including within the pons, consistent with chronic microvascular ischemic\n changes. There are no areas of abnormal magnetic susceptibility. The\n remainder of the - white matter differentiation is preserved.\n\n IMPRESSION: Worsening alignment of the type 2 dens fracture with posterior\n displacement resulting in severe canal narrowing at the foramen magnum. There\n is cord compression at this level. Please refer to the cervical spine MRI of\n the same day for further discussion of the findings.\n\n No evidence of an acute infarct.\n\n Large amount of chronic microvascular ischemic change.\n\n MRA.\n\n TECHNIQUE: 3D time-of-flight MRA of the circle of .\n\n FINDINGS: The circle of is normal anteriorly. The posterior\n circulation area of apparent high-grade stenosis within the left vertebral\n artery, just proximal to its insertion on the basilar, does not appear to be\n significant on the source images and likely represents post-processing\n artifact on the MIPS.\n\n No aneurysms are identified.\n\n (Over)\n\n 2:09 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? brain injury\n Admitting Diagnosis: C1-C2 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Normal circle of MRA.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-04-20 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 955694, "text": " 2:11 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: ? c-spine\n Admitting Diagnosis: C1-C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall / cardiac arrest / not move UE / c1 & c2 fx\n REASON FOR THIS EXAMINATION:\n ? c-spine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Type II dens fracture.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through\n the cervical spine with sagittal STIR sequence.\n\n COMPARISON EXAMINATION: cervical spine CT.\n\n FINDINGS: Since that examination, there has been a large amount of posterior\n displacement of the dens and anterior arch of C1 with at least 8 mm worth of\n posterior displacement. There is now severe canal compromise at the foramen\n magnum as well as cord compression as evidenced by increased T2 signal within\n the spinal cord at this level. Dr. was informed of these findings by\n telephone at 1:15 p.m. on .\n\n There is fluid within the fracture plane with separation of the fracture\n fragments. There is prevertebral soft tissue edema present. The remainder of\n the cervical spine shows no evidence of bone marrow edema or abnormal\n alignment. There is soft tissue edema in the prevertebral space and\n nasopharynx and anterior to the C1 vertebral body.\n\n IMPRESSION: Significant worsening of the alignment of the dens fracture with\n posterior displacement and new cord compression since the \n cervical spine CT. I have contact the covering service by telephone as\n noted above.\n\n A large amount of prevertebral soft tissue edema. Ligamentous injury cannot\n be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2192-04-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 955665, "text": " 6:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation attempt\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p arrest\n REASON FOR THIS EXAMINATION:\n s/p intubation attempt\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n INDICATION: 78-year-old woman status post arrest, status post intubation\n attempt.\n\n COMPARISON: Not available.\n\n FINDINGS: Cardiac silhouette is not enlarged. There is a tortuous aorta.\n There are increased pulmonary interstitial markings, suggestive of\n interstitial lung disease. There is bibasilar linear atelectasis. There are\n no sizeable pleural effusions. Pulmonary vascularity is normal. There is a\n deformity of the left clavicle, consistent with old fracture. There are\n multiple rim calcifications in the abdomen. There is a single dilated\n featureless loop of bowel.\n\n There is an age-indeterminate L2 vertebral body compression fracture\n deformity.\n\n IMPRESSION:\n 1. Age-indeterminate compression fracture deformity of L2 vertebral body.\n\n 2. Bibasilar atelectasis.\n\n 3. Featureless distended loop of bowel.\n\n 4. Findings of chronic interstitial lung disease.\n\n" }, { "category": "Radiology", "chartdate": "2192-04-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 955666, "text": " 6:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P ARREST; FALL; EVAL FOR BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fall, no reflexes\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:33 PM\n no intracranial injury, r nasal bone fx\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST, AT 1838 HOURS\n\n HISTORY: Fall and areflexic.\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n brain and reconstructed at stacked 5-mm increments. No intravenous contrast\n was administered.\n\n COMPARISON: None.\n\n FINDINGS: The patient is intubated. There are two high-attenuation foci\n within the soft tissues along the right side of the face. Both result in\n significant streak artifacts in the respective axial sections. These are\n within the superficial soft tissues and irregularly shaped. Their etiology\n and time course are unknown.\n\n There is a comminuted fracture of C1 consistent with type\n fracture. This will be detailed in the accompanying cervical spine CT report.\n There is a displaced fracture of the right nasal bone. The skull base and\n calvarium are otherwise intact. There are opacified ethmoid air cells with\n air-fluid levels noted in bilateral sphenoid and maxillary sinuses. There is\n near complete opacification of bilateral frontal sinuses as well. Mild\n rightward nasal septal deviation is noted, likely chronic. The globes are\n intact. There are bilateral cataracts evident.\n\n Intracranially, the ventricles are prominent but midline. Likewise, the\n cortical sulci and subarachnoid cisterns are prominent. These findings\n reflect an overall generalized brain parenchymal volume loss which is within\n normal limits accounting for the patient's stated age of 78 years. The \n matter-white matter interface is well defined. There is low attenuation\n adjacent to the ventricles consistent with chronic microvascular disease.\n There may be a small lacunar infarction in the anterior limb of the left\n internal capsule. There is no CT evidence of acute cortical stroke. There is\n no intracranial hemorrhage. A scalp contusion is noted over the forehead\n midline.\n\n IMPRESSION: No intracranial injury identified. There is a C1 fracture which\n will be detailed in the accompanying cervical spine report. There is a right\n nasal bone fracture. Sinus fluid may be related to the indwelling\n (Over)\n\n 6:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P ARREST; FALL; EVAL FOR BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n endotracheal tube.\n\n" }, { "category": "Radiology", "chartdate": "2192-04-19 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 955667, "text": " 6:19 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P ARREST; FALL; EVAL FOR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p arrest, fall\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:32 PM\n C1 () fx, Type II dens fx\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE CT WITHOUT CONTRAST, AT 1842 HOURS\n\n HISTORY: Status post cardiac arrest and fall.\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n cervical spine and reconstructed at 2.5-mm increments utilizing bone and soft\n tissue window algorithms. Coronal and sagittal reformatted images were\n generated.\n\n COMPARISON: None.\n\n FINDINGS: There is a three-part fracture of the C1 ring midline at the\n anterior arch and at both pedicle laminar junctions. This is consistent with\n type fracture. Additionally there is an oblique fracture in the\n coronal plane through the odontoid process terminating the base posteriorly.\n This is most consistent with a type 2 odontoid fracture. There is\n approximately 1-mm of posterior displacement of the dens on the C2 body. No\n significant canal encroachment is noted. Bilateral occipital condyles are\n appropriately located on C1. No further fracture is evident. There is\n diffuse degenerative disease throughout the remainder of the cervical spine\n most notably at C5-C6 and C6-C7. There is marginal osteophyte formation at\n these levels, however, no critical canal stenosis or bony neural foraminal\n encroachment is appreciated. An LMA is present. Prevertebral soft tissue\n swelling is noted anterior to the upper cervical spine. Otherwise the\n prevertebral soft tissues are relatively unremarkable. Interlobular septal\n thickening is noted in the included lung apices likely secondary to volume\n overload. Minimal calcified plaque is noted at bilateral carotid siphons.\n\n IMPRESSION:\n 1. C1 ring fracture ( fracture).\n 2. Odontoid process fracture with approximate 1-2 mm of posterior\n displacement of the dens.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 955688, "text": " 12:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate position of ETT\n Admitting Diagnosis: C1-C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with C1/C2 unstable neck fracture. s/p endotracheal\n intubation\n REASON FOR THIS EXAMINATION:\n please evaluate position of ETT\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of endotracheal tube placement.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip terminates 4.6 cm above the carina. The cardiomediastinal\n silhouette is unchanged. The film is overpenetrated and does the precise\n evaluation of lung parenchyma is difficult but seems to be grossly unchanged\n compared to the previous film including the marked interstitial abnormalities\n and bibasilar areas of fibrosis. Comparing to the previous film the stomach\n is less extended.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-04-20 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 955772, "text": " 2:16 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: eval: fx\n Admitting Diagnosis: C1-C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n eval: fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman, status post fall, to evaluate for fractures.\n\n PRIOR STUDY: MRI of the lumbar spine done on .\n\n TECHNIQUE: Non-contrast CT of the thoracic spine was performed with sagittal\n and coronal reformats.\n\n FINDINGS:\n\n There is diffuse osteopenia of the thoracic vertebral bodies.\n\n There is a compression fracture with collapse of the vertebral body height\n involving most likely the L1 vertebral body (counting according to the ribs,\n considering the last rib as the 12th rib). There is a small retropulsed\n fragment extending into the spinal canal. However, the L1 vertebral body as\n well as the spinal canal were incompletely included on the present study of\n the thoracic spine. Anterior and posterior osteophytes are noted at multiple\n levels in the thoracic vertebrae. No significant canal stenosis is noted in\n the thoracic spine. The prevertebral soft tissues are unremarkable.\n\n Again noted is bilateral lower lobe lung collapse with small bilateral\n effusions. The collapsed lower lobe on the right side appears to be increased\n compared to the recent CT of the abdomen done on the same day at 4:49 a.m.\n\n IMPRESSION:\n 1. Collapse of L1 vertebral body (increased compared to the study) with\n a small retropulsed fragment/posterior osteophyte extending into the spinal\n canal.\n 2. Collapse of the lower lobes of lungs on both sides, increased on the right\n side compared to the earlier scan of the abdomen done on and 4:49 a.m.\n 3. Small bilateral pleural effusions.\n\n Findings were discussed with the clinical team at CC5B by Dr. on ,\n at 3:20 p.m.\n\n\n" }, { "category": "ECG", "chartdate": "2192-04-19 00:00:00.000", "description": "Report", "row_id": 114404, "text": "Normal sinus rhythm. T wave inversions in the inferior and lateral leads\nsuggesting possible inferior ischemia. Compared to the previous tracing\nof the inferior and lateral T wave abnormalities are new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2192-04-19 00:00:00.000", "description": "Report", "row_id": 114403, "text": "Normal sinus rhythm. Compared to tracing # 1 the T wave inversions are more\nprominent in the anterolateral leads and have resolved in the inferior leads.\nTRACING #2\n\n" }, { "category": "Nursing/other", "chartdate": "2192-04-20 00:00:00.000", "description": "Report", "row_id": 1414481, "text": "(Continued)\nall or possible outcomes are established. She wishes the patient to be DNR at current time, will re-address in morning once plan established. has spoke with trauma team as well as ICU resident and RN. She will call early this morning. She lives in MA and went home for night.\n\nPLAN-Follow up with MRI/CT scan\n -PLan for EEG\n -Repeat head CT\n -Needs OGT placed\n -Cycle cardiac enzymes\n -Update family/HCP\n\n\n" }, { "category": "Nursing/other", "chartdate": "2192-04-20 00:00:00.000", "description": "Report", "row_id": 1414482, "text": "Respiratory Care: Pt is an 81 yo F, s/p arrest, fall C1 and C2 fx as well as facial fx's. Was intubated with LMA by EMS after multiple attempts to intubate. Re-intubated fiberoptically after arriving to tsicu. Travelled to MRI and CT results pending. No morning RSBI done due to unstable spine. Pt is currently DNR status per family.\n" }, { "category": "Nursing/other", "chartdate": "2192-04-20 00:00:00.000", "description": "Report", "row_id": 1414483, "text": "Resp Care: Pt remains intubated via #6.5 ETT secured 20cm at lip. BS rel clear, sl coarse bilat. Sx'd for small to mod amts thick rusty sputum. Transported to and from CT scan w/o incident. Weaned to PSV. Tol well. Plan: Extub to CMO per family request. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2192-04-20 00:00:00.000", "description": "Report", "row_id": 1414480, "text": "T/SICU NURSING ADMISSION NOTE\n\nPt is a 81y/o female admitted to T/SICU from ER after being found down in front of grocery store. Fall unwitnessed, pt without a pulse, CPR was started by bystanders. EMS arrived pt HR 40, Atropine administered HR responded to 100-110's. Pt apnenic, 3 attempted airways, LMA placed. Transfered to ER.\nSCANS DONE:\nCT S-SPINE-C1 ring fracture( fracture) and C2 Type II Dens fracture.\nHEAD CT-Negative for bleed. Right nasal bone fracture.\n\nPt transfered to T/SICU with LMA. Fiberoptically intubated with #6.5 ETT 20LL. Family updated by ICU resident, Trauma team and RN (see social). Arterial line placed. Pt then brought to MRI for head and neck and CT scan for abdomen and pelvis. Results currently pending.\n\nREVIEW OF SYSTEMS:\n\nPLEASE SEE CAREVUEW FOR EXACT DATA:\n\nNEURO-Pt with spontaneous eye opening. Right pupil 1mm and nonreactive, at baseline pupil miotic. Left pupil surgical/cataracts and UTA. Mouth movements, ?attempting to speak. Grunting noted upon intial neuro exam. No movement noted since admission to bilateral UE's. Bilateral LE's move spontaneously/purposfully. Difficult to assess if patient is following commands or spontaneous movement, however when asked to patient will wiggle toes, bend knees to command. Propofol initially at 30mcgs/kg/min, now suspended for neuro exam. Fentanyl given intermitantly for pain. Tolerated 25-50mcgs, PRN. C-collar intact, continues on logroll precautions.\n\nCV-SR-SB 50-70's, no ectopy. Right radial arterial line placed with SBP ranging 110-140's/30-40's, MAPs 60-70. Hypotensive in MRI to 60's, reponded to 500cc fluid bolusx1. PIVx2 bilateral AC #18G placed in ED. HCT 32.7 from 34.5. Coags WNL. Hypothermic on arrival at 94, warming blankets and radiant warmer on temp now 97.4. Cycling cardiac enzymes last drawn at 0200, due 100. Enzymes flat currently. Compression boots.\n\nRESP-Pt orally intubated #6.5ETT 20LL Continues on CMV TV 450 R 14 P5 40%, ABG WNL. Lung sounds initially coarse now clearing however more diminished on RLL. Sats maintained at 100%. Mouth care given per protocol.\n\nGI-Abdomen soft, non-distended. Positive bowel sounds. Needs OGT placed. Protonix as ordered.\n\nGU-Indwelling foley catheter with dark yellow/ blood tinged urine. UOP drifted now adequate. Mag 1.6 and being repleted, other lytes WNL.\n\nINTEG-Skin impaired. Bilateral eyes ecchymotic and abrasion to nose. Bilateral knees ecchymotic with abrasion to right knee.\n\nENDO-ISS ordered, no coverage required.\n\nID-Afebrile WBC's 11.6 No antibiotics at this time.\n\nSOCIAL-Pts daughter is spokesperson and HCP. PT and daughter had conversation one week ago, pt told daughter she would like to be DNR/DRI and no heroic measures to be performed. However due to the fact an LMA was placed on the scene and injuries were not known pt was intubated fiberoptically at bedside to establish safe airway to travel to MRI/CT scan. Daughter is not comfortable signing ICU consent until scans are back and cause of f\n" }, { "category": "Nursing/other", "chartdate": "2192-04-20 00:00:00.000", "description": "Report", "row_id": 1414484, "text": "T-SICU Nsg note\n Pt's daughter arrived to about 0900 this am, pt's son arrived shortly thereafter. Pt's children talked to Dr. , Dr. , also neuro med team about prognosis, plan of care, and pt's wishes not to be intubated nor to have heroic measures. Rabbi also spoke to pt's children at length and spoke to pt. Dr. also spoke to family at length.\n To CT scan for thoracic spine. Back cleared, and pt sitting up.\n Pt on PSV, tolerating 5cm PSV above 5cm PEEP.\n Family ready to extubate pt at 1700. Pt extubated at 1715. Pt making sound \"I\"or \"Ai\", no other sound. Children concerned pt was uncomfortable, 25mcg fentanyl IVP given. Briefly, pt with good HR, BP, resp rate and O2 sat. Then sat fell precipitously to 60%, then to 20%. Medicated with fentanly 35mcg. Pt with bradycardia, then asystole. son and daughter at bedside. Pt pronounced dead about 1755 by Dr. .\n NEOB notified of pt's death.\n Family stayed with pt for awhile. After family left, post-mortem care given.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2177-04-07 00:00:00.000", "description": "Report", "row_id": 1324271, "text": "MICU NPN 0700-:\n\n Pt stable and called out to floor. Awaiting orders and bed assignment.\n\n Neuro: Unchanged. Pt essentially non verbal. She will occasionally follow simple commands. Attempting to hit/pinch nursing staff with turns etc--unable to determine source of pts distress.\n\n CV: Afebrile. Pt in junctional rhythm rate in 50's-60's. Occasional dropped beat. BP stable. Access remains midline catheter and #18 PIV. Clot current in BB. Hct pending from this afternoon. UOP continues to be low throughout day despite initiation of maintenance fluids. MD aware. Small fluid bolus currently infusing--team is managing fluid status conservatively in setting of CHF history. Lytes also pending from this afternoon.\n\n Pulm: Pt weaned to RA. Lungs cta. Occasional dry cough. Abx d/c'd this am by team--no evidence of pna.\n\n GI: Pt NPO. GI to evaluate for possible EGD and PEG placement tommorrow. Abd benign. No stool.\n\n GU: FOley to gravity. Urine is concentrated/amber in appearance.\n\n Skin: Intact.\n\n Family: Pts son, , updated extensively by this RN and Dr. from the medical team. Case manager to contact son today to discuss discharge plans.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-07 00:00:00.000", "description": "Report", "row_id": 1324272, "text": "MICU Nursing Note Addendum:\n Pt had little to no response to fluid bolus. Dr. in to examine pt--no s/sx of failure (02 weaned to off today, no JVD, no crackles). Urine remains concentrated appearing. IVF changed to NS with 20 KCL and urine lytes sent. MD will base further fluid rescusitation based on urine results as pt almost 2 L positive since midnight.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-08 00:00:00.000", "description": "Report", "row_id": 1324273, "text": "pmicu npn 7p-7a\n\n\n the pt had an uneventful noc, awaiting transfer to the floor. she continued to have a persistently low uop despite an additional 250cc ns fluid bolus and subsequently received 10mg iv lasix @0400. she has had a good response to the lasix so far.\n\nreview of systems\n\nrespiratory-> lung exam is essentially cta while she is maintaining sats >95% on room air.\n\ncardiac-> hr 70's, junctional rhythm w/rare pvc's. sbp 90-110's with maps >60.\n\nneuro-> pt is awake and alert, occationally answering questions appropriately using one to two word responses. moving upper extremities up towards her face but unable to move her lower extremities at all.\n\ngi-> abd is soft, nontender w/+bs. no bm overnoc. remains npo with an ngt in place. plan for gi to see pt in the am for a possible edg w/a peg placement. please see abx on call to egd/peg located on the stat sheet. serial hcts stable ~31.\n\ngu-> uop ~10cc/hr for most of the shift. as noted above, the pt received a single 250cc ns fluid challenge w/o results. she the received 10mg iv lasix and initially diuresed ~250cc. she is approx 250cc tfb positive since mn.\n\nid-> afebrile with a normal wbc. she was started on levoquin last noc for a uti.\n\naccess-> right ac midline catheter and a #18g angoicath in the left ac.\n\nsocial-> no contact w/family overnoc.\n\ndispo-> anticipate transfer to medicine later this morning. the transfer note has been written.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-06 00:00:00.000", "description": "Report", "row_id": 1324268, "text": "MICU NPN Admission-:\n Pt admitted from ER with UGIB. CC was coffee ground emesis and black tarry stools. In ER, hct was 10 pts below baseline and her NG was lavaged for heme + contents (cleared after 1 L). Pt transferred to MICU s/p reversal of coagulopathy (1 u FFP, 10 mg SC vit K), protonix and 1 u prbc. Pt admitted for close f/u of hcts and possible scope today or tommorrow.\n\n Neuro: Pt s/p hemorrhagic stroke and is non verbal at baseline. She does open eyes to unpleasant stimuli and, when awake, attempts to pinch/hit nursing staff despite verbal reassurance. If left alone, pt is sleeping and appears comfortable in the bed.\n\n CV: Afebrile. Pt in ? accellerated junctional rhythm. Rare ectopy. Mult EKG's done. BP trending down s/p lasix administered in ER--pt responded well to 250 cc NS fluid bolus. BP stable in low 100's since fluids. Pt recieved 1 u prbc (started in ER), f/u hct (1.5 hours s/p transfusion) 30.5. Pt also recieved 40 meq KCL IV for K+ 3.3 (prior to lasix). Plan for f/u hct and lytes check at 8pm. Of note, pt has midline in R AC (per nsg home doccumentation), it is not a central line.\n\n Pulm: Lungs diminished throughout. Pt maintaining sats on 2 L NP with sats 100%.\n\n GI: NGT with clear aspirates. + plcmt via cxr and air bolus. Abd benign. Pt has heme + stool with temp checks, but she has had no BM's. No N/V.\n\n GU: Foley in place. Drained huge amt after lasix administered in ER.\n\n Family: is pts son and HCP. had mult discussions re: code status with Dr. . At this point pt is DNR, but she will be intubated if necessary. He wants to be contact in the event that pt needs central line. He will call to check status in AM.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-07 00:00:00.000", "description": "Report", "row_id": 1324269, "text": "P-MICU NPN 7p-7a\nSystems Review:\n\nResp: Remains on O2 2l via NC, with O2 sats in the high 90's. LS diminished throughout.\n\nCV: Hypotensive at times with Systolic BP in the mid to high 80's. MAP in the 50's. Pt arousable, but u/o diminishing. Received 4 separate NS bolus' of 250cc's. The 4th one in infusing now. HR 50's-80's junctional rhythm. Receiving electrolyte replacement as appropriate.\n\nNeuro: Non verbal at baseline. Appears to nod appropriately at times, not consistant.\n\nGI: NPO at present. Would not let this RN wipe her mouth out with swab. +BS, no stool. No NG aspirates noted.\n\nGU: Poor u/o, averaging ~10cc/hr. Currently receiving 4th bolus. LS remain diminished and no crackles noted as of yet.\n\nID: afebrile.\n\nSocial: No calls this shift.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-07 00:00:00.000", "description": "Report", "row_id": 1324270, "text": "P-MICU NPN 7p-7a\nNo coffee grounds noted via NGT, HCT stable.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-08 00:00:00.000", "description": "Report", "row_id": 1324274, "text": "MICU A NSG 7A-7PM\nRESP--PT ON RA MOST OF SHIFT, PLACED ON NC POST EGD. LUNGS CTA BILAT WITH DIMINISHED BS IN BASES.\n\nNEURO--PT SLEEPING IN NAPS THROUGHOUT SHIFT. EASILY ROUSABLE AND PLEASANT. S/O HUNGER AND NASAL DISCOMFORT R/T NGT. ABLE TO MOVE ARMS, BUT NO SPONT MOVEMENT IN LEGS. RECEIVED VERSED 1MG IV AND DEMEROL 25MG IV FOR EGD.\n\nCV--REMAINS IN JUNCTIOANL RHYTHM HR 50-60. BP STABLE PT RECEIVED KCL 40MEQ IV AND MAGNESIUM SULFATE 2GM IV. TO ALSO RECEIVE KPHOS 30MMOL IV WHEN BACK FROM EGD.\n\nGI--NGT IN PLACE THIS AM, PT NPO FOR EGD AND PEG PLACEMENT. ABD SOFT WITH GOOD BS. NO BM BUT PT PASSING GAS.\n\nGU--PT RECEIVED 10MG IV X1 WITH GOOD RESPONSE.\n\nSOCIAL--SON IN TO VISIT. FAMILY MEETING HELD TO DISCUSS PT DISPOSITION AND SETTING UP HOME CARE SERVICES. SON WISHES PT TO GO HOME WITH 24 HOUR CARE, AND HAS CONSULTED 2 AGENCIES TO ASSIT IN SETTING UP SERVICES. CASE MANAGMENT INVOLVED. SON WISHES PT TO REMAINS IN HOSPITAL TILL THURDAY TO ALLOW FOR HOME SERVICES TO GET CAREGIVERS IN PLACE.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-09 00:00:00.000", "description": "Report", "row_id": 1324275, "text": "NPN 1900-0700\nNeuro: Pt alert, follows simple commands. moves arms in bed but no movement in legs noted. No c/o pain.\n\nResp: Pt cont on 2L nc c sats 95-100%. RR 19-22, LS clear, diminished at bases.\n\nCV: BP 96/36 - 111/42. HR cont in junct rhythmn c rare pvc 58-67. Chems drawn at 0430 & pending.\n\nGi: PEG in place, dsg dry. Used for meds. +BS, abd non tender. No stool.\n\nGU: u/o mostly 25-35mls/hr, one hr only 10mls. Minimal flds given on this shift.\n\nSocial: Son called twice this shift. He asked to speak to tomorrow, even tho he refused to speak to her today. A number of times he asked about using her G tube to feed pt, apparently he prefers not to do this, saying it will create a precedent, he prefers to use it only for flds. He asked questions about TPN.\n\nPlan: Follow up on am labs, hct, tube feeding orders?. Work with son for discharge plan.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-09 00:00:00.000", "description": "Report", "row_id": 1324276, "text": "MICU NPN 0700-1900\n\nREVIEW OF SYSTEMS:\n\nNEURO: AROUSE TO VOICE, OPENS EYES, FOLLOW SIMPLE COMMANDS, SPEAKS ONE OR WORD STATEMENTS ATTEMPTING TO GET NEEDS MET, MOVES ONLY RIGHT ARM\n\nCV: STABLE BASELINE HR 60'S JUNCTINAL RHYTHM, BP 90'S-100/, LASIX 10MG X1 WITH BRISK RESPONSE\n\nGI; ABD SOFT +BS, NO STOOL, PEG TUBE INTACT, FREE WATER BOLSES 250CC Q4, NO ENTERAL FEEDS PER SONS REQUEST\n\nGU: FOELY INTACT WITH CLEAR YELLOW URINE\n\nSKIN: ELBOWS REDDENED, NO OPEN AREAS\n\nSOCIAL: NUMEROUS CALLS FROM SON, AND HOME CARE COMPANY THAT WILL BE PROVIDING 24 HOUR CARETAKER BEGINNING TOMORROW, CASE MANAGEMENT INVOLVED WITH D/C PLAN TO HOME, VNA CONSULTED AND SERVICES BEING HOSPITAL BED AND LIFT BEING DELIVERED TO SONS HOUSE TOMORROW AM\n\nPLAN: STABLE FOR TRANSFER TO FLOOR AND EVENTUAL DISCHARGE TO HOME WITH 24 HOUR CARE. PLEASE SEE NURSING TRANSFER NOTE\n" }, { "category": "ECG", "chartdate": "2177-04-06 00:00:00.000", "description": "Report", "row_id": 260881, "text": "Probable normal sinus rhythm with first degree A-V block\nVentricular premature complex\nConsider septal infarct\nLeft ventricular hypertrophy\nLow QRS voltages in limb leads\nDiffuse nonspecific ST-T wave changes\nSince previous tracing, ventricular premature complex and further ST segment\ndepression\n\n" }, { "category": "ECG", "chartdate": "2177-04-06 00:00:00.000", "description": "Report", "row_id": 260882, "text": "Probable normal sinus rhythm with first degree A-V block (V2)\nSeptal myocardial infarction, age indeterminate\nLeft ventricular hypertrophy\nLow QRS voltages in limb leads\nIntraventricular conduction delay\nNonspecific inferolateral ST-T wave changes\nSince previous tracing, T waves now decreased in leads l, aVL and flat in lll,\naVF\n\n" }, { "category": "ECG", "chartdate": "2177-04-06 00:00:00.000", "description": "Report", "row_id": 260880, "text": "Probable normal sinus rhythm with first degree A-V block\nProbable old septal infarct\nNonspecific extensive ST-T changes\nLow QRS voltages in limb leads\nLeft ventricular hypertrophy\nSince previous tracing, ventricular premature complex absent\n\n" } ]

[ { "category": "Echo", "chartdate": "2193-02-25 00:00:00.000", "description": "Report", "row_id": 100225, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 149/82\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:28\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Increased IVC diameter\n(>2.1cm) with >55% decrease during respiration (estimated RA pressure\n(0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and 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: basal inferior\n- hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Eccentric MR jet. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The estimated right atrial pressure is 0-10mmHg.\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with XXX. The remaining\nsegments contract normally (LVEF = XX %). The estimated cardiac index is\nnormal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. An\neccentric, XXX directed jet of Moderate (2+) mitral regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nThe left atrium is elongated. Left ventricular wall thicknesses and cavity\nsize are normal. There is mild regional left ventricular systolic dysfunction\nwith focal severe hypokinesis of the basal inferior wall. The remaining\nsegments contract normally (LVEF = 60 %). The estimated cardiac index is\nnormal (>=2.5L/min/m2). 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. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. An eccentric,\nlaterally directed jet of moderate (2+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Normal left ventricular cavity size with mild regional systolic\ndysfunction c/w CAD (PDA distribution). Eccentric jet of moderate mitral\nregurgitation. Moderate pulmonary artery systolic hypertension.\n\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2193-02-26 00:00:00.000", "description": "Report", "row_id": 276195, "text": "Sinus bradycardia. Prominent U waves in the precordial leads. Compared to the\nprevious tracing of heart rate is reduced. Otherwise, no diagnostic\nchange.\n\n" }, { "category": "ECG", "chartdate": "2193-02-24 00:00:00.000", "description": "Report", "row_id": 276196, "text": "Sinus rhythm with premature atrial complexes. Left atrial abnormality.\nnon-diagnostic Q waves in the high lateral leads. Compared to the previous\ntracing of ventricular ectopy is no longer seen and the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2193-02-24 00:00:00.000", "description": "Report", "row_id": 276197, "text": "Sinus tachycardia. The P-R interval is short without evidence of\npre-excitation. Ventricular ectopy. Compared to the previous tracing\nof the rate is faster and ventricular ectopy is new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2193-02-22 00:00:00.000", "description": "Report", "row_id": 276198, "text": "Artifact is present. Sinus rhythm. Atrial ectopy. Compared to the previous\ntracing of atrial ectopy is new.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-03-12 00:00:00.000", "description": "PERC VERTEBROPLSTY, THORACIC", "row_id": 951643, "text": " 9:05 AM\n VERTEBROPLATY Clip # \n Reason: Vertebroplasty please to T1 compression fracture\n Admitting Diagnosis: T1 FRACTURE\n ********************************* CPT Codes ********************************\n * PERC , FLUORO S&I PERC VERTEBRO/KYPHO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with h/o prostate ca, p/w T1 compression fracture, in brace.\n Needs vertebroplasty for pain control/lesion stability\n REASON FOR THIS EXAMINATION:\n Vertebroplasty please to T1 compression fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88 y/o man with history of prostate carcinoma with T1 compression\n fracture. History of severe back pain. Patient refractory to conservative\n medical management.\n\n RADIOLOGISTS: Drs. and , the Attending Neuroradiologist, present\n and supervising throughout the entire procedure.\n\n Informed consent was obtained from the patient and the patient's family after\n explaining the risks, indications, and alternative management in extensive\n detail. Patient clearly understood the risks and benefits and alternatives of\n the procedure and willfully consented to the procedure.\n\n The patient was brought to the fluoroscopy suite and placed on the table in\n the prone position. MAC anesthesia was administered. The lower back was\n prepped and draped in the usual sterile fashion. Initially, using 22 gauge\n spinal needles under local anesthesia with aseptic precautions, the needle was\n placed in the region of both pedicles. Using AP & lateral views, 11 gauge\n needles were then placed through both pedicles into the T1 vertebral body.\n Under fluoroscopic guidance, approximately 1 cc of PMMA (PRLX) . At this\n point, it was decided to terminate this exam as end point of the procedure and\n the needles were removed.\n\n Patient tolerated the procedure well. The patient was sent to the floor with\n orders. 1 gm of IV Ancef was administered prior to the procedure.\n\n IMPRESSION: Successful vertebroplasty of the T1 vertebral body by the\n transpedicular approach.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 951849, "text": " 6:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with known lung cancer, s/p vertebroplasty, change in mental\n status\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with known lung cancer, status post\n vertebroplasty.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no hemorrhage, mass effect, shift of the normally midline\n structures, or major vascular territorial infarct. There is age appropriate\n involution change. The - white matter differentiation is preserved. Again\n seen are chronic appearing lacunar infarcts in the basal ganglia and thalami.\n There are dense basal ganglia calcifications bilaterally. Retention\n cysts/polyps are seen in the maxillary sinuses. Again seen is a focal left\n cerebellar encephalomalacia.\n\n IMPRESSION:\n\n 1. No hemorrhage or mass effect.\n\n 2. Old bilateral basal ganglia and left cerebellar infarcts.\n\n MRI with gadolinium is more sensitive in the detection of metastatic disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-23 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 949053, "text": " 12:17 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ** Please image C5-T4 **\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with T1 compression fracture\n REASON FOR THIS EXAMINATION:\n ** Please image C5-T4 **\n CONTRAINDICATIONS for IV CONTRAST:\n 1 kidney\n ______________________________________________________________________________\n WET READ: DDH SAT 2:49 AM\n bust fx T1; no obvious canal compromise; deg changes c-spine\n\n md\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: T1 compression fracture. Please image.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images through the cervical spine were obtained\n without IV contrast. Coronal and sagittal reformatted images were generated.\n\n CT OF THE CERVICAL SPINE WITHOUT IV CONTRAST: There is a compression fracture\n of the T1 vertebral body as described. There is relatively equivalent loss of\n height throughout the vertebral body. No definite retropulsed fragments are\n seen. Vacuum phenomenon is seen within this vertebral body. There is also a\n fracture through the left lamina at the T1 level. The coronal reformatted\n images demonstrate this fracture through an oval area of relative\n demineralization.\n\n No additional fractures are identified. The cervical and upper thoracic\n vertebral body heights, excluding T1, are maintained. There is intervertebral\n disc space narrowing at multiple levels, greatest at C6/7 and in the proximal\n thoracic spine. The prevertebral soft tissues are unremarkable. The CT does\n not provide intrathecal detail comparable to that of MRI, the central spinal\n canal appears narrowed at multiple levels, related to disc osteophyte\n complexes indenting the ventral thecal sac. These are noted at C3/4, C4/5 and\n C5/6.\n\n Soft tissue window images demonstrate a large round lesion of the left lobe of\n the thyroid at the thoracic inlet. This lesion measures 4.4 x 3.5 cm in\n greatest axial dimensions. There are atherosclerotic calcifications of the\n aortic arch and carotid arteries. There are several small lymph nodes of the\n superior mediastinum. More inferiorly, there is a partially imaged large\n rounded opacity within the posterior left chest. This lesion is not\n completely imaged, but at least measures 6.8 cm in diameter. There are\n coronary artery calcifications.\n\n IMPRESSION:\n 1. Compression fracture of the T1 vertebral body and left lamina. The\n (Over)\n\n 12:17 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ** Please image C5-T4 **\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fracture through the left T1 lamina courses through a rounded area of\n demineralization or lucency, raising the possibility of an underlying bone\n lesion at this locale. This fracture may be unstable given that the vertebral\n body and posterior elements are involved.\n 2. Large rounded opacity in the left lower lobe of the lung, partially\n imaged. While this could represent a rounded pneumonia, a neoplasm is also\n considered and dedicated chest CT is recommended.\n 3. Large rounded lesion of the left lobe of the thyroid. This should be\n further evaluated with ultrasound.\n 4. Advanced atherosclerotic disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 949045, "text": " 10:05 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with PNA\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia, rule out pneumonia.\n\n CHEST, TWO VIEWS.\n\n There is a large (7.5 cm) opacity in the left lower lobe posteriorly. It\n abuts the posterior chest wall and may obscure a portion of the posterior\n diaphragm. No gross effusion is identified. Heart size is at the upper\n limits of normal. No CHF, other focal opacity, or effusion is identified. The\n hilar and mediastinal silhouette is within normal limits for age.\n\n Narrowing of the acromiohumeral distance in the right shoulder is compatible\n with a chronic complete rotator cuff tear.\n\n IMPRESSION:\n\n Focal opacity in the left lower lobe posteriorly. In appropriate clinical\n setting, this could represent an atypical presentation of pneumonia. However,\n given the relatively discrete rounded appearance on the frontal view, the\n possibility of a focal lung mass should be considered. As a result, short-\n term followup to resolution or, alternatively, a chest CT is recommended for\n further assessment. Rounded atelectasis is considered much less likely given\n the absence of diffuse pleural abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-04 00:00:00.000", "description": "THYROID U.S.", "row_id": 950455, "text": " 2:09 PM\n THYROID U.S. Clip # \n Reason: NECK MASS SEEN ON CT, POSSIBLE THYROID CANCER?\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with afib w/rvr, and thyroid nodule and lung masses.\n REASON FOR THIS EXAMINATION:\n Possible thyroid cancer?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old with afib and lung masses, evaluate thyroid nodule\n seen on recent CT.\n\n THYROID ULTRASOUND: Compared to CTA chest of . Due to a recent\n thoracic vertebral fracture, imaging of the thyroid is very limited. Per the\n ordering team, the brace was removed, however, the patient could not move\n during the exam to aid imaging. Allowing for this, the thyroid parenchyma is\n not well visualized. In the region of the upper pole of the left thyroid/left\n supraclavicular region, there is a well-circumscribed 4.1 x 3.0 heterogeneous\n mass. It is impossible to determine on this examination whether this mass is\n exophytic from the left lobe of the thyroid or represents a distinct\n supraclavicular adenopathy.\n\n IMPRESSION:\n 1) Very limited study due to overlying brace and patient immobility. Thyroid\n parenchyma not visualized.\n 2) 4.1-cm mass centered in the expected position of the upper lobe of the left\n thyroid/supraclavicular region. It is impossible to tell on the current study\n whether this lesion is exophytic from the left lobe thyroid or represents\n supraclavicular adenopathy, though the former appears more likely in\n correlation with the recent CTA chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-24 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 949208, "text": " 8:42 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: malignancy screen\n Admitting Diagnosis: T1 FRACTURE\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with prostate ca s/p T1 fracture\n REASON FOR THIS EXAMINATION:\n malignancy screen\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88-year-old male with known prostate cancer status post T1 fracture.\n Evaluate for other malignancies.\n\n FINDINGS: Comparison is made to prior CT spine examination dated .\n\n TECHNIQUE: MDCT acquired axial images were obtained from the thoracic inlet\n to the pubic symphysis with oral and intravenous contrast. Three-minute delay\n images were obtained per protocol. Coronal and sagittal reformations were\n displayed with 5-mm slice thickness and used for better anatomic localization\n of disease.\n\n CT OF THE CHEST/ABDOMEN/PELVIS\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: A large heterogeneously enhancing\n left posterior lung soft tissue mass measuring approximately 8.2 x 4.9 cm\n (series 3, image 33) is identified and appears to contain a well-defined\n circular punctate calcification (likley sequela of old granulomatous disease)\n as well as an additional thin linear calcification noted more laterally\n abutting the pleura. The exact origin of the mass is unclear, however, it\n looks to be centered either within the pleural space itself or the lung and is\n noted to extend into the chest wall and cause mild erosion into the\n surrounding ribs. Additionally, two other foci of enhancing soft tissue masses\n are noted adjacently, one abutting the lateral chest wall pleura measuring\n approximately 1.8 x 2.3 cm and an additional more rounded mass adjacent to the\n descending aorta measuring approximately 3 x 3.9 cm. Additionally, on coronal\n images (series 400B, image 53), there appears to be increased pleural\n thickening without calcification noted slightly more superior to the dominant\n mass. The lung parenchyma appears otherwise unremarkable with no other focal\n nodules identified. There is minor dependent atelectasis within the base of\n the right lobe. Airways appear patent to the subsegmental level and other\n than coronary and aortic vascular calcifications, the heart and great vessels\n appear normal. No axillary or hilar lymphadenopathy is identified and there is\n mild scattered mediastinal lymphadenopathy, the largest conglomerate of nodes\n measuring approximately 1.2 x 2.9 cm in the subcarinal area which contains a\n punctate calcification. A heterogeneously enhancing 3.7 x 3.8 cm left thyroid\n mass is again identified as demonstrated on prior CT spine. It does appear to\n cause mild rightward deviation of the trachea.\n\n CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Non-contrast images\n (Over)\n\n 8:42 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: malignancy screen\n Admitting Diagnosis: T1 FRACTURE\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n display several small punctate calcifications scattered throughout the liver,\n spleen, and right kidney parenchyma likely related to sequela of prior\n granulomatous disease. No focal liver masses are identified and the portal\n vein appears patent. There is evidence of cholelithiasis, without signs of\n acute cholecystitis. The spleen, pancreas, stomach, and adrenal glands all\n appear unremarkable. The patient is noted to be status post left nephrectomy.\n Multiple hypoattenuating lesions are identified within the right kidney, some\n too small to characterize and some which are clearly cystic. One lesion\n measures approximately 2.2 x 1.5 cm extending off the medial right upper pole\n likely representing a hyperdense cyst, with another larger simple cyst\n measuring approximately 5.3 x 7.9 cm likely extending off the interpolar\n region of the right kidney. No pathologically enlarged mesenteric or\n retroperitoneal lymph nodes are identified. There is no free air or free\n fluid noted within the abdomen.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The intrapelvic bowel, prostate,\n and urinary bladder appear grossly normal. No pathologically enlarged pelvic\n or inguinal lymph nodes are identified. No free fluid is noted within the\n pelvis.\n\n BONE WINDOWS: No suspicious osteolytic or osteoblastic lesions are\n identified. Previously noted compression fracture of T1 is noted on sagittal\n images. Additionally, there are multilevel degenerative changes of the spine\n with degenerative disc disease as well as grade 1 anterolisthesis of L5 on S1.\n Remaining vertebral body heights appear well preserved. Additionally, as\n noted above, there appears to be mild cortical erosion of the left posterior\n ninth rib with possible involvement of the posterior eighth rib as well.\n\n IMPRESSION:\n 1. Multiple heterogeneously enhancing soft tissue masses within the posterior\n left lung likely centering within the lung extending into the lateral chest\n wall and causing mild bony erosion. A small linear calcification is noted\n adjacent to the pleura within the dominant mass. Likley reprsenets a primary\n lung carcinoma, with mesothelioma or metastatic lesion from thyroid or renal\n cell carcinoma also within the differential. The lesion appears to be amenable\n to percutaneous biopsy.\n\n 2. Heterogeneously enhancing middle mediastinal left thyroid lesion. This\n likely represents a simple goiter but can be further evaluated with ultrasound\n if clinically indicated.\n\n 3. Cholelithiasis without evidence of acute cholecystitis.\n\n 4. Multiple right renal hypoattenuating lesions, some of which are clearly\n (Over)\n\n 8:42 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: malignancy screen\n Admitting Diagnosis: T1 FRACTURE\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cystic and others which are too small to characterize.\n\n 5. Diffuse atherosclerotic calcifications.\n\n 6. T1 compression fracture with multilevel degenerative changes throughout\n the spine, including grade 1 anterolisthesis of L5 on S1 and mild posterior\n disc protrusion of L3-4 intervertebral disc.\n\n Findings were discussed with the caring physician . on date of exam\n at approximately 10:20 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2193-02-25 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 949331, "text": " 1:13 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: **Please image C5-T4**. Critical protocol is T1 w/ gad\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with T1 compression fracture\n REASON FOR THIS EXAMINATION:\n **Please image C5-T4**. Critical protocol is T1 w/ gad\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of compression deformity of T1, for evaluation.\n\n COMPARISON: CT scan from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained of the\n cervical and thoracic spine.\n\n MR : Again seen is a compression deformity seen involving T1, with\n increased STIR signal abnormality, and slight retropulsion of the posterior\n disc fragment. There is severe spinal canal narrowing at the C3-4 and C4-5\n levels, with central disc bulge and hypertrophy of the ligamentum flavum.\n Additionally, there is mild stenosis of C5-6 and C6-7. At the level of the\n compression deformity, there is mild canal narrowing. There is no evidence of\n cord signal abnormality or epidural hematoma. There are no significant\n prevertebral soft tissue fluid collections identified. Again seen is a large\n heterogeneous mass within the left lobe of the thyroid, seen on the prior\n study.\n\n MR : No fractures are identified within the remaining thoracic\n vertebral bodies. There is no evidence of any other areas of subluxation. The\n signal intensity of the thoracic spinal cord is normal in appearance. There is\n no intracanalicular hematoma. There is a well-rounded approximately 1-cm\n hyperintense T2 focus consistent with a perineural cyst at the level of the\n right T7 vertebral body. Again seen is a small left pleural effusion and ill-\n defined mass within the left lobe, which is better evaluated on prior CT\n scans.\n\n IMPRESSION:\n 1. Again seen is compression deformity involving the T1 vertebral body. There\n is no evidence of cord signal abnormality. Degenerative changes within the\n cervical spine result in areas of spinal canal stenosis, as described above.\n 2. There is left pleural effusion and ill-defined mass in left lower lobe,\n which is better evaluated on prior CT scans.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-26 00:00:00.000", "description": "BONE SCAN", "row_id": 949430, "text": "BONE SCAN Clip # \n Reason: LLL MASS EVAL FOR METS\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 24.5 mCi Tc-m MDP ();\n HISTORY: 88 year old man with left lower lobe lung mass\n\n COMPARISON: CT torso of .\n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections.\n\n There is focally increased uptake in the lower neck which likely corresponds to\n a T1 compression fracture on CT scan.\n\n There is mildly increased uptake in the region of the sacrum and sacroiliac\n joints which correspond to degenerative changes on CT scan.\n\n There is liner uptake in the soft tissue of the medial thighs which correlates\n with heavily calcified vessels on CT scan.\n\n The left kidney and distal left 12th rib are surgically absent.\n\n IMPRESSION: No evidence of osseous metastatic disease. Focal uptake in the\n lower neck likely correlates with T1 compression fracture on CT scan.\n\n\n , M.D.\n , M.D. Approved: WED 5:03 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": "2193-02-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949892, "text": " 4:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for PTX.\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with with recent trauma and T1 fx. Known prostate CA. Now with\n LLL mass and mediastinal . s/p EBUS TBNA, TBBX and bronchial wash.\n REASON FOR THIS EXAMINATION:\n Evaluate for PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with recent trauma and T1 fracture, known\n prostate cancer, now with left lower lobe mass and mediastinal\n lymphadenopathy. The patient is status post endobronchial ultrasound,\n transbronchial node aspiration, transbronchial biopsy and washings. Evaluate\n for pneumothorax.\n\n COMPARISON: PA and lateral chest x-ray dated , CT torso from .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: No pneumothorax is identified on this\n semi-upright chest x-ray. Previously noted left lower lobe mass is now\n paritally obscured, likley due to surrounding hemorrhage. A 7 mm calcification\n associated with the lesion on prior CT, is again noted. Minimal interstitial\n thickening bilaterally is likely related to mild volume overload. The\n cardiomediastinal silhouettes are within normal limits. Pulmonary vasculature\n is not engorged. There are tiny bilateral pleural effusions. The surrounding\n soft tissue and osseous structures demonstrate diffuse degenerative changes\n along the thoracic spine, and within the left shoulder.\n\n IMPRESSION:\n 1. No pneumothorax is identified on this semi-upright film.\n 2. Bilateral interstitial edema consistent with mild volume overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-05 00:00:00.000", "description": "PICC W/O PORT", "row_id": 950612, "text": " 11:40 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: T1 FRACTURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with post-obstructive PNA, poor access, needing IV antibiotics,\n PICC nurse unable to place.\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 88-year-old man with pneumonia and poor venous access, requiring\n intravenous antibiotics.\n\n TECHNIQUE: PICC line placement under fluoroscopic guidance.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: Using ultrasound, the left basilic vein was found to\n be patent and compressible. A pre-procedure timeout was performed to verify\n patient identity and the procedure to be performed. The chosen site along the\n left upper arm was prepped and draped in the usual sterile fashion. Under\n direct ultrasound visualization, the left basilic vein was cannulated with a\n 21-gauge needle, and a 0.018 guidewire passed into the superior vena cava.\n Hard copy ultrasound images were acquired before and after venous access,\n demonstrating patency. The needle was exchanged for a 4.5 French micropuncture\n sheath, and a 43- cm length single- lumen PICC line was advanced over the\n guidewire into the superior vena cava under fluoroscopic guidance. Placement\n of the tip was verified via injection of 4 cc of Optiray-320. A final\n fluoroscopic spot image shows the PICC line to terminate in the superior vena\n cava. The catheter was flushed, and the line secured to the adjacent skin\n with a StatLock device. There were no immediate complications. The patient\n tolerated the procedure well.\n\n IMPRESSION: Successful placement of PICC line, via the left basilic vein,\n terminating in the superior vena cava. Line ready for use.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-01 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 949996, "text": " 9:29 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: T1 FRACTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with left lower lung mass, new afib, new hypoxia this PM\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88-year-old male with left lower lung mass, now with atrial\n fibrillation and hypoxia and concern for PE.\n\n COMPARISON: CT torso .\n\n TECHNIQUE: MDCT continuously acquired axial images of the chest were\n obtained, pre and post-rapid bolus of 100 mL Optiray IV contrast with coronal\n and sagittal reformats.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: The heart and great vessels of\n the chest including pulmonary arteries opacify well. There is no evidence of\n pulmonary embolism. There are extensive atherosclerotic changes of the aorta\n but no acute pathology. There are new bilateral pleural effusions, moderate\n on the left and small on the right. There is new opacity of the majority of\n the right lower lobe and surrounding the left lower lobe masses, probably a\n combination of consolidation and atelectasis. There has been no significant\n short interval change in size of the left lower lobe masses. Also unchanged\n is mediastinal lymphadenopathy and heterogeneous left thyroid enlargement.\n Limited evaluation of the upper abdomen redemonstrates cholelithiasis and a\n right kidney stone.\n\n BONE WINDOWS: Again demonstrated is the compression fracture at T1 and\n multilevel degenerative changes. There is erosion of left-sided ribs by the\n left lower lobe masses.\n\n IMPRESSION:\n 1. No pulmonary embolism.\n 2. New bilateral pleural effusions, moderate on the left and small on the\n right.\n 3. New consolidation and atelectasis of a majority of the right lower lobe\n and portion of the left lower lobe.\n 4. No short interval change in the left lower lobe masses previously detailed\n on the study from five days ago. Biopsy should be considered.\n\n\n\n (Over)\n\n 9:29 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: T1 FRACTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2193-02-25 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 949304, "text": " 8:50 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o mass\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with LLL mass\n REASON FOR THIS EXAMINATION:\n r/o mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old with left lower lobe mass, rule out intracranial\n mass.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial MDCT images through the brain with and without IV contrast\n using 100 cc of nonionic Optiray.\n\n FINDINGS: No enhancing intra- or extraaxial lesions are appreciated. There\n is age appropriate diffuse cortical atrophy. There is no focal mass effect,\n edema, or shift of normally midline structures. There is dense vascular\n calcification of the anterior and posterior circulation. No evidence to\n suggest acute major vascular territorial infarction. Small, chronic-appearing\n lacunes are seen in the basal ganglia and thalami. Small polyp/retention\n cysts in the maxillary sinuses bilaterally. No air fluid levels appreciated.\n No focal osseous destruction. Mastoid processes are well pneumatized.\n\n There is left cerebellar encephalomalacia without an underlying enhancing\n abnormality.\n\n IMPRESSION: No intracranial mass is identified; please note that MRI with\n gadolinium would be more sensitive to evaluate for small metastases.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949969, "text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema, aspiration, pna\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with with recent trauma and T1 fx. s/p bronch on and\n desat, change in mental status, rigors afterwards. given lasix, abx.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema, aspiration, pna\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate for pulmonary edema, aspiration pneumonia. Patient\n post-bronch on and desaturation.\n\n Comparison is made with prior study performed the day before.\n\n FINDINGS:\n Right lower lobe consolidation is increased. This might be due to worsening\n pneumonia, aspiration pneumonia, or hemorrhage. Left lower lobe atelectasis\n is new. There is no pneumothorax. Cardiac size is normal. Previously noted\n left lower lobe mass is totally obscured. Mild volume overload has resolved.\n The right CP angle was not included on the film. A small left pleural\n effusion is stable.\n\n IMPRESSION: No pneumothorax.\n\n Large lower lobe consolidation. This may be due to aspiration, hemorrhage, or\n pneumonia.\n\n New left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950135, "text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change.\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with with recent trauma and T1 fx. s/p bronch on and\n desat, change in mental status, rigors afterwards. Has known LLL mass, new R\n infiltrate. O2 requirements increasing.\n REASON FOR THIS EXAMINATION:\n please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: T1 fracture. Assess interval change. Single portable radiograph of\n the chest demonstrates no change in the cardiomediastinal contour when\n compared with . Increased airspace opacity involving both lungs is\n noted. There are small bilateral pleural effusions. The trachea is midline.\n The aorta is calcified. The bilateral lower lobe opacities seen on the chest\n radiograph of and subsequent CT examination are much less\n conspicuous on the current study. There is deviation of the trachea from the\n midline to the right attributable to the enlarged thyroid seen on recent CT\n examination. No pneumothorax. There is increased airspace opacity involving\n both lungs, new when compared to the previous chest radiograph.\n\n IMPRESSION:\n\n Increased airspace opacity involving both lungs is new when compared to the\n previous chest radiograph and CT. The finding represents mild pulmonary\n edema.\n\n Previously identified bilateral lower lobe opacities are much less conspicuous\n on the current exam.\n\n Deviation of the trachea from the midline to the right attributable to the\n previously seen enlarged thyroid.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 950804, "text": " 2:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please perform noncon ct of chest with high-resolution cuts\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with left lower lung mass, ? HAP/post obstructive pna. Please\n do not remove neck brace.\n REASON FOR THIS EXAMINATION:\n please perform noncon ct of chest with high-resolution cuts through lung mass,\n to differentiate infiltrate vs. mass as possible and eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Prostate cancer. Left lower lobe lung mass.\n\n TECHNIQUE: Axial non-contrast images through the chest.\n\n Comparison was made with CTs on and .\n\n FINDINGS: There is a large heterogeneous mass within the left lower lobe\n measuring approximately 8 x 5 cm, which is unchanged in appearance, and better\n characterized on the prior contrast-enhanced CTs. This mass contains a coarse\n calcification, likely an engulfed granuloma. There is thickening of the left\n lower lobe bronchial posterior wall, as well as a large left infrahilar lymph\n node mass adjacent to the inferior left pulmonary vein measuring approximately\n 3.6 x 2.5 cm. There is a stable moderate left pleural effusion, as well as\n calcified left pleural plaques. There is extension of the soft tissue mass\n into the left lateral chest wall, with erosion of the left eighth and ninth\n ribs. There are multiple subcentimeter prevascular and paratracheal lymph\n nodes as previously described. There is a 1.1 cm lower left paratracheal\n lymph node. Calcifications are noted within the subcarinal nodal mass. There\n is a stable heterogeneous left thyroid mass measuring 3.6 x 3.7 cm, deviating\n the trachea to the right.\n\n Compared with the prior study, there is interval decrease in size in the small\n right pleural effusion, as well as extent of the right lower lobe basilar\n atelectasis/consolidation.\n\n There are atherosclerotic calcifications of the aortic arch and great vessels,\n as well as descending thoracic aorta and ascending aorta. There are mitral\n annular calcifications, as well as coronary artery calcifications. A right\n subclavian central venous catheter terminates in the distal superior vena\n cava.\n\n Limited views of the abdomen demonstrate multiple splenic and liver calcified\n granulomas, as well as cholelithiasis, extensive atherosclerotic vascular\n calcifications, as well as a punctate calcification in the upper pole of the\n right kidney.\n\n The T1 compression fracture was better seen on prior CTs with reformations.\n\n IMPRESSION:\n (Over)\n\n 2:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please perform noncon ct of chest with high-resolution cuts\n Admitting Diagnosis: T1 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No change in large soft tissue mass in the left lower lobe with\n extension/invasion into adjacent chest wall, pleural effusion, and infrahilar\n and mediastinal lymphadenopathy.\n\n 2. Decreased right pleural effusion and improved right basilar\n atelectasis/consolidation.\n\n These findings were discussed with Dr. at 4:50 p.m. on .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-03-01 00:00:00.000", "description": "Report", "row_id": 1336673, "text": "NURSING\n ADMIT FROM FLOOR WITH RAPID AFIB AND RESPIRATORY DISTRESS. HAD GONE FOR A BRONCHOSCOPY AND ON RETURN HAD RAPID AFIB AND INCREASED O2 NEEDS. SEE H/P FOR COMPLETE HISTORY.\n ON ADMIT HR IN THE 120-160 RANGE, INTERMITTANTLY, WITH A RATE IN THE LOW 100'S. DILTIAZEM GTT STARTED AT 5MG, SLOWLY INCREASED TO 10 MG.S WITH LESS BURSTS OF RAPID RATE. AFTER ABOUT ONE HOUR ON THE 10 MG BP BEGAN TO DROP WITH THE BURSTS OF INCREASED RATE. RESIDENT NOTIFIED. CARDIZEM DC'D AND AMIODORONE BOLUS GIVEN AND GTT STARTED AT 1 MG. WITHIN 30 MINUTES RATE DOWN TO THE LOW 100'S WITH SBP IN THE 100'S.TEMPERATURE ON ADMIT 102.2. BLOOD CULTURES AND URINE CULTURE SENT. SPUTUM HAD BEEN SENT FROM BRONCH YESTERDAY. HEPARIN GTT STARTED FOR AFIB AT RATE OF 1450 UNITS/HR.\n LUNGS WITH COARSE BREATH SOUNDS THROUGHOUT.RATE IN THE 18-22 RANGE. SHOVEL MASK AT 40%. O2 NEEDS HAVE NOT INCREASED SINCE ADMISSION. STRONG COUGH, RAISING SPUTUM AND SWALLOWING.\n FOLEY PLACED ON ADMIT WITH 400 ML AT THAT TIME. URINE OUTPUT SINCE HAS BEEN 25-40 ML/HR. ONLY KVO FLUIDS AND IV AMOUNTS FROM MEDICATIONS. NPO X MEDS.\n SWALLOWS PILLS FINE WITH SIPS OF WATER, DOES NEED TO BE UPRIGHT FOR SWALLOWING PILLS. TYLENOL AND OXYCODONE FOR C/O BACK PAIN WITH GOOD EFFECT.\n ORIENTED X0 ON ADMIT. VERY CONFUSED. SINCE THEN IS ORIENTED TO PERSON, NOT PLACE OR TIME. ? AS TO IF MEDS GIVEN DURING BRONCH CAUSED A LITTLE CONFUSION. NOT AGITATED, FOLLOWS COMMANDS.\n CONTINUE AMIODORONE GTT, DECREASE TO 0.5 MG AT 0930. REPEAT LABS SENT AT 0500. FOLLOW URINE OUTPUTS. FREQUENT PULMONARY TOILET. SPINE PRECAUTIONS FOR T1 FRACTURE.\n" }, { "category": "Nursing/other", "chartdate": "2193-03-01 00:00:00.000", "description": "Report", "row_id": 1336674, "text": "SICU NPN\nS-\"In the United States Embassy.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Alert and orientated times . LUE remains weaker than other. Other extremeties normal. C/o constant back pain, treated with Darvocet ATC with better manangement. Converting to NSR on Amiodorone infusion. Weaning Amiodorone infusion as directed per protocol. Heparin infusion discontinued. Pulses palpable throughout. BUE edema present, 2+. L > R. O2 weaned to 4Ls and tolerating well. Chest CT negative for PE but worsening PNA. Cough productive and raising thick tan and rust colored sputum. Breath sounds clear once raised. HUO adequate. Started on D51/2NS times one liter for poor PO intake. DAT to nectar consistency clear liquids. Crushing pill with meds. On Aspiration precautions. S/S evaluation at bedside and pt passing with puree and nectar consistency liquids. Will follow up with pt in a feq days. Passing flatus. No BM today. Afebrile. On broad spectrum Abx. Culture data pending.\n\nA/P:s/p T1 compression fracture with brace in place for 12 weeks in the setting of signigicant PNA.\nOOB tommorow to chair\nEncourage PO intake with respect to aspiration precaution\nAmiodorone infusion to be dc's tommorow afternoon.\nDarvocet ATC\n" }, { "category": "Nursing/other", "chartdate": "2193-03-02 00:00:00.000", "description": "Report", "row_id": 1336675, "text": "condition update\nd: pt alert and oriented. follows commands. left arm slightly weaker than right side. normal strength in bilateral legs. pupils are equal and reactive to light. pt remains in j and brace for fracture. pt medicated with darvocet for pain with good relief.\ncardiac: pt remains in nsr rate in the 70's on .5mg of amiodarone drip. sbp 120-150/40-50's.\nresp: pt remains on 4l nc and 02 sat 98% on current o2 requiredment. pt coughing and raising large amts of thick tan sputum. breath sounds are clear and diminished in the bases.\ngi: po intake is poor. pt able to swallow crushed pills in custard withoud difficulty. pt abd soft with positive bowel sounds.\ngu: foley patent draining minimal amts of clear yellow urine.\na: amdiodarone off at 15:30 . ?pt consult for brace. unable to place iv by sicu rn and iv nurse. picc line ordered for today. pt received 700cc of d51/5ns and Dr. aware.\nr: pt remains in nsr on .5mg of amiodarone darvocet effective in relieving pain.\n\n" }, { "category": "Echo", "chartdate": "2193-03-01 00:00:00.000", "description": "Report", "row_id": 84032, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease. Hypoxia,new Afib.\nHeight: (in) 67\nWeight (lb): 180\nBSA (m2): 1.94 m2\nBP (mm Hg): 133/60\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 13:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. TDI E/e' >15, suggesting PCWP>18mmHg.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR\nmay be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal. Left\nventricular systolic function is grossly preserved although views are\ntechnically suboptimal (EF probably >45%). Regional wall motion could not be\nfully assessed. Tissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall\nmotion are normal. The aortic root is mildly dilated at the sinus level. The\nascending aorta is mildly dilated. The aortic valve leaflets are severely\nthickened/deformed. There is mild aortic valve stenosis (area 1.2-1.9cm2).\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing,\nthe severity of mitral regurgitation may be significantly UNDERestimated.] The\ntricuspid valve leaflets are mildly thickened. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2193-03-19 00:00:00.000", "description": "Report", "row_id": 226657, "text": "Sinus rhythm\nLeft ventricular hypertrophy\nNonspecific ST-T wave changes could be due to left ventricular hypertrophy\nSince previous tracing of , further ST-T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2193-03-13 00:00:00.000", "description": "Report", "row_id": 226658, "text": "Sinus rhythm\nBorderline left ventricular hypertrophy\nSince pervious tracing of , rapid atrial fibrillation absent, ST-T wave\nchanges less pronounced\n\n\n" }, { "category": "ECG", "chartdate": "2193-03-07 00:00:00.000", "description": "Report", "row_id": 226659, "text": "Atrial fibrillation with rapid ventricular response. Consider prior inferior\nwall myocardial infarction. Left ventricular hypertrophy. Non-specific\nST-T wave changes could be due to left ventricular hypertrophy and/or\nrate-related. Compared to the previous tracing of rapid atrial\nfibrillation is new and the ST-T wave changes are more pronounced.\n\n" }, { "category": "ECG", "chartdate": "2193-03-04 00:00:00.000", "description": "Report", "row_id": 226660, "text": "Sinus rhythm\nFirst degree A-V delay\nLeft atrial abnormality\nConsider prior inferior myocardial infarction\nLeft ventricular hypertrophy\nDiffuse nonspecific T wave changes\nSince previous tracing of , atrial fibrillation absent and further ST-T\nwave changes seen\n\n" }, { "category": "ECG", "chartdate": "2193-02-28 00:00:00.000", "description": "Report", "row_id": 226907, "text": "Atrial fibrillation. Diffuse non-specific ST-T wave changes. Non-diagnostic\nQ waves in the inferior leads. Compared to the previous tracing, there is no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2193-02-27 00:00:00.000", "description": "Report", "row_id": 226908, "text": "Atrial fibrillation with a rapid ventricular response. Possible prior inferior\nwall myocardial infarction. Left ventricular hypertrophy. Non-specific\nST-T wave changes. Compared to the previous tracing of no diagnostic\nchange. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2193-02-27 00:00:00.000", "description": "Report", "row_id": 226909, "text": "Atrial fibrillation with rapid ventricular response\nConsider prior inferior myocardial infarction\nLeft ventricular hypertrophy\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2193-02-22 00:00:00.000", "description": "Report", "row_id": 226910, "text": "Sinus rhythm\nBorderline first degree A-V delay\nLeft atrial abnormality\nPrior inferior myocardial infarction\nConsider left ventricular hypertrophy\nSince previous tracing of , atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2193-02-25 00:00:00.000", "description": "Report", "row_id": 226911, "text": "Atrial fibrillation with a fast and at times, extremely rapid ventricular\nresponse. Left ventricular hypertrophy followed by inferior Q wave myocardial\ninfarction. Non-specific ST-T wave change. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Echo", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 96437, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. History of CAD, pacer, CHF with persistent hypotension.\nHeight: (in) 67\nWeight (lb): 187\nBSA (m2): 1.97 m2\nBP (mm Hg): 88/43\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 11:39\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is 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: Dilated RV cavity. Normal RV systolic function.\n\nAORTA: Moderately dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Severe PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nThe right ventricular cavity is dilated. Right ventricular systolic function\nis normal. The aortic root is moderately dilated. The aortic valve leaflets\n(3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is severe pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 266056, "text": "Ventricular paced rhythm\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2187-12-04 00:00:00.000", "description": "Report", "row_id": 1283230, "text": "Nursing Progress Note:\n\nEvents: Pt. now on Levophed gtt.\n\nNeuro: Pt. is alert, oriented, follows commands, assists with turns. She has residual pain from shingles to her head and neck which radiates if touched thus she is very senstive in these areas. She was given 5mg Oxycodone once and 650mg Tylenol once with good effect.\n\nCV: Pt. given multiple fluid boluses throughout day and one in evening with NBP still in low 80s-low 90s systolic and MAPs <60. Decision made to start Levophed as lungs started developing crackles. Pt. now on .06mcg.kg/min Levophed with NBP in 100s-110s/50s and MAPs in 60s (goal > 60). HR 80 V-paced with no ectopy. Pt. has one PIV which is WNL (other one pulled due to infiltration), femoral line is WNL. AM labs showed K+ 3.9, Mag 1.9, Phos 2.3, Calcium 7.5. will notify team\n\nResp: Lungs initially clear but developed crackles after 700cc fluid given. Chest X-ray showed fluid overload so mainentance fluid and bolus stopped. Lungs became clear again after this. RR teens, 02 sats > 92% on room air.\n\nGI: Pt. taking clear liquids in small amounts. BSX4. No BM on shift.\n\nGU: UO has averaging slightly less thatn 30cc/hour overnight. Will discuss with team.\n\nEndo: No sliding scale ordered. AM labs showed Blood glucose of 173, fingerstick done and was 188. Will notify team.\n\nSkin: Intact\n\nSocial: No contace overnight.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-04 00:00:00.000", "description": "Report", "row_id": 1283231, "text": "NPN: Review of Systems\nNeuro:Alert/oriented. MAES. Anxious. C/O chronic pain of right side of neck and right ear. Repositioning and PRN oxycodone provides some relief.\n\nResp: BS are CTA w/ exception of left base which has ronchi. Breathing unlabored. SaO2=98% on RA.\n\nCV: V-paced at 80. Levophed has been off since :30am. MAP=70s-80s. Skin warm/dry. pt edematous. IV not able to place 2nd peripheral IV. Femoral line remains in. INR=6.6. No intervention per MICU team. Coumadin still on hold.\n\nGI: Pt has minimal intake. Drinks w/ meds. refusing to eat more d/t throat discomfort. Notified team and elixir of antacid w/ lidocaine and benadryl given. Pt now drinking broth and says \"it's going down nicely\". No BM\n\nGU: Total of 2L in fluid boluses given over the course of the day for decreased UO. UO-180cc 8am-1800. BUN/Cr=15/1.0 Catheter flushed and balloon deflated/reinflated.\n\nID: Pt has been agreeable to taking nystatin as ordered. Continues on cipro and fluconazole. Afebrile.\n\nSocial: Niece called and anticipates being in to see Pt on thursday.\n\nA: Hemodynamic and pulmonary status stable throughout the day. Good pain relief w/ oxycodone and oral elixer. Decreased uo. Limited IV access d/t edema.\n\nP: Continue to monitor Pt as ordered. Discuss IV access and decreased UO w/ MICU team . Good pain relief w/ current medications.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 1283228, "text": "This is a 89 y old female, who was adm to MICU at 20:00 from EW with Dx of Urosepsis. Since adm pt has been given total of 2500 cc IV boluses with some effect on BP status. No pressors to be started for now MD unless MAP < 50. Now that BP is stable as of this am (90-100) at 6am,- ? call out to floor.\n\nNeuro)\n Pt is alert, awake and oriented to person and place. Pt will follow commands. Pt is VERY HOH to Lt ear (with hearing loss to Rt ear). Pt is DNR/DNI.\n\nCV)\n Pt is 100% V paced (80 bpm) with no ectopy noted. Pt is on coumadin Afib, which is currently held D/T ? GIB/vaginal bleed. Pt has had no evidence of bleed since MICU adm. SBp now stable after total of 2500cc IVB at 90-100 with Map > 60. Pt has PVD with swelling and evidence of venous stasis to lower legs. Mg replaced this am. Labs redrawn at 5am MD . Follow CE for 3rd set. No CP reported by pt.\n\nID)\n Urine and blood cx . Pt is on Vanco and Cipro IV abx as noted. No fevers at this time.\n\nResp)\n LS clear to upper resp area and with bibasal cx's. No resp distress noted. O2sat 96-100% on RA. Pt does need to be inc to DB&C. HOB elevated.\n\nGI)\n Abd soft and with + BS. Pt has one brief episode of nausea when in flat supine pos. Nausea relieved by HOB elevated. No Bm since adm.\n\nGU)\n Good U/O via foley catheter with Light yellow color at 60-80 cc/hr.\n\nSkin)\n Pt adm with redness (unbroken) to coccyx and perirectal area. Double guard and aloe vesta cream applied,- and pt turned q2hrs. ? need for air mattress.\n\nENDO)\n Follow FSBS x 24hrs. Pt need FSBS before lunch and dinner today only.\n\nPlan)\n Follow EL.\n ? c/o to floor.\n F/U cx's.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 1283229, "text": "NSG 7AM-7PM\n\nPLEASE REFER TO CAREVIEW FOR OTHER OBJ DATA.\n\n89 YR OLD FEMALE WITH HX OF CAD, S/P MI/ PACEMAKER, AFIB ON COUMADIN, ADMITTED WITH HYPOTENSION, N/V, GUIAC POS, VAGINAL BLEED. ADMITTED TO MICU FOR MNGT.\n\nPT A/OX3, SPONTENEOUS, FOLLOWS COMMANDS, DENIES CP/ C/O R SIDE OF NECK PAIN/ PAIN RESIDUAL S/P SHINGLES IN THE PAST/ NO INTERVENTION. PT VERY HARD OF HEARING ON R EAR/ HEARING BETTER ON L SIDE.\n\nHEART RYTHM VPACED WITH NO ECTOPY. CARDIAC ENZYMES NEG. REMAINS HYPOTENSIVE/ SBP 70S-100S WITH MAP 40S-60S/ GOAL MAP:61/ HYPOTENSION POSS POOR PO INTAKE AND VOMITING/ MAP TO MAINTAIN WITH FLUID BOLUSES/ NO NEED FOR PRESSORS AT THIS POINT PER TEAM/ RECIVED A TOT OF 2500CC NS THIS SHIFT/ PT LOS POS FOR APPROX 7LITERS.\n\nAFEBRILE/ TMAX:98.8/ UA POS FOR UTI/ REMAINS ON ANTBX VANCO AND CIPRO/\nLACTATE:0.8\nHCT 28.9/ NO SIGN OF BLEED/ COUMADIN HELD/ INR:3.3\n\nRESP UNLABORED AND EVEN/ LUNG SOUNDS CLEAR IN UPPER AIRWAYS/ DIMINISHED AT BASES/ SATO2 94-96% ON RA. CHEST CT NEG FOR PE/ POS BIL PLEURAL EFFUSIONS AND ATELECTASIS.\n\nABD SOFT, POS BS, NO BM. VOMITED APPROX 10CC OF UNDIGESTED FOOD X1/ NO FURTHER C/O OF N/V THIS SHIFT. TOLERATES FLUIDS/ MBS D/C/ PT HAS NO SIGN OF DYSPHAGIA PER SPEECH THERAPIST. AWAITING BARIUM SWALLOW REPORT FROM OSH/ GI TEAM WILL BE CONSULTED.\n\nFOLEY PATENT, DRAINING CLEAR URINE/ UOP MARGINAL 25-80/ OPTIMIZES WITH FLUID BOLUS.\n\nSKIN W/D, SKIN BREAKDOWN TO BIL GLUTEAL/ BARRIER CREAM APPLIED/ ENCOURAGED REPOS.\n\nPIVSX2 AND R FEMORAL CL INTACT.\n\n NIECE CARE PROXY) CALLED.\n\nMONITOR BP/ MAITAIN MAP AT GOAL/ BOLUS AS NEEDED\nWILL C/O WHEN NORMOTENSIVE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-12-05 00:00:00.000", "description": "Report", "row_id": 1283232, "text": "7pm to 7am:\n\nNeuro)\n Pt is alert, awake and oriented. Pt is VERY HOH to Lt ear and with hearing loss to Rt ear. Pt is cooperative with care.\n\nCV)\n Pt remains 100% V paced (80 bpm), with no ectopy noted. All other VSS and WNL's. MAP > 60. Pt has gen anasarca with sl pitting to lower exts. Coumadin for A-fib remains on hold. Unable to place second IVHL D/T poor vascular access,- in order to D/C TLC. Pt needs IV therapy for HL placement.\n\nResp)\n LS CTA with sl diminishedbases. No resp distress noted. Pt needs to be inc to DB&C. 96-99% on RA.\n\nGI)\n Abd soft and with + BS. Pt taking in adequate amounts of PO fluids. Advance diet as tol. No BM on this shift. IVF at KVO.\n\nGU)\n Pt is being tx for urosepsis with IV abx as noted. Pt has had a low U/O via foley catheter as noted at 20-40 cc/hr. Pt given IVbolus x 1 liter with some effect on U/O. Needs F/U.\n\nPain)\n Pt reported Rt ear pain this am, and medicated with oxycodone po.\n\nPLAN:\n ? D/C to floor when U/O improved and BP stable.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-05 00:00:00.000", "description": "Report", "row_id": 1283233, "text": "NSG 7AM-7PM\nPLEASE REFER TO CAREVIEW FOR OTHER OBJ DATA\n\nPT A/OX3, FOLLOWS COMMANDS, MAE IN BED, C/O OF R SIDE H/A, OXYCODONE 5MG GIVEN WITH POS EFFECT.\n\nHEART RYTHM VPACED HR IN 80S WITH NO ECTOPY/ HYPOTENSION/ BE TO HYPOVOLEMIA OR POOR PO INTAKE/ NO ACUTE HYPOTENSIVE EPISODE TODAY/ SBP 90S-110S/ MAP 50S-60S/ NO FLUID BOLUS TODAY/ PT LOS FLUID STATUS 13L/ ANASARCA/ MORE PRONOUNCED ON BIL LOWER EXT/ +. HCT STABLE 26/ INR: 7.6/ OFF COUMADIN/ RECEIVED 1MG OF VITK IV. NO SIGN OF BLEED.\nAFEBRILE/ REMAINS ON CIPRO/ AND VANCO D/CED.\nPIVSX2/ FEMORAL TLC D/CED.\n\nLUNG SOUNDS CLEAR IN UPPER LOBES AND DIMINISHED AT BASES/ SATO2 96-100% ON RA.\n\nABD SOFT, POS BS/ NO BM. BOWEL REGIMEN INITIATED.\n\nFOLEY D/CED AT 1500.\n\nPT WILL BE TRANSFERED TO .\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2121-09-28 00:00:00.000", "description": "Report", "row_id": 1506115, "text": "Resp Care Note, Pt back from OR sedated with propofol. Getting neosynephrine.Temp . Suctioned scant amts clear secretions.Weaning slowly. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2121-09-30 00:00:00.000", "description": "Report", "row_id": 1506122, "text": "SICU NPN:\nS-\"Am I going to be okay, ?\"\n\nSEE CAREUVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Periods of confusion overnight. Found pt with and telemetry lead off. Pt stating \"mice around room.\" Easily re-orientated and reassured by nurse to location and time period. C/o abdominal pain, more so with movement and turning in bed. Dilaudid PCA discontinued as to source possible hallucination. Started on Morphine with better affect. MAEs to commands and spontaneously. Following commands consistently. HR 100-120s, ST with no viewed ectopy. SBPs 140-180s. Standing Lopressor dose increased to 7.5mg Q4h from 5mg Q4h with some affect. Pulses palpable throughout. With episode of confusion pt with vague symptoms general discomfort and not \"feeling good.\" HCT repeated and up slightly from 23 to 24.8 post diureses. EKG performed and showing ischemic changes anteriorly and laterally. Primary team and SICU team aware. Recycling cardiac enzymes with troponins. Cardiology known to pt. Breath sounds clear and dim at bases. Occasionally audible upper expiratory wheezes but clearing with coughing. Remains on Face tent at 10L O2 with 6LNP. ABG compesated respiratory acidosis. AM pending. Diureses with additional 20mg of Lasix IVP with good response. At MN 1L(-). Lytes checked and repleted. 2+ edema apparent in BLEs and BUEs. Remains NPO. Abd firmly distended with (+) bowel sounds. Not passing flatus. Low grade temps. Continue Flagly and Ampicillin. Wife visiting into evening.\n\nA/P:s/p colectectomy, POD#2 continue with moderate to severe abdominal pain, abdominal distention and low HCT. Now with ischemic EKG changes.\n\nCycle CKs, next and last set due at 1400\nQuestion to re-consult cards\nQuestion increased Lopressor dose\nFollow HCTs, possibly transfuse\nSerial EKGs please, next due at 1400\nPrior c/o to floor question to hold off with recent events\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-09-28 00:00:00.000", "description": "Report", "row_id": 1506116, "text": "NURSING NOTE\nPT 64 YO MALE S/P STENT RE-STENOSIS. DEVELOPED BLOODY STOOLS X3, ENDO/COLONOSCOPY DONE, REVEALED BOWEL PERF. TO OR FOR RIGHT COLECTOMY, EX LAP, ARRIVED TO SICU AT 0200\n\n NEURO: PT NOT REVERSED, PUPILS PINPOINT, MIN-SLUGGISH REACTION. NOT OPENING EYES, NOT FOLLOWING COMMANDS, NO RESPONSE TO NOXIOUS STIM. PROPOFOL CONT AT 40MCG/KG/MIN FOR SEDATION.\n CVS: HR NSR/ST UP TO 100S, INTERMITTENTLY 110S, LOPRESSOR HELD FOR SBP 90S-100S ON NEO DRIP AT 1MCG/KG/MIN. POST-OP HCT 28.5 (PRE-OP HCT 35), K 3.5, MAG 1.5, INR 1.2. WEAKLY PALP PP, NEEDS SERIAL CE'S X2.\n RESP: VENTED ON A/C, 600X16, 5/50%. LUNGS COARSE THROUGHOUT, ABG PENDING.\n GI/GU: NGT TO LCWS W/MOD AMT BRN BILIOUS DRNG. ABD SOFT, DISTENDED, NO BS. U/O 100CC SINCE ADM, 500CC LR BOLUS GIVEN PER DR..\n INTEG: ABD DSG C/D/I, NO AREAS OF SKIN BREAKDOWN NOTED.\n\nPLAN: CONT HEMODYNAMIC MONITORING, NEO DRIP FOR SBP>90. CONT ABX, SERIAL HCT/CE'S. REPLETE LYTES, PAIN MGMT, FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2121-09-28 00:00:00.000", "description": "Report", "row_id": 1506117, "text": "SICU NPN\nS-\"My stomach is sore.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Propofol of at 1100. Extubated at 1215. A/O/X/3. Follows commands consistently. Pleasant and cooperative with care. Family at bedside and appropriate interaction noted. MAEs. C/o abdominal pain. Describing as \"sore.\" Fentanyl given intially without affect. Intermitent Dilaudid IVP trialed with better effect. Now starting Dilaudid PCA. HR 100-130s, ST with no viewed ectopy. IV Lopressor held throughout day due to hypotension. K, Mg, and ICa repleted. SBPs labile this morning, SBPs 80s on 1.0mcg/kg/min of Neosynephrine. Multiple fluid boluses given with intermitent response. CVP 11-13. Noted to have temp spike at time. Neosynephrine switched to Levophed and Levophed at 0.1mcg/kg/min. Attempted to wean post extubation but unsuccesful, since SBPs 95-100s. Pulses weakly palpable throughout. CKs cycled with last set pending at 1800. CK noted to increase on 2nd set with minimal CK to MB ratio. If continue to rise will recycle CKs. AM EKG unchanged. Cardiology consulted. Plavix and ASA given despite POD#1. Breath sounda clear while intubated and since extubated diminshed at right base but remaining clear. On FM, 15Ls 70% on O2. O2Sat 93-95%. Encouraged to CDB but unable to due to pain. Evening ABG pending with labs. Coughs rhocerous with minimal sputum production. Remains NPO, NGT to LCS, draining moderate amounts of bilious. Abd with (+) bowel sounds. Abd obese and distended. Bladder pressures moderately high, 27-28. SICU and primary teams aware.Urine outputs marginal intially but improving, now HUO adequate. LR continues at 125cc/hr. (+)I/O. Tm 101.7 Tc 98.4. Pan cultured for temp spike. Continues current abx regimen. Wife, and children at bedside througout day. Wife staying at hotel nearby. Cell phone number in room and in chart.\nA/P: s/p colectectomy POD#1 c/b hypotension\nFollow up with CKs, lytes, and HCT tonight, pending results may or may not recycle CKs\nWean Levophed as tolerated\nEncourage to CDB\nFollow pain scale closely\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-09-28 00:00:00.000", "description": "Report", "row_id": 1506118, "text": "Respiratory Care Note\nPt received on AC as noted. BS slightly coarse bilaterally. Pt suctioned for small amt thick, tan secretions. Pt weaned to PSV 5/5 with VT 544 and RR 21 - follow up ABG metabolic acidosis with normal range PaO2 and PaCO2. Pt has a positive cuff leak test. Pt extubated to cool aerosol without incident.\n" }, { "category": "Nursing/other", "chartdate": "2121-09-29 00:00:00.000", "description": "Report", "row_id": 1506119, "text": "NURSING NOTE\nDilaudid PCA 0.12/6/1.2\n" }, { "category": "Nursing/other", "chartdate": "2121-09-29 00:00:00.000", "description": "Report", "row_id": 1506120, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n NEURO: PT A&O X3, FOLLOWS COMMANDS, MAE'S. PAIN ISSUES OVERNOC, RELUCTANT TO REG USE PCA EVEN THOUGH HAVING ON PAIN SCALE. PT TO PRESS PCA WHENEVER IN PAIN Q5-10 MINS, PAIN IMPROVED THIS AM, , PT ABLE TO DOZE INTERMITTENTLY, TOL T/RP, C/DB. CONT DILAUDID PCA 0.12/10/2.5\n CVS: HR 110S-120S, ST, SBP 100S-140S, LEVO OFF. PT GIVEN LOPRESSOR 5MG FOR RATE CONTROL WHEN PRESSURE TOL'D. CVP 8-13, Tm/c 100.9, K 4.3, HCT 25.8, iCA 1.15\n RESP: FACE MASK CHANGED TO FACE TENT AT 40%/4L VIA NC, O2 SATS>95%. LUNG SNDS CLEAR, C/DB ENC/IS USE DONE W/PT. ABG 7.29/58/92/29\n GI/GU: NGT TO LCWS W/MOD BRN, BILIOUS DRNG. ABD DISTENDED, +BS, NO FLATUS, TENDER MOSTLY TO RUQ/RLQ TO LIGHT PALP. HRLY U/O>50CC, BLADDER PRESSURE REMAINS ELEVATED AT 28, DR. AWARE.\n INTEG: PT /RP REPOSITIONED FREQUENTLY, NO SKIN BREAKDOWN NOTED.\n PLAN: CONT HEMODYNAMIC MONITORING, SERIAL HCT/LABS. ENC IS USE/C&DB, PCA FOR PAIN MGMT.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-09-29 00:00:00.000", "description": "Report", "row_id": 1506121, "text": "Condition Update\nPlease see carevue for specifics.\n\nPt is alert and oriented. C/O abdominal incisional pain of which he uses his dilauded PCA appropriately. Tmax 100.4; ST to 120. IV lopressor given q 4 hours. CVP 15. LS are CTA. 02 sats 95-100% on 40% 02 via face tent and 4L 02 via n/c. Pt desats to 92% while asleep. 20mg 1x dose of lasix given this eve. Pt remaining NPO. IVF infusing. u/o adequate. Abdomen is firm/tender. Abdominal DSD dry and intact. Pt oob to the chair w/ 2 person assist to pivot this afternoon.\n\nPlan: Xfer to floor when bed is available. IVF for hydration while NPO. Dilauded pca for pain mgmt. OOB w/ assist. IV lopressor for rate ctrl.\n" }, { "category": "Echo", "chartdate": "2121-09-25 00:00:00.000", "description": "Report", "row_id": 72713, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension s/p PCI. GI bleed and low hct. Evaluate for pericardial effusion\nHeight: (in) 65\nWeight (lb): 202\nBSA (m2): 1.99 m2\nBP (mm Hg): 110/60\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 17:00\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: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Normal regional LV\nsystolic function. Hyperdynamic LVEF. Mid-cavitary gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Minimally increased\ngradient c/w minimal AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm). Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal, and the cavity is small. Left ventricular systolic function is\nhyperdynamic (EF>75%), without regional wall motion abnormalities. There is\nabnormal flow in the left ventricle, consistent with a mid-cavitary gradient.\nRight ventricular chamber size and free wall motion are normal. The aortic\nroot and the ascending aorta are mildly dilated. The aortic valve leaflets\n(?number) are moderately thickened. There may be minimal aortic valve\nstenosis, however present evaluation of aortic valve area is limited by\nhigh-velocity contamination from the intracavitary gradient. Trace aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Small left ventricular cavity with hyperdynamic left ventricular\nsystolic function. Mid-cavitary gradient. Probable minimal aortic stenosis.\nMildly dilated thoracic aorta.\n\nA repeat transthoracic study to reassess the mid-cavitary gradient and\ndetermine severity of aortic stenosis may be performed following an\nintravenous fluid challenge.\n\nDr. was notified of the findings at 6:15p on the day of the study.\n\n\n" }, { "category": "ECG", "chartdate": "2121-10-01 00:00:00.000", "description": "Report", "row_id": 171445, "text": "Sinus tachycardia\nIncomplete RBBB\nEarly R wave progression and vertical axis\nNondiagnostic Q waves in leads ll, lll, aVF\nConsider right ventricular hypertrophy\nAnterior T wave changes are nonspecific\nSince previous tracing, heart rate increased\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2121-09-30 00:00:00.000", "description": "Report", "row_id": 171446, "text": "Sinus rhythm\nRight bundle branch block\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2121-09-30 00:00:00.000", "description": "Report", "row_id": 171447, "text": "Sinus rhythm\nRight bundle branch block\nSince previous tracing of , rate decreased\n\n" }, { "category": "ECG", "chartdate": "2121-09-29 00:00:00.000", "description": "Report", "row_id": 171448, "text": "Sinus tachycardia\nRight bundle branch block\nSince previous tracing of , the rate has decreased\n\n" }, { "category": "ECG", "chartdate": "2121-09-28 00:00:00.000", "description": "Report", "row_id": 171449, "text": "Sinus tachycardia. Right bundle-branch block. Modest diffuse ST-T wave changes\nare partly primary and non-specific. Since the previous tracing of \nsinus tachycardia rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2121-09-24 00:00:00.000", "description": "Report", "row_id": 171684, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof right bundle-branch block has appeared.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2121-09-27 00:00:00.000", "description": "Report", "row_id": 171450, "text": "Sinus tachycardia. Right bundle-branch block. Diffuse ST-T wave changes,\nconsider ischemia. Compared to the previous tracing of the rate is\nfaster and ST-T wave changes are more prominent.\n\n" }, { "category": "ECG", "chartdate": "2121-09-25 00:00:00.000", "description": "Report", "row_id": 171451, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2121-09-24 00:00:00.000", "description": "Report", "row_id": 171452, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #2\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-27 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 933535, "text": " 8:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval bowel wall perf, SBOIV contrast only\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n Field of view: 46 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with 2 infrarenal aotic aneursysms, HTN, CAD, s/p elective\n cath, with new LGIB, s/p EGD, cauterized for polyps/hemmorhoids, today w/\n severe abd pain, unable to have BM.\n REASON FOR THIS EXAMINATION:\n eval bowel wall perf, SBOIV contrast only\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man with two infrarenal aortic aneurysms,\n hypertension and coronary artery disease, status post elective Cath, with new\n lower GI bleed, recently cauterized for cecal polyps/telangiectasias, now with\n severe abdominal pain.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n pubic symphysis with multiplanar reconstructed images.\n\n CONTRAST: Oral contrast and 130 cc of IV Optiray contrast were administered\n due to the rapid rate of bolus injection required for this study.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: No pulmonary nodules, pleural effusions,\n or parenchymal consolidation is seen at the lung bases. The liver, spleen,\n left kidney, adrenal glands, and pancreas are within normal limits. There is\n a tiny focal hypodensity within the right kidney which is too small to\n characterize. An NG tube is seen within the stomach. There is extensive\n calcification of the gallbladder and within the gallbladder lumen, consistent\n with cholelithiasis or porcelain gallbladder. The aorta demonstrates normal\n caliber throughout its course. There is mild ectasia of the infrarenal aorta\n measuring up to a maximum diameter of 1.9 cm. There is calcification of the\n aorta on its course. Note is made of an accessory left hepatic artery.\n\n There is fluid noted within the mesentery, and there is inflammatory stranding\n around the cecum. Additionally, there is asymmetric thickening within the\n wall of the cecum, which may represent a small amount of intramural\n hemorrhage. Adjacent to the cecum, there are several tiny foci of free\n intraperitoneal air. There is free fluid extending into the pelvis, and there\n is a small amount of free fluid noted around the liver.\n\n The remainder of the colon and small bowel are within normal limits.\n\n CT OF THE PELVIS WITH IV CONTRAST: A small amount of fluid is seen within the\n pelvis. The Foley catheter is seen within the bladder. There is a fat-\n containing right inguinal hernia. Enlarged pelvic lymphadenopathy is seen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions identified.\n (Over)\n\n 8:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval bowel wall perf, SBOIV contrast only\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n Field of view: 46 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Degenerative changes are seen within the lumbar and thoracic spine.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating\n the anatomy and pathology.\n\n IMPRESSION:\n 1. There is stranding and cecal wall thickening within the right lower\n quadrant, with tiny adjacent foci of air. This is consistent with focal\n perforation. There is adjacent fluid within the mesentery and pelvis also\n noted.\n 2. There is calcification of the gallbladder wall and then the gallbladder\n lumen, findings are consistent with a single large calcified stone or\n porcelain gallbladder.\n 3. There is aortic calcification noted, however there is no significant\n aneurysmal dilatation identified.\n\n These findings were discussed with Dr. at 9:20 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2121-09-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 933546, "text": " 1:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval cvl\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with 2 infrarenal aotic aneursysms, HTN, CAD, s/p elective\n cath, with new LGIB, s/p EGD, cauterized for polyps/hemmorhoids, today w/\n severe abd pain, unable to have BM.\n REASON FOR THIS EXAMINATION:\n eval cvl\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n HISTORY: Aortic aneurysm, coronary artery disease, abdominal pain.\n\n One portable view. Comparison with . The right chest wall is not\n entirely included. The lungs remain clear except for minimal streaky density\n at the bases most likely representing subsegmental atelectasis. The heart and\n mediastinal structures are unchanged. An endotracheal tube has been inserted\n and ends at the thoracic inlet. A left internal jugular catheter has been\n placed and terminates in the region of the superior vena cava. A nasogastric\n tube has been inserted and ends below the diaphragm in the region of the\n gastric antrum.\n\n IMPRESSION: Tube and line placement as described. No other significant\n change.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933510, "text": " 5:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval SBO, free air\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with 2 infrarenal aotic aneursysms, HTN, CAD, s/p elective\n cath, with new LGIB, s/p EGD, cauterized for polyps/hemmrhoids, today w/ severe\n abd pain, unable to have BM.\n REASON FOR THIS EXAMINATION:\n eval SBO, free air\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n HISTORY: Abdominal pain, possible free air.\n\n One AP portable view. The lungs are clear except for minimal streaky density\n at the left base which probably represents subsegmental atelectasis. No free\n air is identified. The heart and mediastinal structures are unremarkable.\n The bony thorax is grossly intact.\n\n IMPRESSION: No active disease.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2169-12-24 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 812281, "text": " 4:02 PM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: bone fixation\n Admitting Diagnosis: AMPUTATION OF 4TH FINGER LEFT HAND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/p L 4rth proximal phalanx complete amputation now reattached\n REASON FOR THIS EXAMINATION:\n bone fixation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left fourth proximal phalanx complete amputation, re-\n attached.\n\n LEFT HAND, 3 VIEWS: Films dated presented now for official\n interpretation.\n\n LEFT HAND, 4 VIEWS:\n\n Details considerably obscured by overlying cast. However, a side plate and\n multiple screws transfix the left proximal phalanx, which is in overall\n anatomic alignment on these views. The PIP joint also appears anatomic.\n Limited assessment of the fourth MCP joint is also grossly anatomic.\n\n\n" }, { "category": "Radiology", "chartdate": "2169-12-21 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 812019, "text": " 12:25 PM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: s/p amputation of 4th digit on left hand., Please x-ray hand\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with no pmh\n REASON FOR THIS EXAMINATION:\n s/p amputation of 4th digit on left hand.\n Please x-ray hand and amputated finger (in bag at bedside)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Amputation of 4th digit.\n\n THREE VIEWS OF THE LEFT HAND AND TWO VIEWS OF THE AMPUTATED DIGIT: There is\n amputation of the 4th digit at the level of the distal portion of the proximal\n phalanx. No dislocations are identified. No fractures are identified. The\n amputated digit appears intact from the distal portion of the proximal phalanx\n to the distal tuft. Evaluation of the amputated digit is somewhat limited due\n to overlying radio-opaque material.\n\n IMPRESSION: Amputation of the 4th digit at the level of the distal portion of\n the proximal phalanx.\n\n" }, { "category": "Nursing/other", "chartdate": "2169-12-22 00:00:00.000", "description": "Report", "row_id": 1276337, "text": "npn\nLeft arm up on 2 pillows wrapped to elbow in lg padded drsg. left mid finger doppler checks done q1- see flow sheet. foley to gravity, ivf tko, tol clear liq diet, ? to advance to house diet.\n" }, { "category": "Nursing/other", "chartdate": "2169-12-23 00:00:00.000", "description": "Report", "row_id": 1276338, "text": "NURSING UPDATE\n VITAL SIGNS WITHIN NORMAL PARAMETERS. DEXTRAN IV CONTINUES @ 30CC/H. LEFT ARM ELEVATED, DRESSINGS AND WRAPS INTACT, ROOM HEAT MAINTAINED >70 DEG. LEFT REATTACHED DIGIT WARM WITH GOOD CAPILLARY REFILL, GRAFT PULSES EASILY DOPPLERABLE. PT MAINTAINING GOOD PAIN CONTROL WITH MSO4 PCA PUMP.\n" }, { "category": "Nursing/other", "chartdate": "2169-12-22 00:00:00.000", "description": "Report", "row_id": 1276336, "text": "ADMITTED FROM OR S/P (L)DIGIT REATTACHMENT. ARM ELEVATED, WRAPPED W/SPLINT AND ACE. GOOD PULSES, CAP REFILL AND CIRCULATION.\nDEXTRAN INFUSING @ 30 ML FOR INCREASE OSMOTIC PRESSURE TO DIGITS. ROOM KEPT WARM FOR OPTIMAL PERFUSION.\nPAIN IN GOOD CONTROL W/MSO4 PCA.\n" } ]

[ { "category": "Nursing", "chartdate": "2193-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 670951, "text": "63 year old male, complaining of DOE in the past. Cardiac cath showed\n two vessel disease. Today, CABG x 3 completed.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt arrived on Propofol. Sedation vacation provided x 2.\n First occurrence, pt too agitated, so continued Propofol to rest.\n Second vacation, patient initially doing well, but later became\n tachypneic and mouthing words,\nI can\nt breathe\n. MAEs to command.\n NP , administered 1 mg Versed IV and re-started Propofol.\n Morphine 2mg IV given x 2 for pain. Fever of 38-38.2 noted. Tylenol\n given as ordered.\n Pt has outstanding CO/CI (7.5/3.1 with SvO2 in 70s. BP\n required Neo gtt to maintain SBP 90-120. UE pulses difficult to\n palpate, dopplerable. LE pulses easily palpable. Chest tube putting\n out sanguinous drainage. No leak noted, no crepitus noted. Multiple\n PVCs noted. Magnesium given IV as prophylacsis (sp?).\n Abdomen soft, obese. OGT to continuous intermittent\n suction. Brown/bilious drainage noted. Later clamped tube to\n administer medications.\n Attempted to wean ventilator to and , but patient\n became anxious, tachypneic.. Lungs clear in upper airways, diminished\n in lower airways bilaterally.\n Foley catheter to bedside drainage. Clear yellow urine\n noted.\n Skin intact other than surgical incisions. Incisions CDI.\n Insulin gtt running per CVICU protocol.\n Plan:\n Discontinue Propofol and start Precedex as ordered. Monitor\n hemodynamics closely. Turn and position to facilitate pulmonary\n toileting.\n" }, { "category": "Nursing", "chartdate": "2193-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 671004, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n -Pt in a NSR with PVC\ns rate in the 80\ns. SBP 80\ns-90\ns with a MAP in\n the low 60\ns. SVO2 70 with CO of ..\n -pt transitioned from propofol to precedex titrated up to 0.7 pt awake\n alert following commands but extremely anxious. Attempted to wean to\n Cpap 5 with IPS of 5 but RR up to 40\ns pt angitated stating his back\n was hurting and he couldn\nt breath. No change in sats. Remained 98%.\n -chest tubes draining serous sangunious drainage 40-50cc every 2 hours.\n - urine outputs 30cc/hr\n -pt blood sugars elevated\n Action:\n Pt given morphine 4mg and started on Torodol 30mg bolus then 15mg every\n 6 hours as needed. IPPS increased to 18. pt settled down RR down to\n 20\ns and pt sleeping, after 1hour pt awake reqesting to try again Vent\n weaned down to cpap 5 and ips 5.\n -Neo drip titrated up to maintain sbp >90.\n -insulin drip titrated to protocol\n Response:\n Pt remained calm, ABG\ns good and pt extubated by midnight without any\n difficulty. On extubation pt stated having that tube in is the worse\n thing to experience because you can not communicate.\n Pt denies pain states he is a litlle uncomfortable but does not\n require pain med.\n -pt presently on neo at 1.25mcg/kg/min with sbp 95-100\n -Insulin drip off this am for bs of 86\n Plan:\n Wean Neo as tolerated, Increase activity as tolerated. Assess pain and\n offer pain meds .\n" }, { "category": "Nursing", "chartdate": "2193-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 671005, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n -Pt in a NSR with PVC\ns rate in the 80\ns. SBP 80\ns-90\ns with a MAP in\n the low 60\ns. SVO2 70 with CO of ..\n -pt transitioned from propofol to precedex titrated up to 0.7 pt awake\n alert following commands but extremely anxious. Attempted to wean to\n Cpap 5 with IPS of 5 but RR up to 40\ns pt angitated stating his back\n was hurting and he couldn\nt breath. No change in sats. Remained 98%.\n -chest tubes draining serous sangunious drainage 40-50cc every 2 hours.\n - urine outputs 30cc/hr\n -pt blood sugars elevated\n Action:\n Pt given morphine 4mg and started on Torodol 30mg bolus then 15mg every\n 6 hours as needed. IPPS increased to 18. pt settled down RR down to\n 20\ns and pt sleeping, after 1hour pt awake reqesting to try again Vent\n weaned down to cpap 5 and ips 5.\n -Neo drip titrated up to maintain sbp >90.\n -insulin drip titrated to protocol\n Response:\n Pt remained calm, ABG\ns good and pt extubated by midnight without any\n difficulty. On extubation pt stated having that tube in is the worse\n thing to experience because you can not communicate.\n Pt denies pain states he is a litlle uncomfortable but does not\n require pain med.\n -pt presently on neo at 1.25mcg/kg/min with sbp 95-100\n -Insulin drip off this am for bs of 86\n Plan:\n Wean Neo as tolerated, Increase activity as tolerated. Assess pain and\n offer pain meds .\n" }, { "category": "Nursing", "chartdate": "2193-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 671141, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n NSR-ST 90\ns-105, occasional PVC\ns. Neo gtt weaned off by 1100, SBP\n 88-141. Pacer wires not checked d/t HR. up in chair all day d/t\n chronic back pain. Pedal pulses palpated. Chest tubes to sx, 160cc\n serosanguinous drainage., no air leak or crepitus noted. R radial aline\n for BP monitoring. Lungs diminished bases. Blood sugar 233 at 1200.\n Action:\n Lopressor 12.5mg po x 2 for HR. A line dc\nd. peripheral IV placed.\n Cough and dDB, IS use q2h. vicodin 2 po q4h for pain, toradol x 2 for\n pain, robaxin 750mg po x 2. regular insulin 12 units sc at 1200,\n clargine 20 units sc at 1200.\n Response:\n BP stable after lopressor. Pain level down to 2 with coughing after\n vicodin, toradol robaxin.\n Plan:\n Back to bed to dc cordis. Qid ssri coverage, clargine qd. Vicodin for\n pain. Increase activity. Transfer to 6 at .\n" }, { "category": "Physician ", "chartdate": "2193-04-27 00:00:00.000", "description": "ICU Note - CVI", "row_id": 671091, "text": "CVICU\n HPI:\n POD 1\n s/p CABGx3 (LIMA-LAD, SVG-OM2, SVG-dx1) \n EF 55 (PFO) wt 120kg cr 0.9 hgb a1c 7.3\n PMH: Hypertension, Hyperlipidemia (recently diagnosed), Diabetes,\n Pneumonia, s/p Persistent epistaxis requiring surgical clipping,\n s/p a fall down a flight of stairs, now with cervical and\n lumbar disc disease, COPD\n : methocarbamol 750 qid prn, glipizide 10'', lasix 20qam, KCl 10qpm,\n lisinopril 20', avandia 4', doxazosin 1', diazepam 10'prn, metformin\n 1000'', vicodin prn, advair 100/50', proair 90mcg 2puffs''''prn, ECASA\n 325', zocor 40', Vit C 500'\n Current medications:\n Acetaminophen, Albuterol 0.083% Neb Soln, Aspirin EC, Docusate Sodium,\n Fluticasone-Salmeterol Diskus (100/50), Furosemide,\n Hydrocodone-Acetaminophen, Insulin, Ketorolac, Methocarbamol, Morphine\n Sulfate, Ranitidine, Simvastatin, Vancomycin\n 24 Hour Events:\n Received from OR, required pressors and fluids for hemodynamics\n Weaned from sedation with agitation requiring resedation x2, then able\n to extubate\n PA CATHETER - START 12:15 PM\n OR RECEIVED - At 12:15 PM\n CORDIS/INTRODUCER - START 12:15 PM\nARTERIAL LINE - START 12:15 PM\n INTUBATION - At 12:30 PM\n came from OR sedated intubated to CVICU at 1215PM\n INVASIVE VENTILATION - START 12:30 PM\n INVASIVE VENTILATION - STOP 11:41 PM\n PA CATHETER - STOP 06:25 AM\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Unknown;\n Cleocin Hcl (Oral) (Clindamycin Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:36 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 05:49 PM\n Morphine Sulfate - 09:15 PM\n Other medications:\n Flowsheet Data as of 01:23 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.9\nC (98.5\n HR: 100 (63 - 101) bpm\n BP: 108/52(69) {78/46(58) - 120/67(86)} mmHg\n RR: 27 (9 - 33) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 14 (10 - 23) mmHg\n PAP: (46 mmHg) / (26 mmHg)\n CO/CI (Fick): (9.8 L/min) / (4 L/min/m2)\n CO/CI (CCO): (6.1 L/min) / (2.4 L/min/m2)\n SvO2: 77%\n Total In:\n 6,495 mL\n 687 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,895 mL\n 687 mL\n Blood products:\n 600 mL\n Total out:\n 1,306 mL\n 1,275 mL\n Urine:\n 980 mL\n 945 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,189 mL\n -588 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 680 (680 - 680) mL\n Vt (Spontaneous): 550 (480 - 600) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n Plateau: 23 cmH2O\n SPO2: 97%\n ABG: 7.41/41/80./24/0\n Ve: 12.5 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 249 K/uL\n 11.6 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 112 mEq/L\n 142 mEq/L\n 33.7 %\n 15.1 K/uL\n [image002.jpg]\n 11:18 AM\n 12:36 PM\n 12:49 PM\n 01:46 PM\n 05:40 PM\n 05:46 PM\n 07:17 PM\n 11:29 PM\n 04:00 AM\n 04:07 AM\n WBC\n 11.9\n 17.6\n 15.1\n Hct\n 31.7\n 36.8\n 34.8\n 33.7\n Plt\n \n Creatinine\n 0.9\n 0.9\n TCO2\n 29\n 25\n 20\n 24\n 25\n 27\n Glucose\n 118\n 82\n Other labs: PT / PTT / INR:15.1/37.2/1.3, Differential-Neuts:76.0 %,\n Lymph:20.6 %, Mono:2.5 %, Eos:0.6 %, Fibrinogen:156 mg/dL, Lactic\n Acid:1.7 mmol/L, Mg:2.6 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, vicodin and toradol\n prn\n Cardiovascular: Aspirin, Statins, Discontinue PA monitor, wean neo for\n sbp > 90 and then start betablockers if b/p stable off neo\n Pulmonary: IS, cough and deep breath, oob to chair, neb treatments prn\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Clear liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO, start lasix for diuresis with goal 1000 ml\n negative for 24 hours\n Hematology: stable hct\n Endocrine: RISS, Lantus (R), goal BG < 150\n Infectious Disease: vancomycin for periop antibiotics, wbc 15 down from\n 17, urine culture preop < 10,000, recheck u/a and culture\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: P.T., Nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Cordis/Introducer - 12:15 PM\n Arterial Line - 12:15 PM\n 16 Gauge - 12:15 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\n" }, { "category": "Nursing", "chartdate": "2193-04-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 671148, "text": "Demographics\n Attending MD:\n C.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 73 Inch\n Admission weight:\n 121 kg\n Daily weight:\n Allergies/Reactions:\n Keflex (Oral) (Cephalexin Monohydrate)\n Unknown;\n Cleocin Hcl (Oral) (Clindamycin Hcl)\n Rash;\n Precautions:\n PMH: COPD, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: hyperlipidemia, cardiomyopathy, gout, arthritis,\n prior tobacco use. Pneumonia (); persistent epistaxis requiring\n surgical clipping; s/p fall down flight of stairs, now with\n cerival and lumbar disc disease. Cannot have MRI due to residual\n shrapnel from previous trauma.\n Surgery / Procedure and date: CABG x 3 (lima->LAD, SVG->Diag,\n SVG->distal left circumflex). EZ intubation, CPB 80, XCT 62. SB in\n OR, AV paced, then A-paced to CVICU. Pt out of OR on neo, propofol,\n insulin. Pre-EF ~40% with noted anterior hypokinesis. Post-EF 50%\n with minimal to no hypokinesis.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:68\n Temperature:\n 98.6\n Arterial BP:\n S:109\n D:64\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,227 mL\n 24h total out:\n 1,895 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.6 mV\n Temporary atrial sensitivity setting:\n 0.8 mV\n Temporary atrial stimulation threshold :\n 3.5 mA\n Temporary atrial stimulation setting:\n 7 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 9 mV\n Temporary ventricular stimulation threshold :\n 3.5 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:00 AM\n Potassium:\n 4.1 mEq/L\n 04:07 AM\n Chloride:\n 112 mEq/L\n 04:00 AM\n CO2:\n 24 mEq/L\n 04:00 AM\n BUN:\n 14 mg/dL\n 04:00 AM\n Creatinine:\n 0.9 mg/dL\n 04:00 AM\n Glucose:\n 82 mg/dL\n 04:00 AM\n Hematocrit:\n 33.7 %\n 04:00 AM\n Finger Stick Glucose:\n 214\n 06:00 PM\n Valuables / Signature\n Patient valuables: Home\n Other valuables:\n Clothes: Sent home with:wife\n / :\n No money / \n Cash / Credit cards sent home with: wife\n Jewelry: wife\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: \n Coronary artery bypass graft (CABG)\n Assessment:\n NSR-ST 90\ns-105, occasional PVC\ns. Neo gtt weaned off by 1100, SBP\n 88-141. Pacer wires not checked d/t HR. up in chair all day d/t\n chronic back pain. Pedal pulses palpated. Chest tubes to sx, 160cc\n serosanguinous drainage., no air leak or crepitus noted. R radial aline\n for BP monitoring. Lungs diminished bases. Blood sugar 233 at 1200.\n Action:\n Lopressor 12.5mg po x 2 for HR. A line dc\nd. peripheral IV placed.\n Cough and dDB, IS use q2h. vicodin 2 po q4h for pain, toradol x 2 for\n pain, robaxin 750mg po x 2. regular insulin 12 units sc at 1200,\n clargine 20 units sc at 1200.\n Response:\n BP stable after lopressor. Pain level down to 2 with coughing after\n vicodin, toradol robaxin.\n Plan:\n Back to bed to dc cordis. Qid ssri coverage, clargine qd. Vicodin for\n pain. Increase activity. Transfer to 6 at .\n" }, { "category": "Nursing", "chartdate": "2193-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 670956, "text": "63 year old male, complaining of DOE in the past. Cardiac cath showed\n two vessel disease. Today, CABG x 3 completed.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt arrived on Propofol. Sedation vacation provided x 2.\n First occurrence, pt too agitated, so continued Propofol to rest.\n Second vacation, patient initially doing well, but later became\n tachypneic and mouthing words,\nI can\nt breathe\n. MAEs to command.\n NP , administered 1 mg Versed IV and re-started Propofol.\n Morphine 2mg IV given x 2 for pain. Fever of 38-38.2 noted. Tylenol\n given as ordered.\n Pt has outstanding CO/CI (7.5/3.1 with SvO2 in 70s. BP\n required Neo gtt to maintain SBP 90-120. UE pulses difficult to\n palpate, dopplerable. LE pulses easily palpable. Chest tube putting\n out sanguinous drainage. No leak noted, no crepitus noted. Multiple\n PVCs noted. Magnesium given IV as prophylacsis (sp?).\n Abdomen soft, obese. OGT to continuous intermittent\n suction. Brown/bilious drainage noted. Later clamped tube to\n administer medications.\n Attempted to wean ventilator to and , but patient\n became anxious, tachypneic.. Lungs clear in upper airways, diminished\n in lower airways bilaterally.\n Foley catheter to bedside drainage. Clear yellow urine\n noted.\n Skin intact other than surgical incisions. Incisions CDI.\n Insulin gtt running per CVICU protocol.\n Plan:\n Discontinue Propofol and start Precedex as ordered. Monitor\n hemodynamics closely. Turn and position to facilitate pulmonary\n toileting.\n" }, { "category": "Echo", "chartdate": "2193-04-26 00:00:00.000", "description": "Report", "row_id": 89379, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Intraop TEE for elective CABG. Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. Left ventricular function.\nHeight: (in) 73\nWeight (lb): 266\nBSA (m2): 2.43 m2\nBP (mm Hg): 124/65\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 09:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: LA not well visualized. No spontaneous echo contrast in the body\nof the LA. No mass/thrombus in the LAA. No spontaneous echo contrast is\nseen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across\nthe interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta. Simple atheroma in aortic arch. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: The patient was under general anesthesia throughout the\nprocedure. The patient received antibiotic prophylaxis. The TEE probe was\npassed with assistance from the anesthesioology staff using a laryngoscope. No\nTEE related complications. The patient appears to be in sinus rhythm.\nHouseofficer caring for the patient was notified of the results by e-mail. See\nConclusions for post-bypass data The post-bypass study was performed while the\npatient was receiving vasoactive infusions (see Conclusions for listing of\nmedications).\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium. No\nmass/thrombus is seen in the left atrium or left atrial appendage. No\nspontaneous echo contrast is seen in the left atrial appendage. A patent\nforamen ovale is present. A left-to-right shunt across the interatrial septum\nis seen at rest. Left ventricular wall thickness, cavity size, and global\nsystolic function are normal (LVEF>55%). Regional left ventricular wall motion\nis normal. Right ventricular chamber size and free wall motion are normal. The\nascending aorta is mildly dilated. There are simple atheroma in the aortic\narch. There are simple atheroma in the descending thoracic aorta. There are\nthree aortic valve leaflets. The aortic valve leaflets (3) are mildly\nthickened. There is no aortic valve stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including phenylephrine. Preserved biventricular systolic function\npost cpb. Anterior wall is improved. Aortic contour is normal post\ndecannulation..\n\n\n" }, { "category": "ECG", "chartdate": "2193-04-26 00:00:00.000", "description": "Report", "row_id": 243443, "text": "Sinus rhythm. Ventricular ectopy. Non-specific intraventricular conduction\ndelay. Non-specific ST-T wave changes. Compared to the previous tracing\nleft axis deviation is no longer present. The QRS duration is slightly\nlonger and ventricular ectopy is new.\n\n" }, { "category": "Radiology", "chartdate": "2193-04-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1074994, "text": " 1:35 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD s/p CABG. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , there has been performance of a\n CABG procedure. The endotracheal tube tip lies approximately 6.5 cm above the\n carina. Right IJ Swan-Ganz catheter extends to the right pulmonary artery.\n Nasogastric tube appears to extend well into the stomach.\n\n This information was telephoned to .\n\n\n" }, { "category": "Radiology", "chartdate": "2193-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1075272, "text": " 12:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumo s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for pneumo s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: Patient status post chest tube removal.\n\n FINDINGS: Comparison is made to previous study from .\n\n The endotracheal tube, nasogastric tube, and Swan-Ganz catheter have been\n removed. There has also been removal of the left-sided chest tube. There are\n low lung volumes. There are no pneumothoraces identified. There is some\n atelectasis versus early infiltrate at the left base. There are no signs for\n overt pulmonary edema. Median sternotomy wires are present.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2156-06-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 965880, "text": " 6:53 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate central line placement. r/o pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o esophageal cancer, who presents with change in MS\n /agitation. Recently finished 7 days of Levoquine for RLL pneumonia. s/p\n central line placement\n REASON FOR THIS EXAMINATION:\n please evaluate central line placement. r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old male with esophageal cancer, presenting with altered\n mental status and agitation. Please evaluate central line placement.\n\n FINDINGS: Single AP upright portable chest radiograph is reviewed and\n compared to study from the same day at 4:01 p.m. Evaluation is limited due to\n technique and patient body habitus. There has been interval placement of\n right subclavian approach central venous catheter, with tip projecting over\n the cavoatrial junction. Cardiomediastinal contours are unchanged. Lung\n volumes are low, but allowing for this, the lungs are clear. There is no\n definite pleural effusion. There is no pneumothorax.\n\n IMPRESSION: Status post placement of right subclavian approach central venous\n catheter, with catheter tip projecting over the cavoatrial junction.\n\n" }, { "category": "Radiology", "chartdate": "2156-06-21 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 965893, "text": " 10:32 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: assess abdomen\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with distended abdomen\n REASON FOR THIS EXAMINATION:\n assess abdomen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with distended abdomen.\n\n No comparison is available.\n\n TECHNIQUE: Supine and upright radiographs of the abdomen were obtained. This\n study is somewhat limited.\n\n No free intra-abdominal air or air-fluid levels are detected. Normal bowel\n gas pattern is noted. Gas is noted within the rectum, sigmoid colon. The\n visualized portions of the lung bases are not well assessed. The patient is\n status post left hip hemiarthroplasty.\n\n IMPRESSION: No evidence of bowel obstruction or free intra-abdominal air is\n identified.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-06-23 00:00:00.000", "description": "Report", "row_id": 1635859, "text": "MICU 7 RN Report 1900-0700\n\nNo significant event overnight.\n\nNeuro: Alert oriented x3, MAE,equal strength,PEARL, no c/o any pain, slept fairly.\n\nCV: HR 80s,NSR occassional PVC's, Run of slow v tach noted while pt sleeping.Pt enquired for any chest pain and denied. Bp 104/55.RJL Ns KVO.PIV in both arms working well.\n\nResp: LS Coarse, Spo2 >88% on 2lit nc,Strong productive cough+, spit out thik yellow sputum occassionaly.\n\nGI/GU: Abd soft distended, BS hypoactive.On po diet. Foley draining clear urine,output > 30ml/hr, AM lytes awaiting.\n\nID: T max 97.4 Abx piperacillin cont.\n\nSkin: Sacral region dark pink without breakdown.\n\nSocial: Full code.\n\nPlan: CAT scan in AM.\n Monitor I/O\n Monitor abd girth and Bs\n" }, { "category": "Nursing/other", "chartdate": "2156-06-23 00:00:00.000", "description": "Report", "row_id": 1635860, "text": "NPN MICU-7 7am-7pm\n86 yo male with Metastatic Liver and Esophageal Ca, admitted from NH with Sepsis, source- UTI/PNX. Sepsis is now resovled. Family meeting held and is now a DNR/DNI.\n\nNeuro: Is A&Ox3, speech is difficult to understand, has no dentures in place family is working on locating them. PERL,& MAE's.\n\nC/V: BP-120-140's/70, HR 80-98 ST with occ PVC's. K+4.5. No co's C/P. CVP when central line was in place . Bilat 2-3+ pitting edema of bilat lower extremities continues.\n\nID: Temp 97.8 PO max WBC elevated to 17.5, had been on IV Zosyn but was d/c'd and was changed to PO Bactrim, to cover UTI and PNX. Presep Central line Cath was d/c'd, has 2 perpherial IV's in place.\n\nGU: U/O 30-60cc/hr, BUN/CRE are returning to WNL's 42/1.1.\n\nGI: Had been scheduled for Torso CT scan this AM so was NPO and was drinking Barocat prep for the scan, but CT was cancelled. Rec'd an early dinner and is taking PO's fairly well does need to be fed, and does become SOB with activity. Had one lrge soft brown stool. remains extremily distended, ?ing cause, U/S done yesterday showed increased diffuse Liver lesions, but no ascities or blockages.\n\nRespir: Remains on 2L NP with O2sats 88-94%, does have COPD. L/S course @ bases has congested/productive cough, that he swallows. With such a distended does become SOB with any activity and occ @ rest.\n\nSocial/Status: This AM on MICU rounds, pt state that he had had enough and was in pain and was talking about dying. A discussion with pt and the entire MICU team and this RN was was held and the pt was very clear about his wishes, and stated that he did not want to be put through anymore invasive tests and would not want to be intubated or have CPR done, but he would like to be comfortable and rec pain med.\nHis HCP his Son was called in and his farthers discission was discussed but he had a very difficult time accepting that discission.Social services, the Palliative Care service and Case Management and MICU team discussed his case and then the team had and Family meeting with the son and daughter. the pt's status and plan of care was discussed and is a DNR/DNI, and will rec pain med for discomfort but is not \"Comfort Care\" as yet. Has rec'd Morphine 2mg IV times one for back pain and over all discomfort with good response.\n\nA/P: Continue to assess for pain and administer Morphine as needed for comfort. Monitor VS's and I&O's. Assess temps and continue antibx's. Support pt and family through this difficult time.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-06-24 00:00:00.000", "description": "Report", "row_id": 1635861, "text": "7pm-7am\n\n86 y/o male pt with PMH of DM/HTN/Metastatic liver and Ca esophagus got admitted on with resp distress and alteration in MS.\n\nCode status;DNR/DNI\n\nCVS;HR 75-84 NSR occasional pvc,s NBP 100/120-45/55.one PIV on rt hand remains patent.Lower extimities are edematous,pedal pulses are palpable.\n\nRESP;RR 16-24 breathing efforts are normal,no c/o SOB, SPO2 90-96 with NC 2 L.\n\nNEURO;Alert and oriented X3 moves all extrimities off the bed.\n\nGI/GU;Abd soft distented BS + tolerating oral diet well No bowel movement at this shift.voiding via foley,s catheter 25-30 ml.\n\nSKIN;warm dry and intact.\n\nNo contact from family at this shift.\n\nPLAN;? c/o to floor.\nPain management.\nICU monitoring.\nupdate with family.\n" }, { "category": "Nursing/other", "chartdate": "2156-06-24 00:00:00.000", "description": "Report", "row_id": 1635862, "text": "Nursing Progress Note 0700-1400\nPt transferred to rehab w/ EMS. Daughter and wife left to meet him there. Pt was stable on 2L of O2. Please see dischare not in chart and care vue for additional info.\n" }, { "category": "Nursing/other", "chartdate": "2156-06-22 00:00:00.000", "description": "Report", "row_id": 1635857, "text": "MICU 7 RN report 1900-0700\n\n 82 yo M admitted from ED w/ H/O metastatic esophageal CA,DM,HTN,COPD w/ c/o dyspnea, low sats,confusion sys BP < 80s @ Rehab.He was Rx for RLL pneumonia w/ Levaquine @ . In ED found to have Lactate 5.3, wbc 18.4, sepsis protocol started. On admsn he expressed anger and resisting to care but later on he start to be cooperative.Ns 250 ml bolus given.\n\nNeuro: Alert oriented x3, PEARL, MAE equal strength, Denies any pain,Received Trazedone 25mg PO for sleep.\n\nCV: HR 76-98 NSR No ectopy,Sys BP 100-130, Map > 70s.CVP 7-10,Received 3lit fluid in ED. RJL Ns KVO, Anasarca, Am labs K+ 5.1, Crit 28.5, lactate 1.6.On Heparin SQ. SVO2 dropped 85 to 70s.\n\nResp: LS clear,RR 30 spo2 88-93% on 2lit NC.Strong cough expectorating yellow thick sputum.\n\nGI: Abd Tender distended,Bs X4 hypoactive, pd 1 large Bm X ray abd done results awaiting. PO diet.\n\nGU: Foley Urine >30ml/hr,Urine lytes done results pending.\n\nSkin: Intact,sacral area pink.\n\nID: T max 99.3, Abx vancomycin,piperacillin.\n\nEndo: FS q6 Insulin sliding scale\n\nSocial: Full code Son called and updated.\n\nPlan: Sepsis proctocol,awaiting culture results\n ? CT scan abd\n Fluid replacement to maintain CVP Goal and for U/O >30cc/hr\n Monitor for fluid overload LS,and Spo2,RR\n ? need for inhalers to Rx COPD\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-06-22 00:00:00.000", "description": "Report", "row_id": 1635858, "text": "NPN 7AM-7PM MICU-7\n81 YO male with resolving Sepsis, with ? of UTI/PNX.\n\nS/O: Neuro: Alert but a little confused in the AM, but cleared by late in the AM. PERL, moves all extremities. No c/o's pain. Very cooperative. speech is a little difficult to understand due to not having dentures in place, asked Son to bring them in.\n\nRespir: Remians on 2L NP's with O2 sats 88-95%, does become DOE, does not tolerate activity. L/S clear but has productive cough, that he swallows @ times. With activity can become ex wheezy. No acute SOB noted.\n\nC/V: BP-99-130/60, HR-90's wityh occ PVC's noted. AM K+-5.1 repeat lytes are PND. No c/o's CP. CVP- . Lower extremities ahave + pitting edma.\n\nID: Temp 98.8 PO max, WBC-15.9, remains on IV Zosyn for probable UTI, IV Vanco was d/c'd. Presep cath remains in place but are not follwing SVO2, were running 70-72.\n\nGI: Was NPO until early evening s/ U/S, for very distended , with neg BS's. No N/V, no c/o's pain. Awaiting results from U/S. Taking PO's well now.\n\nGU: U/O 40-80cc/hr, BUN/CRE-52/1.4, repeat lytes are PND.\n\nSocial: Son earlier and was updated on pt's condition.\n\nA/P: Continue to monitor temps check culture results, continue IV Zosyn. Monitor I&O's and VS/CVP's adminitster NS IVB's if needed. Assess MS's. Update family as needed.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 965910, "text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o esophageal cancer, who presents with change in MS\n /agitation. Recently finished 7 days of Levoquine for RLL pneumonia. s/p\n central line placement\n REASON FOR THIS EXAMINATION:\n assess for PNA\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumonia. Patient with history of esophageal\n cancer, change in mental status.\n\n Comparison is made with prior study performed the day before.\n\n Right subclavian vein catheter tip is in the cavoatrial junction.\n Cardiomediastinal contours are unchanged. There are low lung volumes,\n otherwise the lungs are clear. There is no pneumothorax or pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 965860, "text": " 3:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o esophageal cancer, who presents with change in MS\n /agitation. Recently finished 7 days of Levoquine for RLL pneumonia\n REASON FOR THIS EXAMINATION:\n r/o acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Pneumonia.\n\n A single AP view of the chest is obtained on at 16:25 hours. Most\n recent study is . There appears to be cardiomegaly. There are\n significantly reduced lung volumes bilaterally. The film is also quite\n lordotically, making evaluation somewhat difficult. No major consolidations\n are identified.\n\n IMPRESSION:\n\n Suboptimal study due to markedly reduced lung volumes with no acute\n consolidation. Right hemidiaphragm elevation. Probable cardiomegaly. This\n will be better evaluated with PA and lateral views of the chest when the\n patient could tolerate this.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-06-22 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 965999, "text": " 2:10 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: PLEASE ASSESS FOR ASCITES, MET ESOPHAGEAL CA WITH ABDOMINAL DISTENTION\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with metastatic esophageal cancer with distended belly\n REASON FOR THIS EXAMINATION:\n Please assess for ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with metastatic esophageal cancer and distended\n belly. Assess for ascites.\n\n COMPARISON: PET scan, .\n\n FINDINGS: The liver is full of nodular hypo- and hyper-echoic masses. These\n nodules are scattered throughout the left and right lobes of the liver. They\n range in size from a few mm up to approximately 1.5 cm and they are consistent\n with widespread metastases. There is no biliary dilatation and the common\n duct measures 2 mm. The portal vein is patent with hepatopetal flow. There\n is a small amount of perihepatic ascites. The kidneys show no hydronephrosis,\n stones, or masses. The right kidney measures 12.6 cm and a simple cyst\n measuring 1.7 x 2.3 x 2.6 cm is identified on the upper pole. There are\n several cysts on the left kidney, one of which is multiseptated. These range\n in size from 6.9 to 3 cm. The presence of these cysts preclude accurate\n measurement of the left kidney. The spleen is unremarkable and measures 12.4\n cm. There is no fluid identified in the left upper quadrant.\n There is no ascites present in the pelvis.\n\n IMPRESSION:\n 1. Multiple nodules throughout the liver consistent with widespread\n metastases.\n 2. Small amount of perihepatic ascites.\n\n\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2187-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696771, "text": "85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n Thoracic / lumbar / sacral fracture (TLS without spinal cord injury)\n Assessment:\n Pt alert and oriented x3, MAE\ns, intact sensation bilaterally, pt\n denies any numbness or tingling. Minimal to moderate back pain. Pt on\n room air with sats in the high 90s.\n Action:\n -log roll and cspine precautions (awaiting cervical spine clearance)\n -morphine IVP given for pain\n -q4hr neuro exams\n Response:\n Pt exam remains unchanged. Pain relieved and pt resting comfortably\n with pain management\n Plan:\n Awaiting orthospine to decide if pt needs to go to the OR to stabilize\n and fix T3 burst fx or just a brace is needed.\n" }, { "category": "Physician ", "chartdate": "2187-08-23 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 696762, "text": "Chief Complaint: back pain\n HPI:\n 85F s/p fall down 11 stairs, transfer from with T3 burst fx,\n T3 spinous process fracture, L5 compression fracture\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lovastatin 20', HCTZ 25', Atenolol 25', Amitriptiline 50' qhs\n Past medical history:\n Family / Social history:\n HTN, shingles\n Lives at home with husband\n Flowsheet Data as of 10:32 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: 91 (91 - 94) bpm\n BP: 138/53(74) {138/53(74) - 155/70(94)} mmHg\n RR: 16 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 108 mL\n PO:\n TF:\n IVF:\n 108 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -68 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, 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: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\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): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n Assessment And Plan:\n Neurologic: - q 4 hour neuro checks, log roll precautions, c collar in\n place, Ortho spine to decide in am OR vs brace\n Cardiovascular: stable, cont home meds\n Pulmonary: NC as needed\n Gastrointestinal: NPO until decision re: OR\n Renal: Foley, UOP adequate\n Hematology: hct stable\n Infectious Disease: afebrile, no antibiotics\n Endocrine: RISS\n Fluids: maint at 75\n Electrolytes:\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 08:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor in am\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2187-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696795, "text": "85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n Thoracic / lumbar / sacral fracture (TLS without spinal cord injury)\n Assessment:\n Pt alert and oriented x3, MAE\ns, intact sensation bilaterally, pt\n denies any numbness or tingling. Back pain ranging from . Pt on room\n air with sats in the high 90s.\n Action:\n -log roll and cspine precautions (awaiting cervical spine clearance)\n -morphine IVP given for pain\n -q4hr neuro exams\n Response:\n Pt exam remains unchanged. Pain relieved and pt resting comfortably\n with pain management\n Plan:\n Awaiting orthospine to decide if pt needs to go to the OR to stabilize\n and fix T3 burst fx or just a brace is needed. Change to longer acting\n po meds for pain once off NPO.\n -unable to draw morning labs\n multiple nurses tried, HO tried and IV\n nurse was unable to obtains morning labs. Extremely difficult access.\n ?Picc or aline if going to OR\n" }, { "category": "Nursing", "chartdate": "2187-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696806, "text": "85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n Thoracic / lumbar / sacral fracture (TLS without spinal cord injury)\n Assessment:\n Pt alert and oriented x3, MAE\ns, intact sensation bilaterally, pt\n denies any numbness or tingling. Back pain ranging from . Pt on room\n air with sats in the high 90s.\n Action:\n -log roll and cspine precautions (awaiting cervical spine clearance)\n -morphine IVP given for pain\n -q4hr neuro exams\n Response:\n Pt exam remains unchanged. Pain relieved and pt resting comfortably\n with pain management\n Plan:\n Awaiting orthospine to decide if pt needs to go to the OR to stabilize\n and fix T3 burst fx or just a brace is needed. Change to longer acting\n po meds for pain once off NPO.\n -unable to draw morning labs\n multiple nurses tried, HO tried and IV\n nurse was unable to obtains morning labs. Extremely difficult access.\n ?Picc or aline if going to OR\n" }, { "category": "Physician ", "chartdate": "2187-08-24 00:00:00.000", "description": "Intensivist Note", "row_id": 696800, "text": "SICU\n HPI:\n Chief complaint:\n 85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n PMHx:\n HTN, shingles\n Current medications:\n Heparin 5000 UNIT SC TID\n Hydrochlorothiazide 25 mg PO DAILY\n Amitriptyline 50 mg PO HS\n Insulin SC\n Atenolol 25 mg PO DAILY\n Morphine Sulfate 2-4 mg IV Q4H:PRN pain\n Atorvastatin 10 mg PO DAILY\n Famotidine 20 mg PO BID\n 24 Hour Events:\n admitted to ICU for neuro checks\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:13 AM\n Morphine Sulfate - 05:01 AM\n Other medications:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.7\nC (98.1\n HR: 82 (77 - 96) bpm\n BP: 111/50(67) {96/42(56) - 155/75(94)} mmHg\n RR: 21 (13 - 23) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 221 mL\n 413 mL\n PO:\n Tube feeding:\n IV Fluid:\n 221 mL\n 413 mL\n Blood products:\n Total out:\n 375 mL\n 450 mL\n Urine:\n 375 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -154 mL\n -38 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n THORACIC / LUMBAR / SACRAL FRACTURE (TLS WITHOUT SPINAL CORD INJURY)\n Assessment and Plan: ASSESSMENT AND PLAN: 85F s/p fall w/T3 burst fx\n and L5 compression fx\n NEURO: moving all extremities, alert and oriented, log roll\n precautions, c collar in place\n Neuro checks Q: 4 hrs\n Pain: Morphine prn\n CVS: Stable, HCTZ/atenolol for BP control\n PULM: stable NC\n GI: NPO for possible OR \n RENAL: Foley in place, good UOP\n HEME: Hct stable 41.8\n ENDO: RISS\n ID: afebrile, no abx\n TLD: PIV, foley\n IVF: D5 1/2 NS at 75 ml / hr\n CONSULTS: Trauma / Ortho Spine\n BILLING DIAGNOSIS: T3 fracture\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - SQH, boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: in chart\n Lines:\n 20 Gauge - 04:06 AM\n Code status: Full code\n Disposition: Floor\n Total time spent: 32 min\n" }, { "category": "Nursing", "chartdate": "2187-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 696865, "text": "85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n Thoracic / lumbar / sacral fracture (TLS without spinal cord injury)\n Assessment:\n Pt alert and oriented x3, MAE\ns, intact sensation bilaterally, pt\n denies any numbness or tingling. Back pain ranging from only with\n turning. Pt on room air with sats in the high 90s.\n Action:\n log roll and cspine precautions, morphine IVP given for pain PRN\n Response:\n Pt exam remains unchanged. Pain relieved and pt resting comfortably\n with pain management\n Plan:\n Pt needs MRI, checklist sent awaiting to hear back from MRI re: time,\n pt will needs an antianxiety prior to scan, trauma team made aware,\n" }, { "category": "Nursing", "chartdate": "2187-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 696866, "text": "85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n Thoracic / lumbar / sacral fracture (TLS without spinal cord injury)\n Assessment:\n Pt alert and oriented x3, MAE\ns, intact sensation bilaterally, denies\n any numbness or tingling. Back pain ranging from only with turning.\n Pt on room air with sats in the high 90s.\n Action:\n log roll and cspine precautions maintained, morphine IVP given for pain\n PRN\n Response:\n Pt exam remains unchanged. Pain relieved and pt resting comfortably\n with pain management\n Plan:\n Pt needs MRI, checklist sent awaiting to hear back from MRI re: time,\n pt will needs an anti-anxiety prior to scan, trauma team made aware.\n Ortho spine requesting CTO brace for spine stabilization (likely for\n two months), no or intervention planned at this time\n **Of note-UOP low this morning, pt fluid bloused 500cc NS at this time.\n Trauma team aware, believe pt is dry***\n" }, { "category": "Nursing", "chartdate": "2187-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 696868, "text": "Demographics\n Attending MD:\n W.\n Admit diagnosis:\n S/P FALL\n Code status:\n Full code\n Height:\n Admission weight:\n 71 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: shingles\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:42\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,395 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 01:35 AM\n Potassium:\n 4.2 mEq/L\n 01:35 AM\n Chloride:\n 101 mEq/L\n 01:35 AM\n CO2:\n 31 mEq/L\n 01:35 AM\n BUN:\n 15 mg/dL\n 01:35 AM\n Creatinine:\n 1.0 mg/dL\n 01:35 AM\n Glucose:\n 132 mg/dL\n 01:35 AM\n Hematocrit:\n 35.1 %\n 01:35 AM\n Finger Stick Glucose:\n 128\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: pts husband brought in clothing this morning, in black\n bag, to be transferred with patient\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: pt wearing yellow ring on left ring finger\n Transferred from: TSICU cc565\n Transferred to: CC605\n Date & time of Transfer: 12:00 PM\n 85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture. Brace needed for T3\n burst fracture, still working up L5 compression fracture. Pt needs MRI\n to determine old vs new fx\n Thoracic / lumbar / sacral fracture (TLS without spinal cord injury)\n Assessment:\n Pt alert and oriented x3, MAE\ns, intact sensation bilaterally, denies\n any numbness or tingling. Back pain ranging from only with turning.\n Pt on room air with sats in the high 90s.\n Action:\n log roll and cspine precautions maintained, morphine IVP given for pain\n PRN\n Response:\n Pt exam remains unchanged. Pain relieved and pt resting comfortably\n with pain management\n Plan:\n Pt needs MRI, checklist sent waiting to hear back from MRI re: time, pt\n will need an anti-anxiety prior to scan, trauma team made aware. Ortho\n spine requesting CTO brace for spine stabilization (likely for two\n months), no or intervention planned at this time\n **Of note-UOP low this morning, pt fluid bloused 500cc NS at this time.\n Trauma team aware, believe pt is dry***\n" }, { "category": "Physician ", "chartdate": "2187-08-24 00:00:00.000", "description": "Intensivist Note", "row_id": 696835, "text": "SICU\n HPI:\n Chief complaint:\n 85F s/p fall down 11 stairs, transfer from with T3 burst fx, T3\n spinous process fracture, L5 compression fracture\n PMHx:\n HTN, shingles\n Current medications:\n Heparin 5000 UNIT SC TID\n Hydrochlorothiazide 25 mg PO DAILY\n Amitriptyline 50 mg PO HS\n Insulin SC\n Atenolol 25 mg PO DAILY\n Morphine Sulfate 2-4 mg IV Q4H:PRN pain\n Atorvastatin 10 mg PO DAILY\n Famotidine 20 mg PO BID\n 24 Hour Events:\n admitted to ICU for neuro checks\n Allergies:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:13 AM\n Morphine Sulfate - 05:01 AM\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.7\nC (98.1\n HR: 82 (77 - 96) bpm\n BP: 111/50(67) {96/42(56) - 155/75(94)} mmHg\n RR: 21 (13 - 23) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 221 mL\n 413 mL\n PO:\n Tube feeding:\n IV Fluid:\n 221 mL\n 413 mL\n Blood products:\n Total out:\n 375 mL\n 450 mL\n Urine:\n 375 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -154 mL\n -38 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n THORACIC / LUMBAR / SACRAL FRACTURE (TLS WITHOUT SPINAL CORD INJURY)\n Assessment and Plan: ASSESSMENT AND PLAN: 85F s/p fall w/T3 burst fx\n and L5 compression fx\n NEURO: moving all extremities, alert and oriented, log roll\n precautions, c collar in place, MRI spine, probable brace\n Neuro checks Q: 4 hrs\n Pain: Morphine prn\n CVS: Stable, HCTZ/atenolol for BP control\n PULM: stable NC\n GI: NPO for possible OR \n RENAL: Foley in place, good UOP\n HEME: Hct stable 41.8\n ENDO: RISS\n ID: afebrile, no abx\n TLD: PIV, foley\n IVF: D5 1/2 NS at 75 ml / hr\n CONSULTS: Trauma / Ortho Spine\n BILLING DIAGNOSIS: T3 fracture\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - SQH, boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: in chart\n Lines:\n 20 Gauge - 04:06 AM\n Code status: Full code\n Disposition: Floor\n Total time spent: 32 min\n" }, { "category": "ECG", "chartdate": "2187-08-25 00:00:00.000", "description": "Report", "row_id": 233580, "text": "Sinus rhythm. Compared to the previous tracing of there is no change.\n\n" }, { "category": "ECG", "chartdate": "2187-08-23 00:00:00.000", "description": "Report", "row_id": 233581, "text": "Sinus rhythm. Baseline artifact. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2187-08-30 00:00:00.000", "description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT", "row_id": 1098453, "text": " 2:23 PM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: r/o fracture or other processes\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fall 8 days ago now with c/o right posterior shoulder\n pain and echymosis noted over region\n REASON FOR THIS EXAMINATION:\n r/o fracture or other processes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall with complaint of right shoulder pain.\n\n COMPARISON: None.\n\n THREE VIEWS RIGHT SHOULDER: There is no fracture or dislocation. There is\n moderate degenerative change about the acromioclavicular and glenohumeral\n joints. A curvilinear radiopacity overlies the right superior mediastinum at\n the level of the fourth posterior costovertebral articulation. This may\n relate to recent interventional procedure or may lie extrinsic to the patient,\n and should be clinically correlated.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-08-25 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1097679, "text": " 1:40 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: Please assess for ligamentous injury\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall with spinal fractures and point tenderness in the\n cervical spine\n REASON FOR THIS EXAMINATION:\n Please assess for ligamentous injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 6:05 PM\n No evidence of ligamentous disruption identified in the cervical, thoracic and\n lumbar region. Degenerative changes in the cervical region. Fracture of T3\n vertebra could be subacute to chronic in absence of high signal on inversion\n recovery images and demonstrate retropulsion which indents and deforms the\n anterior aspect of the spinal cord. No abnormal signal seen within the spinal\n cord. Acute/subacute compression of L5 vertebra is noted with moderate spinal\n stenosis at L4-5 level.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the cervical, thoracic, and lumbar spine.\n\n CLINICAL INFORMATION: Patient is status post fall with point tenderness, rule\n out ligamentous injury.\n\n CERVICAL SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient-echo axial\n images of the cervical spine were acquired.\n\n FINDINGS: There is no evidence of ligamentous disruption seen in the cervical\n region. At the craniocervical junction and C2-3 and C3-4, mild degenerative\n change is seen. At C4-5, mild anterolisthesis of C4 over C5 is seen secondary\n to facet degenerative changes. Evaluation of foramina is limited due to\n motion on the axial images. At C5-6, there is disc bulging and posterior\n ridging with mild-to-moderate spinal stenosis and minimal extrinsic\n indentation on the spinal cord. Foraminal evaluation is limited.\n\n At C6-7 and C7-T1, mild degenerative changes are identified. There is mild\n increased soft tissue signal seen in the posterior soft tissues of the neck\n which could be secondary to focal trauma. However, there is no evidence of\n focal ligamentous disruption of the ligamentum flavum or interspinous ligament\n seen. There is no abnormal signal seen within the spinal cord.\n\n IMPRESSION: Degenerative changes in the cervical region. Mild\n anterolisthesis of C4 over C5 and mild-to-moderate spinal stenosis at C5-6. No\n evidence of ligamentous disruption. Other changes as above.\n\n THORACIC SPINE:\n\n (Over)\n\n 1:40 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: Please assess for ligamentous injury\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n thoracic spine were acquired. The axial images are limited by motion.\n\n FINDINGS: The T3 vertebra demonstrates compression with low T1 and T2 signal\n with minimal increased signal on inversion recovery images. There is\n retropulsion of the posterior inferior portion identified which indents the\n anterior aspect of the spinal cord. No definite abnormal signal seen within\n the spinal cord. The T5 vertebra demonstrates compression of the superior\n endplate with decreased T1 and T2 signal indicating chronic compression.\n\n Multilevel degenerative changes are seen in the thoracic region. There is no\n abnormal signal within the spinal cord.\n\n IMPRESSION: The T3 fracture demonstrates retropulsion of the inferior portion\n which indents and deforms the anterior aspect of the spinal cord. Absence of\n significant increased signal on the compressed vertebral body on inversion\n recovery images indicates the fracture to be subacute or chronic in nature.\n The appearances are not typical for pathologic fracture.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were obtained.\n\n FINDINGS: From L1-2 to L3-4, degenerative disc disease is seen. At L4-5,\n facet degenerative changes result in mild anterolisthesis of L4 over L5 with\n moderate spinal stenosis and bilateral foraminal narrowing.\n\n There is compression of L5 vertebra identified with low T1 signal and high\n signal on inversion recovery images indicative of acute/subacute compression.\n The paraspinal soft tissues are unremarkable.\n\n IMPRESSION: Compression of L5 vertebra is noted with increased signal on\n inversion recovery images which could be due to acute/subacute compression.\n Mild retropulsion of the posterior superior portion is seen which in\n combination of disc degenerative change and facet degenerative changes result\n in moderate spinal stenosis at L4-5 level. Mild degenerative changes at other\n levels in the lumbar region.\n\n\n\n\n (Over)\n\n 1:40 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: Please assess for ligamentous injury\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2187-08-25 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1097680, "text": ", W. TSICU 1:40 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: Please assess for ligamentous injury\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall with spinal fractures and point tenderness in the\n cervical spine\n REASON FOR THIS EXAMINATION:\n Please assess for ligamentous injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of ligamentous disruption identified in the cervical, thoracic and\n lumbar region. Degenerative changes in the cervical region. Fracture of T3\n vertebra could be subacute to chronic in absence of high signal on inversion\n recovery images and demonstrate retropulsion which indents and deforms the\n anterior aspect of the spinal cord. No abnormal signal seen within the spinal\n cord. Acute/subacute compression of L5 vertebra is noted with moderate spinal\n stenosis at L4-5 level.\n\n" }, { "category": "Radiology", "chartdate": "2187-08-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1097435, "text": " 6:01 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please re-read ct head\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n please re-read ct head\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:20 PM\n No acute intracranial hemorrhage, edema or mass.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 85-year-old woman status post fall downstairs.\n\n TECHNIQUE: MDCT axial images of the head were obtained without administration\n of intravenous contrast at Hospital at 12:12 p.m. and displayed in\n soft tissue and bone algorithm with coronal reformats. Second opinion is\n requested by ED staff.\n\n COMPARISON: Not available at the .\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, shift of normally\n midline structures or hydrocephalus. There is mild in extent periventricular\n white matter hypodensities, compatible with chronic microvascular infarction.\n There is a tiny multifocal hypodensity in the right basal ganglia, consistent\n with lacunar infarction. The extraaxial spaces and ventricles are prominent,\n consistent with age-related involutional changes. The -white matter\n differentiation is preserved.\n\n There is stranding in the left frontal and right aspect of the vertex\n subcutaneous tissues. Imaged osseous structures are intact. The paranasal\n sinuses and mastoid air cells are well- aerated.\n\n IMPRESSION: No acute intracranial process, including no hemorrhage, edema or\n mass. No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2187-08-23 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 1097436, "text": " 6:02 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: T3 fracture seen on CT c-spine, please eval thoracic spine f\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n T3 fracture seen on CT c-spine, please eval thoracic spine for injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:40 PM\n Acute T3 burst fracture with 50% loss of vertebral body height and 3 mm\n retropulsion. Mildly angulated T3 spinous process fracture. No other\n fracture.\n ______________________________________________________________________________\n FINAL REPORT\n CT THORACIC SPINE WITHOUT INTRAVENOUS CONTRAST.\n\n INDICATION: 85-year-old woman status post fall downstairs.\n\n COMPARISON: Not available at the .\n\n TECHNIQUE: MDCT axial images of the thoracic spine were obtained without\n administration of intravenous contrast.\n\n Coronal and sagittal reformatted images were obtained.\n\n FINDINGS: There is an acute burst fracture of T3 vertebral body with\n approximately 50% loss of vertebral body height and 3-mm retropulsion into the\n spinal canal, with remaining spinal canal measuring approximately 11 mm at\n this level. No large paraspinal hematoma is present. Additionally, there is\n a mildly displaced fracture of T3 spinous process.\n\n Limited evaluation of the lungs demonstrates dependent atelectasis\n bilaterally. There is a large hiatal hernia, containing proximal stomach.\n\n There is a partially calcified 15-mm structure superior to the left adrenal\n gland, which may represent a calcified splenic artery aneurysm.\n\n IMPRESSION: Acute T3 burst fracture with approximately 50% loss of vertebral\n body height and mild retropulsion into the spinal canal. CT does not provide\n sufficient soft tissue detail to evaluate the spinal cord, and if clinically\n indicated, MR may be obtained to evaluate for acute spinal cord edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-08-23 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1097430, "text": " 5:24 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old female with trauma.\n\n COMPARISON: Not available at the .\n\n FINDINGS: The lung volumes are low, acentuating cardiomediastinal silhouette.\n Evaluation of lung parenchyma is slightly limited by motion artifact. Biapical\n scarring is noted. There is no focal consolidation, pleural effusion or\n pneumothorax. Known T3 burst fracture is not well evaluated on this\n radiograph. Minimally displaced mid shaft right clavicular fracture is not\n acute.\n\n IMPRESSION:\n 1. No acute cardiopulmonary process.\n\n 2. Known T3 burst fracture not well evaluated.\n\n 3. Old right clavicular fracture.\n\n" }, { "category": "Radiology", "chartdate": "2187-08-23 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1097431, "text": " 5:54 PM\n CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: please re-read CT abdomen/pelvis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall down set of stairs\n REASON FOR THIS EXAMINATION:\n please re-read CT abdomen/pelvis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:10 PM\n L5 compression fracture with 50-75% loss of vertebral body height and 5 mm\n retropulsion, of uncertain chronicity. Otherwise no acute traumatic injury in\n the abdomen or pelvis.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST\n\n INDICATION: 85-year-old woman status post fall down set of stairs.\n\n COMPARISON: Not available at the .\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained\n following the administration of intravenous contrast at Hospital on\n , at 12:35 p.m. Coronal and sagittal reformatted images\n were obtained. Second opinion was requested by emergency room staff.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: Mild dependent atelectasis is noted at\n the lung bases bilaterally. There is a large hiatal hernia, containing\n proximal stomach. The liver is normal in size and attenuation, without focal\n lesion or biliary ductal dilatation. The gallbladder is non-distended. The\n spleen is not enlarged. There is a partially calcified aneurysm of the\n splenic artery. There are tiny bilateral renal low-attenuation lesions, too\n small to definitely characterize, probably represent renal cysts. There is\n fatty atrophy of the pancreas. Abdominal loops of large and small bowel are\n unremarkable. There is no free air and no free fluid in the abdomen. Normal\n appendix is seen, containing appendicolith. There are calcified ileocecal\n lymph nodes, compatible with prior granulomatous disease. There is no\n retroperitoneal lymphadenopathy.\n\n The uterus contains calcified and non-calcified fibroids. There is low-\n attenuation material seen in the endometrial cavity. The rectum, distal\n ureters, and urinary bladder are unremarkable. There is no free pelvic fluid\n and no pathological inguinal or pelvic adenopathy.\n\n BONE WINDOWS: Demonstrate a compression fracture of L5, with morphology\n suggesting chronicity. There is retropulsion with narrowing of the spinal\n canal in this level.\n\n There are multilevel degenerative changes.\n\n There are atherosclerotic calcifications of the abdominal aorta, which is\n (Over)\n\n 5:54 PM\n CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: please re-read CT abdomen/pelvis\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n normal in caliber.\n\n IMPRESSION:\n\n 1. Compression fracture of L5, with morphology suggesting chronicity. No\n evidence of acute traumatic injury in the abdomen or pelvis.\n\n 2. Low-attenuation material in the endometrial cavity. Non-urgent further\n evaluation with pelvic ultrasound is recommended to exclude endometrial\n hypertrophy versus carcinoma.\n\n 3. Large hiatal hernia.\n\n" }, { "category": "Radiology", "chartdate": "2187-08-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1098046, "text": " 12:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? intracranial process accounting for ams\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall with t3 burst fx with retropulsion and l5\n compression fracture now with altered mental status x 2 days\n REASON FOR THIS EXAMINATION:\n ? intracranial process accounting for ams\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status in the past two days, s/p fall with T3 and\n L5 vertebral fractures.\n\n COMPARISON: CT head done .\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect or other CT\n signs of an acute major vascular territorial infarction. The ventricles and\n extra-axial CSF spaces are prominent, consistent with moderate cerebral\n atrophy. Also noted are supratentorial white matter hypodensities which are\n likely related to chronic microvascular ischemic changes at this age. Also\n noted is a tiny hypodensity in the right putamen consistent with a chronic\n lacunar infarct.\n\n Visualized paranasal sinuses appear unremarkable.\n\n IMPRESSION:\n\n No evidence of acute intracranial abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2187-08-23 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1097433, "text": " 6:00 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please re-read ct-spine\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n please re-read ct-spine\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:15 PM\n T3 burst fracture redemonstrated. No other acute fracture. Multilevel DJD,\n most pronounced at C5-6 level with posterior osteophyted narrowing the spinal\n canal. Grade 1 anterolisthesis of C4 on C5. CT does not provide sufficient\n detail to evaluate spinal cord.\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE WITHOUT CONTRAST\n\n INDICATION: 85-year-old woman status post fall from stairs.\n\n COMPARISON: Not available at the .\n\n TECHNIQUE: MDCT axial images of the cervical spine were obtained without\n administration of intravenous contrast at Hospital at 12:30 p.m.\n Coronal and sagittal reformatted images were obtained and displayed in soft\n tissue and bone reformatted algorithms. The study was transferred to \n with the patient. The receiving ED physicians are requesting a second opinion\n interpretation.\n\n FINDINGS: Burst fracture of T3 is partially imaged and is better evaluated on\n subsequently obtained thoracic spine dedicated CT. There is no other\n fracture. There is straightening of normal cervical lordosis. There is grade\n 1 anterolisthesis of L4 on L5. There are multilevel degenerative changes,\n most pronounced at C5-6 level, with prominent posterior disc osteophyte\n complex, leading to spinal canal narrowing. There is no prevertebral soft\n tissue hematoma. The airway is patent. Incidentally noted is medial course\n of the left carotid artery.\n\n Limited evaluation of the lung apices demonstrates biapical scarring with\n traction bronchiectasis. There is granuloma in the right upper lobe on series\n 13, image 183. The mastoid air cells are pneumatized and well-aerated.\n\n IMPRESSION:\n\n 1. T3 burst fracture incompletely evaluated, described in detail on dedicated\n thoracic spine CT.\n\n 2. No other fracture.\n\n 3. Multilevel degenerative changes in the cervical spine, most pronounced at\n C5-6 level, leading to spinal canal stenosis, which predisposes to spinal cord\n injury.\n (Over)\n\n 6:00 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please re-read ct-spine\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2187-08-28 00:00:00.000", "description": "PERC VERTEBROPLSTY, THORACIC", "row_id": 1098102, "text": " 4:04 PM\n VERTEBROPLATY Clip # \n Reason: vertebroplasty of L5 +/- T3\n Admitting Diagnosis: S/P FALL\n ********************************* CPT Codes ********************************\n * PERC , KYPHOPLASTY, LUMBAR *\n * FLUORO S&I PERC VERTEBRO/KYPHO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with T3 burst fx and 3mm retropulsion L5 compression fracture\n REASON FOR THIS EXAMINATION:\n vertebroplasty of L5 +/- T3\n ______________________________________________________________________________\n FINAL REPORT\n VERTEBROPLASTY\n\n CLINICAL HISTORY: History of severe back pain and acute/subacute compression\n fracture of T3 and L5 vertebral bodies. Patient has been refractory to\n conservative medical treatment.\n\n OPERATORS: , N.P., and , M.D., the attending\n neuroradiologist who was present and supervising throughout the entire\n procedure.\n\n PRIMARY OPERATOR: Dr. .\n\n PROCEDURE: Informed consent was obtained after explaining the indications,\n risks and alternative management to the patient.\n\n The patient was brought to the fluoroscopy suite and placed on the table in\n prone position. MAC anesthesia was administered. The lower back was prepped\n and draped in the usual sterile fashion. Initially using a 22-gauge spinal\n needle under local anesthesia and aseptic precautions, the needle was placed\n in the region of the left pedicle of L5. Using AP and lateral views, an 11-\n gauge needle was placed through the left L5 pedicle into the L5 vertebral\n body. Under fluoroscopic guidance, approximately 3 cc of PMMA was\n administered. The cement flowed freely from the left to right pedicle. At\n this point, it was decided to terminate this as the endpoint at this level,\n and the needle was removed. The upper back was prepped and draped in the\n usual sterile fashion. Initially using a 22-gauge spinal needle under local\n anesthesia and aseptic precautions, the needle was placed in the region of the\n left pedicle of T3. Using AP and lateral views, an 11-gauge needle was placed\n through the left T3 pedicle and into the T3 vertebral body. Under\n fluoroscopic guidance, approximately 4 cc of PMMA was administered. The\n cement flowed freely from the left to the right pedicle. At this point, it\n was decided to terminate as the endpoint of the procedure.\n\n The patient tolerated the procedure well. The patient was sent to the PACU\n with post-procedure orders. 1 g of Ancef was given prior to the procedure.\n\n IMPRESSION: Successful vertebroplasty of the T3 vertebral body and the L5\n vertebral body.\n (Over)\n\n 4:04 PM\n VERTEBROPLATY Clip # \n Reason: vertebroplasty of L5 +/- T3\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-08-27 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 1097864, "text": " 11:52 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: pre-op for lumbar (L5) vertebroplasty\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with HTN, falls with spine fracture\n REASON FOR THIS EXAMINATION:\n pre-op for lumbar (L5) vertebroplasty\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op evaluation for lumbar vertebroplasty in this 85-year-old\n woman with history of fall and fracture of L5 vertebra.\n\n LUMBAR SPINE CT\n\n TECHNIQUE: Contiguous axial CT sections were obtained through the lumbar\n spine without intravenous contrast. Sagittal and coronal reconstructions were\n performed.\n\n FINDINGS: Again noted is a wedge compression fracture of the L5 vertebral\n body with mild sclerosis. Correlating with the MR study done before, this\n represents an acute/subacute compression fracture of L5 vertebral body. There\n is minimal retropulsion of the fractured vertebral body, but no significant\n narrowing of the thecal sac noted at this level.\n\n L3-L4 intervertebral disc level: There is diffuse disc bulge at this level\n with hypertrophy of the ligamentum flavum bilaterally, bilateral facet joint\n degenerative disease. There is minimal spinal canal narrowing.\n\n L4-L5 intervertebral disc level: There is again diffuse disc bulge noted at\n this level with ligamentum flavum hypertrophy and severe degenerative disease\n in the facet joints bilaterally. There is no significant thecal sac\n compression.\n\n L5-S1 intervertebral disc level: There is mild diffuse disc bulge, without\n thecal sac compression.\n\n Incidentally noted is a calcified uterine fibroid.\n\n Also noted is atheromatous calcification of the abdominal aorta.\n\n IMPRESSION: Acute/subacute compression fracture of L5 vertebral body, with\n retropulsion.No significant spinal canal stenosis noted at this level.\n\n" } ]

[ { "category": "ECG", "chartdate": "2133-03-06 00:00:00.000", "description": "Report", "row_id": 307642, "text": "Normal sinus rhythm. Prominent voltage in the precordial leads consistent with\nprobable left ventricular hypertrophy. T wave inversions in leads VI-V2 suggest\npossible anteroseptal ischemia. Compared to the previous tracing of \nthe T wave inversions across the precordium have largely normalized. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-03-11 00:00:00.000", "description": "Report", "row_id": 1303685, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: AT START OF SHIFT ANESTHESIA WAS CALLED FOR EMERGENT INTUBATION. PT. OBTUNDED, HYPERCARBIC, HYPOXIC ? ASPIRATION. AFTER INTUBATION, PT. WITH NOTABLE HYPOTENSION. RECEIVED APPROX. 3.5L FLUID. CENTRAL LINE PLACED. PT. AWOKE WITH INCREASED AGITATION. VALIUM 10MG IVP GIVEN AT 2100 AND SINCE, PT. HAS VERY CALM. SLEEPING THROUGHOUT MOST OF SHIFT. BLOOD GASES MUCH IMPROVED OVER SHIFT. THROUGHOUT SHIFT PT. SUCTIONED FOR LARGE AMOUNTS OF THICK GREENISH/TAN SECRETIONS. SPECIMEN SENT TO LAB.\n\nNEURO: PT. NOT ON ANY SEDATION. HE AROUSES TO NOXIOUS STIMULI. MAE IN BED. REMAINS IN 4PT. RESTRAINTS AS WHEN PT. AWAKENS, HE IS EXTREMELY AGITATED. ALSO FOR TUBE PROTECTION AS PT. WAS A DIFFICULT INTUBATION. PUPILS EQUAL AND REACTIVE.\n\nRESP: PT. ORALLY INTUBATED. ON AC: 50%/500/16/5. SEE CAREVIEW FOR LATEST BLOOD GAS. BREATH SOUNDS COARSE THROUGHOUT ALL LUNG FIELDS. SUCTIONED FOR COPIOUS AMOUNTS OF VERY THICK GREENISH/TAN SECRETIONS. PT. STARTED ON LEVAQUIN FOR PROBABLE ASPIRATION.\n\nCV: PT. NSR/ST WITH NO ECTOPY NOTED. S/P INTUBATION, PT.'S SBP DROPPED AS LOW AS 49. AFTER MULTIPLE BOLUSES (3.5L) PT.'S SBP HAS REMAINED LOW 80'S TO MID 110'S. CVP 7-9. + PULSES. NO EDEMA PRESENT. MIDNIGHT K+ OF 3.4 REPLETED WITH 40MEQ KCL AND MG+ OF 1.5 REPLETED WITH 2GM MAG SULFATE. AM LABS PENDING.\n\nGI: PT. NPO AT THIS TIME. HE REMAINS ON BANANA BAG AT 75CC/HR. ? PLACEMENT OF OGT IF INTUBATION PROLONGED. ABD. SOFT. BS+. NO BM THIS SHIFT.\n\nGU: CONDOM CATH IN PLACE DRAINING CLEAR YELLOW URINE.\n\nACCESS: R SC TL\n 3 'S\n\nPLAN: CONTINUE WITH CURRENT POC. WEAN VENT AS TOLERATED. CONT. ON ANTIBIOTIC THERAPY FOR PROBABLE ASPIRATION PNEUMONIA. PRN VALIUM AND ATIVAN FOR AGITATION. REPLETE AM LYTES AS NEEDED. PT. REMAINS FULL CODE. NO CONTACT WITH FAMILY / SIGNIFICANT OTHER THIS SHIFT.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-11 00:00:00.000", "description": "Report", "row_id": 1303686, "text": "RESPIRATORY CARE:\n\nPt orally intubated at start of shift for acute resp. decompensation. Intubated #8.0ETT, taped at 21cm's at lip. BS's equal and coarse, +ETCO2. Sxing large amounts purulent secretions from ETT, spec sent. Changes made on vent overnight, to optimize oxygenation and ventilation. See flowsheet for changes and further data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-11 00:00:00.000", "description": "Report", "row_id": 1303687, "text": "resp Care\n\nPt was weaned and extubated without incident. Cuff leak present prior and no stridor noted after.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-11 00:00:00.000", "description": "Report", "row_id": 1303688, "text": " 4 NURSING PROGRESS NOTE 0700-1900\nRESP--WEANED AND EXTUBATED AT 1530. STRONG COUGH. SPUTUM IS THICK TAN/YELLOW IN COLOR. BIL. BREATH SOUNDS ARE CLEAR NOW AND DIMINISHED IN BASES. SPONT RESP 16-20. SAO2 ON 50% FACE TENT >97%.\n\nCARDIAC--HR 80'S SR WITHOUT ECTOPY. SBP 100-120'S. CVP 5-12.\n\nNEURO-- AND ORIENTED X2. SPEECH IS SLURRED AT TIMES. FOLLOWS COMMANDS CONSISTENTLY. MAE SPONT. PEARL AT 2-3MM. PLEASANT AND COOPERATIVE. PT HAS BEEN SLEEPING MOST OF SHIFT BUT AROUSES EASILY , AT TIMES CONFUSED. CIWA SCALE <6. VALIUM GIVEN X1 AT 0730. NO HALDOL GIVEN AS OF THIS TIME.\n\nPAIN--DENIES PAIN. NO PAIN MED GIVEN.\n\nID-AFEBRILE. SPUTUM AS ABOVE. REMAINS ON ABX.\n\nGI--OGT INSERTED THIS AM BUT D/CED WITH EXTUBATION. +BS. NO STOOL. TO START CL. LIQ LATER TODAY.\n\nGU--FOLEY CATH INSERTED THIS AM. UO ~30CC HR OF CLEAR YELLOW URINE.\n\nENDO--UNREMARKABLE AT PRESENT.\n\nSKIN--ABRASIONS ON BILAT. ELBOWS. DUODERM INTACT. BUTTOCKS AND BACK WITHOUT BREAKDOWN.\n\nCOPING--GIRLFRIEND, , IN TO VISIT. SHE HAS PHONED THIS AFTERNOON TO CHECK IN. AT TIME, PT WAS INTUBATED BUT SHE WAS INFORMED BY THIS RN THAT PT GET EXTUBATED LATER TODAY. SHE STATES THAT \" SAYS THAT HE DOESN'T WANT TO STOP DRINKING. HE WANTS TO BE WITH HIS FATHER AND BROTHER WHO HAVE DIED DUE TO ETOH ILLNESSES.\" PT HAS CHILDREN AS WELL AS GRANDCHILDREN. PT IS NOW UNRESTRAINED\n\nA--TOL. EXTUBATION. AND LETHARGIC. NO NEED FOR HALDOL AS OF THIS TIME.\n\nP--CON'T TO REDIRECT AND REORIENT AS NEEDED. HALDOL PRN. START PO'S LATER TODAY. OOB AS TOLERATED. RESTRAIN AS NEEDED. OFFER SUPPORT. ENCOURAGE PULM TOILET.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-11 00:00:00.000", "description": "Report", "row_id": 1303689, "text": " 4 NURSING PROGRESS NOTE 0700-1900\nTOLERATING CL. LIQS WITHOUT DIFFICULTIES.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-12 00:00:00.000", "description": "Report", "row_id": 1303690, "text": "Shift Note: 1900-0700\nNeuro: Pt lethargic though easily arousable to voice, now oriented X3 though vague at times. CIWA remains <5 t/o shift. Pt denies pain, Nausea, vomitting. MAE, follows commands, pleasant and cooperative.\n\nResp: SpO2 remains >95% on RA. BBS CTA. Pt w/ strong loose cough. Tmax 99.3, continues on vanc and zosyn as ordered.\n\nCV: HR remains 70's to 90's, SR w/ no appreciable ectopy. BP remains stable.\n\nFEN: Tolerating clear liquids, diet advanced to regular though pt has since been sleeping. Abd soft, non-tender w/ BS present. Fluid status +9L, pt now autodiuresing. Foley catheter patent and draining clear yellow urine >100ml/hr. Will check am labs.\n\nSocial: Call received from - pt's girlfriend. Updated on pt status and POC.\n\nPlan: Continue to monitor resp status and VS. Continue abx as ordered, encourage C+DB exercises. Anticipate call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-12 00:00:00.000", "description": "Report", "row_id": 1303691, "text": "NURSING DISCHARGE NOTE 1430\nPT IS D/C TO HOME VIA CAB AND CAB VOUCHER. GIRLFRIEND, IS WITH PT. PT IS MEDICALLY CLEARED TO GO HOME. HE HAS BEEN GIVEN D/C INSTRUCTIONS WITH PRESCRIPTIONS. HE WILL BE ON LEVOFLOXICIN X10 DAYS. HE IS ALSO D/ ON MVI,FOLATE, AND NICOTINE PATCH.\n\nOF NOTE, PT HAS VERY UNSTABLE GAIT AND UNSTABLE BALANCE. GIRLFRIEND, STATES THAT HE HAS \"NERVE DAMAGE\" IN HIS LEGS FROM 3 CAR ACCIDENTS AND ALWAYS WALKS LIKE THIS. PT HAS BEEN INSTRUCTED TO MD IF TEMP INCREASES, OR SOB. PLS REFER TO DISCHARGE PLAN IN CAREWEB OF COMPUTER.\n\nALL LINES D/. FOLEY D/ AND PT HAS VOIDED. HE IS READY TO GO HOME.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-08 00:00:00.000", "description": "Report", "row_id": 1303679, "text": "MICU/SICU NPN ICU day #2\nS: \"I need pants\"\n\nO:\n\nNeuro: pt is confused, oriented to self, restless, frequently attempting to climb out of bed, reports headache and mild body aches, CIWA 13-21, medicated q1-2 hours with 20mg Valium for a total of 310mg in the last 24 hours\n\nPulm: LS CTA, weak cough\n\nCV: AVSS, please see flowsheet for data\n\nGI/GU: abd soft, NT/ND, BS present, incontinent of large amts urine\n\nInteg: skin is W/D/I, left wrist is swollen but pt denies pain\n\nA:\n\nacute confusion r/t alcohol withdrawal\nhigh risk for injury, trauma r/t acute confusion/agitation\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue assess CIWA scale q1h while awake and medicate as appropriate, consider adding Haldol or Zyprexa, ADAT\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-03-08 00:00:00.000", "description": "Report", "row_id": 1303680, "text": "NPN M/SICU (0700 -1900)\n\nEvents: Pt became increasingly aggitated starting @ 1700 recieved 10mg ativan. Incontinent of stool and urine multiple times. cath currently in place and draining apporpiratley.\n\nReview of Systems:\n\nNeuro: Confused, MAE, able to track and follow commands inconsistently, no c/o pain, see flow sheet for CIWA evaluations.\n\nCV: ST w/ no appreciable ventricular ectopy BP 120s systolic,please refer to flow sheet for objective data.\n\nResp: LS CTA, RR 18 -22 -SOB,in no acute distress\n\nGU/GI: cath draining clear yellow, NPO diet was advanced to clear liquids. +BS, large BM.\n\nAccess: R 20 G\n\nPlan: Cont. to monitor CIWA medicate as necessary. Cont to monitor/maintain heme/resp status. Posb c/o to floor tomorrow?\n" }, { "category": "Nursing/other", "chartdate": "2133-03-09 00:00:00.000", "description": "Report", "row_id": 1303681, "text": "MICU/SICU NPN ICU day #3\nEvents: pt became acutely agitated and combative ~0300 requiring IV diazepam\n\nS: \" I need fresh air, I have to get out of here, I need ot make money\"\n\nO:\n\nNeuro: pt is , oriented to self and place, frequently climbing over foot of bed or over siderails, lap belt on for safety, med x2 with PO diazepam and x1 with IV diazepam with fair effect, CIWA scores 16-33 overnight\n\nPulm: LS CTA\n\nCV: VSS, please see flowsheet\n\nInteg: C/W/D/I\n\nGI/GU: tolerating sips of liquids, abd soft, NT/ND, BS present, incontinent large amts urine\n\nA:\n\nhigh risk for injury, trauma r/t restlesness/agitation\naltered nutrition, LBR r/t poor caloric intake > 48h\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue to assess CIWA scale q1-2h while awake, consider adding Haldol/Zyprexa for management of acute agitation, consider psych eval, ADAT, activity progression, continue 1:1 sitter for safety\n" }, { "category": "Nursing/other", "chartdate": "2133-03-09 00:00:00.000", "description": "Report", "row_id": 1303682, "text": " nsg note: 7:00-19:00\nthis is a 48 y.o. man adm with hx ivda, etoh withdrawal in past, last here for etoh withdrawal requiring icu admit and intubation. pt drinks 4 pints vodka/day. pt had seizures x2 day of admit per pt's girlfriend whom he lives with. ciwa 28 on admit and as high as 33 last night. remains on 1:1 sitters in 4 point soft restraints with lap belt in place as pt still experiencing agitated to dangerous level of agitation state. refusing po meds, received total of 80mg iv valium and 50mg iv ativan since 7am which seems to settle him for 1/2 hr to an hour.\n\nneuro: perrl 2mm brisk. ? oriented x1. only stating his name. uncooperative with other questions or care. ciwa scale ranging . frequently trying to climb oob with lap belt and soft wrist restraints on for safety. bedside sitter remains.\n\ncv: vss- see flow sheet. k and magnesium repleted.\n\nresp: lungs cta, sp02 mid to high 90s. did read in low 90s but not accurate pleth and pt becomes too agitated to replace probe but calms down when left alone.\n\ngi/gu: abd soft, nt, +bs, no bm, refusing po intake. incontinent x1 and voiding adequate amts clear yellow urine via condom cath presently on. receiving iv ns with mvi, vitamin b12, and folate at 100cc/hr x 1 liter presently. then receives d5/12 at 125cc/hr.\n\nskin: clean, warm, dry and intact. does have dsd over r thigh which pt refusing to let this rn take off to assess.\n\nsocial: social worker by to speak to pt who was not cooperative with questions asked of him. sw to retry tomorrow. pt lives with girlfriend who has a 1 yr old dtr (his step dtr). pt is anxious to get back home to see his girlfriend and step dtr. but otherwise with slurred speech, not cooperative with care and questions asked.\n\nplan: continue 1:1 sitters, valium and ativan prn for ciwa >10. no haldol per team as pt with hx of seizures. try po valium and ativan when pt agreeable to. continue ivf as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-10 00:00:00.000", "description": "Report", "row_id": 1303683, "text": "7P-7AM Nsg Progress Note\nNEURO: change of shift, pt agitated, CIWA scale greater than 10, pt received 20 mg Valium po at 7 pm and 9 pm., also 10 mg Valium po at 12 midnight. received Ativan 4 mg at 9pm, 2 mg at 12 AM and 1 AM. slept the whole night!!!! (in reviewing the med sheets - pt has received approx 505 mg Valium (mostly , IV) since admission, and >125 mg IV Ativan. pt oriented to person only, trying to get OOB, pull off condom cath, and IV. SR up x 4, bed in low position, pt in 4 pt restraints, sitter x 24 hrs.\n\nCV/FLUIDS: bp stable 140/90-150/98 HR 95-110 ST no vea noted. IVF KVO. able to take in sips of H20.\n\nGI: no stool, on clear liquids. protonix changed to IV\n\nGU: condom catheter intact, draining >300 cc's urine.\n\nRESP: on RA, rr22-30 O2 sats 96% lungs clear anteriorly. pt snores when sleeping.\n\nPLAN: continue to monitor CIWA scale, if >10 give Valium po. monitor CV/RESP status. safety precautions, sitter x 24hrs, RTC.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-10 00:00:00.000", "description": "Report", "row_id": 1303684, "text": " nsg note: 7:00-19:00\nevents: pt remains on 1:1 sitters s/p day #5 adm with etoh withdrawal receiving po valium and iv ativan for withdrawal s&s for ciwa scale >10. pt received total of 30mg po valium and 2mg iv ativan this shift. ativan d/c'd as pt no longer withdrawing from etoh and now showing signs of \"intoxication\" from benzos. valium dosing weaned. pt more lethargic this afternoon with periods of snoring occluding his airway and choking on saliva-suctioned out waking up pt with agitation. agitation relieved with rest.\n\nneuro: not cooperative with assessing orientation. pt yelling out \"stop asking me questions, i want to go home.\" kicking in bed tensing arms clotting off iv x2 alternating with periods of somulence nearly occluding airway. perrla 2mm brisk. 1:1 sitter at bedside. ciwa scale ranging . remains with 4 point soft wrist restraints on and vest restraint on d/t agitation sliding down in bed with feet over side rails at times. went down for head ct to r/o subdural hematoma with preliminary read negative for bleed.\n\n\ncv: hr ranging 90s-100s sr/st with no ectopy noted. bp ranging 130s-170s/80s-100s. k 3.5. attempted to replete with 40meq po but pt refusing. receiving d5w with mvi,folate, thiamine at 75cc/hr via single . md aware.\n\nresp: lungs cta, sp02 ranging 93-99% on rm air but did drop to 91% this afternoon with 2lnc applied with sats in mid 90s. pt then pulling off o2 in early eve dropping sats to 88% with periods of occluding airway choking as stated above. mask placed on pt instead of nasal cannula to keep 02 on. sat continued to drop to low 80s. nrb placed and abg being obtained with possible intubation to maintain airway.\n\ngi/gu: abd soft, nt, +bs, no bm. taking sips po liquids in am but refusing and then too sleepy in pm. condom cath draining adequate amts clear yellow urine.\n\nskin: red areas on elbows and blister on upper thigh with dsd.\n\nsocial: sw spoke with pt's girlfriend whom he lives with and will speak in depth to her tomorrow. pt has a 1 yr old dtr with girlfriend and she has 2 more of her own children who live with them. pt lost his brother and father recently to etoh abuse and not interested in stopping his drinking per pt's girlfriend.\n\nplan: continue ciwa scale, 1:1 sitters, f/u with abg and possible intubation. valium prn agitation. will need iv kcl repletion if k continues to drop as pt too lethargic to take it po. magnesium was repleted today.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-07 00:00:00.000", "description": "Report", "row_id": 1303677, "text": "Admit Note: 1900-0700\nThis is a 48 yr male w/ hx ETOH withdrawl, required ICU admit and intubation for withdrawl 11/. Pt reports drinking 4 pints of vodka/day, last drink at 2200. Taken to EW by girlfriend PM reporting pt had seizure X2. CIWA 28 in EW, pt given banana bag and ativan 4mg IV and transferred to for further care.\n\nPlease see careview for all objective data:\n\nROS:\n\nNeuro: Pt , OX2 vague and confused at times. CIWA 28 on arrival requiring frequent ativan doses. CIWA somewhat better controlled now with pt receiving total Ativan 34mg IV in this shift, in addition to 4mg given in EW. Bilat soft wrist restraints in place as ordered for safety. Remains free of s/s seizure. Did self D/C X 1 at 0630. 1:1 sitter not available for this shift per clinical adivisor, though 1:1 sitter requested for am for safety.\n\nResp: BBS diminshed t/o. CXR done this am. SpO2 remains 96-100% on RA. Pt remains free of s/s respiratory distress or depression.\n\nCV: HR 90's to 110, SR to ST w/ no appreciable ectopy. BP remains stable.\n\nFEN: Remains NPO. Abd soft, non-tender w/ BS present. Receiving D5 1/2 NS w/ 40 mEq KCL at 100ml/hr and Kphos over 6 hr as ordered. Also given mag sulfate 4gm IV as ordered. Am labs sent. Pt incontinent of large amounts of urine requiring several bed changes.\n\nSocial: No contact from family this shift.\n\nPlan: Continue to monitor VS and Resp status closely. Continue Ativan as ordered to maintain CIWA <10. Will need psych/addiction consult. 1:1 sitter and bilat soft wrist restraints for safety.\n" }, { "category": "Nursing/other", "chartdate": "2133-03-07 00:00:00.000", "description": "Report", "row_id": 1303678, "text": "7A-7PM Nsg Progress Note\nNEURO: pt remains agitated throughout the day. pt oriented to person only, no seizure activity. CIWA scale >10 (14-17) pt receiving 20 mg po Valium q 30-45 minutes. pt has received a total of 170 mg of Valium po, and 56 mg Ativan IV ~~ still remains agitated, trying to get oob, hands restrained x2 for safety, SR up x4, nurse in with pt all shift (sitter unavailable)\npt receiving MVI, folic acit, thisamine HCL po (pt able to take po's)\nalso on Nicotine patch.\n\nCV/FLUIDS: BP 120-146/70-80 HR 90-126 ST no vea noted. IVF D51/2 NS @ 100 cc/hr. unable to place foley - using diapers, pt changed x5\n\nGI: NPO, belly soft, +bs. on Protonix 40 mg po q 24hrs\n\nID: t max 99.8 ax, WBC 10.0 no antibx.\n\nRESP: pt on RA, O2 sats 96% rr~22 regular, lungs clear, decreased at bases.\n\nIV ACCESS: with agitation - 2 IV's infiltrated. IV NURSE placed new #20 r lower arm.\n\nPLAN: continue with 20 mg Valium po q 30-45 minutes, if CIWA scale greater than 10. monitor closely!! safety precautions. draw CHEM 7 when available. monitor CV/RESP status. social service consult (she stopped by - pt unable to speak with social worker). she will check in \n" } ]

[ { "category": "Echo", "chartdate": "2186-01-27 00:00:00.000", "description": "Report", "row_id": 87464, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 105/53\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 13:58\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\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferolateral - hypo;\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. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Eccentric MR jet. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. No TS. Mild [1+] TR. Mild 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 elongated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is normal. There is a suggestion of focal mid\ninfero-lateral LV hypokinesis (?focal infarct?). Overall left ventricular\nsystolic function is preserved (LVEF=55%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No masses or vegetations are seen on the aortic valve. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. No mass or vegetation is seen on the mitral\nvalve. An eccentric, posteriorly directed jet of moderate to severe (3+)\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the degree of MR\nhas significantly increased. A focal wall motion abnormality of the LV (mid\ninfero-lateral hypokinesis) is now suggested. If indicated, a TEE would be\nbetter to exclude endocarditis. A cardiac MRI would determine if there has\nbeen an infarct in the area of the mid infero-lateral wall at the level of the\nposterior papillary muscle (I.e. ischemic MR).\n\n\n" }, { "category": "General", "chartdate": "2186-01-26 00:00:00.000", "description": "CVL and Art line procedure notes", "row_id": 621922, "text": "PROCEDURE NOTE: CENTRAL LINE\n Unable to use metavision procedure form for unclear reason.\n Procedure: right IJ CVL\n Indication: shock\n Operators: , , \n Full barrier precautions. Single-pass, real-time ultrasound guidance\n placement of 20cm oximetric cathether. Oozing afterward.\n PROCEDURE NOTE: ARTERIAL LINE\n Unable to use metavision procedure form for unclear reason.\n Procedure: left radial arterial line\n Real-time ultrasound guidance used due to coagulopathy\n Operators: , \n Full barrier precautions. Two passes, good waveform, good transduction.\n" }, { "category": "Nursing", "chartdate": "2186-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622202, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622376, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues on PPF and fent gtt. Easily arousable and moves\n all extremities\n SBP 90\ns. MAP 57-60 with dips into high 80\ns and MAP 50.\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated but occasionally\n running positive\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n RLE incision oozing serous drainage. Teams aware\n Action:\n Neo resumed\n Labs per protocol\n BFR 250 to prevent clotting\n PBP changed to 2800\n Dressing changed at bedside by primary team\n RLE elelvated\n Abx per ID recs\n Albumin 25%\n Response:\n Currently positive\n Some clots present in filter\n SBP 95-101. MAP 57-61. Remains on 0.5 Neo\n Plan:\n cont with CRRT\n cont on abx\n wean vent as tolerated\n" }, { "category": "Physician ", "chartdate": "2186-01-29 00:00:00.000", "description": "Intensivist Note", "row_id": 622454, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n RLE cellulitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n Albumin 25% (12.5g / 50mL) 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Ciprofloxacin 6. D10 7. Dextrose 50% 8. Dextrose 50% 9. Fentanyl\n Citrate 10. Fentanyl Citrate\n 11. Glucagon 12. Heparin 13. Heparin CRRT 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Meropenem\n 18. Methadone 19. Pantoprazole 20. Phenylephrine 21. Potassium Chloride\n 10 mEq / 100 mL SW (CRRT Only)\n 22. Potassium Chloride 23. Propofol 24. Prismasate (B22 K4)* 25.\n Prismasate (B22 K4) 26. Rifaximin\n 27. Sodium Chloride 0.9% Flush 28. Sodium Chloride 0.9% Flush 29.\n Sodium CITRATE 4% 30. Sodium Phosphate\n 31. Vancomycin\n 24 Hour Events:\n OR SENT - At 10:41 AM\n OR RECEIVED - At 12:05 PM\n TRANSTHORACIC ECHO - At 01:28 PM\n mild to moderate MR , pulm pressure ok\n EKG - At 02:00 AM\n Post operative day:\n POD#2 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Vancomycin - 09:10 AM\n Ciprofloxacin - 08:00 PM\n Clindamycin - 10:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Heparin Sodium - 500 units/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 04:29 AM\n Propofol - 12:30 PM\n Fentanyl - 01:02 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Pantoprazole (Protonix) - 12:10 AM\n Other medications:\n Flowsheet Data as of 03:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 35.7\nC (96.3\n HR: 73 (71 - 82) bpm\n BP: 95/40(55) {95/39(55) - 118/51(67)} mmHg\n RR: 20 (11 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 19 (14 - 23) mmHg\n Total In:\n 5,569 mL\n 1,033 mL\n PO:\n Tube feeding:\n 482 mL\n 152 mL\n IV Fluid:\n 4,802 mL\n 822 mL\n Blood products:\n 50 mL\n Total out:\n 5,009 mL\n 1,106 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 21 cmH2O\n Plateau: 24 cmH2O\n Compliance: 45 cmH2O/mL\n SPO2: 99%\n ABG: 7.32/37/80./18/-6\n Ve: 8.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, ascites\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+)\n Skin: (Incision: Purulent), RLE dressing w/serosanguinous staining\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 38 K/uL\n 10.5 g/dL\n 128 mg/dL\n 3.1 mg/dL\n 18 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 104 mEq/L\n 133 mEq/L\n 30.3 %\n 10.6 K/uL\n [image002.jpg]\n 10:07 PM\n 04:02 AM\n 04:22 AM\n 07:03 AM\n 08:28 AM\n 10:19 AM\n 02:02 PM\n 06:50 PM\n 10:00 PM\n 10:09 PM\n WBC\n 7.9\n 11.7\n 10.6\n Hct\n 29.1\n 30.5\n 30.3\n Plt\n 38\n 44\n 38\n Creatinine\n 3.0\n 2.6\n 3.1\n TCO2\n 24\n 22\n 23\n 22\n 23\n 20\n 20\n Glucose\n 66\n 69\n 87\n 86\n 109\n 88\n 84\n 129\n 128\n Other labs: PT / PTT / INR:21.9/50.3/2.0, ALT / AST:32/68, Alk-Phos / T\n bili:45/13.3, Lactic Acid:1.7 mmol/L, Albumin:4.0 g/dL, Ca:8.5 mg/dL,\n Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT: 43M with cirrhosis, sepsis, RLE\n fascitis s/p RLE debridement and fasciotomies\n Neurologic:\n -- intubated and sedated with propofol\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl gtt, fentanyl IV prn\n breakthrough pain\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60 (currently off)\n -- albumin prn\n Pulmonary:\n -- intubated on CMV, ARDS protocol, wean PEEP\n Gastrointestinal / Abdomen:\n -- dobhoff in place\n -- TF advancing to goal\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- GI prophy: pantoprazole\n Nutrition:\n -- Novasource Renal Full advance to goal 40/hr (25kcal/kg)\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even\n Hematology:\n -- serial Hct (goal > 28): Hct......\n -- chronic thrombocytopenia (goal Platelets >30): Plt.....\n -- coagulopathic secondary to liver disease (goal INR < 2): INR.....\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph), GNR (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, clinda, vanco\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE\n Imaging:\n Fluids: D10 @ 10cc/hr, Albumin 25% prn hypotension\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 09:58 PM 40. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n 18 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622544, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Lightly sedated on PPF and fent gtts. Easily arousable and\n moves all extremities\n SBP 90\ns. MAP 57-60 with dips into high 80\ns and MAP 50.\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated\n Heparin gtt for CRRT anticoagulation\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n Action:\n Neo gtt\n Labs per protocol\n Bair hugger on/off\n VAC dressings applied by surgical team at bedside\n RLE elelvated\n Abx per ID recs\n Response:\n Currently negative\n SBP 95-101. MAP 57-61. Remains on 1 mcg Neo.\n Plan:\n cont with CRRT\n check PTT q 6, CRRT labs per protocol\n cont on abx\n wean vent as tolerated\n VAC dsg to right thigh tomorrow (bedside)\n" }, { "category": "Nursing", "chartdate": "2186-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623907, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Normothermic. HR 90-110 sinus tach & MAP 60-70. WBC count elevated\n and lactate up to 3. Pt on low dose Argatroban gtt, PTT 94. CVVH on,\n running patient even, CVP ~ 10. Patient making small amounts urine.\n CPAP 5/5, lung sounds clear. Patient opens eyes to stimulation, moves\n extremities but does not follow commands. Large amounts brown/black\n guiac + stool, HCT drop to 23. Wound vac dressings intact with large\n brown serous drainage. Blood glucose consistently elevated (>180),\n sicu resident aware.\n Action:\n Neo gtt weaned off. Pan cultured. Patient given 2 units prbcs &\n argatroban gtt off. Patient remains on Fentanyl gtt and given Ativan\n given as needed.\n Response:\n Patient remains septic.\n Plan:\n Await culture results. Repeat HCT. ? insulin gtt\n" }, { "category": "Physician ", "chartdate": "2186-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 624081, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n septic \n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure\n Current medications:\n Dilaudid 15mg PO PRN, Methadone 64', Lasix 120\", Aldactone 100',\n Rifaximin 200 QOD, Testosterone gel\n .\n 24 Hour Events:\n - argatroban gtt stopped for decrease in Hct and elevated PTT and\n melanatoic stool. Transfused 4u PRBC.2FFP and 1cryopreceptate.\n Worsening LFT and cougulation. Ct scan head no acute change, US Liver\n no evidence of thrombosis\n Post operative day:\n POD#10 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 11:47 AM\n Vancomycin - 09:50 PM\n Fluconazole - 03:00 AM\n Infusions:\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 09:15 PM\n Other medications:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.4\n HR: 107 (81 - 111) bpm\n BP: 103/43(62) {79/23(45) - 125/52(69)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 98.5 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 11 (5 - 15) mmHg\n Total In:\n 5,254 mL\n 1,574 mL\n PO:\n Tube feeding:\n 578 mL\n IV Fluid:\n 1,592 mL\n 348 mL\n Blood products:\n 2,515 mL\n 777 mL\n Total out:\n 4,355 mL\n 1,100 mL\n Urine:\n 95 mL\n NG:\n 600 mL\n Stool:\n Drains:\n 850 mL\n Balance:\n 899 mL\n 474 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 774 (194 - 774) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 20\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.40/40/86/21/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress, intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), sinus tachycardia\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 8.3 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 5.2 mEq/L\n 48 mg/dL\n 105 mEq/L\n 136 mEq/L\n 23.8 %\n 19.7 K/uL\n [image002.jpg]\n 10:01 AM\n 10:14 AM\n 03:20 PM\n 03:40 PM\n 05:07 PM\n 09:17 PM\n 09:35 PM\n 10:30 PM\n 02:05 AM\n 02:22 AM\n WBC\n 22.9\n 22.8\n 22.4\n 19.7\n Hct\n 24.9\n 23.1\n 23.8\n 20.7\n 23.8\n Plt\n 74\n 75\n 48\n Creatinine\n 2.0\n 2.2\n 2.1\n TCO2\n 22\n 25\n 24\n 26\n Glucose\n 11\n 116\n 108\n Other labs: PT / PTT / INR:33.7/70.1/3.4, CK / CK-MB / Troponin T:41//,\n ALT / AST:3124/8687, Alk-Phos / T bili:317/15.3, Amylase /\n Lipase:184/287, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:85 mg/dL, Lactic Acid:4.0 mmol/L, Albumin:3.3\n g/dL, LDH:154 IU/L, Ca:11.0 mg/dL, Mg:2.7 mg/dL, PO4:10.3 mg/dL\n Assessment and Plan\n HEPARIN-INDUCED THROMBOCYTOPENIA, RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph\n Neurologic:\n -- Neuro checks Q: 1 hr;\n -- arousable, moves all extremities\n -- pain control: methadone = half the dose every other day\n -- if extubated, would recommend intermittent ketamine or precedex for\n drsg \n -- Ctscan Head no acute change f/up final read\n Cardiovascular: -- currently on neo\n -- albumin prn (got , , , )\n -- lactate trending up to 3.1\n Pulmonary: -- intubated CEPAP . ?need for early trach for neuro\n process\n Gastrointestinal / Abdomen: -- dobhoff in place, TF On hold for now\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 2. Likely secondary to lactulose.\n Guaiac positive +++.\n -- starting PPI\n -- elevated LFTs: ALT 3124 AST 8687 , TBili 15.3 Consistent w/ liver\n failure\n -- f/u PM LFTs\n -- CK level 41\n -- f/u liver u/s-doppler final read, no evidence of portal/hepatic v\n thrombosis\n -- ammonia level () = 80\n Nutrition: -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol. On hold for now\n Renal: -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal running even. dialysate off.\n Hematology: -- HIT positive. Serotonin release assay need medical path\n director approval before being processed.\n --Hematology less likely HIT positive in the setting of Coagulopathy\n and ? DIC, It is ok to resume heparin if need be\n -- Agratroban gtt started and stopped due to decreased Hct\n and dark/melanotic stools.\n -- serial Hct (goal > 28) - Hct 23.2 -> 2u PRBCs () ->\n 28->23(2UPRBC,\n -- chronic thrombocytopenia (goal Platelets >30): Plt 81\n -- coagulopathic secondary to liver disease (goal INR < 2): INR\n 4.1->7.6 (2FFP), 1unit cryoprecepetate \n -- transfuse if bleeding\n -- Citrate in CVVH filter, repleting Ca2+\n --Monitor for DIC\n Endocrine: -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n -- tapered hydrocortisone 50 q8h\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant) and\n pasturella\n -- blood cultures pending (all others negative up to date)\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n -- erythromycin ointment b/l eyes (started )\n -- WBC trending up 22. Pancultured . Afebrile.\n --Vancomycin and Fluc added to meropenam\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff, flexiseal, NGT\n Wounds: --RLE fasciotomies, saph vein exposed. white gauze covering,\n vac over @ 75, lower vac @ 125.\n --diffuse maculopapular rash in axillae, over abdomen, along flanks\n (worse in dependent areas)\n Imaging:\n Fluids: KVO\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n 20 Gauge - 01:07 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2186-02-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 624090, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: Noted\n Labs:\n Value\n Date\n Glucose\n 78 mg/dL\n 06:43 AM\n Glucose Finger Stick\n 71\n 10:00 AM\n BUN\n 48 mg/dL\n 06:43 AM\n Creatinine\n 2.8 mg/dL\n 06:43 AM\n Sodium\n 138 mEq/L\n 06:43 AM\n Potassium\n 4.9 mEq/L\n 06:43 AM\n Chloride\n 106 mEq/L\n 06:43 AM\n TCO2\n 19 mEq/L\n 06:43 AM\n PO2 (arterial)\n 86 mm Hg\n 02:22 AM\n PCO2 (arterial)\n 40 mm Hg\n 02:22 AM\n pH (arterial)\n 7.40 units\n 02:22 AM\n pH (urine)\n 6.5 units\n 12:24 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 02:22 AM\n Albumin\n 3.3 g/dL\n 02:33 AM\n Calcium non-ionized\n 10.8 mg/dL\n 06:43 AM\n Phosphorus\n 11.5 mg/dL\n 06:43 AM\n Ionized Calcium\n 0.97 mmol/L\n 06:57 AM\n Magnesium\n 2.7 mg/dL\n 06:43 AM\n ALT\n 3640 IU/L\n 06:43 AM\n Alkaline Phosphate\n 366 IU/L\n 06:43 AM\n AST\n IU/L\n 06:43 AM\n Amylase\n 184 IU/L\n 05:03 AM\n Total Bilirubin\n 15.2 mg/dL\n 06:43 AM\n WBC\n 18.9 K/uL\n 06:43 AM\n Hgb\n 8.4 g/dL\n 06:43 AM\n Hematocrit\n 23.7 %\n 06:43 AM\n Current diet order / nutrition support: NPO, Tube Feed: Nutren [1]2.0@\n 42ml/hr with 35g beneprotein\n GI: Abd soft/ distended/guaiac positive stools\n Assessment of Nutritional Status\n 43M with cirrhosis, sepsis, RLE fascitis s/p RLE debridement and\n fasciotomies POD #10 Blood & tissue cx Pasteurella Multocida & coag neg\n staph. Received blood products for drop in Hct (5units PRBC, 4\n unitsFFP).\n Clinically worsening, pending family meeting to discuss code.\n Was receiving tube feeds via NGT, currently on hold.\n Medical Nutrition Therapy Plan\n Will follow-up with plan/ progress/ goals of care.\n Please page with questions #\n 11:06\nReferences\n 1. mailto:2.0@%2042ml/hr\n" }, { "category": "Nursing", "chartdate": "2186-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624067, "text": "Hepatic failure\n Assessment:\n HR 100-110 sinus tach, MAP 55-65 on neo gtt, cvp ~ ,\n lactate 4, wbc 22\n HCT 20-23, INR 3, plt count 70\ns, fibrinogen < 100\n LFTs all extremely elevated\n Dark brown melana from fecal bag, ngt lavage with mod brown\n output (no obvious bleeding)\n Vac dressings in place with mod brown serous output\n Patient occasionally opens eyes, otherwise unresponsive\n (does not move extremities or withdraw to pain)\n Patient remains on cpap 5/5, lung sounds clear, pa02 80\n Action:\n CVVH off, hypotensive when reinitiated and neo titrated up\n Multiple blood products given, see flowsheet\n Frequent labs sent\n Abdom & pelvic ct scan done\n Response:\n Patient remains coagulopathic\n Transplant resident, dr. , in contact with patient\n mother overnight & discussed patients condition\n Plan:\n Family meeting, ? address code status\n Provide support\n Labs pending, ? ffp gtt\n" }, { "category": "Nursing", "chartdate": "2186-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624000, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Neuro: ptTemperature labile with bearhugger used at times.. HR 90-110\n sinus tach & MAP 60-70. Required increasing doses of neo this evening\n (max 1.5). HCT dropped, treated with 1 unit PRBC. Endorsed other PRBC\n and cryoprecipitate to oncoming RN. WBC count elevated and lactate\n stable. Coags increased PT/PTT/INR 66/113/7.6. Patient taken off\n CVVH during time of instability. Seems to do better off CVVH. Making\n little amount of urine. GI guaic positive. Abdomen soft, non-tender.\n NGT inserted but no residuals to aspirate.. CPAP 5/5, lung sounds\n clear with diminished bases. Increased fiO2 to 50% due to decreased\n sat ~94. O2 sat stable at this time. Patient opens eyes to\n stimulation, moves extremities but does not follow commands. Large\n amounts brown/black guiac + stool, HCT drop to 23. Wound vac dressings\n intact with large brown serous drainage. Blood glucose consistently\n elevated (>180), sicu resident aware. Blood glucose coverage with\n tightened scale.\n Action:\n Neo gtt weaned down. Blood products infusing. CT of head completed, as\n well as abdominal US. CVVH dc\n Response:\n Patient remains septic.\n Plan:\n Await culture results. Repeat coags, CBC tonight. Monitor LFTs for\n possibly worsening liver function.\n" }, { "category": "Nursing", "chartdate": "2186-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623998, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 21 this am, PTT 90-100\n Argatroban infusing. Could not decrease dose below 0.5cc/hr\n due to pump limitations. Discussed thoroughly with PharmD and\n Transplant team.\n Action:\n PTT checked q 6 hours\n Argatroban infusing at 0.085mcg/kg/min (0.5cc/hr) for entire\n shift until above issue resolved with concentration of med. Team\n aware.\n Followed for signs bleeding\n Response:\n Argatroban placed in 60cc syringe (50mg in 50cc) to be\n infused at 0.05mcg/kg/min or (0.3cc/hr).\n Plan:\n Cont to follow coags, goal PTT ~ 60-80\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperthermic today (~99.0-99.1)\n HR 70-80\ns NSR & MAP ~60, CVP ~ 10\n Restarted neosynephrine for MAP >= 60\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Intubated on cpap 5/5\n Left IJ dialysis catheter issues with negative pressure\n alarms on CVVH. Discussed with renal fellow and SICU MD.\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Fent decreased to 50mcg/hr.\n Versed dc\nd today, Ativan ordered PRN.\n After multiple instances of alarming and blousing of fluid\n to resolve issue, decided to change catheter over wire. Too much fluid\n was being infused to resolve high access pressures compared to pulling\n of 50cc/hr.\n Response:\n Stable\n Weaning down Neo as much as possible\n Left IJ dialysis catheter changed over wire. Red line with\n good flow, blue line with poor aspiration. Can only push fluids\n easily. Lines reversed for CVVH treatment.\n Plan:\n Continue with current icu monitoring and treatment\n Improving mental status, ? extubation soon\n Next PTT at midnight, .\n" }, { "category": "Nursing", "chartdate": "2186-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623999, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n Coags increased over entire shift. Latest PTT ~7. WBC\n increased from 14 to 22. PTT stable today.\n Argatroban infusing. Could not decrease dose below 0.5cc/hr\n due to pump limitations. Discussed thoroughly with PharmD and\n Transplant team.\n Action:\n PTT checked q 6 hours\n Argatroban infusing at 0.085mcg/kg/min (0.5cc/hr) for entire\n shift until above issue resolved with concentration of med. Team\n aware.\n Followed for signs bleeding\n Response:\n Argatroban placed in 60cc syringe (50mg in 50cc) to be\n infused at 0.05mcg/kg/min or (0.3cc/hr).\n Plan:\n Cont to follow coags, goal PTT ~ 60-80\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperthermic today (~99.0-99.1)\n HR 70-80\ns NSR & MAP ~60, CVP ~ 10\n Restarted neosynephrine for MAP >= 60\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Intubated on cpap 5/5\n Left IJ dialysis catheter issues with negative pressure\n alarms on CVVH. Discussed with renal fellow and SICU MD.\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Fent decreased to 50mcg/hr.\n Versed dc\nd today, Ativan ordered PRN.\n After multiple instances of alarming and blousing of fluid\n to resolve issue, decided to change catheter over wire. Too much fluid\n was being infused to resolve high access pressures compared to pulling\n of 50cc/hr.\n Response:\n Stable\n Weaning down Neo as much as possible\n Left IJ dialysis catheter changed over wire. Red line with\n good flow, blue line with poor aspiration. Can only push fluids\n easily. Lines reversed for CVVH treatment.\n Plan:\n Continue with current icu monitoring and treatment\n Improving mental status, ? extubation soon\n Next PTT at midnight, .\n" }, { "category": "Social Work", "chartdate": "2186-02-06 00:00:00.000", "description": "Social Work Progress Note", "row_id": 624127, "text": "Social Work Progress Note, Transplant Service\n Covering for . Paged by SICU to offer supportive\n intervention to pt\ns family coping with pt\ns rapid decline. Met with\n pt\ns mother, 2 sisters at bedside to offer support. They are\n understandably distraught, sharing range of emotions as they anticipate\n pt\ns passing including anger and sadness that he cannot have a liver\n transplant, something he had eagerly anticipated. Pt\ns mo (herself a\n SW) expresses concerns for how pt\ns roommate, described as emotionally\n fragile, will react to seeing pt. She is coming into hospital with a\n family member. Reassured pt\ns mo that RN staff will provide support,\n and that psychiatry can be consulted in ED as well if indicated. Pts\n 15/16 yo niece /nephew also plan to visit, discussed how teens cope\n with loss as pt\ns mother is already aware.\n Discussed with nursing staff. Reassured family that will f/u\n with them by phone and is avail for cont phone support/community\n referrals as needed.\n \n" }, { "category": "Physician ", "chartdate": "2186-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 623937, "text": "TITLE:\n SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n fascitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 15. Lorazepam 2-4 mg IV Q4H:PRN agitation/anxiety Order date: @\n 1414\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 0825\n 16. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 3. Argatroban 0.05 mcg/kg/min IV DRIP INFUSION\n hold until further notice Order date: @ 0142\n 17. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 18. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 5. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043\n 19. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 20. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO map>60 Order\n date: @ \n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631\n 21. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date: \n @ 1821\n 22. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 23. Prismasate (B22 K4)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 2500 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 0825\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 24. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 25. 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: @ 1631\n 12. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 0941\n 26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 27. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 14. Lactulose 30 mL PO/NG DAILY\n due to high ammonia levels Order date: @ 1112\n 28. Sodium Phosphate IV Sliding Scale Order date: @ 1525\n 24 Hour Events:\n PAN CULTURE - At 12:40 AM\n - back on neo. titrated off midaz, on ativan prn. HD line rewired.\n - argatroban gtt stopped for decrease in Hct and elevated PTT and\n melanatoic stool. Transfused 2u PRBC.\n Post operative day:\n POD#9 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 12:37 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 03:11 PM\n Lorazepam (Ativan) - 02:46 AM\n Other medications:\n Flowsheet Data as of 05:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.8\nC (98.2\n HR: 111 (77 - 118) bpm\n BP: 97/42(59) {97/36(53) - 140/55(77)} mmHg\n RR: 16 (7 - 21) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 12 (5 - 13) mmHg\n Total In:\n 3,378 mL\n 1,162 mL\n PO:\n Tube feeding:\n 1,008 mL\n 214 mL\n IV Fluid:\n 2,249 mL\n 328 mL\n Blood products:\n 560 mL\n Total out:\n 4,166 mL\n 795 mL\n Urine:\n 318 mL\n 65 mL\n NG:\n Stool:\n 400 mL\n Drains:\n 1,000 mL\n Balance:\n -788 mL\n 367 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (720 - 1,077) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.35/44/129/24/-1\n Ve: 11.2 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n : (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 7.8 g/dL\n 250 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 5.2 mEq/L\n 61 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.2 %\n 14.5 K/uL\n [image002.jpg]\n 02:23 PM\n 08:57 PM\n 03:46 AM\n 04:06 AM\n 09:45 AM\n 10:08 AM\n 03:44 PM\n 03:58 PM\n 10:53 PM\n 11:03 PM\n WBC\n 6.0\n 14.5\n Hct\n 26.3\n 23.2\n Plt\n 21\n 48\n Creatinine\n 0.8\n 1.2\n 1.4\n TCO2\n 28\n 24\n 26\n 26\n 29\n 25\n Glucose\n 124\n 180\n 181\n \n Other labs: PT / PTT / INR:35.5/98.4/3.6, ALT / AST:28/63, Alk-Phos / T\n bili:77/22.5, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:95 mg/dL, Lactic Acid:3.0 mmol/L, Albumin:3.3\n g/dL, LDH:154 IU/L, Ca:8.9 mg/dL, Mg:2.5 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HEPARIN-INDUCED THROMBOCYTOPENIA, RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic:\n -- intubated and sedated with fent gtt & ativan prn (titrated off of\n midazolam gtt)\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n -- if extubated, would recommend intermittent ketamine or precedex for\n drsg \n :\n -- placed back on neo\n -- albumin prn (got , , , )\n Pulmonary:\n -- intubated CPAP 5/5. trach for neuro process next week. CXR for\n increase in hypoxemia.\n Gastrointestinal / Abdomen:\n -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 2. Likely secondary to lactulose.\n Guaiac positive +++.\n -- trend TBili\n -- ammonia level () = 80\n Nutrition:\n -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off propofol.\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal running even. dialysate off.\n Hematology:\n -- HIT positive. Serotonin release assay need medical path director\n approval before being processed.\n -- Agratroban gtt started and stopped . PTT check q6h with\n goal 80.\n -- serial Hct (goal > 28) - Hct 23.2 -> 2u PRBCs ()\n -- chronic thrombocytopenia (goal Platelets >30): Plt 48\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- transfuse if bleeding\n -- Citrate in CVVH filter, repleting Ca2+\n Endocrine:\n -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n -- tapered hydrocortisone 50 Q6h -> q8h ()\n ID:\n -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant) and\n pasturella\n -- blood cultures pending (all others negative up to date)\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n -- erythromycin ointment b/l eyes (started )\n -- WBC trending up 14.5. Pancultured . Afebrile.\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff, flexiseal\n Wounds:\n --RLE fasciotomies, saph vein exposed. white gauze covering, vac over @\n 75, lower vac @ 125.\n --diffuse maculopapular rash in axillae, over abdomen, along flanks\n (worse in dependent areas)\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: West 1, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boot x 1\n Stress ulcer: begin PPI given dark stools\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2186-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622648, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing.\n Normothermic early noc with bair hugger off but dropped temp to 96\n through evening.\n CRRT in progress, received pt 2.6L positive for the day.\n Heparin gtts infusing via prisma circuit.\n Rt leg incision continues to ooze copious serous drainage.\n Action:\n Throughout evening, PFR increased to remove optimal amount of fluid for\n day.\n Phenylephrine titrated to maintain map>55.\n Labs Q6hours.\n Continuous lyte repletion in progress.\n Bair hugger reapplied.\n Rt leg dressing reinforced to absorb drainage.\n Clindamycin discontinued from antibiotic regimen.\n Response:\n Removed increased fluid through pm, ended day 0.3L positive, pt\n tolerated well but have been aiming for goal of even fluid\n balance after mn since pt slightly more acidotic.\n Required slight increase in pressor support toward this am.\n Electrolytes in balance.\n Hct 30.6, Plts 32, and INR 2.1 this am, Dr aware.\n No signs of bleeding.\n WBC slightly elevated to 12.4 this am, pt afebrile\n Weight down 2kg in last 24hours, fluid calculations are not including\n copious amount of serous fluid loss into bed.\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n VAC dressing to be applied to right thigh by team today.\n Mother will be in this am and wishes to speak with Dr , Dr\n (team resident) notified of this in pm.\n" }, { "category": "Nursing", "chartdate": "2186-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622649, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing@ 0.5mcg/kg/min.\n Normothermic with bair hugger on.\n CRRT in progress, prisma circuit clotted off @ 2100.\n Heparin gtts infusing via prisma circuit @ 300units/hr.\n Vac dressings intact on Rt leg.\n Plts 21 in pm, Dr notified who in turn notified transplant\n team, no new orders.\n Pt has started stooling.\n Action:\n Was able to return blood but unable to flush lg clots through or\n recirculate. Prisma circuit restarted @ 2300.\n Late evening, PFR increased briefly to remove optimal amount of fluid\n for day.\n Labs Q6hours.\n Continuous electrolyte repletion in progress.\n Bair hugger continued.\n Rt leg vac dressings monitored frequently for bleeding.\n Fecal collection pouch applied.\n Response:\n BP stable with map>55. Titration of neo not required.\n Thigh vac dressing collecting copious serous drainage, minimal drainage\n from lower leg.\n Electrolytes in balance.\n Hct stable.\n No signs of bleeding.\n WBC slightly elevated to 12.4 this am, pt afebrile\n Weight down 1kg in last 24hours.\n Negative fluid balance attained mostly through leg drainage.\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n Change over to new tube feed regimen when formula obtained today.\n" }, { "category": "Nursing", "chartdate": "2186-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623517, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623820, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 20\ns, PTT 60\n Patient off all heparin\n Action:\n Argatroban started & repeat PTT checked\n Followed for signs bleeding\n Response:\n PTT 90 and gtt decreased\n Plan:\n Cont to follow coags, goal PTT ~ 80\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Slightly hypothermic, 96-97\n HR 70-80\ns NSR & MAP 60-70, CVP ~ 10\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Intubated on cpap 5/5\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Fent/versed gtt continues\n Response:\n Stable\n Hypotension resolved\n Plan:\n Continue with current icu monitoring and treatment\n ? trial off cvvh\n Improving mental status, ? extubation soon\n" }, { "category": "Physician ", "chartdate": "2186-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 623604, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n . IV access: Temporary central access (ICU) Order date: @ 1631\n 16. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 0825 17. Meropenem 1000 mg IV Q12H Order\n date: @ 0850\n 3. Albumin 25% (12.5g / 50mL) 12.5 g IV ONCE Duration: 1 Doses Order\n date: @ 18. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 19. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 5. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043 20. Midazolam 0.5-2\n mg/hr IV DRIP TITRATE TO decreased agitation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0922\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 21.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO map>60 Order date:\n @ \n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631 22. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date: \n @ 1821 23. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 24. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 25. Prismasate (B22 K4)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 2500 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 0825\n 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 26. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 12. Heparin 5000 UNIT SC BID Order date: @ 1631 27. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1631\n 13. Hydrocortisone Na Succ. 100 mg IV ONCE Duration: 1 Doses Order\n date: @ 28. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 29. Sodium CITRATE 4% 1.5\n mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 15. Lactulose 30 mL PO/NG TID\n due to high ammonia levels Order date: @ 1816 30. Sodium\n Phosphate IV Sliding Scale Order date: @ 1525\n 24 Hour Events:\n Hypotension. ? related to plts???\n Rash - ? above?\n Given steroids for possible corticoid deficiency ( pos test in past,\n now hypotensive)\n Post operative day:\n POD#7 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:23 AM\n Meropenem - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Phenylephrine - 1 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:08 AM\n Other medications:\n : Dilaudid 15mg PO PRN, Methadone 64', Lasix 120\", Aldactone 100',\n Rifaximin 200 QOD, Testosterone gel\n Flowsheet Data as of 05:04 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: 36.8\nC (98.2\n HR: 79 (78 - 95) bpm\n BP: 109/36(55) {88/27(45) - 137/50(75)} mmHg\n RR: 7 (7 - 15) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 6 (2 - 10) mmHg\n Total In:\n 8,986 mL\n 2,207 mL\n PO:\n Tube feeding:\n 1,008 mL\n 204 mL\n IV Fluid:\n 7,267 mL\n 1,568 mL\n Blood products:\n 494 mL\n 375 mL\n Total out:\n 10,348 mL\n 1,825 mL\n Urine:\n 269 mL\n 135 mL\n NG:\n Stool:\n 1,460 mL\n Drains:\n 1,000 mL\n Balance:\n -1,362 mL\n 382 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 947 (646 - 947) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: 7.33/47/132/25/-1\n Ve: 7.6 L/min\n PaO2 / FiO2: 330\n Physical Examination\n General Appearance: No acute distress, ill, jaundiced\n HEENT: PERRL, icteric sclerae\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: No(t) 3+, 4+), (Temperature: Warm)\n Right Extremities: (Edema: 4+), (Temperature: Warm)\n Skin: Rash: diffuse red, maculopapular.- improved, Jaundice, (Incision:\n Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 26 K/uL\n 9.5 g/dL\n 176 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 34 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 10:31 AM\n 12:20 PM\n 02:14 PM\n 04:25 PM\n 04:33 PM\n 08:00 PM\n 08:13 PM\n 11:51 PM\n 02:33 AM\n 02:51 AM\n WBC\n 5.9\n 9.8\n 8.0\n Hct\n 25.2\n 27.7\n 28.4\n Plt\n 23\n 18\n 39\n 26\n Creatinine\n 1.5\n 1.5\n 1.5\n TCO2\n 25\n 27\n 26\n 26\n 26\n Glucose\n 151\n 111\n 147\n 147\n 140\n 193\n 176\n Other labs: PT / PTT / INR:22.2/64.3/2.1, ALT / AST:25/74, Alk-Phos / T\n bili:75/22.5, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:95 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:3.0\n g/dL, LDH:154 IU/L, Ca:9.7 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic: -- intubated and sedated with fent gtt & midazolam prn\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n -- chronic pain consult: consider weaning off midaz/fent and starting\n precedex gtt.\n --if extubated, would recommend intermittent ketamine for drsg \n -- consider head ct if no improvement in mental status\n Cardiovascular: --dropped pressure 8p\n -- restarted neo 8p\n -- albumin prn (got , , , ) gave last night.\n -- lactate 1.7\n Pulmonary: -- intubated CPAP 5/5. reconsider trach.\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 1. Likely secondary to lactulose.Will\n decrease to once daily. Guaiac positive.\n -- rising TBili\n -- ammonia level () = 80\n Nutrition: Tube feeding, goal.\n Renal: -- Q4h calcium checks for Citrate toxicity\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg held when dropped pressure\n Hematology: -- serial Hct (goal > 28)\n -- chronic thrombocytopenia (goal Platelets >30): Plt\n 12->23->18->39->26 post unit plts . tx another unit plt & prbc.\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- Citrate in CVVH filter rather than heparin\n --Fibrinogen 90, Hapto <5 ?acute on chronic dic.\n Endocrine: RISS, -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n --hydrocortisone 100mg given 8p when restarted pressors . continue\n 50 q6\n Infectious Disease: Check cultures, -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella). Sensitive to doxycycline.\n -- blood cultures pending, repeated yesterday\n --Tm 99.6 on cvvh -pancultured\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n -- cipro d/c'ed \n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff, flexiseal\n Wounds: --RLE fasciotomies, saph vein exposed. white gauze covering,\n vac over @ 75, lower vac @ 125.\n --diffuse maculopapular rash in axillae, over abdomen, along flanks\n (worse in dependent areas)- improved.\n Imaging: CXR today\n Fluids: KVO, Albumin 25% prn hypotension. goal even i/o or slightly\n positive\n Consults: Vascular surgery, Transplant, ID dept, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic), Liver failure\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Comments: tolerating @ goal\n Glycemic Control:\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP bundle:\n Comments: restart stress ulcer prophylaxis in setting of low bp?\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "ECG", "chartdate": "2186-02-06 00:00:00.000", "description": "Report", "row_id": 223724, "text": "Sinus tachycardia. Otherwise, normal tracing. Since the previous tracing\nof sinus tachycardia is now present.\n\n" }, { "category": "ECG", "chartdate": "2186-02-01 00:00:00.000", "description": "Report", "row_id": 223725, "text": "Sinus rhythm. Normal tracing. Since the previous tracing of there is no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-01-31 00:00:00.000", "description": "Report", "row_id": 223726, "text": "Sinus rhythm. Normal tracing. Since the previous tracing of there is no\nsignificant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2186-01-29 00:00:00.000", "description": "Report", "row_id": 223727, "text": "Sinus rhythm. Normal tracing. Since the previous tracing of \nlow T wave amplitude is improved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-01-28 00:00:00.000", "description": "Report", "row_id": 223728, "text": "Sinus rhythm. Low T wave amplitude is non-specific. Since the previous\ntracing of sinus tachycardia is absent and low T wave amplitude is\nseen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2186-01-26 00:00:00.000", "description": "Report", "row_id": 223729, "text": "Sinus tachycardia. Otherwise, findings are within normal limits. Compared to\nthe previous tracing of there is no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2186-01-26 00:00:00.000", "description": "Report", "row_id": 223730, "text": "Sinus tachycardia. Otherwise, tracing is within normal limits. Compared to the\nprevious tracing of there is no significant diagnostic change.\n\n" }, { "category": "Nursing", "chartdate": "2186-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623694, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Arouses to voice, not following commands, but has nodded yes\n and no approriatly to family. Agitated with movement/turning. PERRLA.\n Remains on CPAP 5/5.\n Received on Neo gtt @ 0.75mcg/kg/min to maintain MAP >60.\n Fentanyl gtt and for pain\n MAP 52-56\n Abd softly distended. Tube feeds at goal via pedi tube (in\n stomach).\n Flexiseal in place with large amounts of liquid stool.\n Making small amts clear icteric urine\n Vac dressings intact\n RLE wet-dry dressings intact\n Continues on CRRT to remove 50ml/hr as tolerated. Continues\n on Citrate-filter working well.\n Pt received with Plt 12.\n Action:\n Midaz gtt continued for agitation\n Lactulose continued for high ammonia levels\n Labs per protocol\n RLE wet to dry dressings changed\n 1 unit of Plts as ordered.\n Response:\n Tolerating fluid removal.\n Neo remains off\n Plt 23 s/p transfusion.\n Plan:\n Cont Crrt to remove fluid as tolerated.\n Monitor labs as ordered, carefully follow Ca levels and\n monitor for acidosis\n Cont monitor for bleeding and notify primary team\n immediately if blood observed from VAC\n Attempt wean from midaz gtt. SICU and Transplant Team aware\n of agitation without sedation. Formulate a better sedation method,\n ?ativan PRN.\n Cont provide support to pt and family\n" }, { "category": "Nursing", "chartdate": "2186-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623021, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - sedated on Fentanyl and versed gtt\n - wakes with stimulation but does not follow commands\n - hr stable\n - afebrile\n - maps 58-62\n - lungs clear\n - min amt icteric urine\n - crrt running -50cc/hr to even as tolerated\n - filter clotted @ 0930\n - ptt therapeutic\n - wound vac to thigh and calf with thigh areas to vac @ 75 and\n calf area to vac @ 125\n - lg amt liquid stool output Flexi Seal.\n Action:\n - Crrt resumed @ 1200\n - No changes to vent settings.\n - Weaning Vercid as ordered, currently 0.5mg/hr.\n - Continued Neo @ 0.5mcg/kg/min.\n Response:\n - no s/sx bleeding\n - resp status stable\n - Awaiting pending labs.\n - cont to monitor liver function, lytes, i/o.\n" }, { "category": "Nursing", "chartdate": "2186-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623853, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 21 this am, PTT 90-100\n Argatroban infusing. Could not decrease dose below 0.5cc/hr\n due to pump limitations. Discussed thoroughly with PharmD and\n Transplant team.\n Action:\n PTT checked q 6 hours\n Argatroban infusing at 0.085mcg/kg/min (0.5cc/hr) for entire\n shift until above issue resolved with concentration of med. Team\n aware.\n Followed for signs bleeding\n Response:\n Argatroban placed in 60cc syringe (50mg in 50cc) to be\n infused at 0.05mcg/kg/min or (0.3cc/hr).\n Plan:\n Cont to follow coags, goal PTT ~ 60-80\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperthermic today (~99.0-99.1)\n HR 70-80\ns NSR & MAP ~60, CVP ~ 10\n Restarted neosynephrine for MAP >= 60\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Intubated on cpap 5/5\n Left IJ dialysis catheter issues with negative pressure\n alarms on CVVH. Discussed with renal fellow and SICU MD.\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Fent decreased to 50mcg/hr.\n Versed dc\nd today, Ativan ordered PRN.\n After multiple instances of alarming and blousing of fluid\n to resolve issue, decided to change catheter over wire. Too much fluid\n was being infused to resolve high access pressures compared to pulling\n of 50cc/hr.\n Response:\n Stable\n Weaning down Neo as much as possible\n Left IJ dialysis catheter changed over wire. Red line with\n good flow, blue line with poor aspiration. Can only push fluids\n easily. Lines reversed for CVVH treatment.\n Plan:\n Continue with current icu monitoring and treatment\n Improving mental status, ? extubation soon\n Next PTT at midnight, .\n" }, { "category": "Physician ", "chartdate": "2186-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 623788, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n RLE Pasteurella fasciitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 15. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 0825 16. Meropenem 1000 mg IV Q12H Order\n date: @ 0850\n 3. Argatroban 0.1 mcg/kg/min IV DRIP INFUSION Order date: @ 0130\n 17. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 18. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 5. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043 19. Midazolam 0.5-2\n mg/hr IV DRIP TITRATE TO decreased agitation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0922\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 20.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO map>60 Order date:\n @ \n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631 21. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date: \n @ 1821 22. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 23. Prismasate (B22 K4)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 2500 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 0825\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 24. Rifaximin 400 mg PO/NG TID Order date: @\n 1434\n 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 25. 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: @ 1631\n 12. Hydrocortisone Na Succ. 50 mg IV Q6H Order date: @ 1112 26.\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 27. Sodium CITRATE 4% 1.5\n mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 14. Lactulose 30 mL PO/NG DAILY\n due to high ammonia levels Order date: @ 1112 28. Sodium\n Phosphate IV Sliding Scale Order date: @ 1525\n 24 Hour Events:\n Had been back on neo but now off again. Still cont . Vacs changed -\n fascia look good. Mental status improved. CVVH continued with citrate.\n HIT positive- argatroban gtt started.\n Post operative day:\n POD#8 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:23 AM\n Meropenem - 12:25 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Argatroban - 0.1 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:19 AM\n Fentanyl - 01:32 AM\n Other medications:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 35.7\nC (96.3\n HR: 76 (70 - 83) bpm\n BP: 121/42(62) {118/40(61) - 139/52(77)} mmHg\n RR: 6 (6 - 13) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 8 (7 - 15) mmHg\n Total In:\n 6,913 mL\n 884 mL\n PO:\n Tube feeding:\n 1,008 mL\n 221 mL\n IV Fluid:\n 5,380 mL\n 634 mL\n Blood products:\n 375 mL\n Total out:\n 6,696 mL\n 1,093 mL\n Urine:\n 441 mL\n 50 mL\n NG:\n Stool:\n Drains:\n 500 mL\n 500 mL\n Balance:\n 217 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,244 (842 - 1,244) mL\n PS : 5 cmH2O\n RR (Spontaneous): 6\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 11\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: 7.33/47/142/25/-1\n Ve: 7 L/min\n PaO2 / FiO2: 355\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n : (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: Rash: Maculopapular rash on back\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 21 K/uL\n 8.9 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 47 mg/dL\n 107 mEq/L\n 140 mEq/L\n 26.3 %\n 6.0 K/uL\n [image002.jpg]\n 08:13 PM\n 11:51 PM\n 02:33 AM\n 02:51 AM\n 08:23 AM\n 01:01 PM\n 02:23 PM\n 08:57 PM\n 03:46 AM\n 04:06 AM\n WBC\n 9.8\n 8.0\n 9.5\n 6.0\n Hct\n 27.7\n 28.4\n 28.9\n 26.3\n Plt\n 39\n 26\n 29\n 21\n Creatinine\n 1.5\n 1.2\n TCO2\n 26\n 26\n 25\n 28\n 24\n 26\n Glucose\n 140\n 193\n 176\n 161\n 135\n 124\n 180\n 181\n Other labs: PT / PTT / INR:22.2/90.5/2.1, ALT / AST:28/63, Alk-Phos / T\n bili:77/22.5, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:95 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:3.3\n g/dL, LDH:154 IU/L, Ca:9.9 mg/dL, Mg:2.6 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n HEPARIN-INDUCED THROMBOCYTOPENIA, RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with HCV cirrhosis presenting with sepsis, RLE\n fascitis s/p I&D and debridement\n Neurologic: -- intubated and sedated with fent gtt & midazolam gtt for\n agitation. Will stop midaz gtt. Intermittent Ativan or change to\n propofol if BP tolerates.\n -- arousable, moves all extremities, answers yes/no questions\n -- pain control: methadone po, fentanyl\n --if extubated, would recommend intermittent ketamine or precedex for\n drsg \n : --off neo overnight\n -- albumin prn (got , , , )\n Pulmonary: -- intubated CPAP 5/5. ?need for early trach for neuro\n process\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose dose to 1/day\n -- profuse stooling. Cdiff neg x 2. Likely secondary to lactulose.\n Guaiac positive.\n -- trend TBili\n -- ammonia level () = 80\n Nutrition: -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol.\n Renal: -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal running even. dialysate off today\n Hematology: -- HIT positive. Serotonin release assay pending.\n Agratroban gtt started. PTT check q6h with goal 80.\n -- serial Hct (goal > 28) - today 26.3\n -- chronic thrombocytopenia (goal Platelets >30): Plt\n 12->23->18->39->26>29\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- Citrate in CVVH filter rather than heparin, repleting Ca2+\n Endocrine: -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n --hydrocortisone continue 50 Q6h\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella). Sensitive to doxycycline.\n -- blood cultures pending, repeated yesterday\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff, flexiseal\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: Transplant, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:58 PM 42 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Argatroban (TM))\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: 31 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2186-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623136, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Lightly sedated on fentanyl and low dose versed gtt\n - Versed gtt of @ per transplant\n ok for prn bolus\n - HR 70-80 NSR with no ectopy except 1 4 beat run VT\n - Neo gtt weaned up overnight for MAPS in mid to high 50\n - Noted to have dip in BP with agitation or pain\n - Lungs clear initially but becoming rhonchrous\n - CRRT filter clotting this evening and completely clotted by\n 2345.\n - VAC to 2 thigh area\ns to 75 mm suction although machine at\n time with fluctuating pressures and alarms for partial blockage\n - VAC to calf area @ 125 mm suction functioning well with no\n issues\n - Area to lower calf and ankle with 3 open areas\n WD dressing\n intact\n Action:\n - Multiple bolus of versed required overnight for patient to\n tolerate even minimal stimulation\n - Fentanyl gtt increased to improve pain control/sedation\n - Albumin 5% given for increasing pressor requirement and low\n CVP (per transplant recomondations)\n - Ambu bagged and lavaged for large mucus plug\n - Renal and transplant consulted by SICU resident and citrate\n initiated to decrease frequency of filter clotting\n - Pre filter replacement increased to 4000 to dilute blood and\n decrease clotting\n - Replacement fluid changed to K4 d/t elevated bicarb and\n decreased k\n - VAC canister and then VAC machine changed out to\n troubleshoot VAC\n - Dressing changed and wounds on lower right leg packed per\n surgery\ns recs\n Response:\n - Good relief from prn versed but moments of distress still\n noted\n - Neo down slightly after albumin and CVP up\n - Improved filter pressures and minimal clots in filter noted\n after citrate initialted\n -\n Plan:\n" }, { "category": "Physician ", "chartdate": "2186-01-31 00:00:00.000", "description": "Intensivist Note", "row_id": 622886, "text": "TITLE:\n SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n sepsis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846\n 19. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 3. Alteplase 1mg/Flush Volume ( Dialysis/Pheresis Catheters ) 1\n mg IV ONCE MR1 Duration: 1 Doses\n Alteplase 1mg/ 1.2 mL (Dialysis/Pheresis Catheters Order date: @\n 1821\n 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Alteplase 1mg/Flush Volume ( Dialysis/Pheresis Catheters ) 1\n mg IV ONCE MR1 Duration: 1 Doses\n Alteplase 1mg/ 1.3 mL (Dialysis/Pheresis Catheters Order date: @\n 1821\n 21. Midazolam 0.5-2 mg IV Q2H:PRN anxiety Order date: @ 1105\n 5. Albumin 25% (12.5g / 50mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 0459\n 22. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1821\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 23. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 7. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order\n date: @ 2252\n 8. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 25. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631\n 26. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 10. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date:\n @ 1821\n 27. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 11. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 28. Prismasate (B32 K2)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate:2500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 2335\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 29. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 30. 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: @ 1631\n 14. Heparin 5000 UNIT SC BID Order date: @ 1631\n 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Heparin CRRT IV Sliding Scale\n No Initial Bolus\n Initial Infusion Rate: 500 units/hr\n Part of CRRT Protocol Order date: @ 2133\n 32. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 33. Sodium Phosphate IV Sliding Scale Order date: @ 1525\n 17. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 24 Hour Events:\n EKG - At 03:40 AM\n - d/c'ed GI prophy, changed sedation to versed, 25g albumin IV\n bolus x 1\n - 25g albumin IV bolus x1\n Post operative day:\n POD#4 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Clindamycin - 10:00 PM\n Vancomycin - 08:25 AM\n Ciprofloxacin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 150 units/hour\n Other ICU medications:\n Midazolam (Versed) - 07:50 PM\n Other medications:\n Flowsheet Data as of 05:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.3\n HR: 77 (68 - 87) bpm\n BP: 111/41(61) {99/37(52) - 159/82(101)} mmHg\n RR: 17 (17 - 37) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 11 (11 - 17) mmHg\n Total In:\n 4,308 mL\n 1,002 mL\n PO:\n Tube feeding:\n 925 mL\n 210 mL\n IV Fluid:\n 3,063 mL\n 791 mL\n Blood products:\n 50 mL\n Total out:\n 5,737 mL\n 1,211 mL\n Urine:\n 142 mL\n 39 mL\n NG:\n Stool:\n Drains:\n 1,475 mL\n 500 mL\n Balance:\n -1,429 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 49.5 cmH2O/mL\n SPO2: 97%\n ABG: 7.40/40/119/23/0\n Ve: 11 L/min\n PaO2 / FiO2: 298\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, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), vac dressings in place RLE\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 18 K/uL\n 9.9 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 31 mg/dL\n 103 mEq/L\n 134 mEq/L\n 29.3 %\n 9.6 K/uL\n [image002.jpg]\n 10:08 PM\n 04:00 AM\n 04:17 AM\n 10:03 AM\n 10:20 AM\n 02:00 PM\n 03:39 PM\n 10:00 PM\n 03:08 AM\n 03:24 AM\n WBC\n 12.2\n 11.2\n 9.6\n Hct\n 31.1\n 29.5\n 29.3\n Plt\n 21\n 22\n 18\n Creatinine\n 2.6\n 2.4\n 2.8\n 1.8\n TCO2\n 21\n 22\n 20\n 23\n 26\n Glucose\n 120\n 114\n 123\n 136\n 100\n 98\n Other labs: PT / PTT / INR:24.6/79.8/2.4, ALT / AST:28/78, Alk-Phos / T\n bili:67/20.8, Lactic Acid:1.7 mmol/L, Albumin:4.0 g/dL, Ca:8.3 mg/dL,\n Mg:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic:\n -- intubated and sedated with midazolam\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60\n -- albumin prn (got , , )\n -- lactate 1.7\n Pulmonary:\n -- intubated on CMV, ARDS protocol, wean PEEP. ?need for early trach\n -- cmv 20x500/0.4/8, 7.40/40/119/26/0\n Gastrointestinal / Abdomen:\n -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n Nutrition:\n -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off propofol.\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg.\n Hematology:\n -- serial Hct (goal > 28): Hct 29.3\n -- chronic thrombocytopenia (goal Platelets >30): Plt 18. no bleeding,\n no transfusion @ this time.\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.4\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, (vanco d/cd )\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: n/a\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2186-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623131, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Lightly sedated on fentanyl and low dose versed gtt\n - Versed gtt of @ per transplant\n ok for prn bolus\n - HR 70-80 NSR with no ectopy except 1 4 beat run VT\n - Neo gtt weaned up overnight for MAPS in mid to high 50\n - Noted to have dip in BP with agitation or pain\n - Lungs clear initially but becoming rhonchrous\n - CRRT filter clotting this evening and completely clotted by\n 2345.\n - VAC to 2 thigh area\ns to 75 mm suction although machine at\n time with fluctuating\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2186-02-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 623247, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 98.8 kg\n 99.8 kg ( 04:00 AM)\n 29.5\n Pertinent medications: calcium gluconate repletion, heparin, ABX,\n others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 04:39 PM\n Glucose Finger Stick\n 137\n 10:00 AM\n BUN\n 33 mg/dL\n 10:00 AM\n Creatinine\n 1.5 mg/dL\n 10:00 AM\n Sodium\n 134 mEq/L\n 10:00 AM\n Potassium\n 3.9 mEq/L\n 04:39 PM\n Chloride\n 101 mEq/L\n 10:00 AM\n TCO2\n 24 mEq/L\n 10:00 AM\n PO2 (arterial)\n 112 mm Hg\n 04:39 PM\n PCO2 (arterial)\n 42 mm Hg\n 04:39 PM\n pH (arterial)\n 7.36 units\n 04:39 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 04:39 PM\n Albumin\n 3.6 g/dL\n 05:45 PM\n Calcium non-ionized\n 9.1 mg/dL\n 12:13 PM\n Phosphorus\n 3.8 mg/dL\n 10:00 AM\n Ionized Calcium\n 0.96 mmol/L\n 04:39 PM\n Magnesium\n 2.3 mg/dL\n 10:00 AM\n ALT\n 26 IU/L\n 02:44 AM\n Alkaline Phosphate\n 70 IU/L\n 02:44 AM\n AST\n 85 IU/L\n 02:44 AM\n Total Bilirubin\n 23.9 mg/dL\n 02:44 AM\n WBC\n 8.9 K/uL\n 02:44 AM\n Hgb\n 10.1 g/dL\n 02:44 AM\n Hematocrit\n 29.0 %\n 10:00 AM\n Current diet order / nutrition support: NPO; Nutren 2.0 @ 42mL/hr + 35\n g Beneprotein x 24hr\n GI: Abd soft/distended, present bowel sounds\n Specifics: 43 y.o. M with HCV cirrhosis presenting with sepsis, RLE\n fasciitis, abd pain, GNR bacteremia, now s/p I&D and debridement of\n RLE. Patient remains intubated on CVVH and continues to receive\n nutrition support via NGT feeds. Propofol weaned and tube feed rate\n increased to 42mL/hr which RN reports patient is tolerating. Patient\n with large stool output, however noted previously receiving lactulose\n which was discontinued today, C. diff negative x1. Will continue to\n follow and monitor tube feed tolerance/stool output.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n current tube feeds: Nutren 2.0 @ 42 mL/hr + 35 g Beneprotein to provide\n 2140 kcal and 111 g protein.\n Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel daily, replete as needed.\n Other: Following #\n" }, { "category": "Physician ", "chartdate": "2186-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 623740, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n RLE Pasteurella fasciitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 15. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 0825 16. Meropenem 1000 mg IV Q12H Order\n date: @ 0850\n 3. Argatroban 0.1 mcg/kg/min IV DRIP INFUSION Order date: @ 0130\n 17. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 18. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 5. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043 19. Midazolam 0.5-2\n mg/hr IV DRIP TITRATE TO decreased agitation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0922\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 20.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO map>60 Order date:\n @ \n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631 21. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date: \n @ 1821 22. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 23. Prismasate (B22 K4)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 2500 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 0825\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 24. Rifaximin 400 mg PO/NG TID Order date: @\n 1434\n 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 25. 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: @ 1631\n 12. Hydrocortisone Na Succ. 50 mg IV Q6H Order date: @ 1112 26.\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 27. Sodium CITRATE 4% 1.5\n mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 14. Lactulose 30 mL PO/NG DAILY\n due to high ammonia levels Order date: @ 1112 28. Sodium\n Phosphate IV Sliding Scale Order date: @ 1525\n 24 Hour Events:\n Had been back on neo but now off again. Still cont . Vacs changed -\n fascia look good. Mental status improved. CVVH continued with citrate.\n HIT positive- argatroban gtt started.\n Post operative day:\n POD#8 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:23 AM\n Meropenem - 12:25 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Argatroban - 0.1 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:19 AM\n Fentanyl - 01:32 AM\n Other medications:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 35.7\nC (96.3\n HR: 76 (70 - 83) bpm\n BP: 121/42(62) {118/40(61) - 139/52(77)} mmHg\n RR: 6 (6 - 13) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 8 (7 - 15) mmHg\n Total In:\n 6,913 mL\n 884 mL\n PO:\n Tube feeding:\n 1,008 mL\n 221 mL\n IV Fluid:\n 5,380 mL\n 634 mL\n Blood products:\n 375 mL\n Total out:\n 6,696 mL\n 1,093 mL\n Urine:\n 441 mL\n 50 mL\n NG:\n Stool:\n Drains:\n 500 mL\n 500 mL\n Balance:\n 217 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,244 (842 - 1,244) mL\n PS : 5 cmH2O\n RR (Spontaneous): 6\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 11\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: 7.33/47/142/25/-1\n Ve: 7 L/min\n PaO2 / FiO2: 355\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n : (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: Rash: Maculopapular rash on back\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 21 K/uL\n 8.9 g/dL\n 181 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 47 mg/dL\n 107 mEq/L\n 140 mEq/L\n 26.3 %\n 6.0 K/uL\n [image002.jpg]\n 08:13 PM\n 11:51 PM\n 02:33 AM\n 02:51 AM\n 08:23 AM\n 01:01 PM\n 02:23 PM\n 08:57 PM\n 03:46 AM\n 04:06 AM\n WBC\n 9.8\n 8.0\n 9.5\n 6.0\n Hct\n 27.7\n 28.4\n 28.9\n 26.3\n Plt\n 39\n 26\n 29\n 21\n Creatinine\n 1.5\n 1.2\n TCO2\n 26\n 26\n 25\n 28\n 24\n 26\n Glucose\n 140\n 193\n 176\n 161\n 135\n 124\n 180\n 181\n Other labs: PT / PTT / INR:22.2/90.5/2.1, ALT / AST:28/63, Alk-Phos / T\n bili:77/22.5, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:95 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:3.3\n g/dL, LDH:154 IU/L, Ca:9.9 mg/dL, Mg:2.6 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n HEPARIN-INDUCED THROMBOCYTOPENIA, RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with HCV cirrhosis presenting with sepsis, RLE\n fascitis s/p I&D and debridement\n Neurologic: -- intubated and sedated with fent gtt & midazolam gtt for\n agitation\n -- arousable, moves all extremities, answers yes/no questions\n -- pain control: methadone po, fentanyl\n --if extubated, would recommend intermittent ketamine or precedex for\n drsg \n : --off neo overnight\n -- albumin prn (got , , , )\n Pulmonary: -- intubated CPAP 5/5. ?need for early trach for neuro\n process\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose dose to 1/day\n -- profuse stooling. Cdiff neg x 2. Likely secondary to lactulose.\n Guaiac positive.\n -- trend TBili\n -- ammonia level () = 80\n Nutrition: -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol.\n Renal: -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal running even. dialysate off today\n Hematology: -- HIT positive. Serotonin release assay pending.\n Agratroban gtt started. PTT check q6h with goal 80.\n -- serial Hct (goal > 28) - today 26.3\n -- chronic thrombocytopenia (goal Platelets >30): Plt\n 12->23->18->39->26>29\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- Citrate in CVVH filter rather than heparin, repleting Ca2+\n Endocrine: -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n --hydrocortisone continue 50 Q6h\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella). Sensitive to doxycycline.\n -- blood cultures pending, repeated yesterday\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff, flexiseal\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: Transplant, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:58 PM 42 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Argatroban (TM))\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 Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2186-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623753, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 20\ns, PTT\n Patient off all heparin\n Action:\n Argatroban started & repeat PTT checked\n Followed for signs bleeding\n Response:\n PTT 90 and Argat gtt decreased\n Plan:\n Goal ptt\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Slightly hypothermic, 96-97\n HR 70-80\ns NSR & MAP 60-70, CVP ~ 10\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Response:\n Stable\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623755, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 20\ns, PTT 60\n Patient off all heparin\n Action:\n Argatroban started & repeat PTT checked\n Followed for signs bleeding\n Response:\n PTT 90 and gtt decreased\n Plan:\n Cont to follow coags, goal PTT ~ 80\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Slightly hypothermic, 96-97\n HR 70-80\ns NSR & MAP 60-70, CVP ~ 10\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Intubated on cpap 5/5\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Fent/versed gtt continues\n Response:\n Stable\n Hypotension resolved\n Plan:\n Continue with current icu monitoring and treatment\n ? trial off cvvh\n Improving mental status, ? extubation soon\n" }, { "category": "Physician ", "chartdate": "2186-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 622656, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n sepsis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 16. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n KVO Order date: @ 0812 17. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 3. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846 18. Pantoprazole 40 mg IV Q24H\n Order date: @ \n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 19. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60\n Order date: @ 2252\n 5. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319 20. Potassium\n Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 21.\n Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631 22. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO comfort on\n vent Order date: @ 1631\n 8. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 23. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1846\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 24. Prismasate (B22 K4)\n Continuous at 2200 ml/hr\n Infuse Replacement fluid: Prefilter Rate: Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1646\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 25. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 11. Heparin 5000 UNIT SC BID Order date: @ 1631 26. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1631\n 12. Heparin CRRT IV Sliding Scale\n No Initial Bolus\n Initial Infusion Rate: 500 units/hr\n Part of CRRT Protocol Order date: @ 1646 27. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 28. Sodium CITRATE 4% 1.5\n mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 14. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631 29. Sodium\n Phosphate IV Sliding Scale Order date: @ 1525\n 15. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 24 Hour Events:\n EKG - At 10:00 AM\n BLOOD CULTURED - At 02:37 PM\n Post operative day:\n POD#3 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Clindamycin - 10:00 PM\n Vancomycin - 08:25 AM\n Ciprofloxacin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin Sodium - 300 units/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Propofol - 20 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n : Dilaudid 15mg PO PRN, Methadone 64', Lasix 120\", Aldactone 100',\n Rifaximin 200 QOD, Testosterone gel\n Flowsheet Data as of 04:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.9\nC (98.4\n HR: 82 (70 - 84) bpm\n BP: 110/40(59) {94/35(53) - 120/51(71)} mmHg\n RR: 21 (15 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 14 (14 - 22) mmHg\n Total In:\n 5,603 mL\n 754 mL\n PO:\n Tube feeding:\n 964 mL\n 169 mL\n IV Fluid:\n 4,459 mL\n 495 mL\n Blood products:\n Total out:\n 5,786 mL\n 1,341 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n 550 mL\n 500 mL\n Balance:\n -183 mL\n -587 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n Plateau: 24 cmH2O\n Compliance: 43.9 cmH2O/mL\n SPO2: 98%\n ABG: 7.30/38/119/19/-6\n Ve: 8.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : bil bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 4+), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: 4+), (Pulse - Dorsalis pedis: Present)\n Skin: RLE fasciotomies draining serous fluid\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n mEq/L\n mEq/L\n Am labs pending\n 06:50 PM\n 10:00 PM\n 10:09 PM\n 04:00 AM\n 04:17 AM\n 10:05 AM\n 04:42 PM\n 04:51 PM\n 10:00 PM\n 10:08 PM\n WBC\n 10.6\n 12.4\n 13.7\n 12.2\n Hct\n 30.3\n 30.6\n 31.1\n 31.1\n Plt\n 38\n 32\n 33\n 21\n Creatinine\n 3.1\n 2.6\n 2.4\n 2.6\n TCO2\n 20\n 20\n 20\n 20\n 19\n 19\n Glucose\n 84\n 129\n 128\n 112\n 107\n 97\n 110\n 109\n 118\n 120\n Other labs: PT / PTT / INR:23.0/60.8/2.2 (stable), ALT / AST:27/59,\n Alk-Phos / T bili:63/17.3, Lactic Acid:1.8 mmol/L, Albumin:4.0 g/dL,\n Ca:8.4 mg/dL, Mg:2.5 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic: -- intubated and sedated with propofol\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl gtt, fentanyl IV prn\n breakthrough pain\n Cardiovascular: -- phenylephrine gtt prn MAP < 60 (currently off)\n -- albumin prn (got )\n Pulmonary: -- intubated on CMV, ARDS protocol, wean PEEP\n -- cmv 20x500/0.5/12, 7.31/39/144/21/6\n Gastrointestinal / Abdomen: -- dobhoff in place\n -- TF to be changed to Nutren 2.0 w/ 35gm beneprotein. Goal 35cc/h on\n PPF, 42cc/h when off PPF.\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- GI prophy: pantoprazole\n Nutrition: -- Novasource Renal Full advance to goal 40/hr (25kcal/kg)\n d/c in am.\n -- TF to be changed to Nutren 2.0 w/ 35gm beneprotein. Goal 35cc/h on\n PPF, 42cc/h when off PPF.\n Renal: CVVH, -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even. -100 \n Hematology: -- serial Hct (goal > 28): Hct...\n -- chronic thrombocytopenia (goal Platelets >30): Plt 21. no bleeding,\n no transfusion @ this time.\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.1\n --will transfuse if bleeding or under goal\n --q6PTT for CVVH\n Endocrine: RISS\n Infectious Disease: -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph), GNR (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, (vanco d/cd )\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging: CXR today\n Fluids: LR@10cc/h, Albumin 25% prn hypotension\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic), Liver failure, Acute renal failure\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 11:58 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 622731, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n sepsis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 16. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n KVO Order date: @ 0812 17. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 3. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846 18. Pantoprazole 40 mg IV Q24H\n Order date: @ \n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 19. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60\n Order date: @ 2252\n 5. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319 20. Potassium\n Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 21.\n Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631 22. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO comfort on\n vent Order date: @ 1631\n 8. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 23. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1846\n 9. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 24. Prismasate (B22 K4)\n Continuous at 2200 ml/hr\n Infuse Replacement fluid: Prefilter Rate: Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1646\n 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 25. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 11. Heparin 5000 UNIT SC BID Order date: @ 1631 26. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1631\n 12. Heparin CRRT IV Sliding Scale\n No Initial Bolus\n Initial Infusion Rate: 500 units/hr\n Part of CRRT Protocol Order date: @ 1646 27. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 28. Sodium CITRATE 4% 1.5\n mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 14. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631 29. Sodium\n Phosphate IV Sliding Scale Order date: @ 1525\n 15. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 24 Hour Events:\n EKG - At 10:00 AM\n BLOOD CULTURED - At 02:37 PM\n Post operative day:\n POD#3 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Clindamycin - 10:00 PM\n Vancomycin - 08:25 AM\n Ciprofloxacin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin Sodium - 300 units/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Propofol - 20 mcg/Kg/min\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n : Dilaudid 15mg PO PRN, Methadone 64', Lasix 120\", Aldactone 100',\n Rifaximin 200 QOD, Testosterone gel\n Flowsheet Data as of 04:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.9\nC (98.4\n HR: 82 (70 - 84) bpm\n BP: 110/40(59) {94/35(53) - 120/51(71)} mmHg\n RR: 21 (15 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 14 (14 - 22) mmHg\n Total In:\n 5,603 mL\n 754 mL\n PO:\n Tube feeding:\n 964 mL\n 169 mL\n IV Fluid:\n 4,459 mL\n 495 mL\n Blood products:\n Total out:\n 5,786 mL\n 1,341 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n 550 mL\n 500 mL\n Balance:\n -183 mL\n -587 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 24 cmH2O\n Plateau: 24 cmH2O\n Compliance: 43.9 cmH2O/mL\n SPO2: 98%\n ABG: 7.30/38/119/19/-6\n Ve: 8.8 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : bil bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 4+), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: 4+), (Pulse - Dorsalis pedis: Present)\n Skin: RLE fasciotomies draining serous fluid\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n mEq/L\n mEq/L\n Am labs pending\n 06:50 PM\n 10:00 PM\n 10:09 PM\n 04:00 AM\n 04:17 AM\n 10:05 AM\n 04:42 PM\n 04:51 PM\n 10:00 PM\n 10:08 PM\n WBC\n 10.6\n 12.4\n 13.7\n 12.2\n Hct\n 30.3\n 30.6\n 31.1\n 31.1\n Plt\n 38\n 32\n 33\n 21\n Creatinine\n 3.1\n 2.6\n 2.4\n 2.6\n TCO2\n 20\n 20\n 20\n 20\n 19\n 19\n Glucose\n 84\n 129\n 128\n 112\n 107\n 97\n 110\n 109\n 118\n 120\n Other labs: PT / PTT / INR:23.0/60.8/2.2 (stable), ALT / AST:27/59,\n Alk-Phos / T bili:63/17.3, Lactic Acid:1.8 mmol/L, Albumin:4.0 g/dL,\n Ca:8.4 mg/dL, Mg:2.5 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic: -- intubated and sedated with propofol\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl gtt, fentanyl IV prn\n breakthrough pain\n Cardiovascular: -- phenylephrine gtt prn MAP < 60 (currently off)\n -- albumin prn (got )\n Pulmonary: -- intubated on CMV, ARDS protocol, wean PEEP\n -- cmv 20x500/0.5/12, 7.31/39/144/21/6\n Gastrointestinal / Abdomen: -- dobhoff in place\n -- TF to be changed to Nutren 2.0 w/ 35gm beneprotein. Goal 35cc/h on\n PPF, 42cc/h when off PPF.\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- GI prophy: pantoprazole\n Nutrition: -- Novasource Renal Full advance to goal 40/hr (25kcal/kg)\n d/c in am.\n -- TF to be changed to Nutren 2.0 w/ 35gm beneprotein. Goal 35cc/h on\n PPF, 42cc/h when off PPF.\n Renal: CVVH, -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even. -100 \n Hematology: -- serial Hct (goal > 28): Hct...\n -- chronic thrombocytopenia (goal Platelets >30): Plt 21. no bleeding,\n no transfusion @ this time.\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.1\n --will transfuse if bleeding\n --q6PTT for CVVH\n Endocrine: RISS\n Infectious Disease: -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph), GNR (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, (vanco d/cd )\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging: CXR today\n Fluids: LR@10cc/h, Albumin 25% prn hypotension\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic), Liver failure, Acute renal failure\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 11:58 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI Would D/C , given tolerating TF.\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2186-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623319, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\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: ICU\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 Cuff Management:\n Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2186-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 623898, "text": "TITLE:\n SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n fascitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 15. Lorazepam 2-4 mg IV Q4H:PRN agitation/anxiety Order date: @\n 1414\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 0825\n 16. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 3. Argatroban 0.05 mcg/kg/min IV DRIP INFUSION\n hold until further notice Order date: @ 0142\n 17. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 18. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 5. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043\n 19. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 20. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO map>60 Order\n date: @ \n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631\n 21. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date: \n @ 1821\n 22. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 23. Prismasate (B22 K4)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 2500 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 0825\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 24. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 25. 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: @ 1631\n 12. Hydrocortisone Na Succ. 50 mg IV Q8H Order date: @ 0941\n 26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 27. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 14. Lactulose 30 mL PO/NG DAILY\n due to high ammonia levels Order date: @ 1112\n 28. Sodium Phosphate IV Sliding Scale Order date: @ 1525\n 24 Hour Events:\n PAN CULTURE - At 12:40 AM\n - back on neo. titrated off midaz, on ativan prn. HD line rewired.\n - argatroban gtt stopped for decrease in Hct and elevated PTT and\n melanatoic stool. Transfused 2u PRBC.\n Post operative day:\n POD#9 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 12:37 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 03:11 PM\n Lorazepam (Ativan) - 02:46 AM\n Other medications:\n Flowsheet Data as of 05:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.8\nC (98.2\n HR: 111 (77 - 118) bpm\n BP: 97/42(59) {97/36(53) - 140/55(77)} mmHg\n RR: 16 (7 - 21) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 12 (5 - 13) mmHg\n Total In:\n 3,378 mL\n 1,162 mL\n PO:\n Tube feeding:\n 1,008 mL\n 214 mL\n IV Fluid:\n 2,249 mL\n 328 mL\n Blood products:\n 560 mL\n Total out:\n 4,166 mL\n 795 mL\n Urine:\n 318 mL\n 65 mL\n NG:\n Stool:\n 400 mL\n Drains:\n 1,000 mL\n Balance:\n -788 mL\n 367 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (720 - 1,077) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.35/44/129/24/-1\n Ve: 11.2 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n : (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 7.8 g/dL\n 250 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 5.2 mEq/L\n 61 mg/dL\n 108 mEq/L\n 139 mEq/L\n 23.2 %\n 14.5 K/uL\n [image002.jpg]\n 02:23 PM\n 08:57 PM\n 03:46 AM\n 04:06 AM\n 09:45 AM\n 10:08 AM\n 03:44 PM\n 03:58 PM\n 10:53 PM\n 11:03 PM\n WBC\n 6.0\n 14.5\n Hct\n 26.3\n 23.2\n Plt\n 21\n 48\n Creatinine\n 0.8\n 1.2\n 1.4\n TCO2\n 28\n 24\n 26\n 26\n 29\n 25\n Glucose\n 124\n 180\n 181\n \n Other labs: PT / PTT / INR:35.5/98.4/3.6, ALT / AST:28/63, Alk-Phos / T\n bili:77/22.5, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:95 mg/dL, Lactic Acid:3.0 mmol/L, Albumin:3.3\n g/dL, LDH:154 IU/L, Ca:8.9 mg/dL, Mg:2.5 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HEPARIN-INDUCED THROMBOCYTOPENIA, RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic:\n -- intubated and sedated with fent gtt & ativan prn (titrated off of\n midazolam gtt)\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n -- if extubated, would recommend intermittent ketamine or precedex for\n drsg \n :\n -- placed back on neo\n -- albumin prn (got , , , )\n Pulmonary:\n -- intubated CPAP 5/5. ?need for early trach for neuro process\n Gastrointestinal / Abdomen:\n -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 2. Likely secondary to lactulose.\n Guaiac positive +++.\n -- trend TBili\n -- ammonia level () = 80\n Nutrition:\n -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off propofol.\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal running even. dialysate off.\n Hematology:\n -- HIT positive. Serotonin release assay need medical path director\n approval before being processed.\n -- Agratroban gtt started and stopped . PTT check q6h with\n goal 80.\n -- serial Hct (goal > 28) - Hct 23.2 -> 2u PRBCs ()\n -- chronic thrombocytopenia (goal Platelets >30): Plt 48\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- transfuse if bleeding\n -- Citrate in CVVH filter, repleting Ca2+\n Endocrine:\n -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n -- tapered hydrocortisone 50 Q6h -> q8h ()\n ID:\n -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant) and\n pasturella\n -- blood cultures pending (all others negative up to date)\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n -- erythromycin ointment b/l eyes (started )\n -- WBC trending up 14.5. Pancultured . Afebrile.\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff, flexiseal\n Wounds:\n --RLE fasciotomies, saph vein exposed. white gauze covering, vac over @\n 75, lower vac @ 125.\n --diffuse maculopapular rash in axillae, over abdomen, along flanks\n (worse in dependent areas)\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: West 1, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boot x 1\n Stress ulcer: n/a\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2186-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623849, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 21 this am, PTT 90-100\n Argatroban infusing. Could not decrease dose below 0.5cc/hr\n due to pump limitations. Discussed thoroughly with PharmD and\n Transplant team.\n Action:\n PTT checked q 6 hours\n Argatroban infusing at 0.085mcg/kg/min (0.5cc/hr) for entire\n shift until above issue resolved with concentration of med. Team\n aware.\n Followed for signs bleeding\n Response:\n Argatroban placed in 60cc syringe (50mg in 50cc) to be\n infused at 0.05mcg/kg/min or (0.3cc/hr).\n Plan:\n Cont to follow coags, goal PTT ~ 60-80\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Hyperthermic today (~99.0-99.1)\n HR 70-80\ns NSR & MAP ~60, CVP ~ 10\n Restarted neosynephrine for MAP >= 60\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Intubated on cpap 5/5\n Left IJ dialysis catheter\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Fent/versed gtt continues\n Response:\n Stable\n Hypotension resolved\n Plan:\n Continue with current icu monitoring and treatment\n ? trial off cvvh\n Improving mental status, ? extubation soon\n" }, { "category": "Respiratory ", "chartdate": "2186-02-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623893, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n :\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Cannot protect\n airway, 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" }, { "category": "Nutrition", "chartdate": "2186-02-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 623238, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 98.8 kg\n 99.8 kg ( 04:00 AM)\n 29.5\n Pertinent medications: calcium gluconate, heparin, ABX,\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 04:39 PM\n Glucose Finger Stick\n 137\n 10:00 AM\n BUN\n 33 mg/dL\n 10:00 AM\n Creatinine\n 1.5 mg/dL\n 10:00 AM\n Sodium\n 134 mEq/L\n 10:00 AM\n Potassium\n 3.9 mEq/L\n 04:39 PM\n Chloride\n 101 mEq/L\n 10:00 AM\n TCO2\n 24 mEq/L\n 10:00 AM\n PO2 (arterial)\n 112 mm Hg\n 04:39 PM\n PCO2 (arterial)\n 42 mm Hg\n 04:39 PM\n pH (arterial)\n 7.36 units\n 04:39 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 04:39 PM\n Albumin\n 3.6 g/dL\n 05:45 PM\n Calcium non-ionized\n 9.1 mg/dL\n 12:13 PM\n Phosphorus\n 3.8 mg/dL\n 10:00 AM\n Ionized Calcium\n 0.96 mmol/L\n 04:39 PM\n Magnesium\n 2.3 mg/dL\n 10:00 AM\n ALT\n 26 IU/L\n 02:44 AM\n Alkaline Phosphate\n 70 IU/L\n 02:44 AM\n AST\n 85 IU/L\n 02:44 AM\n Total Bilirubin\n 23.9 mg/dL\n 02:44 AM\n WBC\n 8.9 K/uL\n 02:44 AM\n Hgb\n 10.1 g/dL\n 02:44 AM\n Hematocrit\n 29.0 %\n 10:00 AM\n Current diet order / nutrition support: NPO; Nutren 2.0 @ 42mL/hr + 35\n g Beneprotein x 24hr\n GI: Abd soft/distended, present bowel sounds\n Specifics: 43 y.o. M with HCV cirrhosis presenting with sepsis, RLE\n fasciitis, abd pain, GNR bacteremia, now s/p I&D and debridement of\n RLE. Patient remains intubated on CVVH and continues to receive\n nutrition support via NGT feeds. Propofol off and tube feed rate\n increased to 42mL/hr which RN reports pt is tolerating. Patient with\n stool output 1150 mL x 16 hr today however, noted pt previously\n receiving lactulose which was discontinued today. C. diff negative x1.\n Will continue to follow and monitor tube feed tolerance/stool output.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n current tube feed: Nutren 2.0 @ 42 mL/hr + 35 g Beneprotein to provide\n 2140 kcal and 111 g protein.\n Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel daily, replete as needed.\n Other: Following #\n" }, { "category": "Physician ", "chartdate": "2186-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 623312, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n .\n Chief complaint:\n Multiorgan failure\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. 2. 20 gm Calcium Gluconate/ 500 mL D5W 3. Calcium Gluconate 4.\n Calcium Gluconate 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n 6. Citrate Dextrose 3% (ACD-A) CRRT 7. Cosyntropin 8. Dextrose 50% 9.\n Dextrose 50% 10. Erythromycin 0.5% Ophth Oint\n 11. Fentanyl Citrate 12. Fentanyl Citrate 13. Fentanyl Citrate 14.\n Glucagon 15. Heparin 16. Insulin\n 17. Lactulose 18. Magnesium Sulfate 19. Meropenem 20. Methadone 21.\n Midazolam 22. Miconazole Powder 2%\n 23. Midazolam 24. Phenylephrine 25. Potassium Chloride 10 mEq / 100 mL\n SW (CRRT Only) 26. Potassium Chloride\n 27. Prismasate (B32 K2)* 28. Prismasate (B22 K4) 29. Rifaximin 30.\n Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush\n 32. Sodium CITRATE 4% 33. Sodium Phosphate\n 24 Hour Events:\n - Albumin IV x 1. ID recs: d/c cipro, cont meropenem. off pressor,\n cortisol stim test\n Post operative day:\n POD#6 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:23 AM\n Meropenem - 12:03 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Midazolam (Versed) - 1 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Fentanyl - 10:15 AM\n Midazolam (Versed) - 10:02 PM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Flowsheet Data as of 03:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.2\nC (97.1\n HR: 93 (83 - 93) bpm\n BP: 103/35(54) {102/34(52) - 154/79(99)} mmHg\n RR: 14 (11 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 6 (5 - 13) mmHg\n Total In:\n 8,930 mL\n 1,451 mL\n PO:\n Tube feeding:\n 1,008 mL\n 151 mL\n IV Fluid:\n 7,521 mL\n 1,209 mL\n Blood products:\n 250 mL\n Total out:\n 10,031 mL\n 703 mL\n Urine:\n 216 mL\n 30 mL\n NG:\n Stool:\n Drains:\n 1,325 mL\n Balance:\n -1,101 mL\n 748 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): 600 (518 - 684) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 7 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 97%\n ABG: 7.37/40/150/23/-1\n Ve: 11.1 L/min\n PaO2 / FiO2: 375\n Physical Examination\n General Appearance: intubated sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Noxious stimuli),\n Moves all extremities\n Labs / Radiology\n 22 K/uL\n 10.1 g/dL\n 123 mg/dL\n 1.5 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 8.9 K/uL\n [image002.jpg]\n 04:57 AM\n 06:24 AM\n 06:35 AM\n 10:00 AM\n 10:26 AM\n 12:33 PM\n 04:30 PM\n 04:39 PM\n 08:34 PM\n 12:16 AM\n Hct\n 29.0\n Creatinine\n 1.8\n 1.5\n 1.5\n TCO2\n 24\n 25\n 23\n 22\n 25\n 23\n 24\n Glucose\n 130\n 122\n 148\n 139\n 123\n 128\n 123\n Other labs: PT / PTT / INR:24.6/74.4/2.4, ALT / AST:26/85, Alk-Phos / T\n bili:70/23.9, Lactic Acid:1.7 mmol/L, Albumin:3.6 g/dL, Ca:9.1 mg/dL,\n Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph\n Neurologic: -- intubated and sedated with midazolam prn\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n Cardiovascular: -- off pressor, HD stable\n -- albumin prn (got , , , )\n -- lactate 1.9\n -- stim test 9-->13--> 13.8\n Pulmonary: -- intubated on CMV, ARDS protocol, weaned PEEP to 5. ?need\n for early trach\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- Profuse stooling. Cdiff neg x 1. Likely secondary to lactulose\n -- rising TBili\n -- ammonia level () = 80\n Nutrition: TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol.\n Renal: -- Q4h calcium checks for Citrate toxicity\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg.\n Hematology: -- serial Hct (goal > 28)\n -- chronic thrombocytopenia (goal Platelets >30): Plt 18, trend\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n -- Citrate in CVVH filter rather than heparin\n Endocrine: RISS\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- Wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella). Sensitive to doxycycline.\n -- blood cultures pending\n -- ABX: (consider switching to doxy)\n -- cipro d/c'ed \n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Transplant, ID dept, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, Liver\n failure\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:16 AM 42 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2186-02-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623542, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Intolerant of\n weaning attempts\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": "2186-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 624038, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: 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 Comments: remain on minimal PSV.\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 Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~20.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Ct scan belly/pelvis\n ~0100\n none\n" }, { "category": "Nursing", "chartdate": "2186-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624039, "text": "Hepatic failure\n Assessment:\n HR 100-110 sinus tach, MAP 55-65 on neo gtt, cvp ~ ,\n lactate 4, wbc 22\n HCT 20-23, INR 3, plt count 70\n LFTs all extremely elevated\n Dark brown melana from fecal bag, ngt lavage with mod brown\n output (no obvious bleeding)\n Vac dressings in place with mod brown serous output\n Patient occasionally opens eyes, otherwise unresponsive\n (does not move extremities of withdraw to pain)\n Patient remains on cpap 5/5, lung sounds clear\n Action:\n Multiple blood products given, see flowsheet\n Frequent labs sent\n Abdom & pelvic ct scan done\n Response:\n Patient remains coagulopathic\n Transplant resident, dr. , in contact with patient\n mother overnight & discussed patients condition\n Plan:\n Family meeting, ? address code status\n" }, { "category": "Respiratory ", "chartdate": "2186-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622865, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ICU\n Reason: Emergent (1st time); Comments: Worsening oxygenation and\n inability to lie flat, for line placement.\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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved; Comments:\n Received vented on CMV mode, triggering slightly over the vent. Likely\n plan is to do AM RSBI. ICU team will then reassess whether or not\n patient is stable enough to begin vent weaning.\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": "2186-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622818, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt received on AC as noted. PEEP weaned slowly throughout\n shift from 12cm to 8cm. Pt tolerating well. ABG's are\n 7.33/36/145/20/-6.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Plan to continue on current settings at this time and\n wean settings as tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2186-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623226, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\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:\n Procedure location:\n Reason:\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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / 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 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:\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 remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear, diminished at the bases , suctioned intermittently\n for small to moderate amounts of thick tan secretions, switched from AC\n to PSV, so far vent change has been well tolerated, SPO2 remained upper\n 90s, no distress occurred, will continues to be followed.\n" }, { "category": "Social Work", "chartdate": "2186-02-03 00:00:00.000", "description": "Social Work Progress Note", "row_id": 623664, "text": "Social Work Progress Note, Transplant Service:\n Clinical data: Met with pt\ns mother, , and girlfriend,\n , at their request to provide emotional support around coping\n with pt\ns recent critical medical issues. Pt is currently intubated,\n sedated and on pressors. Pt\ns mother recounted events leading up to\n pt\ns hospitalization, including strong advisement by multiple family\n members and pt\ns gf to pt to seek medical attention, advice that he\n ignored. Pt\ns mother described pt as stubborn, wanting to remain has\n active and functional as possible. Pt\ns gf expressed frustration with\n herself around not making the pt seek medical attention earlier; SW and\n pt\ns mother provided emotional support around pt\ns responsibility for\n seeking medical attention. Pt\ns mother and gf asked various questions\n re:transplant process, including what can be expected for recovery.\n Pt\ns mother noted that she and pt\ns three sisters remain hopeful for\n pt\ns recovery, but stated that they understand the severity of pt\n condition and potential for not surviving. SW encouraged pt\ns mother\n and gf to attend to selfcare needs as a way for sustaining themselves\n during this challenging time. Pt\ns mother inquired about lodging\n options and assistance with parking fees. SW provided a list of area\n hotels and inns and also provided parking stickers. Pt\ns mother and gf\n to meet with Dr later this afternoon.\n Clinical assessment/plan: Pt\ns mother appears to be coping remarkably\n well and seems to have excellent mutual support from pt\ns 3 sisters and\n gf. They seem very well informed and have realistic expectations\n ongoing critical health issues. They will benefit from ongoing\n emotional support. Pt\ns mother and gf made aware of oncall SW support\n available over the weekend. SW will f/u with pt\ns family on Monday.\n \n Transplant Social Worker\n #\n" }, { "category": "Respiratory ", "chartdate": "2186-02-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623974, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\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:\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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Tracheostomy planned\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 13:30\n" }, { "category": "Respiratory ", "chartdate": "2186-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 624141, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n 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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\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:\n Patient made DNR/DNI removed from mechanical ventilation as previously\n discussed by clinical team and family.\n" }, { "category": "Respiratory ", "chartdate": "2186-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622868, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ICU\n Reason: Emergent (1st time); Comments: Worsening oxygenation and\n inability to lie flat, for line placement.\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved; Comments:\n Received vented on CMV mode, triggering slightly over the vent. Likely\n plan is to do AM RSBI. ICU team will then reassess whether or not\n patient is stable enough to begin vent weaning.\n" }, { "category": "Physician ", "chartdate": "2186-01-31 00:00:00.000", "description": "Intensivist Note", "row_id": 622948, "text": "TITLE:\n SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n sepsis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846\n 19. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 3. Alteplase 1mg/Flush Volume ( Dialysis/Pheresis Catheters ) 1\n mg IV ONCE MR1 Duration: 1 Doses\n Alteplase 1mg/ 1.2 mL (Dialysis/Pheresis Catheters Order date: @\n 1821\n 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Alteplase 1mg/Flush Volume ( Dialysis/Pheresis Catheters ) 1\n mg IV ONCE MR1 Duration: 1 Doses\n Alteplase 1mg/ 1.3 mL (Dialysis/Pheresis Catheters Order date: @\n 1821\n 21. Midazolam 0.5-2 mg IV Q2H:PRN anxiety Order date: @ 1105\n 5. Albumin 25% (12.5g / 50mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 0459\n 22. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1821\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 23. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 7. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order\n date: @ 2252\n 8. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 25. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631\n 26. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 10. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date:\n @ 1821\n 27. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 11. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 28. Prismasate (B32 K2)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate:2500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 2335\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 29. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 30. 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: @ 1631\n 14. Heparin 5000 UNIT SC BID Order date: @ 1631\n 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Heparin CRRT IV Sliding Scale\n No Initial Bolus\n Initial Infusion Rate: 500 units/hr\n Part of CRRT Protocol Order date: @ 2133\n 32. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 33. Sodium Phosphate IV Sliding Scale Order date: @ 1525\n 17. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 24 Hour Events:\n EKG - At 03:40 AM\n - d/c'ed GI prophy, changed sedation to versed, 25g albumin IV\n bolus x 1\n - 25g albumin IV bolus x1. Alteplase to HD line and filter for\n CVVH machine clotting frequently.\n Post operative day:\n POD#4 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Clindamycin - 10:00 PM\n Vancomycin - 08:25 AM\n Ciprofloxacin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 150 units/hour\n Other ICU medications:\n Midazolam (Versed) - 07:50 PM\n Other medications:\n Flowsheet Data as of 05:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.3\n HR: 77 (68 - 87) bpm\n BP: 111/41(61) {99/37(52) - 159/82(101)} mmHg\n RR: 17 (17 - 37) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 11 (11 - 17) mmHg\n Total In:\n 4,308 mL\n 1,002 mL\n PO:\n Tube feeding:\n 925 mL\n 210 mL\n IV Fluid:\n 3,063 mL\n 791 mL\n Blood products:\n 50 mL\n Total out:\n 5,737 mL\n 1,211 mL\n Urine:\n 142 mL\n 39 mL\n NG:\n Stool:\n Drains:\n 1,475 mL\n 500 mL\n Balance:\n -1,429 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 49.5 cmH2O/mL\n SPO2: 97%\n ABG: 7.40/40/119/23/0\n Ve: 11 L/min\n PaO2 / FiO2: 298\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, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), vac dressings in place RLE\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 18 K/uL\n 9.9 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 31 mg/dL\n 103 mEq/L\n 134 mEq/L\n 29.3 %\n 9.6 K/uL\n [image002.jpg]\n 10:08 PM\n 04:00 AM\n 04:17 AM\n 10:03 AM\n 10:20 AM\n 02:00 PM\n 03:39 PM\n 10:00 PM\n 03:08 AM\n 03:24 AM\n WBC\n 12.2\n 11.2\n 9.6\n Hct\n 31.1\n 29.5\n 29.3\n Plt\n 21\n 22\n 18\n Creatinine\n 2.6\n 2.4\n 2.8\n 1.8\n TCO2\n 21\n 22\n 20\n 23\n 26\n Glucose\n 120\n 114\n 123\n 136\n 100\n 98\n Other labs: PT / PTT / INR:24.6/79.8/2.4, ALT / AST:28/78, Alk-Phos / T\n bili:67/20.8, Lactic Acid:1.7 mmol/L, Albumin:4.0 g/dL, Ca:8.3 mg/dL,\n Mg:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic:\n -- intubated and sedated with midazolam because of hypotension.\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60\n -- albumin prn (got , , )\n -- lactate 1.7\n Pulmonary:\n -- intubated on CMV, ARDS protocol, wean PEEP. Now down to 40 % %\n PEEP\n -- cmv 20x500/0.4/8, 7.40/40/119/26/0\n Gastrointestinal / Abdomen:\n -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. F/u Cdiff\n Nutrition:\n -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off propofol.\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg.\n -- consider replacing HD access line with longer cath.\n Hematology:\n -- serial Hct (goal > 28): Hct 29.3\n -- chronic thrombocytopenia (goal Platelets >30): Plt 18. no bleeding,\n no transfusion @ this time.\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.4\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, (vanco d/cd )\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: n/a\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Physician ", "chartdate": "2186-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 623385, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n .\n Chief complaint:\n Multiorgan failure\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. 2. 20 gm Calcium Gluconate/ 500 mL D5W 3. Calcium Gluconate 4.\n Calcium Gluconate 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n 6. Citrate Dextrose 3% (ACD-A) CRRT 7. Cosyntropin 8. Dextrose 50% 9.\n Dextrose 50% 10. Erythromycin 0.5% Ophth Oint\n 11. Fentanyl Citrate 12. Fentanyl Citrate 13. Fentanyl Citrate 14.\n Glucagon 15. Heparin 16. Insulin\n 17. Lactulose 18. Magnesium Sulfate 19. Meropenem 20. Methadone 21.\n Midazolam 22. Miconazole Powder 2%\n 23. Midazolam 24. Phenylephrine 25. Potassium Chloride 10 mEq / 100 mL\n SW (CRRT Only) 26. Potassium Chloride\n 27. Prismasate (B32 K2)* 28. Prismasate (B22 K4) 29. Rifaximin 30.\n Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush\n 32. Sodium CITRATE 4% 33. Sodium Phosphate\n 24 Hour Events:\n - Albumin IV x 1. ID recs: d/c cipro, cont meropenem. off pressor,\n cortisol stim test\n Post operative day:\n POD#6 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:23 AM\n Meropenem - 12:03 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Midazolam (Versed) - 1 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Fentanyl - 10:15 AM\n Midazolam (Versed) - 10:02 PM\n Heparin Sodium (Prophylaxis) - 10:11 PM\n Other medications:\n Flowsheet Data as of 03:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.2\nC (97.1\n HR: 93 (83 - 93) bpm\n BP: 103/35(54) {102/34(52) - 154/79(99)} mmHg\n RR: 14 (11 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 6 (5 - 13) mmHg\n Total In:\n 8,930 mL\n 1,451 mL\n PO:\n Tube feeding:\n 1,008 mL\n 151 mL\n IV Fluid:\n 7,521 mL\n 1,209 mL\n Blood products:\n 250 mL\n Total out:\n 10,031 mL\n 703 mL\n Urine:\n 216 mL\n 30 mL\n NG:\n Stool:\n Drains:\n 1,325 mL\n Balance:\n -1,101 mL\n 748 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): 600 (518 - 684) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 7 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 97%\n ABG: 7.37/40/150/23/-1\n Ve: 11.1 L/min\n PaO2 / FiO2: 375\n Physical Examination\n General Appearance: intubated sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Noxious stimuli),\n Moves all extremities\n Labs / Radiology\n 22 K/uL\n 10.1 g/dL\n 123 mg/dL\n 1.5 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 8.9 K/uL\n [image002.jpg]\n 04:57 AM\n 06:24 AM\n 06:35 AM\n 10:00 AM\n 10:26 AM\n 12:33 PM\n 04:30 PM\n 04:39 PM\n 08:34 PM\n 12:16 AM\n Hct\n 29.0\n Creatinine\n 1.8\n 1.5\n 1.5\n TCO2\n 24\n 25\n 23\n 22\n 25\n 23\n 24\n Glucose\n 130\n 122\n 148\n 139\n 123\n 128\n 123\n Other labs: PT / PTT / INR:24.6/74.4/2.4, ALT / AST:26/85, Alk-Phos / T\n bili:70/23.9, Lactic Acid:1.7 mmol/L, Albumin:3.6 g/dL, Ca:9.1 mg/dL,\n Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph\n Neurologic: -- intubated and sedated with midazolam gtt. Will change\n to Ativan prn.\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl Pain to se.\n Cardiovascular: -- off pressor, HD stable\n -- albumin prn (got , , , )\n -- lactate 1.9\n -- stim test 9-->13--> 13.8\n Pulmonary: -- intubated on CMV, ARDS protocol, weaned PEEP to 5. ?need\n for trach if unable to control sedation.\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- Profuse stooling. Cdiff neg x 1. Likely secondary to lactulose\n -- rising TBili\n -- ammonia level () = 80\n Nutrition: TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol.\n Renal: -- Q4h calcium checks for Citrate toxicity\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O negative.\n Hematology: -- serial Hct (goal > 28)\n -- chronic thrombocytopenia (goal Platelets >30): Plt 12- give plts.\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n -- Citrate in CVVH filter rather than heparin\n Endocrine: RISS\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- Wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella). Sensitive to doxycycline.\n -- blood cultures pending\n -- ABX: (consider switching to doxy)\n -- cipro d/c'ed \n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery, Transplant, ID dept, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, Liver\n failure\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:16 AM 42 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 624029, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n septic \n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5\n Current medications:\n Dilaudid 15mg PO PRN, Methadone 64', Lasix 120\", Aldactone 100',\n Rifaximin 200 QOD, Testosterone gel\n .\n 24 Hour Events:\n - argatroban gtt stopped for decrease in Hct and elevated PTT and\n melanatoic stool. Transfused 4u PRBC.2FFP and 1cryopreceptate.\n Worsening LFT and cougulation. Ct scan head no acute change, US Liver\n no evidence of thrombosis\n Post operative day:\n POD#10 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 11:47 AM\n Vancomycin - 09:50 PM\n Fluconazole - 03:00 AM\n Infusions:\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 09:15 PM\n Other medications:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.4\n HR: 107 (81 - 111) bpm\n BP: 103/43(62) {79/23(45) - 125/52(69)} mmHg\n RR: 14 (12 - 21) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 98.5 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 11 (5 - 15) mmHg\n Total In:\n 5,254 mL\n 1,574 mL\n PO:\n Tube feeding:\n 578 mL\n IV Fluid:\n 1,592 mL\n 348 mL\n Blood products:\n 2,515 mL\n 777 mL\n Total out:\n 4,355 mL\n 1,100 mL\n Urine:\n 95 mL\n NG:\n 600 mL\n Stool:\n Drains:\n 850 mL\n Balance:\n 899 mL\n 474 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 774 (194 - 774) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 20\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.40/40/86/21/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress, intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), sinus tachycardia\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 48 K/uL\n 8.3 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 5.2 mEq/L\n 48 mg/dL\n 105 mEq/L\n 136 mEq/L\n 23.8 %\n 19.7 K/uL\n [image002.jpg]\n 10:01 AM\n 10:14 AM\n 03:20 PM\n 03:40 PM\n 05:07 PM\n 09:17 PM\n 09:35 PM\n 10:30 PM\n 02:05 AM\n 02:22 AM\n WBC\n 22.9\n 22.8\n 22.4\n 19.7\n Hct\n 24.9\n 23.1\n 23.8\n 20.7\n 23.8\n Plt\n 74\n 75\n 48\n Creatinine\n 2.0\n 2.2\n 2.1\n TCO2\n 22\n 25\n 24\n 26\n Glucose\n 11\n 116\n 108\n Other labs: PT / PTT / INR:33.7/70.1/3.4, CK / CK-MB / Troponin T:41//,\n ALT / AST:3124/8687, Alk-Phos / T bili:317/15.3, Amylase /\n Lipase:184/287, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:85 mg/dL, Lactic Acid:4.0 mmol/L, Albumin:3.3\n g/dL, LDH:154 IU/L, Ca:11.0 mg/dL, Mg:2.7 mg/dL, PO4:10.3 mg/dL\n Assessment and Plan\n HEPARIN-INDUCED THROMBOCYTOPENIA, RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph\n Neurologic: Neuro checks Q: 1 hr, -- intubated and sedated with fent\n gtt & midazolam prn (titrated off of midazolam gtt)\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n -- if extubated, would recommend intermittent ketamine or precedex for\n drsg \n --Ctscan Head no acute change f/up final read\n Cardiovascular: -- currently on neo\n -- albumin prn (got , , , )\n -- lactate trending up to 3.1\n Pulmonary: -- intubated CEPAP . ?need for early trach for neuro\n process\n Gastrointestinal / Abdomen: -- dobhoff in place, TF On hold for now\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 2. Likely secondary to lactulose.\n Guaiac positive +++.\n -- starting PPI\n -- elevated LFTs: ALT 3124 AST 8687 , TBili 15.3 Consistent w/ liver\n failure\n -- f/u PM LFTs\n -- CK level 41\n -- f/u liver u/s-doppler final read, no evidence of portal/hepatic v\n thrombosis\n -- ammonia level () = 80\n Nutrition: -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol. On hold for now\n Renal: -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal running even. dialysate off.\n Hematology: -- HIT positive. Serotonin release assay need medical path\n director approval before being processed.\n --Hematology less likely HIT positive in the setting of Coagulopathy\n and ? DIC, It is ok to resume heparin if need be\n -- Agratroban gtt started and stopped due to decreased Hct\n and dark/melanotic stools.\n -- serial Hct (goal > 28) - Hct 23.2 -> 2u PRBCs () ->\n 28->23(2UPRBC,\n -- chronic thrombocytopenia (goal Platelets >30): Plt 81\n -- coagulopathic secondary to liver disease (goal INR < 2): INR\n 4.1->7.6 (2FFP), 1unit cryoprecepetate \n -- transfuse if bleeding\n -- Citrate in CVVH filter, repleting Ca2+\n --Monitor for DIC\n Endocrine: -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n -- tapered hydrocortisone 50 q8h\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant) and\n pasturella\n -- blood cultures pending (all others negative up to date)\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n -- erythromycin ointment b/l eyes (started )\n -- WBC trending up 22. Pancultured . Afebrile.\n --Vancomycin and Fluc added to meropenam\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff, flexiseal, NGT\n Wounds: --RLE fasciotomies, saph vein exposed. white gauze covering,\n vac over @ 75, lower vac @ 125.\n --diffuse maculopapular rash in axillae, over abdomen, along flanks\n (worse in dependent areas)\n Imaging:\n Fluids: KVO\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n 20 Gauge - 01:07 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2186-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 624136, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\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: Normal quiet breathing;\n Comments: Patient made DNR/DNI switched from PSV to CMV\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: Made CMO by family.\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Comfort measures only; Comments: awaiting for other\n family members to arrive before removing mechanical support.\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 Patient is made DNI/DNR by family,but awaiting for other family\n members to arrive before withdrawing mechanical support. Now on\n pressors,switched from PSV to A/C with acceptable ABG. BS clear,patient\n without secretion.FFP, RBC.Normal saline boluses provided,not candidate\n for liver transplant.\n" }, { "category": "Nursing", "chartdate": "2186-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622930, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - sedated on Fentanyl and versed gtt\n - wakes with stimulation but does not follow commands\n - hr stable\n - afebrile\n - maps 58-62\n - lungs clear but diminished @ bases r > l\n - min amt icteric urine\n - crrt running -50cc/hr to even as tolerated\n - elevated return pressure\n - elevated filter pressure with increasing clots\n - filter clotted @ 0340\n - ptt therapeutic\n - wound vac to thigh and calf with thigh areas to vac @ 75 and\n calf area to vac @ 125\n - lg amt liquid stool output via fecal bag\n Action:\n - albumin 25% x 2\n - return port tpa and able to dwell x 2 hrs\n - Crrt resumed\n - Cdiff spec sent\n - Peep weaned to 5\n Response:\n - pts 18 this am\n team aware\n - ptt over therapeutic\n heparin gtt decreased\n - inr > 2- team aware\n - no s/sx bleeding\n - tbili up\n - wbc down\n - resp status stable\n - cont to monitor liver function, lytes, i/o.\n" }, { "category": "Nursing", "chartdate": "2186-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623535, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n BP decreasing at the beginning of the shift, systolic in low 90\ns with\n MAPS decreasing to 50\ns, witnessed by Dr. . CVP 6-8. Temp\n rising to 99.7 on bair hugger with CRRT running. Goal of CRRT was 50cc\n negative/hr at that time. Lungs clear on CPAP 5PS and 5 Peep. Pt\n becoming increasingly agitated, sitting upright in bed and trying to\n pull at ET tube, biting down on tube, low dose Versed and Fentanyl gtts\n at that time requiring many boluses. Not following commands, but\n opening eyes to voice and minimal stimulation, wincing in pain with any\n intervention. MAE. Pt found to have rashy areas on arms, abdomen and\n parts of back, ? petechia vs. rash, shown to Dr. and Dr. .\n UOP increasing throughout the night, averaging 20-30cc/hr of amber\n urine. HCT decreased to 25 and platelets 18 at .\n Action:\n Team notified of decreasing BP and Neo resumed for a MAP >60. Albumin\n 12g, Hydrocortisone 100mg, 1unit of PRBCs and 1 bag of Platelets given.\n Decision made to keep pt\ns fluid balance\neven\n as new goal for CRRT\n (per Dr. . Bair hugger temporarily stopped and pt pan\n cultured. Pt responding to boluses and slight increase in Fentanyl and\n Versed gtts, Fentanyl dose increased first per Dr. . HIT panel sent\n and pending.\n Response:\n Pt responding well to all BP interventions, Neo weaned down to .5mcgs\n this am. Continues to tolerate CRRT with even fluid balance. Breathing\n comfortably on current vent settings, however slight rise in PCO2 due\n to sedation? Versed decreased and resp rate increasing, will recheck\n ABG this am.\n Plan:\n Continue to monitor labs closely per CRRT protocol. Fluid balance to\n remain even until BP can tolerate removal of fluid. Wean Neo if\n possible and continue current vent setting with repeat ABGs.\n" }, { "category": "Nursing", "chartdate": "2186-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624130, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt on triple pressors, max dosage ordered.\n FFP, RBCs as ordered this am.\n NS boluses as ordered.\n Lactate 7.0\n HCT 22.4\n AST \n ALT 3813\n Alk Phos 404.\n Action:\n Family mtg with Dr. from Transplant Service @ bedside with 2\n sisters and Mother.\n prognosis given.\n Emotional support to family.\n Transplant SW @ bedside.\n Response:\n Family wishes to maintain pt on pressors until rest of family arrives.\n DNR/DNI.\n Plan:\n CMO and extubate when family ready to withdraw care.\n" }, { "category": "Nursing", "chartdate": "2186-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623357, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Arouses to voice, not following commands. Agitated with\n movement/turning. PERRL. Sclera in left eye very red.\n Remains on CPAP 5/5.\n Fentanyl gtt for pain\n MAP 52-56\n Abd softly distended. Tube feeds at goal via pedi tube (in\n stomach).\n Flexiseal in place with large amounts of liquid stool.\n Making small amts clear icteric urine\n Vac dressings intact\n RLE wet-dry dressings intact\n Continues on CRRT to remove 50ml/hr as tolerated. Received\n pt 1 L negative. Continues on Citrate-filter working well.\n Hct stable. Plt 12. Dr. aware. No intervention at this\n time.\n Action:\n Midaz gtt restarted for agitation\n Fent and midaz boluses given for comfort while\n turning/dressing changes\n Lactulose resumed for high ammonia levels\n Labs per protocol\n RLE wet to dry dressings changed\n Response:\n Tolerating fluid removal.\n Neo remains off\n Plan:\n Cont Crrt to remove fluid as tolerated.\n Monitor labs as ordered, carefully follow Ca levels and\n monitor for acidosis\n Cont monitor for bleeding and notify primary team\n immediately if blood observed from VAC\n Cont provide support to pt and family\n" }, { "category": "Physician ", "chartdate": "2186-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 623190, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fasciitis s/p I&D\n and debridement\n Chief complaint:\n RLW fasciitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846 19. Meropenem 1000 mg IV Q12H Order\n date: @ 0850\n 3. Albumin 5% (12.5g / 250mL) 12.5 g IV ONCE Duration: 1 Doses Order\n date: @ 0234 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses Order date: @\n 0354 21. Midazolam 0.5-2 mg IV Q2H:PRN anxiety Order date: @\n 1105\n 5. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses Order date: @\n 0644 22. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 23. Midazolam 2 mg IV ONCE Duration: 1 Doses Order date: @\n 0549\n 7. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319 24.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order date:\n @ 2252\n 8. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043 25. Potassium\n Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 9. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 26.\n Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1631 27. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date:\n @ 1821 28. Prismasate (B22 K4)\n Continuous at 4200 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 4000 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 2250\n 12. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 29. Rifaximin 400 mg PO/NG TID Order date:\n @ 1434\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 30. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1631\n 14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Heparin 5000 UNIT SC BID Order date: @ 1631 32. Sodium\n CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 33. Sodium Phosphate IV\n Sliding Scale Order date: @ 1525\n 17. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 24 Hour Events:\n Profuse stooling. F/u Cdiff. Alteplase to HD line and filter for CVVH\n machine clotting frequently. Heparin then changed to Citrate. Given\n Albumin for transient hypotension. Still on neo\n Post operative day:\n POD#5 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Meropenem - 12:00 AM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Heparin Sodium - 50 units/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Fentanyl - 03:45 AM\n Midazolam (Versed) - 06:10 AM\n Other medications:\n Flowsheet Data as of 08:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 87 (76 - 92) bpm\n BP: 123/45(65) {99/33(54) - 154/79(99)} mmHg\n RR: 17 (14 - 22) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 9 (5 - 15) mmHg\n Total In:\n 4,883 mL\n 3,163 mL\n PO:\n Tube feeding:\n 1,012 mL\n 346 mL\n IV Fluid:\n 3,761 mL\n 2,567 mL\n Blood products:\n 50 mL\n 250 mL\n Total out:\n 5,850 mL\n 2,321 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n Stool:\n 910 mL\n Drains:\n 1,500 mL\n 500 mL\n Balance:\n -967 mL\n 842 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 518 (0 - 518) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 99%\n ABG: 7.36/43/121/23/-1\n Ve: 10.9 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: No(t) Rash: , Jaundice\n Neurologic: No(t) Follows simple commands, Moves all extremities\n Labs / Radiology\n 22 K/uL\n 10.1 g/dL\n 122 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.9 %\n 8.9 K/uL\n [image002.jpg]\n 10:15 AM\n 04:23 PM\n 05:45 PM\n 08:26 PM\n 10:25 PM\n 02:44 AM\n 02:53 AM\n 04:57 AM\n 06:24 AM\n 06:35 AM\n WBC\n 7.7\n 8.9\n Hct\n 28.4\n 28.9\n Plt\n 19\n 22\n Creatinine\n 1.5\n 1.8\n TCO2\n 25\n 26\n 28\n 28\n 28\n 24\n 25\n Glucose\n 121\n 107\n 120\n 104\n 104\n 130\n 122\n Other labs: PT / PTT / INR:24.6/75.3/2.4, ALT / AST:26/85, Alk-Phos / T\n bili:70/23.9, Lactic Acid:1.9 mmol/L, Albumin:3.6 g/dL, Ca:8.3 mg/dL,\n Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic: -- intubated and sedated with midazolam prn\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n Cardiovascular: -- phenylephrine gtt prn MAP < 60 Will test for adrenal\n insufficiency.\n -- albumin prn (got , , , )\n -- lactate 1.9\n Pulmonary: -- intubated on CMV, ARDS protocol, weaned PEEP. ?need for\n early trach\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 1\n Nutrition: -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol.\n Renal: -- Q4h calcium checks for Citrate toxicity\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg.\n -- consider replacing HD access line\n Hematology: -- serial Hct (goal > 28)\n -- chronic thrombocytopenia (goal Platelets >30): Plt 22, trend\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n -- Citrate in CVVH filter rather than heparin\n Endocrine: RISS . Will stim test.\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro--> d/c cipro, f/u doxycycline sensitivities\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125. Vac change today\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: General surgery, Vascular surgery, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:17 PM 42 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2186-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623723, "text": "Heparin-Induced Thrombocytopenia\n Assessment:\n PLT count 20\ns, PTT\n Patient off all heparin\n Action:\n Argatroban started & repeat PTT checked\n Followed for signs bleeding\n Response:\n PTT 90 and Argat gtt decreased\n Plan:\n Goal ptt\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Slightly hypothermic, 96-97\n HR 70-80\ns NSR & MAP 60-70, CVP ~ 10\n Creat & electrolytes within normal range, patient makes\n small amounts concentrated urine\n Action:\n Neo gtt weaned off, running patient even on cvvh\n Labs followed every 6 hours per crrt protocol\n Response:\n Stable\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2186-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623455, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\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: 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 Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear and diminished, suctioned intermittently for small to\n moderate amounts of thick tan secretions , SPO2 remained upper 90s, no\n distress occurred, remains on minimal settings, no distress occurred,\n will continues to be followed.\n" }, { "category": "Respiratory ", "chartdate": "2186-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622907, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ICU\n Reason: Emergent (1st time); Comments: Worsening oxygenation and\n inability to lie flat, for line placement.\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynamic instability, Underlying illness not resolved; Comments:\n Received vented on CMV mode, triggering slightly over the vent. AM RSBI\n 37. ICU team will reassess whether or not patient is stable enough to\n begin vent weaning.\n 06:19\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622606, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Lightly sedated on PPF and fent gtts. Easily arousable and\n moves all extremities\n Neo at 1 mcg. SBP 90\ns. MAP 57-60 with dips into high 80\n and MAP 50 when attempting to wean Neo.\n Hypothermic 96.4-97\n Continues on CRRT to keep even as tolerated\n Heparin gtt for CRRT anticoagulation\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n PTT 70\n Action:\n Neo gtt titrated for MAP >55\n Heparin gtt decreased to 300 units per s/s\n Labs per protocol\n Bair hugger on/off\n VAC dressings applied by surgical team at bedside\n RLE elelvated\n Vanco dc\nd by ID team\n CRRT with goal to keep even for today\n Response:\n Tolerating CRRT. Currently slightly negative. Heparin gtt\n continuous for anticoagulation.\n SBP 95-101. MAP 57-61. Remains on 1 mcg Neo.\n VAC dressings intact. If any bleeding noted, clamp the\n tubing and page surgery.\n Plan:\n cont with CRRT\n check PTT q 6, CRRT labs per protocol\n cont on abx\n wean vent as tolerated\n change TF\ns to Nutren 2.0 with beneprotein in am per\n Nutrition recs\n" }, { "category": "Respiratory ", "chartdate": "2186-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623028, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean to psv if tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved;\n Comments: tried weaning to psv but failed, minute ventilation\n decreased by half.\n" }, { "category": "Nursing", "chartdate": "2186-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623270, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Mr. is easily arousable to stimulation. He moves all extremities\n in bed and lifts and holds upper extremities. He does not follow\n commands but opens eyes to voice.\n Lungs clear bilaterally with moderate white to tan sputum. Strong cough\n and gag today.\n Neo gtt to maintain Map>55.\n Abd softly distended. Tube feeds at goal via pedi tube(not post\n pyloric). Flexiseal in place with large amounts of liquid stool.\n Ammonia level elevated to 80.\n Urine output low, urine icteric.\n Vac dressing changed per Dr. this am. Wounds clean and with\n less drainage.\n Continues on CRRT to remove 50ml/hr as tolerated. Citrate with good\n filter function.\n Action:\n Continues on Fentanyl gtt with bolus for dsg change. Midaz prn required\n for agitation when coughing and attempting to sit up.\n Changed to Cpap 5/5.\n Resume Lactulose due to high ammonia level. Cdiff cx sent.\n Tot Ca level slightly increased with lowered Ionized Ca levels on\n Citrate. Discussed with renal service. Ph stable.\n Response:\n Tolerating fluid removal.\n Plan:\n Cont Crrt to remove fluid as tolerated. Monitor labs as ordered, follow\n Ca levels and potential acidocis closely.\n" }, { "category": "Nursing", "chartdate": "2186-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622218, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement and returned to OR for re-exploration of leg\n wound and further debridement.\n He is sedated on low dose Propofol and Fentanyl with occasional boluses\n when turning and repositioning. He moves all extremities in bed and is\n easily aroused with stimulation but not enough to follow commands.\n (RASS+3).\n He is slightly hypothermic to 96-97.\n Initially on Neo for MAP >60 which has been weaned off since AM, back\n on briefly intraop. Borderline hypotension this afternoon with mean of\n 58-59.\n 20min episode of vent bigeminy this afternoon-well perfused beats and\n labs stable. Resolved by itself.\n CRRT to keep even. No urine output.\n Hypoglycemia to 60\n Leg wound with ace wrap, foot to groin and large amounts of\n serous/serosang drainage. Area of redness left leg unchanged. Chest\n rash unchanged. Anasarca.\n Hct 24/PLT 30/INR 2.1 preop.\n Action:\n Bair hugger on. D10 infusion for hypoglycemia with D50 1/2amp x1.\n Antibiotic coverage reviewed by ID and changed for improved coverage.\n Transfused with 1 PRBC, PLT and FFP.\n Response:\n Improved Hct, INR, PLT, Glucose. Temp stable.\n Plan:\n Continue current plan of care. Albumin for hypotension. Avoid\n restarting Neo. CRRT. Dressing change in sicu Sunday and possible vac.\n Family updated by Dr. .\n" }, { "category": "Physician ", "chartdate": "2186-01-28 00:00:00.000", "description": "Intensivist Note", "row_id": 622275, "text": "TITLE:\n SICU\n HPI: sepsis\n Chief complaint: 43M with HCV cirrhosis presenting with sepsis, RLE\n fascitis s/p I&D and debridement\n PMHx: Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype\n 1, Hx of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr\n 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Meropenem 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 0850\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846\n 19. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 3. Albumin 5% (25g / 500mL) 25 g IV ONCE Duration: 1 Doses Order date:\n @ 1757\n 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 21. Neutra-Phos 2 PKT PO/NG ONCE Duration: 1 Doses Order date: @\n 2328\n 5. Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @\n 0850\n 22. Pantoprazole 40 mg IV Q24H Order date: @ \n 6. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319\n 23. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order\n date: @ 2252\n 7. Clindamycin 600 mg IV Q6H Order date: @ 1631\n 24. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. D10\n Continuous at 10 ml/hr Order date: @ 0720\n 25. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 26. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO comfort on vent\n Order date: @ 1631\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1631\n 27. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1846\n 11. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 28. Prismasate (B22 K4)\n Continuous at 2200 ml/hr\n Infuse Replacement fluid: Prefilter Rate: Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1846\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 29. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 30. 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: @ 1631\n 14. Heparin 5000 UNIT SC BID Order date: @ 1631\n 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 32. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 33. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 1515\n 17. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 34. Vancomycin 1000 mg IV Q 24H Order date: @ 1542\n 24 Hour Events:\n OR SENT - At 10:41 AM\n OR RECEIVED - At 12:05 PM\n TRANSTHORACIC ECHO - At 01:28 PM\n mild to moderate MR , pulm pressure ok\n - to OR for RLE debridement. Transfused 1 FFP, 1 PLT, 2 PRBC\n Post operative day:\n POD#1 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Vancomycin - 09:00 AM\n Meropenem - 12:00 AM\n Ciprofloxacin - 04:00 AM\n Clindamycin - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:30 PM\n Fentanyl - 12:00 AM\n Dextrose 50% - 04:29 AM\n Other medications:\n Flowsheet Data as of 05:30 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: 35.9\nC (96.7\n HR: 77 (77 - 84) bpm\n BP: 99/45(60) {93/41(57) - 131/72(88)} mmHg\n RR: 20 (18 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 20 (19 - 27) mmHg\n Total In:\n 6,605 mL\n 1,295 mL\n PO:\n Tube feeding:\n 60 mL\n 55 mL\n IV Fluid:\n 4,044 mL\n 1,155 mL\n Blood products:\n 2,246 mL\n Total out:\n 4,648 mL\n 953 mL\n Urine:\n 84 mL\n 14 mL\n NG:\n 800 mL\n Stool:\n Drains:\n Balance:\n 1,957 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, No Spon Resp\n PIP: 27 cmH2O\n Plateau: 24 cmH2O\n Compliance: 43.1 cmH2O/mL\n SPO2: 97%\n ABG: 7.36/38/104/20/-3\n Ve: 11.7 L/min\n PaO2 / FiO2: 173\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, intubated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: Trace, No(t) 1+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: ACE wrap in place, serosanginous d/c\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 38 K/uL\n 9.9 g/dL\n 69 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 46 mg/dL\n 106 mEq/L\n 136 mEq/L\n 29.1 %\n 7.9 K/uL\n [image002.jpg]\n 06:45 AM\n 10:27 AM\n 10:33 AM\n 01:20 PM\n 04:00 PM\n 04:09 PM\n 10:00 PM\n 10:07 PM\n 04:02 AM\n 04:22 AM\n WBC\n 6.8\n 7.4\n 7.5\n 7.9\n Hct\n 26.5\n 28.5\n 27.9\n 29.1\n Plt\n 30\n 38\n 34\n 38\n Creatinine\n 3.4\n 3.6\n 3.4\n TCO2\n 24\n 25\n 24\n 23\n 24\n 22\n Glucose\n 72\n 91\n 84\n 73\n 68\n 64\n 85\n 66\n 69\n Other labs: PT / PTT / INR:24.3/50.3/2.3, ALT / AST:32/68, Alk-Phos / T\n bili:45/13.3, Lactic Acid:1.6 mmol/L, Albumin:4.2 g/dL, Ca:8.6 mg/dL,\n Mg:2.3 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies\n Neurologic:\n -- intubated and sedated with propofol\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl gtt, fentanyl IV prn\n breakthrough pain\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60\n -- albumin prn\n -- echocardiogram - EF 55%. Moderate to severe MR, mild pulmonary\n artery systolic hypertension. No visible vegetations. A focal wall\n motion abnormality of the LV (mid infero-lateral hypokinesis) is now\n suggested. ? Involving papillary muscles c/w ischemic disease\n Pulmonary:\n -- intubated on CMV, ARDS protocol\n Gastrointestinal / Abdomen:\n -- dobhoff in place\n -- TF started at low rate\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- GI prophy: pantoprazole\n Nutrition:\n -- Novasource Renal Full strength @ 10cc/hr\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even\n Hematology:\n -- serial Hct (goal > 28): Hct 29.1\n -- chronic thrombocytopenia (goal Platelets >30): Plt 66\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.3\n -- Transfused : 1 FFP, 1 PLT, 2 PRBC\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: gram positive bacteria\n -- blood cultures pending\n -- ID consulted\n -- ABX: , cipro, clinda, vanco\n -- do not recommend IVIG as that can worsen renal failure and ARDS\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE\n Imaging: CXR\n Fluids: D10 @ 10cc/hr, Albumin 25% prn hypotension\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2186-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623146, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Lightly sedated on fentanyl and low dose versed gtt\n - Versed gtt of @ per transplant\n ok for prn bolus\n - HR 70-80 NSR with no ectopy except 1 4 beat run VT\n - Neo gtt weaned up overnight for MAPS in mid to high 50\n - Noted to have dip in BP with agitation or pain\n - Lungs clear initially but becoming rhonchrous\n - CRRT filter clotting this evening and completely clotted by\n 2345.\n - VAC to 2 thigh area\ns to 75 mm suction although machine at\n time with fluctuating pressures and alarms for partial blockage\n - VAC to calf area @ 125 mm suction functioning well with no\n issues\n - Area to lower calf and ankle with 3 open areas\n WD dressing\n intact\n Action:\n - Multiple bolus of versed required overnight for patient to\n tolerate even minimal stimulation\n - Fentanyl gtt increased to improve pain control/sedation\n - Albumin 5% given for increasing pressor requirement and low\n CVP (per transplant recommendations)\n - Ambu bagged and lavaged for large mucus plug\n - Renal and transplant consulted by SICU resident and citrate\n initiated to decrease frequency of filter clotting\n - Heparin gtt discontinued\n - Pre filter replacement increased to 4000 to dilute blood and\n decrease clotting\n - Replacement fluid changed to K4 d/t elevated bicarb and\n decreased k\n - VAC canister and then VAC machine changed out to\n troubleshoot VAC\n - Dressing changed and wounds on lower right leg packed per\n surgery\ns recs\n Response:\n - Good relief from prn versed but moments of distress still\n noted\n - Neo down slightly after albumin and CVP up\n - Improved filter pressures and minimal clots in filter noted\n after citrate initiated\n - Ionized calcium down slightly with addition of citrate\n although serum calcium also down\n - 2 grams calcium gluc given x2 per renal\n - Will address increasing parameters for CRRT calcium\n gluconate gtt rate after 0700 serum ca is back\n renal concerned for\n toxicity\n Plan:\n - Continue on IV ABX\n - Team to change wound vac this afternoon\n - Q2 ionized calcium and Q4 serum calcium to monitor for\n toxicity\n - Remove fluid as tolerated\n - Wean neo as tolerated\n - Support family\n" }, { "category": "Physician ", "chartdate": "2186-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 623151, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fasciitis s/p I&D\n and debridement\n Chief complaint:\n RLW fasciitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846 19. Meropenem 1000 mg IV Q12H Order\n date: @ 0850\n 3. Albumin 5% (12.5g / 250mL) 12.5 g IV ONCE Duration: 1 Doses Order\n date: @ 0234 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses Order date: @\n 0354 21. Midazolam 0.5-2 mg IV Q2H:PRN anxiety Order date: @\n 1105\n 5. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses Order date: @\n 0644 22. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 23. Midazolam 2 mg IV ONCE Duration: 1 Doses Order date: @\n 0549\n 7. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319 24.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order date:\n @ 2252\n 8. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043 25. Potassium\n Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 9. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 26.\n Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1631 27. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date:\n @ 1821 28. Prismasate (B22 K4)\n Continuous at 4200 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 4000 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 2250\n 12. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 29. Rifaximin 400 mg PO/NG TID Order date:\n @ 1434\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 30. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1631\n 14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Heparin 5000 UNIT SC BID Order date: @ 1631 32. Sodium\n CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 33. Sodium Phosphate IV\n Sliding Scale Order date: @ 1525\n 17. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 24 Hour Events:\n Profuse stooling. F/u Cdiff. Alteplase to HD line and filter for CVVH\n machine clotting frequently. Heparin then changed to Citrate. Given\n Albumin for transient hypotension. Still on neo\n Post operative day:\n POD#5 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Meropenem - 12:00 AM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Heparin Sodium - 50 units/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Fentanyl - 03:45 AM\n Midazolam (Versed) - 06:10 AM\n Other medications:\n Flowsheet Data as of 08:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 87 (76 - 92) bpm\n BP: 123/45(65) {99/33(54) - 154/79(99)} mmHg\n RR: 17 (14 - 22) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 9 (5 - 15) mmHg\n Total In:\n 4,883 mL\n 3,163 mL\n PO:\n Tube feeding:\n 1,012 mL\n 346 mL\n IV Fluid:\n 3,761 mL\n 2,567 mL\n Blood products:\n 50 mL\n 250 mL\n Total out:\n 5,850 mL\n 2,321 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n Stool:\n 910 mL\n Drains:\n 1,500 mL\n 500 mL\n Balance:\n -967 mL\n 842 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 518 (0 - 518) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 99%\n ABG: 7.36/43/121/23/-1\n Ve: 10.9 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Skin: No(t) Rash: , Jaundice\n Neurologic: No(t) Follows simple commands, Moves all extremities\n Labs / Radiology\n 22 K/uL\n 10.1 g/dL\n 122 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 101 mEq/L\n 134 mEq/L\n 28.9 %\n 8.9 K/uL\n [image002.jpg]\n 10:15 AM\n 04:23 PM\n 05:45 PM\n 08:26 PM\n 10:25 PM\n 02:44 AM\n 02:53 AM\n 04:57 AM\n 06:24 AM\n 06:35 AM\n WBC\n 7.7\n 8.9\n Hct\n 28.4\n 28.9\n Plt\n 19\n 22\n Creatinine\n 1.5\n 1.8\n TCO2\n 25\n 26\n 28\n 28\n 28\n 24\n 25\n Glucose\n 121\n 107\n 120\n 104\n 104\n 130\n 122\n Other labs: PT / PTT / INR:24.6/75.3/2.4, ALT / AST:26/85, Alk-Phos / T\n bili:70/23.9, Lactic Acid:1.9 mmol/L, Albumin:3.6 g/dL, Ca:8.3 mg/dL,\n Mg:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic: -- intubated and sedated with midazolam\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n Cardiovascular: -- phenylephrine gtt prn MAP < 60\n -- albumin prn (got , , , )\n -- lactate 1.9\n Pulmonary: -- intubated on CMV, ARDS protocol, weaned PEEP. ?need for\n early trach\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 1\n Nutrition: -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off\n propofol.\n Renal: -- Q4h calcium checks for Citrate toxicity\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg.\n -- consider replacing HD access line\n Hematology: -- serial Hct (goal > 28)\n -- chronic thrombocytopenia (goal Platelets >30): Plt 18, trend\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n -- Citrate in CVVH filter rather than heparin\n Endocrine: RISS\n Infectious Disease: -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro--> d/c cipro, f/u doxycycline sensitivities\n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125. Vac change today\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: General surgery, Vascular surgery, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:17 PM 42 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nutrition", "chartdate": "2186-02-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 623252, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 98.8 kg\n 99.8 kg ( 04:00 AM)\n 29.5\n Pertinent medications: calcium gluconate repletion, heparin, ABX,\n others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 04:39 PM\n Glucose Finger Stick\n 137\n 10:00 AM\n BUN\n 33 mg/dL\n 10:00 AM\n Creatinine\n 1.5 mg/dL\n 10:00 AM\n Sodium\n 134 mEq/L\n 10:00 AM\n Potassium\n 3.9 mEq/L\n 04:39 PM\n Chloride\n 101 mEq/L\n 10:00 AM\n TCO2\n 24 mEq/L\n 10:00 AM\n PO2 (arterial)\n 112 mm Hg\n 04:39 PM\n PCO2 (arterial)\n 42 mm Hg\n 04:39 PM\n pH (arterial)\n 7.36 units\n 04:39 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 04:39 PM\n Albumin\n 3.6 g/dL\n 05:45 PM\n Calcium non-ionized\n 9.1 mg/dL\n 12:13 PM\n Phosphorus\n 3.8 mg/dL\n 10:00 AM\n Ionized Calcium\n 0.96 mmol/L\n 04:39 PM\n Magnesium\n 2.3 mg/dL\n 10:00 AM\n ALT\n 26 IU/L\n 02:44 AM\n Alkaline Phosphate\n 70 IU/L\n 02:44 AM\n AST\n 85 IU/L\n 02:44 AM\n Total Bilirubin\n 23.9 mg/dL\n 02:44 AM\n WBC\n 8.9 K/uL\n 02:44 AM\n Hgb\n 10.1 g/dL\n 02:44 AM\n Hematocrit\n 29.0 %\n 10:00 AM\n Current diet order / nutrition support: NPO; Nutren 2.0 @ 42mL/hr + 35\n g Beneprotein x 24hr\n GI: Abd soft/distended, present bowel sounds\n Specifics: 43 y.o. M with HCV cirrhosis presenting with sepsis, RLE\n fasciitis, abd pain, GNR bacteremia, now s/p I&D and debridement of\n RLE. Patient remains intubated on CVVH and continues to receive\n nutrition support via NGT feeds. Propofol weaned and goal tube feed\n rate increased to 42mL/hr which RN reports patient is tolerating.\n Patient with large stool output, however noted previously receiving\n lactulose which was discontinued today, C. diff negative x1. Will\n continue to follow and monitor tube feed tolerance/stool output.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n current tube feeds: Nutren 2.0 @ 42 mL/hr + 35 g Beneprotein to provide\n 2140 kcal and 111 g protein.\n Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel daily, replete as needed.\n Other: Following #\n" }, { "category": "Nutrition", "chartdate": "2186-02-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 623253, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 98.8 kg\n 99.8 kg ( 04:00 AM)\n 29.5\n Pertinent medications: calcium gluconate repletion, heparin, ABX,\n others noted\n Labs:\n Value\n Date\n Glucose\n 123 mg/dL\n 04:39 PM\n Glucose Finger Stick\n 137\n 10:00 AM\n BUN\n 33 mg/dL\n 10:00 AM\n Creatinine\n 1.5 mg/dL\n 10:00 AM\n Sodium\n 134 mEq/L\n 10:00 AM\n Potassium\n 3.9 mEq/L\n 04:39 PM\n Chloride\n 101 mEq/L\n 10:00 AM\n TCO2\n 24 mEq/L\n 10:00 AM\n PO2 (arterial)\n 112 mm Hg\n 04:39 PM\n PCO2 (arterial)\n 42 mm Hg\n 04:39 PM\n pH (arterial)\n 7.36 units\n 04:39 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 04:39 PM\n Albumin\n 3.6 g/dL\n 05:45 PM\n Calcium non-ionized\n 9.1 mg/dL\n 12:13 PM\n Phosphorus\n 3.8 mg/dL\n 10:00 AM\n Ionized Calcium\n 0.96 mmol/L\n 04:39 PM\n Magnesium\n 2.3 mg/dL\n 10:00 AM\n ALT\n 26 IU/L\n 02:44 AM\n Alkaline Phosphate\n 70 IU/L\n 02:44 AM\n AST\n 85 IU/L\n 02:44 AM\n Total Bilirubin\n 23.9 mg/dL\n 02:44 AM\n WBC\n 8.9 K/uL\n 02:44 AM\n Hgb\n 10.1 g/dL\n 02:44 AM\n Hematocrit\n 29.0 %\n 10:00 AM\n Current diet order / nutrition support: NPO; Nutren 2.0 @ 42mL/hr + 35\n g Beneprotein x 24hr\n GI: Abd soft/distended, present bowel sounds\n Specifics: 43 y.o. M with HCV cirrhosis presenting with sepsis, RLE\n fasciitis, abd pain, GNR bacteremia, now s/p I&D and debridement of\n RLE. Patient remains intubated on CVVH and continues to receive\n nutrition support via NGT feeds. Propofol weaned and goal tube feed\n rate increased to 42mL/hr which RN reports patient is tolerating.\n Patient with large stool output, however noted previously receiving\n lactulose which was discontinued today, C. diff negative x1. Will\n continue to follow and monitor tube feed tolerance/stool output.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n current tube feeds: Nutren 2.0 @ 42 mL/hr + 35 g Beneprotein to provide\n 2140 kcal and 111 g protein.\n Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel daily, replete as needed.\n Other: Following #\n ------ Protected Section ------\n Addendum: Monitor tube feed tol with residual checks q4hr, hold if\n >200mL.\n ------ Protected Section Addendum Entered By: \n on: 06:04 PM ------\n" }, { "category": "Nursing", "chartdate": "2186-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622214, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622473, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing.\n Normothermic early noc with bair hugger off but dropped temp to 96\n through evening.\n CRRT in progress, received pt 2.6L positive for the day.\n Heparin gtts infusing via prisma circuit.\n Rt leg incision continues to ooze copious serous drainage.\n Action:\n Throughout evening, PFR increased to remove optimal amount of fluid for\n day.\n Phenylephrine titrated to maintain map>55.\n Labs Q6hours.\n Continuous lyte repletion in progress.\n Bair hugger reapplied.\n Rt leg dressing reinforced to absorb drainage.\n Clindamycin discontinued from antibiotic regimen.\n Response:\n Removed increased fluid through pm, ended day 0.3L positive, pt\n tolerated well but have been aiming for goal of even fluid\n balance after mn since pt slightly more acidotic.\n Required slight increase in pressor support toward this am.\n Electrolytes in balance.\n Hct 30.6, Plts 32, and INR 2.1 this am, Dr aware.\n No signs of bleeding.\n WBC slightly elevated to 12.4 this am, pt afebrile\n Weight down 2kg in last 24hours, fluid calculations are not including\n copious amount of serous fluid loss into bed.\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n VAC dressing to be applied to right thigh by team today.\n Mother will be in this am and wishes to speak with Dr , Dr\n (team resident) notified of this in pm.\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622588, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Lightly sedated on PPF and fent gtts. Easily arousable and\n moves all extremities\n Neo at 1 mcg. SBP 90\ns. MAP 57-60 with dips into high 80\n and MAP 50 when attempting to wean Neo.\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated\n Heparin gtt for CRRT anticoagulation\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n PTT 70\n Action:\n Neo gtt titrated for MAP >55\n Heparin gtt decreased to 300 units per s/s\n Labs per protocol\n Bair hugger on/off\n VAC dressings applied by surgical team at bedside\n RLE elelvated\n Vanco dc\nd by ID team\n CRRT with goal to keep even for today\n Response:\n Tolerating CRRT. Currently negative\n SBP 95-101. MAP 57-61. Remains on 1 mcg Neo.\n Plan:\n cont with CRRT\n check PTT q 6, CRRT labs per protocol\n cont on abx\n wean vent as tolerated\n VAC dsg to right thigh tomorrow (bedside)\n" }, { "category": "Physician ", "chartdate": "2186-01-26 00:00:00.000", "description": "metavision logout caused duplicate note", "row_id": 621919, "text": "Chief Complaint: severe sepsis / septic shock\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 43-year-old man with cirrhosis on transplant list now with lower\n extremity cellulitis, abdominal pain, GNR bacteremia, relative\n hypotension, and elevated lactate to 6.2.\n Symptoms began Monday, including fever to 102.5. Also reports \"spider\n bite.\" Admitted to , transferred here. Arrived\n last night. Other issues as detailed by Dr. note today.\n Now endorses diffuse pain, but especially leg and abdomen (probably\n RUQ).\n Just now seen by surgery, who feel leg is not necrotizing fasciitis or\n compartment syndrome.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, History somewhat\n limited by encephalopathy.\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n see resident note\n Past medical history:\n Family history:\n Social History:\n cirrhosis\n HCV\n CKD with baseline creat about 1.1 - 1.4\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: see resident note\n Review of systems:\n Flowsheet Data as of 11:43 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 (97\n HR: 95 (95 - 95) bpm\n RR: 14 (14 - 14) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,363 mL\n PO:\n TF:\n IVF:\n 108 mL\n Blood products:\n 1,255 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,363 mL\n Respiratory\n SpO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): place, person, month, year, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n [image002.jpg]\n Labs reviewed in OMR. Esp notable for bandemia, thrombocytopenia,\n anemia, coagulopathy, bilirubin 6.2, acute renal failure, lactate 6.2\n OSH BCx reportedly GNR.\n OSH CT LE reportedly negative for abscess\n Assessment and Plan\n 43-year-old man with cirrhosis now with septic shock / severe sepsis\n and GNR bacteremia. Potential sources include leg and abdomen. Seen\n by surgery, who feel this is not necrotizing fasciitis and that he does\n not have compartment syndrome.\n Septic shock / severe sepsis with occult hypoperfusion\n EGDT (place CVL under cover of platelets and FFP)\n ABX: vanco, cefepime, clinda (for toxin)\n Risks of drotrecogin outweigh benefits given\n thrombocytopenia, liver disease, etc.\n CT abdomen and leg (no IV contrast)\n Acute renal failure\n Renal following\n Likely ATN\n Hemodynamic management\n Cirrhosis\n Lactulose, rifaxamin\n No evidence of ascites on ultrasound\n Reasonable to give albumin in setting of cirrhosis / shock\n Hypoxemia\n Multiple potential etiologies (sepsis, liver dz, etc.)\n need intubation\n Other issues as per Dr. \ns note\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:46 AM\n 20 Gauge - 10:47 AM\n Comments:\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: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n Required intubation for hypoxemia.\n Central line placed.\n Art line placed.\n Discussed further with Dr. . To OR for exploration urgently.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:59 ------\n ------ Added by auto log oyt ------\n ------ Protected Section Error Entered By: , MD\n on: 16:23 ------\n" }, { "category": "Nursing", "chartdate": "2186-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623260, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623322, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Arouses to voice, not following commands. Agitated with\n movement/turning. PERRL. Sclera in left eye very red.\n Remains on CPAP5/5.\n Fentanyl gtt for pain\n MAP 52-56\n Abd softly distended. Tube feeds at goal via pedi tube (in\n stomach).\n Flexiseal in place with large amounts of liquid stool.\n Making small amts clear icteric urine\n Vac dressings intact\n RLE wet-dry dressings intact\n Continues on CRRT to remove 50ml/hr as tolerated. Received\n pt 1 L negative.\n Action:\n Midaz gtt restarted for agitation\n Fent and midaz boluses given for comfort while\n turning/dressing changes\n Lactulose resumed for high ammonia levels\n Labs per protocol\n RLE wet to dry dressings changed\n Response:\n Tolerating fluid removal.\n Neo remains off\n T. Ca and I. Ca\n Plan:\n Cont Crrt to remove fluid as tolerated.\n Monitor labs as ordered, carefully follow Ca levels and\n monitor for acidosis\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622470, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing.\n Normothermic early noc with bair hugger off but dropped temp to 96\n through evening.\n CRRT in progress, received pt 2.6L positive for the day.\n Heparin gtts infusing via prisma circuit.\n Rt leg incision continues to ooze copious serous drainage.\n Action:\n Throughout evening, PFR increased to remove optimal amount of fluid for\n day.\n Phenylephrine titrated to maintain map>55.\n Labs Q6hours.\n Continuous lyte repletion in progress.\n Bair hugger reapplied.\n Rt leg dressing reinforced to absorb drainage.\n Clindamycin discontinued from antibiotic regimen.\n Response:\n Removed increased fluid through pm, ended day 0.5L positive, pt\n tolerated well but have been aiming for goal of even fluid\n balance after mn since pt slightly more acidotic.\n Required slight increase in pressor support toward this am.\n Electrolytes in balance.\n Hct ,Plts , and INR this am, Dr aware.\n No signs of bleeding.\n WBC slightly elevated to this am, pt afebrile\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n VAC dressing to be applied to right thigh by team today.\n Mother will be in this am and wishes to speak with Dr , Dr\n (team resident) notified of this in pm.\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622471, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing.\n Normothermic early noc with bair hugger off but dropped temp to 96\n through evening.\n CRRT in progress, received pt 2.6L positive for the day.\n Heparin gtts infusing via prisma circuit.\n Rt leg incision continues to ooze copious serous drainage.\n Action:\n Throughout evening, PFR increased to remove optimal amount of fluid for\n day.\n Phenylephrine titrated to maintain map>55.\n Labs Q6hours.\n Continuous lyte repletion in progress.\n Bair hugger reapplied.\n Rt leg dressing reinforced to absorb drainage.\n Clindamycin discontinued from antibiotic regimen.\n Response:\n Removed increased fluid through pm, ended day 0.5L positive, pt\n tolerated well but have been aiming for goal of even fluid\n balance after mn since pt slightly more acidotic.\n Required slight increase in pressor support toward this am.\n Electrolytes in balance.\n Hct 30.6, Plts 32, and INR 2.1 this am, Dr aware.\n No signs of bleeding.\n WBC slightly elevated to 12.4 this am, pt afebrile\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n VAC dressing to be applied to right thigh by team today.\n Mother will be in this am and wishes to speak with Dr , Dr\n (team resident) notified of this in pm.\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622589, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Lightly sedated on PPF and fent gtts. Easily arousable and\n moves all extremities\n Neo at 1 mcg. SBP 90\ns. MAP 57-60 with dips into high 80\n and MAP 50 when attempting to wean Neo.\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated\n Heparin gtt for CRRT anticoagulation\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n PTT 70\n Action:\n Neo gtt titrated for MAP >55\n Heparin gtt decreased to 300 units per s/s\n Labs per protocol\n Bair hugger on/off\n VAC dressings applied by surgical team at bedside\n RLE elelvated\n Vanco dc\nd by ID team\n CRRT with goal to keep even for today\n Response:\n Tolerating CRRT. Currently negative Heparin gtt continuous\n for anticoagulation.\n SBP 95-101. MAP 57-61. Remains on 1 mcg Neo.\n VAC dressings intact. If any bleeding noted, clamp the\n tubing and page surgery.\n Plan:\n cont with CRRT\n check PTT q 6, CRRT labs per protocol\n cont on abx\n wean vent as tolerated\n VAC dsg to right thigh tomorrow (bedside)\n" }, { "category": "Nursing", "chartdate": "2186-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623324, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Arouses to voice, not following commands. Agitated with\n movement/turning. PERRL. Sclera in left eye very red.\n Remains on CPAP 5/5.\n Fentanyl gtt for pain\n MAP 52-56\n Abd softly distended. Tube feeds at goal via pedi tube (in\n stomach).\n Flexiseal in place with large amounts of liquid stool.\n Making small amts clear icteric urine\n Vac dressings intact\n RLE wet-dry dressings intact\n Continues on CRRT to remove 50ml/hr as tolerated. Received\n pt 1 L negative. Continues on Citrate.\n Action:\n Midaz gtt restarted for agitation\n Fent and midaz boluses given for comfort while\n turning/dressing changes\n Lactulose resumed for high ammonia levels\n Labs per protocol\n RLE wet to dry dressings changed\n Response:\n Tolerating fluid removal.\n Neo remains off\n T. Ca and I. Ca\n Plan:\n Cont Crrt to remove fluid as tolerated.\n Monitor labs as ordered, carefully follow Ca levels and\n monitor for acidosis\n Cont provide support to pt and family\n" }, { "category": "Respiratory ", "chartdate": "2186-01-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622381, "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:\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 :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2186-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622579, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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:\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: 27 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 Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: 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": "Physician ", "chartdate": "2186-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 622110, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n Albumin 25% (12.5g / 50mL), CefePIME, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Clindamycin, Fentanyl, Heparin, Insulin, Lactulose,\n Magnesium Sulfate, MetRONIDAZOLE (FLagyl) , Pantoprazole,\n Phenylephrine, Propofol Rifaximin, Vancomycin\n 24 Hour Events:\n INTUBATION - At 01:00 PM\n INVASIVE VENTILATION - START 01:00 PM\n MULTI LUMEN - START 01:59 PM\n ARTERIAL LINE - START 02:04 PM\n IABP LINE - START 02:05 PM\n MULTI LUMEN - STOP 02:21 PM\n IABP LINE - STOP 02:21 PM\n ARTERIAL LINE - STOP 02:21 PM\n INVASIVE VENTILATION - STOP 02:21 PM\n ARTERIAL LINE - START 07:50 PM\n MULTI LUMEN - START 07:51 PM\n DIALYSIS CATHETER - START 08:00 PM\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Clindamycin - 04:06 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Dextrose 50% - 04:33 AM\n Other medications:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 82 (75 - 95) bpm\n BP: 97/43(59) {74/40(52) - 129/68(85)} mmHg\n RR: 20 (14 - 20) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 271 (15 - 271) mmHg\n Total In:\n 2,774 mL\n 1,635 mL\n PO:\n Tube feeding:\n IV Fluid:\n 960 mL\n 1,035 mL\n Blood products:\n 1,814 mL\n 550 mL\n Total out:\n 119 mL\n 669 mL\n Urine:\n 30 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,655 mL\n 966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 95%\n ABG: 7.40/39/107/22/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : b/l, Rhonchorous : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: No(t) Trace, 1+), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Purulent), ACE wrap in place, serosanginous d/c\n Neurologic: Moves all extremities, Sedated, spontaneous moves\n extremities, does not follow commands\n Labs / Radiology\n 50 K/uL\n 8.9 g/dL\n 62 mg/dL\n 4.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 66 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.9 %\n 8.0 K/uL\n [image002.jpg]\n 07:56 PM\n 08:08 PM\n 10:18 PM\n 10:30 PM\n 12:30 AM\n 12:43 AM\n 04:18 AM\n 04:25 AM\n WBC\n 8.9\n 8.7\n 8.0\n Hct\n 28.1\n 27.7\n 24.9\n Plt\n 48\n 57\n 56\n 50\n Creatinine\n 4.7\n 4.3\n TCO2\n 28\n 29\n 27\n 25\n Glucose\n 63\n 54\n 54\n 62\n Other labs: PT / PTT / INR:21.3/43.1/2.0, Lactic Acid:2.5 mmol/L,\n Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 43M HCV with sepsis, RLE fascitis s/p RLE\n debridement\n Neurologic: sedated on fentanyl, propfol, daily wakeup\n Cardiovascular: minimal neo, wean as tolerated. Hemo stable this AM.\n ECHO to RO endocarditis with Pasturella on blood cx\n Pulmonary: intubated on CMV, ARDS protocol lung protective, CXR\n unchanged this AM\n remain intubated for OR.\n Gastrointestinal / Abdomen: NPO, NGT in place, rifaximine, lactulose\n for chronic liver failure.\n Nutrition: NPO, start TF after returning from the OR\n Renal: acute on chronic renal failure (baseline Cr 1.5), foley in\n place, on CVVHD, goal run even for now.\n Hematology: f/u Hct (goal > 28), goals: Platelets > 50 hang before OR,\n INR < 2\n Endocrine: Insulin gtt for glucose < 150.\n ID: Vanc, cefepime, clinda, flagyl for GNR blood (OSH - ), GNR on R\n calf, f/u cultures\n Pasturella from OSH this AM, f/u ID recs but will\n discuss adding Carbapenem and d/c Vanco and Cefepime.\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, NGT\n Wounds: RLE\n wet to dry with ace wrap.\n Imaging:\n Fluids: Albumin 25% TID x 3 days PRN hypotension. D10 @10\n Consults: West 1, Vasc, ID\n Billing Diagnosis: sepsis; respiratory failure; liver failure; acute\n renal failure\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Code status:FULL\n Disposition:SICU\n Time spent: 33 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2186-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623494, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Arouses to voice, not following commands. Agitated with\n movement/turning. PERRL. Sclera in left eye very red.\n Remains on CPAP 5/5.\n Fentanyl gtt for pain\n MAP 52-56\n Abd softly distended. Tube feeds at goal via pedi tube (in\n stomach).\n Flexiseal in place with large amounts of liquid stool.\n Making small amts clear icteric urine\n Vac dressings intact\n RLE wet-dry dressings intact\n Continues on CRRT to remove 50ml/hr as tolerated. Continues\n on Citrate-filter working well.\n Pt received with Plt 12.\n Action:\n Midaz gtt continued for agitation\n Lactulose continued for high ammonia levels\n Labs per protocol\n RLE wet to dry dressings changed\n 1 unit of Plts as ordered.\n Response:\n Tolerating fluid removal.\n Neo remains off\n Plt 23 s/p transfusion.\n Plan:\n Cont Crrt to remove fluid as tolerated.\n Monitor labs as ordered, carefully follow Ca levels and\n monitor for acidosis\n Cont monitor for bleeding and notify primary team\n immediately if blood observed from VAC\n Attempt wean from midaz gtt. SICU and Transplant Team aware\n of agitation without sedation. Formulate a better sedation method,\n ?ativan PRN.\n Cont provide support to pt and family\n" }, { "category": "Physician ", "chartdate": "2186-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 623552, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n . IV access: Temporary central access (ICU) Order date: @ 1631\n 16. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 0825 17. Meropenem 1000 mg IV Q12H Order\n date: @ 0850\n 3. Albumin 25% (12.5g / 50mL) 12.5 g IV ONCE Duration: 1 Doses Order\n date: @ 18. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645 19. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 5. Citrate Dextrose 3% (ACD-A) CRRT 180 mL/hr DIALYS ASDIR\n CRRT Protocol. Monitor systemic ionized calcium q6h. Adjust according\n to renal recommendations. Order date: @ 0043 20. Midazolam 0.5-2\n mg/hr IV DRIP TITRATE TO decreased agitation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0922\n 6. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631 21.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO map>60 Order date:\n @ \n 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631 22. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date: \n @ 1821 23. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ 24. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ 25. Prismasate (B22 K4)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate: 2500 Postfilter Rate: 200\n Replacement Solution for CRRT Order date: @ 0825\n 11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631 26. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 12. Heparin 5000 UNIT SC BID Order date: @ 1631 27. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1631\n 13. Hydrocortisone Na Succ. 100 mg IV ONCE Duration: 1 Doses Order\n date: @ 28. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631 29. Sodium CITRATE 4% 1.5\n mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 15. Lactulose 30 mL PO/NG TID\n due to high ammonia levels Order date: @ 1816 30. Sodium\n Phosphate IV Sliding Scale Order date: @ 1525\n 24 Hour Events:\n Post operative day:\n POD#7 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Ampicillin\n Unknown;\n Levofloxacin\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:23 AM\n Meropenem - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Phenylephrine - 1 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:08 AM\n Other medications:\n : Dilaudid 15mg PO PRN, Methadone 64', Lasix 120\", Aldactone 100',\n Rifaximin 200 QOD, Testosterone gel\n Flowsheet Data as of 05:04 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: 36.8\nC (98.2\n HR: 79 (78 - 95) bpm\n BP: 109/36(55) {88/27(45) - 137/50(75)} mmHg\n RR: 7 (7 - 15) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.8 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 6 (2 - 10) mmHg\n Total In:\n 8,986 mL\n 2,207 mL\n PO:\n Tube feeding:\n 1,008 mL\n 204 mL\n IV Fluid:\n 7,267 mL\n 1,568 mL\n Blood products:\n 494 mL\n 375 mL\n Total out:\n 10,348 mL\n 1,825 mL\n Urine:\n 269 mL\n 135 mL\n NG:\n Stool:\n 1,460 mL\n Drains:\n 1,000 mL\n Balance:\n -1,362 mL\n 382 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 947 (646 - 947) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 14\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: 7.33/47/132/25/-1\n Ve: 7.6 L/min\n PaO2 / FiO2: 330\n Physical Examination\n General Appearance: No acute distress, ill, jaundiced\n HEENT: PERRL, icteric sclerae\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: No(t) 3+, 4+), (Temperature: Warm)\n Right Extremities: (Edema: 4+), (Temperature: Warm)\n Skin: Rash: diffuse red, maculopapular., Jaundice, (Incision: Clean /\n Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 26 K/uL\n 9.5 g/dL\n 176 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 34 mg/dL\n 105 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 10:31 AM\n 12:20 PM\n 02:14 PM\n 04:25 PM\n 04:33 PM\n 08:00 PM\n 08:13 PM\n 11:51 PM\n 02:33 AM\n 02:51 AM\n WBC\n 5.9\n 9.8\n 8.0\n Hct\n 25.2\n 27.7\n 28.4\n Plt\n 23\n 18\n 39\n 26\n Creatinine\n 1.5\n 1.5\n 1.5\n TCO2\n 25\n 27\n 26\n 26\n 26\n Glucose\n 151\n 111\n 147\n 147\n 140\n 193\n 176\n Other labs: PT / PTT / INR:22.2/64.3/2.1, ALT / AST:25/74, Alk-Phos / T\n bili:75/22.5, Differential-Neuts:85.7 %, Lymph:7.4 %, Mono:4.7 %,\n Eos:1.7 %, Fibrinogen:95 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:3.0\n g/dL, LDH:154 IU/L, Ca:9.7 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic: -- intubated and sedated with fent gtt & midazolam prn\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n -- chronic pain consult: consider weaning off midaz/fent and starting\n precedex gtt.\n --if extubated, would recommend intermittent ketamine for drsg \n -- consider head ct if no improvement in mental status\n Cardiovascular: --dropped pressure 8p\n -- restarted neo 8p\n -- albumin prn (got , , , ) gave last night.\n -- lactate 1.7\n Pulmonary: -- intubated CPAP 5/5. ?need for early trach for neuro\n process\n Gastrointestinal / Abdomen: -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. Cdiff neg x 1. Likely secondary to lactulose.\n Guaiac positive.\n -- rising TBili\n -- ammonia level () = 80\n Nutrition: Tube feeding, goal.\n Renal: -- Q4h calcium checks for Citrate toxicity\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg held when dropped pressure\n Hematology: -- serial Hct (goal > 28)\n -- chronic thrombocytopenia (goal Platelets >30): Plt\n 12->23->18->39->26 post unit plts . tx another unit plt & prbc.\n -- coagulopathic secondary to liver disease (goal INR < 2)\n -- will transfuse if bleeding\n -- Citrate in CVVH filter rather than heparin\n --Fibrinogen 90, Hapto <5 ?acute on chronic dic.\n Endocrine: RISS, -- RISS\n -- cortisol stim test c/w adrenal insufficiency (9-->13-->13.8)\n --hydrocortisone 100mg given 8p when restarted pressors . continue\n q8?\n Infectious Disease: Check cultures, -- OSH BCx: Pasteurella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella). Sensitive to doxycycline.\n -- blood cultures pending, repeated yesterday\n --Tm 99.6 on cvvh -pancultured\n -- ABX: (do not switch to doxy at this time as pt will need\n desensitization and preferred)\n -- cipro d/c'ed \n Lines / Tubes / Drains: RIJ TLC, LIJ HD cath, ETT, Foley, A line,\n dobhoff, flexiseal\n Wounds: --RLE fasciotomies, saph vein exposed. white gauze covering,\n vac over @ 75, lower vac @ 125.\n --diffuse maculopapular rash in axillae, over abdomen, along flanks\n (worse in dependent areas)\n Imaging: CXR today\n Fluids: KVO, Albumin 25% prn hypotension. goal even i/o or slightly\n positive\n Consults: Vascular surgery, Transplant, ID dept, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic), Liver failure\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:03 PM 42 mL/hour\n Comments: tolerating @ goal\n Glycemic Control:\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP bundle:\n Comments: restart stress ulcer prophylaxis in setting of low bp?\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 622080, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n Albumin 25% (12.5g / 50mL), CefePIME, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Clindamycin, Fentanyl, Heparin, Insulin, Lactulose,\n Magnesium Sulfate, MetRONIDAZOLE (FLagyl) , Pantoprazole,\n Phenylephrine, Propofol Rifaximin, Vancomycin\n 24 Hour Events:\n INTUBATION - At 01:00 PM\n INVASIVE VENTILATION - START 01:00 PM\n MULTI LUMEN - START 01:59 PM\n ARTERIAL LINE - START 02:04 PM\n IABP LINE - START 02:05 PM\n MULTI LUMEN - STOP 02:21 PM\n IABP LINE - STOP 02:21 PM\n ARTERIAL LINE - STOP 02:21 PM\n INVASIVE VENTILATION - STOP 02:21 PM\n ARTERIAL LINE - START 07:50 PM\n MULTI LUMEN - START 07:51 PM\n DIALYSIS CATHETER - START 08:00 PM\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Clindamycin - 04:06 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Dextrose 50% - 04:33 AM\n Other medications:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 82 (75 - 95) bpm\n BP: 97/43(59) {74/40(52) - 129/68(85)} mmHg\n RR: 20 (14 - 20) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 271 (15 - 271) mmHg\n Total In:\n 2,774 mL\n 1,635 mL\n PO:\n Tube feeding:\n IV Fluid:\n 960 mL\n 1,035 mL\n Blood products:\n 1,814 mL\n 550 mL\n Total out:\n 119 mL\n 669 mL\n Urine:\n 30 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,655 mL\n 966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 95%\n ABG: 7.40/39/107/22/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : b/l, Rhonchorous : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: No(t) Trace, 1+), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Purulent), ACE wrap in place, serosanginous d/c\n Neurologic: Moves all extremities, Sedated, spontaneous moves\n extremities, does not follow commands\n Labs / Radiology\n 50 K/uL\n 8.9 g/dL\n 62 mg/dL\n 4.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 66 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.9 %\n 8.0 K/uL\n [image002.jpg]\n 07:56 PM\n 08:08 PM\n 10:18 PM\n 10:30 PM\n 12:30 AM\n 12:43 AM\n 04:18 AM\n 04:25 AM\n WBC\n 8.9\n 8.7\n 8.0\n Hct\n 28.1\n 27.7\n 24.9\n Plt\n 48\n 57\n 56\n 50\n Creatinine\n 4.7\n 4.3\n TCO2\n 28\n 29\n 27\n 25\n Glucose\n 63\n 54\n 54\n 62\n Other labs: PT / PTT / INR:21.3/43.1/2.0, Lactic Acid:2.5 mmol/L,\n Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 43M HCV with sepsis, RLE fascitis s/p RLE\n debridement\n Neurologic: sedated on fentanyl, propfol, daily wakeup\n Cardiovascular: minimal neo, wean as tolerated. Hemo stable this AM.\n ECHO to RO endocarditis pos blood cult\n Pulmonary: intubated on CMV, ARDS protocol lung protective, CXR\n unchanged this AM\n Gastrointestinal / Abdomen: NPO, NGT in place, rifaximine, lactulose\n Nutrition: NPO, start TF after returning from the OR\n Renal: acute on chronic renal failure (baseline Cr 1.5), foley in\n place, on CVVH, goal run even\n Hematology: f/u Hct (goal > 28), goals: Platelets > 50 hang before OR,\n INR < 2\n Endocrine: RISS\n ID: Vanc, cefepime, clinda, flagyl for GNR blood (OSH - ), GNR on R\n calf, f/u cultures\n Pasturella from OSH this AM, f/u ID recs.\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, NGT\n Wounds: RLE\n Imaging:\n Fluids: Albumin 25% TID x 3 days PRN hypotension. D10 @10\n Consults: West 1, Vasc, ID\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Patient is critically ill\n ICU Care\n" }, { "category": "Physician ", "chartdate": "2186-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 622083, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n Albumin 25% (12.5g / 50mL), CefePIME, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Clindamycin, Fentanyl, Heparin, Insulin, Lactulose,\n Magnesium Sulfate, MetRONIDAZOLE (FLagyl) , Pantoprazole,\n Phenylephrine, Propofol Rifaximin, Vancomycin\n 24 Hour Events:\n INTUBATION - At 01:00 PM\n INVASIVE VENTILATION - START 01:00 PM\n MULTI LUMEN - START 01:59 PM\n ARTERIAL LINE - START 02:04 PM\n IABP LINE - START 02:05 PM\n MULTI LUMEN - STOP 02:21 PM\n IABP LINE - STOP 02:21 PM\n ARTERIAL LINE - STOP 02:21 PM\n INVASIVE VENTILATION - STOP 02:21 PM\n ARTERIAL LINE - START 07:50 PM\n MULTI LUMEN - START 07:51 PM\n DIALYSIS CATHETER - START 08:00 PM\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Clindamycin - 04:06 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Dextrose 50% - 04:33 AM\n Other medications:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 82 (75 - 95) bpm\n BP: 97/43(59) {74/40(52) - 129/68(85)} mmHg\n RR: 20 (14 - 20) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 271 (15 - 271) mmHg\n Total In:\n 2,774 mL\n 1,635 mL\n PO:\n Tube feeding:\n IV Fluid:\n 960 mL\n 1,035 mL\n Blood products:\n 1,814 mL\n 550 mL\n Total out:\n 119 mL\n 669 mL\n Urine:\n 30 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,655 mL\n 966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 95%\n ABG: 7.40/39/107/22/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : b/l, Rhonchorous : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: No(t) Trace, 1+), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Purulent), ACE wrap in place, serosanginous d/c\n Neurologic: Moves all extremities, Sedated, spontaneous moves\n extremities, does not follow commands\n Labs / Radiology\n 50 K/uL\n 8.9 g/dL\n 62 mg/dL\n 4.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 66 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.9 %\n 8.0 K/uL\n [image002.jpg]\n 07:56 PM\n 08:08 PM\n 10:18 PM\n 10:30 PM\n 12:30 AM\n 12:43 AM\n 04:18 AM\n 04:25 AM\n WBC\n 8.9\n 8.7\n 8.0\n Hct\n 28.1\n 27.7\n 24.9\n Plt\n 48\n 57\n 56\n 50\n Creatinine\n 4.7\n 4.3\n TCO2\n 28\n 29\n 27\n 25\n Glucose\n 63\n 54\n 54\n 62\n Other labs: PT / PTT / INR:21.3/43.1/2.0, Lactic Acid:2.5 mmol/L,\n Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 43M HCV with sepsis, RLE fascitis s/p RLE\n debridement\n Neurologic: sedated on fentanyl, propfol, daily wakeup\n Cardiovascular: minimal neo, wean as tolerated. Hemo stable this AM.\n ECHO to RO endocarditis pos blood cult\n Pulmonary: intubated on CMV, ARDS protocol lung protective, CXR\n unchanged this AM\n Gastrointestinal / Abdomen: NPO, NGT in place, rifaximine, lactulose\n Nutrition: NPO, start TF after returning from the OR\n Renal: acute on chronic renal failure (baseline Cr 1.5), foley in\n place, on CVVH, goal run even\n Hematology: f/u Hct (goal > 28), goals: Platelets > 50 hang before OR,\n INR < 2\n Endocrine: RISS\n ID: Vanc, cefepime, clinda, flagyl for GNR blood (OSH - ), GNR on R\n calf, f/u cultures\n Pasturella from OSH this AM, f/u ID recs.\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, NGT\n Wounds: RLE\n Imaging:\n Fluids: Albumin 25% TID x 3 days PRN hypotension. D10 @10\n Consults: West 1, Vasc, ID\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Patient is critically ill\n ICU Care\n" }, { "category": "Nursing", "chartdate": "2186-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623567, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n BP decreasing at the beginning of the shift, systolic in low 90\ns with\n MAPS decreasing to 50\ns, witnessed by Dr. . CVP 6-8. Temp\n rising to 99.7 on bair hugger with CRRT running. Goal of CRRT was 50cc\n negative/hr at that time. Lungs clear on CPAP 5PS and 5 Peep. Pt\n becoming increasingly agitated, sitting upright in bed and trying to\n pull at ET tube, biting down on tube, low dose Versed and Fentanyl gtts\n at that time requiring many boluses. Not following commands, but\n opening eyes to voice and minimal stimulation, wincing in pain with any\n intervention. MAE. Pt found to have rashy areas on arms, abdomen and\n parts of back, ? petechia vs. rash, shown to Dr. and Dr. .\n UOP increasing throughout the night, averaging 20-30cc/hr of amber\n urine. HCT decreased to 25 and platelets 18 at .\n Action:\n Team notified of decreasing BP and Neo resumed for a MAP >60. Albumin\n 12g, Hydrocortisone 100mg, 1unit of PRBCs and 1 bag of Platelets given.\n Decision made to keep pt\ns fluid balance\neven\n as new goal for CRRT\n (per Dr. . Bair hugger temporarily stopped and pt pan\n cultured. Pt responding to boluses and slight increase in Fentanyl and\n Versed gtts, Fentanyl dose increased first per Dr. . HIT panel sent\n and pending.\n Response:\n Pt responding well to all BP interventions, Neo weaned down to .5mcgs\n this am. Continues to tolerate CRRT with even fluid balance. Breathing\n comfortably on current vent settings, however slight rise in PCO2 due\n to sedation? Versed decreased and resp rate increasing, will recheck\n ABG this am. Platelets increased to 39 following transfusion, down to\n 26 this am, Dr. notified. Hct currently stable.\n Plan:\n Continue to monitor labs closely per CRRT protocol. Fluid balance to\n remain even until BP can tolerate removal of fluid. Wean Neo if\n possible and continue current vent setting with repeat ABGs.\n" }, { "category": "Nutrition", "chartdate": "2186-01-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 622572, "text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 10:05 AM\n Glucose Finger Stick\n 97\n 10:00 PM\n BUN\n 32 mg/dL\n 04:00 AM\n Creatinine\n 2.6 mg/dL\n 04:00 AM\n Sodium\n 133 mEq/L\n 10:05 AM\n Potassium\n 4.5 mEq/L\n 10:05 AM\n Chloride\n 104 mEq/L\n 10:05 AM\n TCO2\n 20 mEq/L\n 04:00 AM\n PO2 (arterial)\n 110 mm Hg\n 10:05 AM\n PCO2 (arterial)\n 37 mm Hg\n 10:05 AM\n pH (arterial)\n 7.32 units\n 10:05 AM\n CO2 (Calc) arterial\n 20 mEq/L\n 10:05 AM\n Albumin\n 4.0 g/dL\n 04:00 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:00 AM\n Phosphorus\n 2.5 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.18 mmol/L\n 10:05 AM\n Magnesium\n 2.4 mg/dL\n 04:00 AM\n ALT\n 29 IU/L\n 04:00 AM\n Alkaline Phosphate\n 57 IU/L\n 04:00 AM\n AST\n 65 IU/L\n 04:00 AM\n Total Bilirubin\n 16.7 mg/dL\n 04:00 AM\n WBC\n 12.4 K/uL\n 04:00 AM\n Hgb\n 10.5 g/dL\n 04:00 AM\n Hematocrit\n 30.6 %\n 04:00 AM\n Current diet order / nutrition support: Novasource Renal @40mL/hr (\n kcals/71 gr protein)\n GI: Abd: soft/distended/hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Change tube feed to Nutren 2.0 w/ 35 grams beneprotein\n @35mL/hr (1804 kcals/97 gr protein)\n Once propofol is off, goal tube feed will be Nutren 2.0 w/\n 28 gr beneprotien @42mL/hr (2115 kcals/105 gr protein)\n Continue w/ residual checks q4 hr, hol dif over 200mL\n Lyte and glucose management as you are\n Following #\n" }, { "category": "Nutrition", "chartdate": "2186-01-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 622575, "text": "Subjective\n Family visiting\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 10:05 AM\n Glucose Finger Stick\n 97\n 10:00 PM\n BUN\n 32 mg/dL\n 04:00 AM\n Creatinine\n 2.6 mg/dL\n 04:00 AM\n Sodium\n 133 mEq/L\n 10:05 AM\n Potassium\n 4.5 mEq/L\n 10:05 AM\n Chloride\n 104 mEq/L\n 10:05 AM\n TCO2\n 20 mEq/L\n 04:00 AM\n PO2 (arterial)\n 110 mm Hg\n 10:05 AM\n PCO2 (arterial)\n 37 mm Hg\n 10:05 AM\n pH (arterial)\n 7.32 units\n 10:05 AM\n CO2 (Calc) arterial\n 20 mEq/L\n 10:05 AM\n Albumin\n 4.0 g/dL\n 04:00 AM\n Calcium non-ionized\n 8.5 mg/dL\n 04:00 AM\n Phosphorus\n 2.5 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.18 mmol/L\n 10:05 AM\n Magnesium\n 2.4 mg/dL\n 04:00 AM\n ALT\n 29 IU/L\n 04:00 AM\n Alkaline Phosphate\n 57 IU/L\n 04:00 AM\n AST\n 65 IU/L\n 04:00 AM\n Total Bilirubin\n 16.7 mg/dL\n 04:00 AM\n WBC\n 12.4 K/uL\n 04:00 AM\n Hgb\n 10.5 g/dL\n 04:00 AM\n Hematocrit\n 30.6 %\n 04:00 AM\n Current diet order / nutrition support: Novasource Renal @40mL/hr (\n kcals/71 gr protein)\n GI: Abd: soft/distended/hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 43 y.o. Male with HCV cirrhosis presenting with sepsis, RLE fasciitis,\n abd pain, GNR bacteremia, now s/p I&D and debridement of RLE. Patient\n remains intubated, sedated and continues on CVVH. Tube feeds started\n via NGT for nutrition and are infusing @ goal. Per discussion w/ RN,\n patient is tolerating well.\n Patient doesn\nt not appear to need a renal formula at this time given\n CVVH and renal lytes WNL. Patient will also likely benefit from a\n higher protein formula in setting of RLE wound.\n Please note current recommended goal is decreased as patient is being\n sedated on propofol providing ~315 kcals/day at current rate.\n Medical Nutrition Therapy Plan - Recommend the Following\n Change tube feed to Nutren 2.0 w/ 35 grams beneprotein\n @35mL/hr (1804 kcals/97 gr protein)\n Once propofol is off, goal tube feed will be Nutren 2.0 w/\n 28 gr beneprotien @42mL/hr (2115 kcals/105 gr protein)\n Continue w/ residual checks q4 hr, hold if over 200mL\n Glucose management as you are\n Lyte management per renal\n Following #\n" }, { "category": "Physician ", "chartdate": "2186-01-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 621905, "text": "Chief Complaint: severe sepsis / septic shock\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 43-year-old man with cirrhosis on transplant list now with lower\n extremity cellulitis, abdominal pain, GNR bacteremia, relative\n hypotension, and elevated lactate to 6.2.\n Symptoms began Monday, including fever to 102.5. Also reports \"spider\n bite.\" Admitted to , transferred here. Arrived\n last night. Other issues as detailed by Dr. note today.\n Now endorses diffuse pain, but especially leg and abdomen (probably\n RUQ).\n Just now seen by surgery, who feel leg is not necrotizing fasciitis or\n compartment syndrome.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, History somewhat\n limited by encephalopathy.\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n see resident note\n Past medical history:\n Family history:\n Social History:\n cirrhosis\n HCV\n CKD with baseline creat about 1.1 - 1.4\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: see resident note\n Review of systems:\n Flowsheet Data as of 11:43 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 (97\n HR: 95 (95 - 95) bpm\n RR: 14 (14 - 14) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,363 mL\n PO:\n TF:\n IVF:\n 108 mL\n Blood products:\n 1,255 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,363 mL\n Respiratory\n SpO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): place, person, month, year, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n [image003.jpg]\n Labs reviewed in OMR. Esp notable for bandemia, thrombocytopenia,\n anemia, coagulopathy, bilirubin 6.2, acute renal failure, lactate 6.2\n OSH BCx reportedly GNR.\n OSH CT LE reportedly negative for abscess\n Assessment and Plan\n 43-year-old man with cirrhosis now with septic shock / severe sepsis\n and GNR bacteremia. Potential sources include leg and abdomen. Seen\n by surgery, who feel this is not necrotizing fasciitis and that he does\n not have compartment syndrome.\n Septic shock / severe sepsis with occult hypoperfusion\n EGDT (place CVL under cover of platelets and FFP)\n ABX: vanco, cefepime, clinda (for toxin)\n Risks of drotrecogin outweigh benefits given\n thrombocytopenia, liver disease, etc.\n CT abdomen and leg (no IV contrast)\n Acute renal failure\n Renal following\n Likely ATN\n Hemodynamic management\n Cirrhosis\n Lactulose, rifaxamin\n No evidence of ascites on ultrasound\n Reasonable to give albumin in setting of cirrhosis / shock\n Hypoxemia\n Multiple potential etiologies (sepsis, liver dz, etc.)\n need intubation\n Other issues as per Dr. \ns note\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:46 AM\n 20 Gauge - 10:47 AM\n Comments:\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: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n ADDENDUM\n Discussed further with Dr. (transplant surgical attending),\n who feels that leg should be explored. I agree.\n Intubated for hypoxemia.\n Central line placed (single needle pass under real-time ultrasound\n guidance) for shock.\n Arterial line placed under real-time ultrasound guidance.\n Discussed with surgical and anesthesia teams.\n Discussed with mother/HCP. questions answered.\n En route to OR now. Has received vanco and cefepime. Will receive\n clindamycin in OR.\n Critically ill. 60 minutes exclusive of procedures.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:22 ------\n" }, { "category": "Respiratory ", "chartdate": "2186-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622191, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR\n" }, { "category": "Respiratory ", "chartdate": "2186-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623729, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Brown / 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: Sedated / Paralyzed,\n Intolerant of weaning attempts, 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" }, { "category": "Respiratory ", "chartdate": "2186-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623843, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\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:\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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2186-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622647, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing.\n Normothermic early noc with bair hugger off but dropped temp to 96\n through evening.\n CRRT in progress, received pt 2.6L positive for the day.\n Heparin gtts infusing via prisma circuit.\n Rt leg incision continues to ooze copious serous drainage.\n Action:\n Throughout evening, PFR increased to remove optimal amount of fluid for\n day.\n Phenylephrine titrated to maintain map>55.\n Labs Q6hours.\n Continuous lyte repletion in progress.\n Bair hugger reapplied.\n Rt leg dressing reinforced to absorb drainage.\n Clindamycin discontinued from antibiotic regimen.\n Response:\n Removed increased fluid through pm, ended day 0.3L positive, pt\n tolerated well but have been aiming for goal of even fluid\n balance after mn since pt slightly more acidotic.\n Required slight increase in pressor support toward this am.\n Electrolytes in balance.\n Hct 30.6, Plts 32, and INR 2.1 this am, Dr aware.\n No signs of bleeding.\n WBC slightly elevated to 12.4 this am, pt afebrile\n Weight down 2kg in last 24hours, fluid calculations are not including\n copious amount of serous fluid loss into bed.\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n VAC dressing to be applied to right thigh by team today.\n Mother will be in this am and wishes to speak with Dr , Dr\n (team resident) notified of this in pm.\n" }, { "category": "Nursing", "chartdate": "2186-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622334, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues on PPF and fent gtt. Easily arousable and moves\n all extremities\n SBP 90\ns. MAP 57-60\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated but occasionally\n running positive\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n RLE incision oozing serous drainage. Teams aware\n Action:\n Labs per protocol\n BFR 250 to prevent clotting\n Dressing changed\n RLE elelvated\n Abx per ID recs\n Response:\n Currently positive\n No clots noted with increased blood flow rate\n Plan:\n cont with crrt\n cont on abx\n wean vent as tolerated\n dressing change at bedside with team today.\n" }, { "category": "Nursing", "chartdate": "2186-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622685, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated and comfortable on Propofol and fentanyl gtts.\n Moving all extremities when awake, upper>lower.\n Phenylephrine gtts infusing@ 0.5mcg/kg/min.\n Normothermic with bair hugger on.\n CRRT in progress, prisma circuit clotted off @ 2100.\n Received pt with heparin gtts infusing via prisma circuit @\n 300units/hr.\n Vac dressings intact on Rt leg.\n Plts 21 in pm, Dr notified who in turn notified transplant\n team, no new orders.\n PTT\ns 60-70.\n Hyperkalemic this am.\n Pt has started stooling.\n Action:\n Was able to return blood but unable to flush lg clots through or\n recirculate. Prisma circuit restarted @ 2300.\n Late evening, PFR increased briefly to remove optimal amount of fluid\n for day.\n Labs Q6hours.\n Continuous electrolyte repletion in progress.\n Bair hugger continued.\n Rt leg vac dressings monitored frequently for bleeding.\n Heparin doses titrated per sliding scale.\n KCL repletions titrated down and stopped @ 0400.\n Fecal collection pouch applied.\n Response:\n BP stable with map>55. Titration of neo not required.\n Thigh vac dressing collecting copious serous drainage, minimal drainage\n from lower leg.\n Electrolytes in balance.\n Hct stable, PTT\ns still elevated @ 70 this am.\n No signs of bleeding.\n WBC slightly elevated to 12.4 this am, pt afebrile\n Weight down 1kg in last 24hours.\n Negative fluid balance attained mostly through leg drainage.\n K+ still 5.3 @ 0600, kcl gtts remain off at this time.\n Plan:\n Maintain CRRT as ordered.\n Start removing fluid as and when per renal recommendations.\n PTT q 6, CRRT labs per protocol\n Wean vent as tolerated.\n Change over to new tube feed regimen when formula obtained today.\n" }, { "category": "Respiratory ", "chartdate": "2186-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622686, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: None\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2186-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622048, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Arrived from intubated and sedated on Propofol and\n Fentanyl gtt\n - When Propofol off pt extremely agitated, attempting to sit\n up and pull at tube, not following commands but did not\n when\n asked if in pain\n - Moving all extremities when sedation off, no movement noted\n on sedation\n - SR 80\ns no ectopy, goal MAP >60, on/off low dose neo , CVP\n 19 upon arrival and increasing\n - Lungs clear but diminished\n - Arrived on 100% fio2 with 10 PEEP\n - FiO2 decreased to 60% after initial ABG and Sats down to low\n 90\ns with paO2 low 70\n - ABD firmly distended with + BS, NGT to SXN putting out thin\n brown/bilious output\n - Minimal urine output noted\n - CRRT initiated after pt settled, running for filtration and\n attempting to run even without taking off additional fluid\n - RLE wrapped in ace wrap from OR with copious amts serosang\n drainage\n - LLE with some area\ns of errythema\n evaluated by transplant\n residents Dr and Dr \n and by Dr \n Action:\n - Propofol weaned down slowly this am to attempt to lessen\n sedation without causing agitation\n - Fentanyl gtt increased for comfort\n - Albumin given per order\n ordered for spontaneous bacterial\n peritonitis, per pharmacy protocol first dose is recommended @ 1.5\n gm/kg. Dose and indicated verified with Dr who verified this\n with Dr \n. Also verified with pharmacist by this RN and Dr\n .\n - FiO2 and PEEP increased overnight\n - FiO2 weaned down with improving ABG\n - Running CRRT even as tolerated but at times running positive\n to maintain lower pressor requirement. Ok to keep low dose neo to\n maintain even fluid balance per Dr .\n - Q2 pulse checks on RLE\n Response:\n - Tolerating lower dose propofol\n - Tolerating even fluid balance this am\n - Improving ABG\ns with increased PEEP\n Plan:\n - Continue to run CRRT to maintain even balance as tolerated\n - Continue with ABX\n - Wean vent as tolerated\n - Back to OR today\n" }, { "category": "Nursing", "chartdate": "2186-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622543, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues on PPF and fent gtt. Easily arousable and moves\n all extremities\n SBP 90\ns. MAP 57-60 with dips into high 80\ns and MAP 50.\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated but occasionally\n running positive\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n RLE incision oozing serous drainage. Teams aware\n Action:\n Neo resumed\n Labs per protocol\n BFR 250 to prevent clotting\n PBP changed to 2800\n Bair hugger on/off\n Dressing changed at bedside by primary team\n RLE elelvated\n Abx per ID recs\n Albumin 25%\n Phos repleted with 15 mmol NaPhos\n Response:\n Currently positive\n Filter clotted at 1600. CRRT reinitiated at 1730. Heparin\n infusing at 500 units/hr. PBP back to per renal fellow.\n SBP 95-101. MAP 57-61. Remains on 0.5 Neo.\n Plan:\n cont with CRRT\n check PTT q 6, CRRT labs per protocol\n cont on abx\n wean vent as tolerated\n VAC dsg to right thigh tomorrow (bedside)\n" }, { "category": "Nursing", "chartdate": "2186-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623885, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Normothermic. HR 90-110 sinus tach & MAP 60-70. WBC count elevated.\n Pt on low dose Argatroban gtt, PTT 94. CVVH on, running patient even,\n CVP ~ 10. Patient making small amounts urine. CPAP 5/5, lung sounds\n clear. Patient opens eyes to stimulation, moves extremities but does\n not follow commands. Large amounts brown/black guiac + stool, HCT drop\n to 23. Wound vac dressings intact with large brown serous drainage.\n Action:\n Neo gtt weaned off. Patient given 2 units prbcs. Argatroban gtt off.\n Patient remains on Fentanyl gtt and given Ativan as needed.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2186-01-28 00:00:00.000", "description": "Intensivist Note", "row_id": 622320, "text": "TITLE:\n SICU\n HPI: sepsis\n Chief complaint: 43M with HCV cirrhosis presenting with sepsis, RLE\n fascitis s/p I&D and debridement\n PMHx: Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype\n 1, Hx of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr\n 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Meropenem 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 0850\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846\n 19. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 3. Albumin 5% (25g / 500mL) 25 g IV ONCE Duration: 1 Doses Order date:\n @ 1757\n 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 21. Neutra-Phos 2 PKT PO/NG ONCE Duration: 1 Doses Order date: @\n 2328\n 5. Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @\n 0850\n 22. Pantoprazole 40 mg IV Q24H Order date: @ \n 6. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319\n 23. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order\n date: @ 2252\n 7. Clindamycin 600 mg IV Q6H Order date: @ 1631\n 24. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 8. D10\n Continuous at 10 ml/hr Order date: @ 0720\n 25. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 9. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 26. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO comfort on vent\n Order date: @ 1631\n 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 1631\n 27. Prismasate (B22 K4)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 1846\n 11. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 28. Prismasate (B22 K4)\n Continuous at 2200 ml/hr\n Infuse Replacement fluid: Prefilter Rate: Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 1846\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 29. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 30. 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: @ 1631\n 14. Heparin 5000 UNIT SC BID Order date: @ 1631\n 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 32. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 33. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 1515\n 17. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 34. Vancomycin 1000 mg IV Q 24H Order date: @ 1542\n 24 Hour Events:\n OR SENT - At 10:41 AM\n OR RECEIVED - At 12:05 PM\n TRANSTHORACIC ECHO - At 01:28 PM\n mild to moderate MR , pulm pressure ok\n - to OR for RLE debridement. Transfused 1 FFP, 1 PLT, 2 PRBC\n Post operative day:\n POD#1 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Vancomycin - 09:00 AM\n Meropenem - 12:00 AM\n Ciprofloxacin - 04:00 AM\n Clindamycin - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:30 PM\n Fentanyl - 12:00 AM\n Dextrose 50% - 04:29 AM\n Other medications:\n Flowsheet Data as of 05:30 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: 35.9\nC (96.7\n HR: 77 (77 - 84) bpm\n BP: 99/45(60) {93/41(57) - 131/72(88)} mmHg\n RR: 20 (18 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 20 (19 - 27) mmHg\n Total In:\n 6,605 mL\n 1,295 mL\n PO:\n Tube feeding:\n 60 mL\n 55 mL\n IV Fluid:\n 4,044 mL\n 1,155 mL\n Blood products:\n 2,246 mL\n Total out:\n 4,648 mL\n 953 mL\n Urine:\n 84 mL\n 14 mL\n NG:\n 800 mL\n Stool:\n Drains:\n Balance:\n 1,957 mL\n 343 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, No Spon Resp\n PIP: 27 cmH2O\n Plateau: 24 cmH2O\n Compliance: 43.1 cmH2O/mL\n SPO2: 97%\n ABG: 7.36/38/104/20/-3\n Ve: 11.7 L/min\n PaO2 / FiO2: 173\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, intubated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: Trace, No(t) 1+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: ACE wrap in place, serosanginous d/c\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 38 K/uL\n 9.9 g/dL\n 69 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 46 mg/dL\n 106 mEq/L\n 136 mEq/L\n 29.1 %\n 7.9 K/uL\n [image002.jpg]\n 06:45 AM\n 10:27 AM\n 10:33 AM\n 01:20 PM\n 04:00 PM\n 04:09 PM\n 10:00 PM\n 10:07 PM\n 04:02 AM\n 04:22 AM\n WBC\n 6.8\n 7.4\n 7.5\n 7.9\n Hct\n 26.5\n 28.5\n 27.9\n 29.1\n Plt\n 30\n 38\n 34\n 38\n Creatinine\n 3.4\n 3.6\n 3.4\n TCO2\n 24\n 25\n 24\n 23\n 24\n 22\n Glucose\n 72\n 91\n 84\n 73\n 68\n 64\n 85\n 66\n 69\n Other labs: PT / PTT / INR:24.3/50.3/2.3, ALT / AST:32/68, Alk-Phos / T\n bili:45/13.3, Lactic Acid:1.6 mmol/L, Albumin:4.2 g/dL, Ca:8.6 mg/dL,\n Mg:2.3 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies\n Neurologic:\n -- intubated and sedated with propofol\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl gtt, fentanyl IV prn\n breakthrough pain\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60. off pressor this AM\n -- albumin prn\n -- echocardiogram - EF 55%. Moderate to severe MR, mild pulmonary\n artery systolic hypertension. No visible vegetations. A focal wall\n motion abnormality of the LV (mid infero-lateral hypokinesis) is now\n suggested. ? Involving papillary muscles c/w ischemic disease\n Pulmonary:\n --intubated on CMV, ARDS protocol PEEP=12\n Gastrointestinal / Abdomen:\n -- dobhoff in place\n -- TF started at low rate\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- GI prophy: pantoprazole\n Nutrition:\n -- Novasource Renal Full strength @ 10cc/hr\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even\n Hematology:\n -- serial Hct (goal > 28): Hct 29.1\n -- chronic thrombocytopenia (goal Platelets >30): Plt 66\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.3\n -- Transfused : 1 FFP, 1 PLT, 2 PRBC\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: gram positive bacteria\n -- blood cultures\n in house cx\ns pending.\n -- ID consulted\n -- ABX: , cipro, clinda, vanco\n -- do not recommend IVIG as that can worsen renal failure and ARDS\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE\n Imaging: CXR\n Fluids: D10 @ 10cc/hr, Albumin 25% prn hypotension\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Physician ", "chartdate": "2186-01-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 621881, "text": "Chief Complaint: severe sepsis / septic shock\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 43-year-old man with cirrhosis on transplant list now with lower\n extremity cellulitis, abdominal pain, GNR bacteremia, relative\n hypotension, and elevated lactate to 6.2.\n Symptoms began Monday, including fever to 102.5. Also reports \"spider\n bite.\" Admitted to , transferred here. Arrived\n last night. Other issues as detailed by Dr. note today.\n Now endorses diffuse pain, but especially leg and abdomen (probably\n RUQ).\n Just now seen by surgery, who feel leg is not necrotizing fasciitis or\n compartment syndrome.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy, History somewhat\n limited by encephalopathy.\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n see resident note\n Past medical history:\n Family history:\n Social History:\n cirrhosis\n HCV\n CKD with baseline creat about 1.1 - 1.4\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: see resident note\n Review of systems:\n Flowsheet Data as of 11:43 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 (97\n HR: 95 (95 - 95) bpm\n RR: 14 (14 - 14) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,363 mL\n PO:\n TF:\n IVF:\n 108 mL\n Blood products:\n 1,255 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,363 mL\n Respiratory\n SpO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): place, person, month, year, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n [image003.jpg]\n Labs reviewed in OMR. Esp notable for bandemia, thrombocytopenia,\n anemia, coagulopathy, bilirubin 6.2, acute renal failure, lactate 6.2\n OSH BCx reportedly GNR.\n OSH CT LE reportedly negative for abscess\n Assessment and Plan\n 43-year-old man with cirrhosis now with septic shock / severe sepsis\n and GNR bacteremia. Potential sources include leg and abdomen. Seen\n by surgery, who feel this is not necrotizing fasciitis and that he does\n not have compartment syndrome.\n Septic shock / severe sepsis with occult hypoperfusion\n EGDT (place CVL under cover of platelets and FFP)\n ABX: vanco, cefepime, clinda (for toxin)\n Risks of drotrecogin outweigh benefits given\n thrombocytopenia, liver disease, etc.\n CT abdomen and leg (no IV contrast)\n Acute renal failure\n Renal following\n Likely ATN\n Hemodynamic management\n Cirrhosis\n Lactulose, rifaxamin\n No evidence of ascites on ultrasound\n Reasonable to give albumin in setting of cirrhosis / shock\n Hypoxemia\n Multiple potential etiologies (sepsis, liver dz, etc.)\n need intubation\n Other issues as per Dr. \ns note\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:46 AM\n 20 Gauge - 10:47 AM\n Comments:\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: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 622029, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n Albumin 25% (12.5g / 50mL), CefePIME, Chlorhexidine Gluconate 0.12%\n Oral Rinse, Clindamycin, Fentanyl, Heparin, Insulin, Lactulose,\n Magnesium Sulfate, MetRONIDAZOLE (FLagyl) , Pantoprazole,\n Phenylephrine, Propofol Rifaximin, Vancomycin\n 24 Hour Events:\n INTUBATION - At 01:00 PM\n INVASIVE VENTILATION - START 01:00 PM\n MULTI LUMEN - START 01:59 PM\n ARTERIAL LINE - START 02:04 PM\n IABP LINE - START 02:05 PM\n MULTI LUMEN - STOP 02:21 PM\n IABP LINE - STOP 02:21 PM\n ARTERIAL LINE - STOP 02:21 PM\n INVASIVE VENTILATION - STOP 02:21 PM\n ARTERIAL LINE - START 07:50 PM\n MULTI LUMEN - START 07:51 PM\n DIALYSIS CATHETER - START 08:00 PM\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Clindamycin - 04:06 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Dextrose 50% - 04:33 AM\n Other medications:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 82 (75 - 95) bpm\n BP: 97/43(59) {74/40(52) - 129/68(85)} mmHg\n RR: 20 (14 - 20) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 271 (15 - 271) mmHg\n Total In:\n 2,774 mL\n 1,635 mL\n PO:\n Tube feeding:\n IV Fluid:\n 960 mL\n 1,035 mL\n Blood products:\n 1,814 mL\n 550 mL\n Total out:\n 119 mL\n 669 mL\n Urine:\n 30 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,655 mL\n 966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 95%\n ABG: 7.40/39/107/22/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : b/l, Rhonchorous : R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: No(t) Trace, 1+), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Purulent), ACE wrap in place, serosanginous d/c\n Neurologic: Moves all extremities, Sedated, spontaneous moves\n extremities, does not follow commands\n Labs / Radiology\n 50 K/uL\n 8.9 g/dL\n 62 mg/dL\n 4.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 66 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.9 %\n 8.0 K/uL\n [image002.jpg]\n 07:56 PM\n 08:08 PM\n 10:18 PM\n 10:30 PM\n 12:30 AM\n 12:43 AM\n 04:18 AM\n 04:25 AM\n WBC\n 8.9\n 8.7\n 8.0\n Hct\n 28.1\n 27.7\n 24.9\n Plt\n 48\n 57\n 56\n 50\n Creatinine\n 4.7\n 4.3\n TCO2\n 28\n 29\n 27\n 25\n Glucose\n 63\n 54\n 54\n 62\n Other labs: PT / PTT / INR:21.3/43.1/2.0, Lactic Acid:2.5 mmol/L,\n Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 43M with sepsis, RLE fascitis s/p RLE debridement\n Neurologic: sedated on fentanyl, propfol, daily wakeup\n Cardiovascular: minimal neo, wean as tolerated\n Pulmonary: intubated on CMV, ARDS protocol, CXR pending\n Gastrointestinal / Abdomen: NPO, NGT in place, rifaximine, lactulose\n Nutrition: NPO, start TF after returning from the OR\n Renal: acute on chronic renal failure (baseline Cr 1.5), foley in\n place, on CVVH, goal run even\n Hematology: f/u Hct (goal > 28), Platelets > 50, INR < 2\n Endocrine: RISS\n ID: Vanc, cefepime, clinda, flagyl for GNR blood (OSH - ), GNR on R\n calf, f/u cultures, f/u ID recs\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, NGT\n Wounds: RLE\n Imaging:\n Fluids: Albumin 25% TID x 3 days\n Consults: West 1, Vasc, ID\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n Patient is critically ill\n ICU Care\n" }, { "category": "Nursing", "chartdate": "2186-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622038, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Arrived from intubated and sedated on Propofol and\n Fentanyl gtt\n - When Propofol off pt extremely agitated, attempting to sit\n up and pull at tube, not following commands but did not\n when\n asked if in pain\n - Moving all extremities when sedation off, no movement noted\n on sedation\n - SR 80\ns no ectopy, goal MAP >60, on/off low dose levophed,\n CVP 19 upon arrival and increasing\n - Lungs clear but diminished\n - Arrived on 100% fio2 with 10 PEEP\n - FiO2 decreased to 60% after initial ABG and Sats down to low\n 90\ns with paO2 low 70\n - ABD firmly distended with + BS, NGT to SXN putting out thin\n brown/bilious output\n - Minimal urine output noted\n - CRRT initiated after pt settled, running for filtration and\n attempting to run even without taking off additional fluid\n - RLE wrapped in ace wrap from OR with copious amts serosang\n drainage\n - LLE with some area\ns of errythema\n evaluated by transplant\n residents Dr and Dr \n and by TRan\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622308, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - remains lightly sedated on propofol and fentanyl gtt\n - wakes to stimulation and becomes very aggiated when awake\n - moves all extremities\n - hemodynamics stable although bp borderline with maps right @\n 60\n - albumin given over evening shift to increase blood pressure\n - running crrt even as tolerated but occasionally running\n positive\n transplant chief aware.\n - Crrt filter clotted after less than 12 hrs use and had\n clotted on previous shift\n Action:\n - monitor hemodynamics and run as close to even as bp will\n tolerate\n - blood flow rate increased to 300 to prevent clotting\n - transplant team aware of blood pressure trends, am labs\n including elevated inr, and frequency of clotting filters\n - right leg elevated\n Response:\n - ~ 300cc positive this am\n - No clots noted with increased blood flow rate\n Plan:\n - cont with crrt\n - cont on abx\n - wean vent as tolerated\n - dressing change at bedside with team today.\n" }, { "category": "Physician ", "chartdate": "2186-01-29 00:00:00.000", "description": "Intensivist Note", "row_id": 622510, "text": "SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n RLE cellulitis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n Albumin 25% (12.5g / 50mL) 4. Chlorhexidine Gluconate 0.12% Oral Rinse\n 5. Ciprofloxacin 6. D10 7. Dextrose 50% 8. Dextrose 50% 9. Fentanyl\n Citrate 10. Fentanyl Citrate\n 11. Glucagon 12. Heparin 13. Heparin CRRT 14. Insulin 15. Lactulose 16.\n Magnesium Sulfate 17. Meropenem\n 18. Methadone 19. Pantoprazole 20. Phenylephrine 21. Potassium Chloride\n 10 mEq / 100 mL SW (CRRT Only)\n 22. Potassium Chloride 23. Propofol 24. Prismasate (B22 K4)* 25.\n Prismasate (B22 K4) 26. Rifaximin\n 27. Sodium Chloride 0.9% Flush 28. Sodium Chloride 0.9% Flush 29.\n Sodium CITRATE 4% 30. Sodium Phosphate\n 31. Vancomycin\n 24 Hour Events:\n OR SENT - At 10:41 AM\n OR RECEIVED - At 12:05 PM\n TRANSTHORACIC ECHO - At 01:28 PM\n mild to moderate MR , pulm pressure ok\n EKG - At 02:00 AM\n Post operative day:\n POD#2 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:50 PM\n Metronidazole - 02:00 AM\n Vancomycin - 09:10 AM\n Ciprofloxacin - 08:00 PM\n Clindamycin - 10:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Heparin Sodium - 500 units/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 04:29 AM\n Propofol - 12:30 PM\n Fentanyl - 01:02 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Pantoprazole (Protonix) - 12:10 AM\n Other medications:\n Flowsheet Data as of 03:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 35.7\nC (96.3\n HR: 73 (71 - 82) bpm\n BP: 95/40(55) {95/39(55) - 118/51(67)} mmHg\n RR: 20 (11 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 19 (14 - 23) mmHg\n Total In:\n 5,569 mL\n 1,033 mL\n PO:\n Tube feeding:\n 482 mL\n 152 mL\n IV Fluid:\n 4,802 mL\n 822 mL\n Blood products:\n 50 mL\n Total out:\n 5,009 mL\n 1,106 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 21 cmH2O\n Plateau: 24 cmH2O\n Compliance: 45 cmH2O/mL\n SPO2: 99%\n ABG: 7.32/37/80/18/-6\n Ve: 8.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, ascites\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+)\n Skin: (Incision: Purulent), RLE dressing w/serosanguinous staining\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 38 K/uL\n 10.5 g/dL\n 128 mg/dL\n 3.1 mg/dL\n 18 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 104 mEq/L\n 133 mEq/L\n 30.3 %\n 10.6 K/uL\n [image002.jpg]\n 10:07 PM\n 04:02 AM\n 04:22 AM\n 07:03 AM\n 08:28 AM\n 10:19 AM\n 02:02 PM\n 06:50 PM\n 10:00 PM\n 10:09 PM\n WBC\n 7.9\n 11.7\n 10.6\n Hct\n 29.1\n 30.5\n 30.3\n Plt\n 38\n 44\n 38\n Creatinine\n 3.0\n 2.6\n 3.1\n TCO2\n 24\n 22\n 23\n 22\n 23\n 20\n 20\n Glucose\n 66\n 69\n 87\n 86\n 109\n 88\n 84\n 129\n 128\n Other labs: PT / PTT / INR:21.9/50.3/2.0, ALT / AST:32/68, Alk-Phos / T\n bili:45/13.3, Lactic Acid:1.7 mmol/L, Albumin:4.0 g/dL, Ca:8.5 mg/dL,\n Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT: 43M with cirrhosis, sepsis, RLE\n fascitis s/p RLE debridement and fasciotomies\n Neurologic:\n -- intubated and sedated with propofol\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl gtt, fentanyl IV prn\n breakthrough pain\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60\n -- albumin prn\n Pulmonary:\n -- intubated on CMV, ARDS protocol, wean PEEP\n Gastrointestinal / Abdomen:\n -- dobhoff in place\n -- TF advancing to goal\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- GI prophy: pantoprazole\n Nutrition:\n -- Novasource Renal Full advance to goal 40/hr (25kcal/kg)\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even\n mild non-gap metabolic acidosis,\n d/w renal regarding change dialysate to B32 solution\n Hematology:\n -- serial Hct (goal > 28): Hct......\n -- chronic thrombocytopenia (goal Platelets >30): transfuse platelets\n for active bleeding.\n -- coagulopathic secondary to liver disease (goal INR < 2): transfuse\n FFP for active bleeding.\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph), GNR (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, clinda, vanco\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE\n Imaging:\n Fluids: D10 @ 10cc/hr, Albumin 25% prn hypotension\n d/c D10 today on\n tube feeds.\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: PPI\n VAP bundle: +\n Comments: ICU consent completed\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 09:58 PM 40. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:50 PM\n Multi Lumen - 07:51 PM\n Dialysis Catheter - 08:00 PM\n 18 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2186-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623036, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - sedated on Fentanyl and versed gtt\n - wakes with stimulation but does not follow commands\n - hr stable\n - afebrile\n - maps 58-62\n - lungs clear\n - min amt icteric urine\n - crrt running -50cc/hr to even as tolerated\n - filter clotted @ 0930\n - ptt therapeutic\n - wound vac to thigh and calf with thigh areas to vac @ 75 and\n calf area to vac @ 125\n - lg amt liquid stool output Flexi Seal.\n Action:\n - Crrt resumed @ 1200\n - No changes to vent settings.\n - Weaning Vercid as ordered, currently 0.5mg/hr.\n - Continued Neo @ 0.5mcg/kg/min.\n Response:\n - no s/sx bleeding\n - resp status stable\n - Awaiting pending labs.\n - cont to monitor liver function, lytes, i/o.\n" }, { "category": "Respiratory ", "chartdate": "2186-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622024, "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: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: No RSBI done due to sedation and no spont resp.\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: Will cont to monitor resp status.\n" }, { "category": "Respiratory ", "chartdate": "2186-01-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622284, "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: Unknown\n Procedure location: ICU\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 Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2186-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622842, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sedated on Propofol\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622843, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement .\n Sedated on Propofol and Fentanyl. Neo gtt to maintain MAP>60. AC vent\n with peep 12. CRRT to maintain even\n50 negative as tolerated. Vac\n dressing with large serous output upper thigh >1L. Fecal bag with large\n stool output.\n Action:\n Weaned off Propofol and transitioned to PRN Midaz. Neo requirement\n increased due to hypotension to MAP50\ns. Peep down to 8 from 12. CRRT\n filter clotted and required new filter but issues with line may be\n affecting pressure as well. TPA dwelled in HD lines x1hr today without\n much effect. Return line positional and sluggish initially to\n flush.Spoke to Renal fellow and he is aware of filter and line issues.\n PBP manipulated for best results and this is ok with him as well.\n Heparin drip increased slightly to improve filter performance-Dr.\n and sicu/transplant team aware and ok\nd. Labs monitored\n closely.\n Response:\n Continued high CRRT return pressures.\n Plan:\n Maintain even fluid status, troubleshoot CRRT and TPA line again. F/u\n labs. Consider changing line in am.\n" }, { "category": "Physician ", "chartdate": "2186-01-31 00:00:00.000", "description": "Intensivist Note", "row_id": 622911, "text": "TITLE:\n SICU\n HPI:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n Chief complaint:\n sepsis\n PMHx:\n Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype 1, Hx\n of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr 1.5)\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1631\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 0154\n 2. 20 gm Calcium Gluconate/ 500 mL D5W Continuous\n Initial Rate: 30 ml/hr\n w/ Sliding Scale\n Monitor ionized calcium. MD >1.3 or <0.9 Part of CRRT\n protocol. Order date: @ 1846\n 19. Meropenem 1000 mg IV Q12H Order date: @ 0850\n 3. Alteplase 1mg/Flush Volume ( Dialysis/Pheresis Catheters ) 1\n mg IV ONCE MR1 Duration: 1 Doses\n Alteplase 1mg/ 1.2 mL (Dialysis/Pheresis Catheters Order date: @\n 1821\n 20. Methadone 64 mg PO/NG DAILY\n please give liquid formulation Order date: @ 1434\n 4. Alteplase 1mg/Flush Volume ( Dialysis/Pheresis Catheters ) 1\n mg IV ONCE MR1 Duration: 1 Doses\n Alteplase 1mg/ 1.3 mL (Dialysis/Pheresis Catheters Order date: @\n 1821\n 21. Midazolam 0.5-2 mg IV Q2H:PRN anxiety Order date: @ 1105\n 5. Albumin 25% (12.5g / 50mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 0459\n 22. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1821\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1645\n 23. Miconazole Powder 2% 1 Appl TP QID:PRN rash\n apply to sacral area Order date: @ 2133\n 7. Ciprofloxacin 400 mg IV Q 8H Order date: @ 1319\n 24. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 Order\n date: @ 2252\n 8. Dextrose 50% 25 gm IV PRN BG<60 Order date: @ 1631\n 25. Potassium Chloride 10 mEq / 100 mL SW (CRRT Only) Continuous\n Initial Rate: 20 ml/hr\n w/ Sliding Scale\n CRRT sliding scale. For K <3.0, increase rate 50% and call renal\n fellow. For K >4.6, decrease rate 50% and recheck K in hours. Order\n date: @ 1846\n 9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1631\n 26. Potassium Chloride 40 mEq / 100 ml SW IV PRN for K < 3.0\n To supplement CRRT KCL infusion sliding scale protocol. Call renal\n fellow for K <3.0 Order date: @ 1846\n 10. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Order date:\n @ 1821\n 27. Prismasate (B32 K2)*\n Continuous at 500 ml/hr\n Dialysate Solution for CRRT Order date: @ 0819\n 11. Fentanyl Citrate 25-200 mcg/hr IV DRIP TITRATE TO comfort on vent\n Order date: @ \n 28. Prismasate (B32 K2)\n Continuous at 2700 ml/hr\n Infuse Replacement fluid: Prefilter Rate:2500 Postfilter Rate:200\n Replacement Solution for CRRT Order date: @ 2335\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN breakthrough pain Order\n date: @ \n 29. Rifaximin 400 mg PO/NG TID Order date: @ 1434\n 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:\n @ 1631\n 30. 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: @ 1631\n 14. Heparin 5000 UNIT SC BID Order date: @ 1631\n 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1631\n 15. Heparin CRRT IV Sliding Scale\n No Initial Bolus\n Initial Infusion Rate: 500 units/hr\n Part of CRRT Protocol Order date: @ 2133\n 32. Sodium CITRATE 4% 1.5 mL DWELL ASDIR catheter not in use\n Renal fellow to specify volume to instill for catheter dwell. Order\n date: @ 1846\n 16. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1631\n 33. Sodium Phosphate IV Sliding Scale Order date: @ 1525\n 17. Lactulose 30 mL PO/NG TID constipation\n hold if having >3 BMs per day Order date: @ 1631\n 24 Hour Events:\n EKG - At 03:40 AM\n - d/c'ed GI prophy, changed sedation to versed, 25g albumin IV\n bolus x 1\n - 25g albumin IV bolus x1. Alteplase to HD line and filter for\n CVVH machine clotting frequently.\n Post operative day:\n POD#4 - right leg wound exploration\n Allergies:\n Sulfa (Sulfonamides)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Clindamycin - 10:00 PM\n Vancomycin - 08:25 AM\n Ciprofloxacin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Phenylephrine - 1.2 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 75 mcg/hour\n Heparin Sodium - 150 units/hour\n Other ICU medications:\n Midazolam (Versed) - 07:50 PM\n Other medications:\n Flowsheet Data as of 05:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.3\n HR: 77 (68 - 87) bpm\n BP: 111/41(61) {99/37(52) - 159/82(101)} mmHg\n RR: 17 (17 - 37) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.3 kg (admission): 98.8 kg\n Height: 72 Inch\n CVP: 11 (11 - 17) mmHg\n Total In:\n 4,308 mL\n 1,002 mL\n PO:\n Tube feeding:\n 925 mL\n 210 mL\n IV Fluid:\n 3,063 mL\n 791 mL\n Blood products:\n 50 mL\n Total out:\n 5,737 mL\n 1,211 mL\n Urine:\n 142 mL\n 39 mL\n NG:\n Stool:\n Drains:\n 1,475 mL\n 500 mL\n Balance:\n -1,429 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 49.5 cmH2O/mL\n SPO2: 97%\n ABG: 7.40/40/119/23/0\n Ve: 11 L/min\n PaO2 / FiO2: 298\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, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), vac dressings in place RLE\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 18 K/uL\n 9.9 g/dL\n 98 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 31 mg/dL\n 103 mEq/L\n 134 mEq/L\n 29.3 %\n 9.6 K/uL\n [image002.jpg]\n 10:08 PM\n 04:00 AM\n 04:17 AM\n 10:03 AM\n 10:20 AM\n 02:00 PM\n 03:39 PM\n 10:00 PM\n 03:08 AM\n 03:24 AM\n WBC\n 12.2\n 11.2\n 9.6\n Hct\n 31.1\n 29.5\n 29.3\n Plt\n 21\n 22\n 18\n Creatinine\n 2.6\n 2.4\n 2.8\n 1.8\n TCO2\n 21\n 22\n 20\n 23\n 26\n Glucose\n 120\n 114\n 123\n 136\n 100\n 98\n Other labs: PT / PTT / INR:24.6/79.8/2.4, ALT / AST:28/78, Alk-Phos / T\n bili:67/20.8, Lactic Acid:1.7 mmol/L, Albumin:4.0 g/dL, Ca:8.3 mg/dL,\n Mg:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 43M with cirrhosis, sepsis, RLE fascitis s/p RLE\n debridement and fasciotomies. Blood & tissue cx Pasteurella Multocida &\n coag neg staph.\n Neurologic:\n -- intubated and sedated with midazolam\n -- arousable, moves all extremities\n -- pain control: methadone po, fentanyl\n Cardiovascular:\n -- phenylephrine gtt prn MAP < 60\n -- albumin prn (got , , )\n -- lactate 1.7\n Pulmonary:\n -- intubated on CMV, ARDS protocol, wean PEEP. ?need for early trach\n -- cmv 20x500/0.4/8, 7.40/40/119/26/0\n Gastrointestinal / Abdomen:\n -- dobhoff in place, TF\n -- Hx of HCV Cirrhosis c/b encephalopathy and hx of ascites: cont\n rifaximine, lactulose\n -- profuse stooling. F/u Cdiff\n Nutrition:\n -- TF: Nutren 2.0 w/ 35gm beneprotein. Goal 42cc/h off propofol.\n Renal:\n -- acute on chronic renal failure (baseline Cr 1.5)\n -- foley in place\n -- Currently on CVVH: goal I/O even/neg.\n -- consider replacing HD access line\n Hematology:\n -- serial Hct (goal > 28): Hct 29.3\n -- chronic thrombocytopenia (goal Platelets >30): Plt 18. no bleeding,\n no transfusion @ this time.\n -- coagulopathic secondary to liver disease (goal INR < 2): INR 2.4\n -- will transfuse if bleeding\n -- q6PTT for CVVH\n Endocrine: RISS\n ID:\n -- OSH BCx: Pasturella.\n -- wound cultures: GPC's (coag neg staph-likely contaminant), GNR\n (likely pasturella)\n -- blood cultures pending\n -- ABX: , cipro, (vanco d/cd )\n T/L/D: RIJ TLC, LIJ HD cath, ETT, Foley, A line, dobhoff\n Wounds: RLE fasciotomies, saph vein exposed. white gauze covering, vac\n over @ 75, lower vac @ 125.\n Imaging:\n Fluids: KVO, Albumin 25% prn hypotension\n Consults: West 1, Vasc, ID, Renal\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: SQH, boot x 1\n Stress ulcer: n/a\n VAP bundle: +\n Comments: ICU consent completed\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Respiratory ", "chartdate": "2186-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 623092, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\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: ICU\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 Cuff Management:\n Press: Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nutrition", "chartdate": "2186-01-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 622151, "text": "Subjective: Patient intubated and sedated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 98.8 kg\n 29.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 122%\n 85.5 kg\n Diagnosis: Leg pain, Elevated Creatinine\n PMHx: Cirrhosis, c/b encephalopathy and hx of ascites, Hep C, genotype\n 1, Hx of prior IVDU, Chronic right leg edema, Chronic renal failure (Cr\n 1.5)\n Food allergies and intolerances: none noted\n Pertinent medications: Propofol, Fentanyl, Neosynephrine, ABx, heparin,\n Lactulose, Protonix, rifaximin, others noted\n Labs:\n Value\n Date\n Glucose\n 73 mg/dL\n 01:20 PM\n Glucose Finger Stick\n 97\n 10:00 AM\n BUN\n 54 mg/dL\n 10:27 AM\n Creatinine\n 3.4 mg/dL\n 10:27 AM\n Sodium\n 137 mEq/L\n 10:27 AM\n Potassium\n 3.8 mEq/L\n 01:20 PM\n Chloride\n 104 mEq/L\n 10:27 AM\n TCO2\n 22 mEq/L\n 10:27 AM\n PO2 (arterial)\n 175 mm Hg\n 01:20 PM\n PCO2 (arterial)\n 41 mm Hg\n 01:20 PM\n pH (arterial)\n 7.35 units\n 01:20 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 01:20 PM\n Albumin\n 4.2 g/dL\n 10:27 AM\n Calcium non-ionized\n 9.0 mg/dL\n 10:27 AM\n Phosphorus\n 2.6 mg/dL\n 10:27 AM\n Ionized Calcium\n 1.12 mmol/L\n 01:20 PM\n Magnesium\n 2.3 mg/dL\n 10:27 AM\n ALT\n 37 IU/L\n 10:27 AM\n Alkaline Phosphate\n 38 IU/L\n 10:27 AM\n AST\n 72 IU/L\n 10:27 AM\n Total Bilirubin\n 11.4 mg/dL\n 10:27 AM\n WBC\n 6.8 K/uL\n 10:27 AM\n Hgb\n 9.4 g/dL\n 10:27 AM\n Hematocrit\n 26.5 %\n 10:27 AM\n Current diet order / nutrition support: Diet: NPO\n GI: abd soft, bowel sounds absent\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: cirrhosis, possible prolonged intubation\n Estimated Nutritional Needs\n Calories: 2140-2565 (25-30 cal/kg)\n Protein: 102-120 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 43 y.o. Male with HCV cirrhosis presenting with sepsis, RLE fasciitis,\n abd pain, GNR bacteremia, now s/p I&D and debridement of RLE. Patient\n remains intubated, sedated and on CVVH. NGT just placed for tube feeds\n and medications. Patient does not appear to need a renal formula at\n this time as his lytes are normal and he is on CVVH. Patient appears\n well-nourished at baseline, however he is still at nutritional risk due\n to chronic medical problems and cirrhosis.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend tube feeding goal of Nutren 2.0 @ 42mL/hr + 28g\n Beneprotien (2115kcals, 105g protein).\n Monitor propofol rate; tube feeds may have to be adjusted if\n propofol rate is increased over current rate of 8.9mL/hr.\n Montior lytes and hydration.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2186-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622403, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues on PPF and fent gtt. Easily arousable and moves\n all extremities\n SBP 90\ns. MAP 57-60 with dips into high 80\ns and MAP 50.\n Hypothermic 96-97\n Continues on CRRT to keep even as tolerated but occasionally\n running positive\n Dialysis cath patent. No hematoma/ecchymosis\n Hct, Plt and INR stable\n RLE incision oozing serous drainage. Teams aware\n Action:\n Neo resumed\n Labs per protocol\n BFR 250 to prevent clotting\n PBP changed to 2800\n Bair hugger on/off\n Dressing changed at bedside by primary team\n RLE elelvated\n Abx per ID recs\n Albumin 25%\n Phos repleted with 15 mmol NaPhos\n Response:\n Currently positive\n Filter clotted at 1600. CRRT reinitiated at 1730. Heparin\n infusing at 500 units/hr. PBP back to per renal fellow.\n SBP 95-101. MAP 57-61. Remains on 0.5 Neo.\n Plan:\n cont with CRRT\n check PTT q 6, CRRT labs per protocol\n cont on abx\n wean vent as tolerated\n VAC dsg to right thigh tomorrow (bedside)\n" }, { "category": "Respiratory ", "chartdate": "2186-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 622492, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Radiology", "chartdate": "2186-02-04 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1123352, "text": " 3:59 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: HD catheter left IJ placement\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with HD catheter left IJ rewired\n REASON FOR THIS EXAMINATION:\n HD catheter left IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:01 P.M. ON \n\n HISTORY: Left IJ line re-wired.\n\n IMPRESSION: AP chest compared to 5:22 a.m.\n\n Left internal jugular line ends at the junction of brachiocephalic veins,\n right internal jugular line ends low in the SVC. ET tube in standard\n placement. Feeding tube passes below the diaphragm and out of view.\n Bibasilar atelectasis and borderline interstitial edema unchanged. Heart size\n top normal. Pleural effusion is minimal if any. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-02-06 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 1123509, "text": " 12:42 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: Hct trending down Hpotensive on Neo ct torso PO and IV contr\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n Field of view: 36 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43M with cirrhosis, sepsis, RLE fascitis s/p RLE debridement and fasciotomies.\n Blood & tissue cx Pasteurella Multocida & coag neg staph\n REASON FOR THIS EXAMINATION:\n Hct trending down Hpotensive on Neo ct torso PO and IV contrast, eval for\n bleeding?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EAGg MON 1:54 AM\n No e/o active bleeding. Moderate simple left pleural effusion. Bibasilar\n consolidative opacities concerning for infection. Cirrhotic liver and ascites.\n Cholelithiasis w/o e/o acute cholecystitis. Unchanged nephrolithiasis. Fluid\n filled colon. Anasarca.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, sepsis, RLE fasciitis, status post RLE debridement and\n fasciotomies. Evaluate for bleeding.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired images from abdomen and pelvis were obtained after\n IV and oral contrast. Coronal and sagittal reformats were reviewed.\n Intravenous contrast was given at the request of the odering physician .\n and the attending surgeon Dr. after discussion with Dr.\n about the risks of worsening renal function from giving iodinated\n contrast to a patient with an elevated creatinine of 2.2 on CVVH. The ordering\n physicians insisted on administering intravenous iodinated contrast with the\n knowledge of the high likelihood of this risk because of the critical and\n unstable condition of the patient without cause known.\n\n CT ABDOMEN: Within the partially visualized lungs, there is a moderate\n pleural effusion in the left with an opacification in the lower lobe with few\n air bronchograms, suggestive of atelectasis. On the right lower lobe, there\n is an irregular consolidation with ground-glass opacities, likely representing\n acute infectious process. There is no pneumothorax. The imaged heart and\n pericardium appear unremarkable.\n\n Again noted is a cirrhotic liver with fine nodular surface and diffuse fatty\n infiltration. There is no focal liver lesion identified. No intra-or\n extra-hepatic biliary dilatation is noted. There is choledocholithiasis\n without signs of cholecystitis. Marked splenomegaly, with the spleen\n measuring 20 cm, without significant change and no evidence of focal lesion.\n There are multiple intraperitoneal varices, including gastroesophageal,\n peripancreatic, perisplenic and periportal. A portal IVC shunt is noted with\n the right posterior portal vein extending with a large collateral to the IVC.\n The stomach, the small and large bowel are unremarkable. Moderate free fluid\n (Over)\n\n 12:42 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W&W/O C\n Reason: Hct trending down Hpotensive on Neo ct torso PO and IV contr\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n Field of view: 36 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in the intraperitoneal is consistent with ascites. No evidence of hematoma is\n identified. There are innumerable small lymph nodes, without CT criteria for\n lymphadenopathy. There is no free air.\n\n CT PELVIS: A rectal and Foley catheters are in place. The bladder and distal\n ureters are unremarkable. The rectum and sigmoid are unremarkable. There is\n no free air or lymphadenopathy. A small amount of free fluid is consistent\n with ascites.\n\n Osseous structures: There are mild multilevel degenerative changes without\n osseous lesions concerning for metastasis or infection.\n\n IMPRESSION:\n\n 1. Chronic liver disease, moderate ascites, stable splenomegaly, multiple\n intraperitoneal varices and portal IVC shunt consistent with portal\n hypertension. No liver lesions. No hematoma.\n\n 2. Moderate left pleural effusion with left lower lobe atelectasis with\n possible right lower lobe acute pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2186-02-05 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1123465, "text": " 2:15 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Liver ultrasound and doppler to r/o portal and hepatic vein\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with hep C with elevated LFTs acutely.\n REASON FOR THIS EXAMINATION:\n Liver ultrasound and doppler to r/o portal and hepatic vein thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated LFTs in a patient with history of hepatitis C.\n\n COMPARISON: CT from as well as an ultrasound dated .\n\n FINDINGS: The liver is markedly coarse in echotexture. There is no focal\n mass. There is no intrahepatic biliary ductal dilation. The nondistended\n gallbladder is notable for large amount of sludge as well as circumferential\n mural edema, findings which are unchanged from the previous study. There is\n no pericholecystic fluid and there is a negative son sign.\n The common bile duct is 5 mm. The main portal vein is patent with normal\n hepatopetal flow and a normal portal waveform. Appropriate directionality of\n flow is also present in the patent posterior right, anterior right, and left\n portal veins. The inferior vena cava is patent as are the middle, left, and\n right hepatic veins which show appropriate caval waveforms. The main, left,\n and right hepatic arteries are also unremarkable. The spleen is enlarged,\n measuring 17 cm. Note is made of small bilateral pleural effusions,\n corresponding to that seen on recent chest radiograph. There is a small\n amount of ascites.\n\n IMPRESSION:\n 1. Overall minimal change from the previous studies, specifically with a\n patent portal venous and hepatic venous system.\n 2. Coarse hepatic echotexture and splenomegaly as well as ascites, together\n consistent with cirrhosis.\n 3. Left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2186-01-26 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1122011, "text": " 1:36 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new ETT, CVL\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n new ETT, CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube and central venous line\n placement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 3.5 cm above the carina. The NG tube tip is in the\n stomach. The right internal jugular line tip is at the level of cavoatrial\n junction.\n\n There is significant interval progression of bilateral perihilar opacities\n consistent with rapid progression of pulmonary edema. Bilateral pleural\n effusions are most likely present accompanied by bibasal atelectasis. The\n rapidity of the change is consistent with pulmonary edema and unlikely to\n represent infectious process, although it cannot be entirely excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-01-26 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1122051, "text": " 5:09 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check line and ett placement / r/o ptx\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man s/p leg debridement for fasciitis with new ett and line\n REASON FOR THIS EXAMINATION:\n please check line and ett placement / r/o ptx\n ______________________________________________________________________________\n WET READ: 8:14 PM\n No sig change. R costophrenic angle not imaged. \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube and line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there is no\n significant change. Monitoring support devices remain in place. Continued\n prominence of perihilar opacities consistent with rapidly progressing\n pulmonary edema. The right costophrenic angle has been excluded from the\n image.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-01-26 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1122061, "text": " 6:52 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new CVVH line\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with nec fasc. right leg, RF\n REASON FOR THIS EXAMINATION:\n new CVVH line\n ______________________________________________________________________________\n WET READ: 8:23 PM\n Stable pulm opacities. no ptx. \n WET READ VERSION #1 8:15 PM\n Mildly improved pulm opacities. no ptx. \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central catheter.\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 almost the junction with the\n superior vena cava. No evidence of pneumothorax. Some increasing\n opacification at the left base with silhouetting of the hemidiaphragm is\n consistent with increased volume loss in the left lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-01-26 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 1121962, "text": " 8:47 AM\n FEMUR (AP & LAT) RIGHT PORT; TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: Please evaluate for free air.\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with h/o HCV who presents with right LE edema and erythema,\n concerning for nec fasc.\n REASON FOR THIS EXAMINATION:\n Please evaluate for free air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old male with history of hepatitis C presenting with\n right lower extremity edema and erythema, concerning for necrotizing\n fasciitis. Evaluate for soft tissue air.\n\n COMPARISON: None available.\n\n FINDINGS: Six views encompassing the right lower extremity extending from the\n hip to the ankle, both in the AP and lateral projections, are submitted for\n review.\n\n The bony structures are unremarkable, with no evidence for fracture or\n malalignment. There is no evidence for osseous destruction. There are no\n suspicious lytic or sclerotic lesions.\n\n The soft tissues of the leg appear diffusely edematous, with reticular\n stranding in the subcutaneous fat. However, there is no definite soft tissue\n air identified.\n\n There are no radiopaque foreign bodies identified.\n\n IMPRESSION:\n No osseous abnormality in the right leg. Subcutaneous edema is identified,\n without definite soft tissue air. CT could be considered for more sensitive\n evaluation for soft tissue gas, if clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2186-01-27 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1122190, "text": " 2:53 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: dobhoff placement\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with dobhoff placed\n REASON FOR THIS EXAMINATION:\n dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with Dobbhoff placement. Evaluate for Dobbhoff\n placement.\n\n COMPARISON: Portable AP chest radiograph, at 5:17 a.m.\n\n TECHNIQUE: Portable chest radiograph, at 1508.\n\n FINDINGS: Dobbhoff tube is noted to pass below the diaphragm with the tip\n projecting over the expected region of the stomach. ET tube is in standard\n placement. The right IJ line tip projects over the mid SVC. Left IJ line tip\n projects over the upper SVC. Continued opacification at the left base is\n consistent with volume loss in the left lower lobe and is unchanged from chest\n radiograph obtained earlier today. Mild opacification in bilateral lower\n hemithoraces may reflect layering effusion or scattered radiation related to\n patient's body habitus.\n\n IMPRESSION:\n\n Dobbhoff tube passes below the diaphragm with tip within the stomach.\n Otherwise, no interval change since chest radiograph obtained earlier today.\n\n" }, { "category": "Radiology", "chartdate": "2186-02-05 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1123486, "text": " 6:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: .\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43M with HCV cirrhosis presenting with sepsis, RLE fascitis s/p I&D and\n debridement\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n WET READ: DLrc SUN 7:29 PM\n NGT with side port just at gastroesophageal junction can be advanced for more\n optimal positioning. Stable position of Dobhoff with tip in distal stomach.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hepatic cirrhosis, sepsis, nasogastric tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, a new nasogastric tube has\n been placed in addition to the prepositioned Dobhoff catheter. The side port\n of the tube is at the level of the gastroesophageal junction. The tip of the\n tube projects over the proximal parts of the stomach. There is no evidence of\n complications, notably no pneumothorax. Position of the Dobhoff catheter is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-02-06 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1123560, "text": " 9:54 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: evaluate for venous thrombosis or venous flow obstruction.\n Admitting Diagnosis: LEG PAIN;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with elevated LFTs, probable septic hepatitis\n REASON FOR THIS EXAMINATION:\n evaluate for venous thrombosis or venous flow obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 43-year-old man with elevated LFTs and probable septic\n hepatitis.\n\n COMPARISON: Liver and Doppler ultrasound .\n\n FINDINGS: The liver has a coarsened hepatic architecture with no focal liver\n lesion identified. No biliary dilatation is seen. The gallbladder is again\n noted to be filled with sludge and the wall is edematous, likely due to\n underlying liver disease. A small amount of ascites is seen in the right\n upper quadrant.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main portal vein, right portal vein and left portal vein are\n patent with hepatopetal flow. The main hepatic artery demonstrates\n appropriate arterial waveforms. The left and middle hepatic veins were\n visualized and are patent.\n\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Coarsened hepatic echotexture, with no focal liver lesion.\n 3. Ascites.\n 4. Edematous gallbladder wall with sludge. The appearance of the gallbladder\n wall is likely due to underlying liver disease.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-05-15 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 867189, "text": " 11:08 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: please check dopplers to assess flow through hepatic artery/\n Admitting Diagnosis: ALCOHOLIC HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 y/o M transferred from , with GI bleed, cirrhosis, acute renal\n failure, now hypotensive on 2 pressors, anuric - need to assess spot for\n paracentesis. also eval for hydronephrosis.\n REASON FOR THIS EXAMINATION:\n please check dopplers to assess flow through hepatic artery/veins\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old with GI bleed and cirrhosis, also with acute renal\n failure, now hypotensive. Assess hepatic flow.\n\n Comparison is made to study performed 11 hours earlier.\n\n FINDINGS:\n Study is limited due to patient body habitus. Grayscale images demonstrate a\n fatty appearing liver. A trace amount of free fluid is seen anterior to the\n liver and anterior to the spleen. The spleen is slightly enlarged measuring\n 13.4 cm. The right kidney measures 10.0 cm and the left kidney measures 13.1\n cm. Views of left kidney are somewhat limited, but both kidneys demonstrate\n normal cortical echogenicity with no focal perinephric collection or\n hydronephrosis.\n\n Pulse color Doppler images demonstrate patent hepatopetal flow with a normal\n portal venous waveform. Normal waveforms are also seen within the left portal\n vein and hepatic arteries. The left hepatic vein is patent with a normal\n venous waveform. Visualization of the remaining hepatic veins is somewhat\n difficult. There is a recanalized and patent umbilical vein, and several\n collateral vessels are seen consistent with cirrhosis and portal hypertension.\n\n IMPRESSION:\n Limited examination, but with patent and normal-appearing hepatic vasculature.\n Findings consistent with cirrhosis and portal hypertension.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 867152, "text": " 9:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement\n Admitting Diagnosis: ALCOHOLIC HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 y/o M w/massive GI bleed, cirrhosis, transferred from , want\n to check ETT placement s/p , s/p difficulty w/vent\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess ET tube placement in patient with massive GI bleed.\n\n PORTABLE SUPINE CHEST: There are no prior films for comparison. The ET tube\n tip is in satisfactory position, approximately 2 cm above the carina. There\n is a right subclavian central line, which has its tip in the region of the\n SVC/RA junction. Tip of a feeding tube is relatively high, and probably in\n the region of the GE junction, not clearly within the stomach.\n\n Lung volumes are markedly reduced. Midline structures are not well evaluated\n in this setting. There is some patchy increased density in the right\n perihilar region which may reflect atelectasis or infiltrate. There is\n nonspecific increased density in the left retrocardiac area with silhouetting\n of left hemidiaphragm. This too could represent atelectasis/infiltrate;\n effusion cannot be excluded. There is no evidence of pneumothorax on this\n supine film.\n\n IMPRESSION: 1) ET tube in satisfactory position.\n 2) Right central line tip approximately at SVC/RA junction.\n 3) Feeding tube tip high, probably in region of GE junction. This was called\n to the nurse caring for this patient.\n 4) Patchy increased density right perihilar and left retrocardiac region.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-15 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 867157, "text": " 12:03 AM\n ABDOMEN U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for ascites, please mark spot to tap\n Admitting Diagnosis: ALCOHOLIC HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 y/o M transferred from , with GI bleed, cirrhosis, acute renal\n failure, now hypotensive on 2 pressors, anuric - need to assess spot for\n paracentesis. also eval for hydronephrosis.\n REASON FOR THIS EXAMINATION:\n eval for ascites, please mark spot to tap\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old transport from with GI bleeding,\n cirrhosis, and acute renal failure. Assess for ascites and hydronephrosis.\n\n FINDINGS: Limited views of the abdomen demonstrate no ascites. Limited views\n of both left and right kidneys demonstrate normal cortical echogenicity and no\n evidence of perinephric fluid collection or hydronephrosis.\n\n The clinical team was present during the examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 867183, "text": " 10:01 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please eval for perforation/free air\n Admitting Diagnosis: ALCOHOLIC HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with multiorgan failure\n REASON FOR THIS EXAMINATION:\n Please eval for perforation/free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multi organ failure, assess for free air.\n\n PORTABLE SUPINE KUB: There are no prior films for comparison. The bowel gas\n pattern is abnormal. There is gaseous distention of the stomach. There are\n also several prominent air-filled loops of small bowel within the mid abdomen,\n largest upper limits of normal. There is no frank large or small bowel\n dilatation seen.\n\n There is an atypical vertically oriented stippled lucency at the periphery of\n the left abdomen (a vaguely similar appearance is seen in the periphery of the\n right abdomen). It is uncertain whether this is a film artifact or not. Note\n that free intraperitoneal air cannot be confidently excluded on a single\n supine film.\n\n Findings discussed with the responsible house staff.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 867222, "text": " 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: ALCOHOLIC HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 y/o M w/massive GI bleed, cirrhosis, transferred from ,\n , s/p difficulty w/vent now with rising PIPs c/w barotrauma\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out pneumothorax.\n\n PORTABLE SUPINE CHEST: Made to film from 1 day earlier. The ET tube tip may\n have moved more proximally, but is still in satisfactory position, just at the\n thoracic inlet. The tip of the right subclavian line appears to be at the\n SVC/RA junction on this low volume rotated film. The position of the Dobbhoff\n catheter is unchanged (the nurse has been informed).\n\n Lung volumes are markedly reduced. Cardiac and mediastinal contours are not\n well evaluated. There is still a large area of nonspecific increased density\n in the left lung base, which silhouettes the hemidiaphragm and lateral\n costophrenic angle. There is also some hazy increased density in the right\n mid chest, perhaps slightly more conspicuous than previously. This too is\n nonspecific in appearance. It could reflect a focus of aspiration.\n\n No pneumothorax is seen on this supine film.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394347, "text": "NURSING PROGRESS NOTE 1900-2210\nPT MADE COMFORT MEASURES AT 2200- PT TIME OF DEATH AT APPROXIMATELY 2210. DR. MADE AWARE.. FAMILY AT BEDSIDE. PLEASE SEE FLOW SHEET AS NEEDED OFR ADDITIONAL INFOMRATION. THANK YOU.\n" }, { "category": "ECG", "chartdate": "2163-05-14 00:00:00.000", "description": "Report", "row_id": 211125, "text": "Normal sinus rhythm\nPossible anterior infarct - age undetermined\nLow QRS voltages in precordial leads\nNonspecific ST-T wave abnormalities\nNo previous tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394340, "text": "Respiratory Care Note:\n Patient admitted from OSH, previously intubated, and sedated after arrival. Initially difficult to ventilate but improved with increased sedation. BS=bilat, decreased bases, coarse t/o. Suctioned for old bloody secretions. He is on maximum ventilatory support with high rate, PEEP, and FIO2 requirements. ABG improved t/o shift with improving metabolic acidosis. He is on CVVHD, multiple vasopressors and is now paralyzed and sedated. See Carevue flowsheet for specifics.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394341, "text": "NURSING ADMISSION AND PROGRESS REPORT 2145-0700\nTHIS IS A 48 Y/O M WITH A PMH OF ETOH ABUSE, HTN, ANEMIA, PAST GI BLEEDS R/T EXCESSIVE NSAID USE THAT INITIALLY PRESENTED TO ON W/ C/O N, V AND HEMATEMSIS. HE DENIED ANY MELENA AT THE TIME AND HAD BEEN CONSTIPATED FOR 2 WEEKS. INITIAL LABS UPON ADMISSION TO OSH WERE SIGNIFICANT FOR PH OF 6.97, HCT OF 20, PLTS OF 39 AND INCREASED LIVER ENZYMES. PT WAS INTUBATED PRIOR TO ENDOSCOPY FOR AIRWAY PROTECTION R/T LARGE AMOUNTS OF HEMATEMESIS. EGD REVEALED FRESH LARGE CLOT TRAVELING DOWN THE ENTIRE LENGTH OF THE ESOPHAGUS BUT NO VARICES OR ACTIVE BLEEDING WAS NOTED. CONCERNT THAT THE BLEEDING WAS FROM NASOPHARYN. ENT CONSULTED- VISULAIZED LACERATION TO RT NASOPHARYNX- EXTENSIVE SURGICAL PACKING PLACED. PT NOTED TO HAVE ACTIVE PANCREATITIS- INTIATED OCTREOTIDE GTT. GIVEN TOTAL OF 9U PRBC, 12U PLTS AND GIVEN 150 MEQ OF BICARB. PT ALSO NOTED TO BE ANURIC- EMERGENTLY DIALYZED PRIOR TO TX TO FOR MANAGEMENT OF HIS RESPIRATORY FAILURE, ARF, GI BLEED, LIEVER FAILURE AND SEVERE METABOLIC ACIDOSIS. PT BECAME AND BEGAN BLEEDING FROM HIS NOSE, MOUTH AND RECTUM- INITIATED LEVOPHED, NEOSYNEPHRINE AND VASOPRESSIN GTTS PRIOR TO ARRIVAL HERE TO THE MICU-A.\n\nREPORT RECEIVED FROM CREW UPON ARRIVAL, PT TX TO MICU A 771 WITH NO UNTOWARD INCIDENCE. PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY.\n\nNEURO: PT WEANED OFF OF PROPOFOL AND INITIATED FENTANYL AT 100MCG/HR AND VERSED AT 5MG/HR. APPEARS TO BE ADEQUATELY SEDATED. PERRLA, 5/SLUGGISH. AFEBRILE- SLIGHTLY HYPOTHERMIC AT 96-97- BAIR HUGGER APPLIED SINCE PT IS NOW ON CONTINUOUS DIALYSIS AND AT INCREASED RISK FOR HYPOTHERMIA. INITIATED CISTAT GTT- ADEQUATELY PARALYZED IN ORDER TO FACILITATE OXYGENATION. NO SPONTANEOUS MOVEMENT NOTED- NO SEIZURE ACTIVITY NOTED.\n\nENT: PT ARRIVED WITH SIGNIFICANT BLEEDING FROM NOSE AND MOUTH- BLEEDING CONTROLED WITH SURGICAL PACKING AND MOUSTACHE DRESSING. INSPECTION OF ORAL CAVITY REVEALS PACKING IN THE RECESS OF PT'S MOUTH. AGGRESIVE ORAL CARE PERFORMED.\n\nRR: INTUBATED. OETT IS SECURE AND PATENT. RETAPED AND REPOSITIONED BY THIS RN AT 22CM/ LIP. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. SEVERAL VENT CHANGES MADE DURING THE SHIFT- CURRENT SETTINGS ARE AC/28/450/100%/18. ABG'S SIGNIFICANT FOR POOR OXYGENATION DESPITE 100% FI02- HAS BEEN STEADILY IMPROVING SINCE PARALYTIC ON BOARD. BILATERAL CHEST EXPANSION NOTED. SUCTIONING SIGNIFICANT FOR MODERATE AMOUNTS OF BLOODY, THICK SECRETIONS. UNABLE TO MAINTAIN GOOD WAVE FORM ON SP02- MICU TEAM IS AWARE- FOLLOWING ABG'S CLOSELY.\n\nCV: S1 AND S2 AS PER AUSCULTATION. INITIALLY, PT REQUIRED MAXIMUM DOSES OF DOPAMINE, VASOPRESSIN, LEVOPHED AND NEOSYNEPHRINE. CURRENTLY, PT IS ON 8MCG/KG/MIN DOPAMINE GTT, 0.2MCG/KG/MIN LEVOPHED GTT AND VASOPRESSIN AT 2.4U/HR. PT HAS HAD LABILE SBP- 70-100'S. GOAL IS FOR MAPS > OR = TO 65. PT RESPONDS TO DOPAMINE THE BEST. PLAN IS TO WEAN OF LEVOPH\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394342, "text": "NURSING ADMISSION AND PROGRESS REPORT 2145-0700\n(Continued)\nED FIRST AS PT. WILL TOLERATE. PT RECEIVED TOTAL OF 3U PRBCS AND 9U FFP. PT REQUIRED EMERGENT REVERSAL OF 6.8INR AND PTT OF > 150. RECEIVED 10MG OF VITAMIN K SUBQ. WEAKLY PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS. PT RECEIVED TOTAL OF 150MEQ OF SODIUM BICARB AND WAS ON GTT FOR APPROXIMATELY 3 HOURS- ACIDEMIA HAS SINCE IMPROVED WITH A PH OF 7.30.\n\nELECTROLYTES: PT RECEIVED TOTAL OF 6AMPS OF CAGLUC AND 80MEQ OF K. CURRENTLY IS ON CAGLUC GTT DUE TO INCREASED REPLETION NEEDS R/T CVVH AND PANCREATITIS.\n\nGI: ABD IS FIRM AND DISTENDED. BS ARE EXTREMELY HYPOACTIVE AND DIFFICULT TO AUSCULTATE. PT ARRIVED WITH DOBHOFF INSERTED ORALLY- CXR SIGNIFICANT THAT IT IS ONLY IN ESOPHAGUS AND NOT IN STOMACH. NO GI ACCESS AT THIS TIME. PT HAS HAD APPROXIMATELY 800CC OF MELENA- RECTAL BAG APPLIED. GU CONSULT OBTAINED, PLANS FOR SCOPE- HOWEVER, DUE TO PT'S UNSTABLE NATURE- UNABLE TO PROCEED. GI TO REEVALUATE THIS AM.\nABD US OBTAINED AT BEDSIDE- NO ASCITES NOTED.\n\nENDO: INSULIN GTT STARTED WITH GOAL OF BS 70-120, OCTREOTIDE GTT IS AT 50MCG/HR. SURGERY CONSULTED FOR PANCREATITIS. OBVIOUSLY NOT A SURGICAL CANDIDATE AT THIS TIME.\n\nRENAL: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. PT IS HOWEVER, CATHETER RETAINED IN ORDER TO MEASURE BLADDER PRESSURES., BLADDER PRESSURE UPON ARRIVAL WAS 28- INCREASED TO 38 PRIOR TO PARALYSIS- HAS SINCE DECREASED TO 17-18. RENAL CONSULTED FOR NEED OF FLUID REMOVAL AND ARF- CVVHD THERAPY INITIATED- CURRENTLY ONGOING AT THE BEDSIDE. NO HEPARIN IN SYSTEM. GOAL IS FOR -100/HR AS PT WILL TOLERATE.\n\nINTEG: GENERALIZED EDEMA NOTED- SCLERAL EDEMA NOTED. BRUISING TO RT ARM. OTHERWISE, NO SIGNS OF REDNESS OR BREAKDOWN TO BUTTOCKS OR BACK.\n\nSOCIAL: HCP IS HIS AND CONDITION DISCUSSED AT LENGTH BY MICU TEAM AND THIS RN. NO QUESTIONS OR ISSUES AT THIS TIME. LIMITS AND VISITING POLICY STRICTLY ENFORCED DUE TO PT'S CRITICAL CONDITION.\n\nPLAN:\n\n1: REEVALUATION FOR SCOPE BY GI.\n2: MAINTAIN SEDATION AND PARALYTIC IN ORDER TO MAXIMIZE OXYGENATION.\n3: WEAN PRESSERS AS PT WILL LEVO WILL BE THE FIRST TO GO.\n4: WEAN VENT AS PT. WILL TOLERATE.\n5: CONTINOUS CVVHD- MONITOR ELECTROLYTES- ESPECIALLY CALCIUM. GOAL OF -100/HR.\n6: BLOOD PRODUCTS AS NEEDED.\n\nPLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394343, "text": "NPN assumed care at 9am-1900\n\n Pt. remains gravely ill and hemodynamically unstable on 4 maximized , CRT, full vent support with paralytic and sedatives. Family updated by Attending Dr. and has decided to make pt. DNR- not withdrawing care at this point d/t pt.'s wishes to have aggressive measures taken.\n\nReview of Systems-\n\n Pt. received on Fentanyl 100mcg/hr and Versed 5mg/hr. Cisatricurium infusing at lowest rate of 0.05mg/kg/hr. Gtts increased this afternoon with episode of increased PEAK AIRWAY PRESSURES. Fentanyl bolused with 100mcg and increased to 150mcg/hr and Versed bolused with 5mg and increased gtt to 7.5mg/hr. Cisatricurium rebolused with 0.05mg/kg and increased to 0.075mg/kg/hr. VS used for assessment of paralytic and sedatives d/t train of four proving unrealiable- VS increased during repositioning for XRAY. Otherwise, no change.\n\nResp- A few vent changes made this shift- increase in RR to compensate for this am acidosis, decreased fio2 to 80% with stable ABGs. Most current 7.38/28/74/17 on 450X36 80% PEEP 15. About 1600, PAP increased to 60's, plateau of 63. Pt. with bilat. BS- ? pneumo CXR taken- results pending. Vent adjusted to optimize pressure, however returned to current volume control settings. Pt. sx'd for no secretion at that time as well. Would aniticpate increasing fio2 again overnoc s/t fluid overload, resistance and increased airway pressures. Sat's undetectable, will obtain frequent ABGs to monitor paO2 as well as pH given load of Na+ HcO3 pt is requiring to maintain BP.\n\nCV- HR 80's NSR with some PACs noted. SBP 68-90/60-70's MAP 60-75 however dampened waveform from arterial line. Pt. received on maximized dosing of Levophed, Vasopressin and Dopamine. Neo restarted and titrated to max of 5mcg/kg/min. Currently, maximized on all 4 vasopressors. BP seemingly responsive to Sodium Bicarb IVP or infusion. Bicarb then added to alternate with for CRT. Also, bicarb peripherally infusing to maintain family wishes of full code. Pt. is gravely mottled from head to toe with absent bowel sounds and does not appear to be perfusing extremeties. HCT down to 30, PLT low this am and received 1u with appropriate rise in count. Also of note, pt. oozing from oral pharnyx- thus transfused with PLT. INR stable at 1.6. Plan- maintain full code status using bicarb to correct for lactic acidemia, maintain max pressor support.\n\nEndo- maintained on insulin infusion BS ranging from 80's-280's. Currently on 6units regular insulin/ hr.\n\nGI- ABD remains firm and distended with bladder pressures rising. Pt. remains NPO. EGD deferred given pt. hemodynamic instablity. No stool, melena output this shift.\n\nGU- U/O minimal. Maintained on CRT with replacement fluid adjusted per renal recs, pls see . No fluid removal attempted since pt. has been persistently hypotensive.\n\nID- Meropenum added to med regimen. Pt. has been hypothermic. BC called back positive, will review, te\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394344, "text": "(Continued)\nam aware.\n\nSocial- Priest in today per family request. Met with Attending to discuss pt. prognosis. Family from NY and pt.'s astranged dtrs to visit this evening. Emotional support offered to family. Would contact SW 'row if appropriate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394345, "text": "\nPT MAINTAINED ON A/C VENTILATION AT 80%. PT IS UNSTABLE WITH POOR GAS EXCHANGE ON CURRENT SETTINGS. SX FOR SCANT AMTS. LAST ABG SHOWED WORSENING ACIDOSIS, OPTIMIZED PRESSORS, CVVHD, PEAK AIRWAY PRESS. OF 64, IN MULTISYSTEM FAILURE WITH VERY POOR PROGNOSIS. FAMILY MEETINGS TODAY BY ATTENDING. PLAN IS TO CONT. ON CURRENT MODE AND SETTINGS, PT IS DNR.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1394346, "text": "Respiratory Therapy\nFamily came to agreement to withdraw care. CVVH D/C'd Vent settings on minimal support. Vent shut off at 22:15 Family in room with Pt. Plan: support family.\n" } ]

[ { "category": "Echo", "chartdate": "2179-01-26 00:00:00.000", "description": "Report", "row_id": 69475, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Flash pulmonary edema.\nHeight: (in) 73\nWeight (lb): 154\nBSA (m2): 1.93 m2\nBP (mm Hg): 111/86\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 15:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Dilated LV cavity. Severe global LV hypokinesis. Severely\ndepressed LVEF.\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. 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: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Compared to the findings of the prior study, left\nventricular systolic function has deteriorated.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity is dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n3. The right ventricular cavity is dilated. Right ventricular systolic\nfunction appears depressed.\n4. The aortic root is mildly dilated.\n5. The aortic valve leaflets are mildly thickened.\n6. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n7. Compared to the findings of the prior study of , left ventricular\nsystolic function has deteriorated.\n\n\n" }, { "category": "ECG", "chartdate": "2179-01-27 00:00:00.000", "description": "Report", "row_id": 165087, "text": "Sinus rhythm\nBorderline first degree AV block\nRight bundle branch block\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2179-01-27 00:00:00.000", "description": "Report", "row_id": 165088, "text": "Atrial fibrillation. Non-specific ST-T wave abnormalities. Since the previous\ntracing of probably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2179-01-26 00:00:00.000", "description": "Report", "row_id": 165089, "text": "Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-01-26 00:00:00.000", "description": "Report", "row_id": 165090, "text": "Atrial fibrillation with a rapid ventricular response. Low limb lead voltage.\nPrior anteroseptal myocardial infarction. Compared to the previous tracing\nof the T waves in leads V4-V6 are now upright and may represent\npseudonormalization and/or resolution of prior ischemia, more likely the\nformer. Followup and clinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2179-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 895507, "text": " 2:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulm edema.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p pacemaker placement and sob/cp now intubated\n\n REASON FOR THIS EXAMINATION:\n ? pulm edema.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post pacemaker placement, shortness of breath and chest\n pain now intubated, evaluate for possible pulmonary edema.\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 6 cm above the level of the carina. An NG tube has been placed reaching\n far below the diaphragm. There is no pneumothorax or any other placement\n related complication. Comparison is made with a previous chest examination of\n and the previously described status post sternotomy with\n evidence of bypass surgery and a permanent pacer in left anterior axillary\n position with a single intracavitary electrode terminating in the apical\n portion of the right ventricle are all unchanged. There is no pulmonary\n vascular congestion but the rather irregular peripheral distribution of the\n pulmonary vasculature with some element of increased interstitial linear\n markings is consistent with rather prominent COPD. The lateral pleural\n sinuses are free. There is a relative prominence of the right hilum, which,\n however, existed already on the previous examination. In the right upper lung\n field and overlying the anterior portion of the second rib, there are some\n increased parenchymal densities which were not seen as prominent on the\n previous examination of . This suggests that the patient either\n may have developed an intercurrent pneumonic infiltrate in this area. A\n follow up examination is therefore recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-01-26 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 895546, "text": " 5:33 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: ? PE, eval cancer, eval for pna\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with h/o COPD, CAD, lung cancer who had tachy and resp failure\n REASON FOR THIS EXAMINATION:\n ? PE, eval cancer, eval for pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76-year-old man with history of COPD and coronary disease, and\n lung cancer. He presents with tachycardia and respiratory failure. A\n pulmonary embolism is suspected clinically.\n\n COMPARISONS: A chest radiograph of the same day showed endotracheal\n intubation and prominence of the right hilar region. A prior chest CT from\n showed a fibronodular opacity in the right upper lobe and\n infiltrative right hilar mass encasing the right upper lobe bronchus,\n suspicious for lung cancer or tuberculosis according to that report. Severe\n emphysema was also noted.\n\n TECHNIQUE: Axial non-contrast CT images of the chest were obtained, as well\n as a CT angiogram of the chest with intravenous contrast. Sagittal and\n coronal reconstructions were also performed.\n\n CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The patient is\n intubated. The endotracheal tube lies between the thoracic inlet and the\n carina. The patient is status post median sternotomy wire, with a two-lead\n pacer in a similar position, and surgical clips in the mediastinum. There is\n also a nasogastric tube which terminates in the stomach.\n\n There are multiple small mediastinal lymph nodes, including prevascular lymph\n nodes. There are also slightly prominent left hilar lymph nodes, as large as\n 18 x 14 mm. Again noted is a right hilar/mediastinal mass. It is little\n changed allowing for differences in technique, and measures 23 x 49 mm in\n axial dimensions. It extends into the right hilum and also shows scattered\n calcifications as before.\n\n The heart, great vessels, and pericardium are unremarkable. Again noted are\n coronary artery calcifications. There is some narrowing of right upper lobe\n pulmonary vein and the right pulmonary artery, which opacifies normally,\n however. There is no evidence of pulmonary embolism.\n\n Again noted is severe bilateral emphysema. There is a similar appearance of\n multiple nodular opacities in the right upper lobe. There is narrowing, but\n not definite obstruction of multiple perihilar segmental bronchi. Again noted\n also is ground-glass opacity in the right upper lobe which is unchanged.\n Because of motion artifact, the lung findings were better evaluated on the\n prior study. However, there are new patchy nodular opacities elsewhere,\n particularly in the left lower lobe and in the right lower lobe which are\n (Over)\n\n 5:33 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: ? PE, eval cancer, eval for pna\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n nonspecific.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Perihilar mass and prominent perihilar lymph nodes, as seen previously.\n 3. Nodular opacities in the right upper lobe as seen previously.\n 4. New vaguely defined bibasilar nodular densities as well.\n 5. Status post sternotomy and coronary artery calcifications.\n 6. Severe emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-01-30 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 896112, "text": " 12:53 PM\n CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate for metastases in brain\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new dx of lung cancer, h/o AFib on coumadin.\n REASON FOR THIS EXAMINATION:\n evaluate for metastases in brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76-year-old man with new diagnosis of lung cancer. A history of\n atrial fibrillation, on Coumadin.\n\n Question metastases.\n\n COMPARISONS: .\n\n There is stable widening of the extra-axial spaces, prominence in the sulci\n and ventricles, consistent with age-related involutional changes. The\n previously noted focus of hyperdensity in the lateral right cerebellum is not\n appreciated on this study. There are cerebellar calcifications, which are\n unchanged, as well as basal ganglia calcifications. Some relative hypodensity\n in the left temporal lobe is unchanged. There are vascular calcifications.\n There is a small calcified extra-axial mass in right frontal region suggestive\n of calcified meningioma, unchanged.\n With the administration of contrast, there are no metastases evident.\n\n There is an opacity in the right maxillary sinus, probably a retention cyst.\n There is sclerosis in the right mastoid air cells, which is unchanged, and to\n a lesser degree on the left.\n\n IMPRESSION: No evidence of metastatic disease.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-01-26 00:00:00.000", "description": "Report", "row_id": 1421108, "text": "CCU Nursing Admission Note 1400-1900\nPlease see Nursing FHPA for complete Information. Pt is a 76 yo male admitted to CCU after having an outpatient Broncho/Biopsy and becoming hypoxic--> Intubation.\n\nS: ETT\n\nO: Resp:placed on vent 100%-600-X 14 5 PEEP, few spontaneous breathes. ABG 94/7.33/53/29/0, FiO2 decreased to 80%. O2 sat remains 100%. PP 17-26 Lungs initially with few exp wheezes, now clear. Sent to CT for R/O PE. ETS-->bloody secretions.\n\nCV: HR 96-11 AF BP 114-120/80-90. Transient increase of HR to 125 and SBP to 150 upon return from CT scan. 20 mg IV lasix given with 750 cc u/o. K 5.0 Mg 2.1\n\nNeuro: patient agitated on admission, attempting to pull out ETT. Hands restrained and given 50mcg boluses of fentanyl and 1-2 mg boluses of Versed. Placed on Versed Gtt @2 mg/hour, Fentanyl gtt @ 50 mcg/hour. MAE. Pupils 2mm, equal and sluggish.\n\nGI: NGT placed, initially with bilious asps. Now with old looking blood.? related to intubation. Abdomen flat with +BS\n\nGU: foley catheter placed. Urine clear yellow, BUN 26, Cr 1.0\n\nSkin: left foot, second toe with dry open area the size of a dime. Right great toe, with ~2mm black blister on tip.\n\nAccess: (2) #18 PIV's\n\nSocial: wife in and updated on patient's status and plan of care.\n\nA: acute hypoxic episode following bronch/biopsy, ?etio. Intubated with adequate oxygenation. Agitation related to intubation, improved with fentanyl and versed. Restrained for patient's safety.\n\nP: continue to wean FiO2 as able. ? a-line tonight. titrate fentanyl and versed to patient's comfort level. contine to assess skin.\n" }, { "category": "Nursing/other", "chartdate": "2179-01-27 00:00:00.000", "description": "Report", "row_id": 1421109, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Most recent abg results determined normal acid-base balance and adequate oxygenation.\n\nRSBI = 33 on 0-PEEP and 5 cm PSV.\n\nPlan is to wean to extubation.\n" }, { "category": "Nursing/other", "chartdate": "2179-01-27 00:00:00.000", "description": "Report", "row_id": 1421110, "text": "76 YR. OLD MAN WITH H/O CAD, COPD, AF, PACEMAKER WHO WAS SCHEDULED FOR OUT-PT BRONCH/LUNG BX FOR LUNG CA W/U . POST PROCEDURE->HYPOXIC WITH SATS 70% & HR 120'S AF. EMERGENTLY INTUBATED, & ADMITTED TO CCU AS MICU BORDER.\n\nNEURO: SEDATED WITH FENT 50MCG/HR & VERSED 2MG/HR. OPENS EYES TO VOICE. MAE. FOLLOWS SIMPLE COMMANDS.\n\nRESP: ON VENT: 60%/IPS 10/PEEP 5. ABG 7.43/40/86/27. DECREASED FIO2 TO 50%. O2 SATS 97-100%. RR 14-18. SX FOR MOD AMTS THICK BLOODY SECRETIONS. SPUTUM C&S, GM STAIN SENT. BS CLEAR UPPER AIRWAYS, COURSE LOWER AIRWAYS, & INTERMITTENTLY WHEEZY. AM RSBI 33.\n\nCARDIAC: HR 100-120 AF. DILTIAZEM 30MG PER NGT Q6HRS STARTED. HR 80-90'S AF. BP 100-114/63-76. CK 42, HCT 35, K 5.0. EKG DONE. NO CHANGES.\n\nGI: NPO. NGT IN PLACE FOR MEDS. DRAINING OLD BLOODY DRAINAGE. HO AWARE. ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 20-40CC/HR->\nDECREASED TO 10CC/HR X2HRS. 250CC NS BOLUS X1 WITH MINIMAL EFFECT.\n\nID: T99.2->98.4(PO).\n\nAM LABS PENDING.\n\nPLAN: WEAN SEDATION.\n EXTUBATE.\n" }, { "category": "Nursing/other", "chartdate": "2179-01-27 00:00:00.000", "description": "Report", "row_id": 1421111, "text": "CCU Nursing Progress Note 7am-7pm\nS: denies pain, states breathing feels \"natural.\"\n\nO: please see CCU flow sheet for complete objective data\n\nResp: weaned from PEEP/PS 5/15 to , tolerated well with MV . Placed on IV NTG gtt to decrease pre-load in preparation for extubation. Successfully extubated, and O2 weaned to keep O2 sat 93%. Currently on 2 L NP with RR mid 20's. Lungs clear, with occassional insp wheezing responding to albuterol MDI. ETS prior to extubation-->old blood. Strong cough.\n\nCV: HR 80's AF with occassional v-paced beat. Receiving diltiazem 30mg q 6 hours. BP 107-115/56-60 on IV NTG at 0.2 mcg/kg/min for pre-load reduction.\n\nNeuro: Patient calm and cooperative. Fentanyl and versed weaned to off. Without sedatives post-extubation. Alert and oriented X3, cooperative with care.\n\nGI: NG asps this am brown/green. This afternoon with cloudy aspirates. Patient with + gag reflex, able to swallow pills. NGT pulled and tolerating clear liqs. Abdomen flat with +BS\n\nGU: foley in draining clear amber urine, 20-50cc/hour. ~800cc's + since midnight. BUN 29, Cr 1.2. Urine culture sent.\n\nSkin: Dried scabbed area on left toe unchanged. Skin nurse in to assess. Recommends leaving it without a dressing, but with socks on to protect it. Also to have team look at it to see if ? X-ray to see if it extends to bone. Patient states that it occurred at home about 1 month ago when he \"bashed his foot\" into something in the middle of the night. He reports that it has been x-rayed. Skin dry, applying aloe vesta skin ointment. Small area to left of coccyx with dried scab, approximately 0.5 cm in diameter. Kept off of back.\n\nSocial: wife in to visit. Updated wife on progress and plan of care.\n\nA: successful extubation, maintaining adequate O2 sats on 2L NP. Lungs with insp wheezes responding to albuterol. Open area on toe unchanged from yesterday. Tolerating advanced diet.\n\nP: continue to enc C&DB. Monitor resp status and keep O2 sat ~93%. Monitor u/o. Increase diet as tolerated. Skin care as per skin care nurse.\n" }, { "category": "Nursing/other", "chartdate": "2179-01-26 00:00:00.000", "description": "Report", "row_id": 1421107, "text": "Resp Care\nPt went to IP for bronch/biopsy. Pt flashed during procedure and required intubation. Pt on A/C and having oxygenation issues. Team ? PE. Pt had chest CT done (pending results). No other changes made.\n" }, { "category": "Nursing/other", "chartdate": "2179-01-28 00:00:00.000", "description": "Report", "row_id": 1421112, "text": "76 YR.OLD MAN SEEN FOR OUT-PT BRONCH/LUNG BX FOR LUNG CA W/U. POST\nPROCEDURE BECAME HYPOXIC WITH O2 SAT 70'S & HR 120'S AF. EMERGENTLY\nINTUBATED, & TRANSFERRED TO CCU AS MICU BORDER. CHEST CT (-) FOR PE.\nCARDIAC ENZYMES FLAT. REMAINED INTUBATED OVER NOC, & WEANED->EXTUBATED SUCCESSFULLY AT 1030. O2 WEANED TO MAINTAIN SAT> OR = 93%.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE WITH CARE.\n\nRESP: O2->2L NP. O2 SAT 95-98%. RR 17-24. C&R THICK SECRETIONS. BS CLEAR WITH CRACKLES L. BASE & INTERMITTENT WHEEZES. USING ATROVENT/\nALBUTEROL MDI'S. NEB X1.\n\nCARDIAC: HR 68-83 AF WITH OCC. PACED BEATS WITH HR<70. BP 102-129/\n59-69. NTG GTT WEANED TO OFF. DENIES CP/SOB.\n\nGI: ABD. SOFT. BS+. NO STOOL. APPETITE GOOD.\n\nGU: FOLEY->CD PATENT & DRAINING CL. YELLOW URINE. U/O 20-120CC/HR. C/O\nDISCOMFORT WITH FOLEY. AFTER SPEAKING WITH RESIDENT, FOLEY D/C'D AT\n0200. VOIDED 50CC CLEAR AMBER URINE IMMEDIATELY.\n\nID: AFEBRILE.\n\nAM LABS PENDING.\n\nPLAN: PULMONARY TOILET/INHALERS AS ORDERED.\n INCREASE ACTIVITY->OOB.\n ??CO TO FLOOR.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-01-28 00:00:00.000", "description": "Report", "row_id": 1421113, "text": "ADDENDUM\nURINE & SPUTUM CX'S PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2179-01-28 00:00:00.000", "description": "Report", "row_id": 1421114, "text": "CCU NPN 7a-7p MICU boarder\nS: \"My breathing feels a little better this afternoon.\"\nO: please see carevue for complete assessment data\nNo events\nNEURO: A&Ox3, pleasant and cooperative w/ care. C/o faint pain in R chest, pleuritic in nature, relieved w/ 650mg tylenol x1. OOB->chair x several hours this afternoon.\n\nCV: HD stable, 100s-120s/60s, HR 70s-80s Afib w/ sporatic v pacing noted throughout the day. No ectopy noted, 20mg KCl PO for K 3.8. Distal pulses by doppler, extremities warm w/ no edema apprecitated.\n\nRESP: breathing comfortably on 2L NC w/ SpO2 >96%. Mildy DOE w/ initial transfer from bed->chair, pt. notably I/E wheezing throughout, relieved w/ alb/atr neb, otherwise clear. Also continuing w/ ALB/ATR nebs, restarted advir. Using IS effectively, intermittent, nonproductive congested cough. Prelim cytology back from bronch , highly suspicious for non-small cell lung CA.\n\nGI: healthy appetite, no c/o N/V/D/C. Abdomen soft, nontender, nondistended. +BS/-BM/+RF.\n\nGU: voiding concentrated amber urine in urinal independently. Encouraging PO fluids.\n\nENDO: no issues, last dose 5mg PO prednisone today.\n\nID: afebrile, no abx.\n\nSKIN: no breakdown noted, coccyx reddeded after sitting in chair, blanching. R hand PIV clotted and removed. L arm 20g patent and intact.\n\nSOC: wife in to visit briefly, assembled belongings for transfer.\n\nA: 76yo man w/ extensive PMH including COPD/emphysema/R Lung CA admitted for emergent intubation following bronch and biopsy . Currently HD and resp stable s/p extubation , c/o to medicine pending available bed.\nP: cont pulm hygine, encourage CDB and IS use, as well as ^ activity. F/u biopsy data. Encourage PO fluids for minimal concentrated urine.\n" } ]

[ { "category": "Radiology", "chartdate": "2158-12-24 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 812276, "text": " 2:32 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABDOMINAL PAIN, ? AAA, RETROPERITONEAL BLEED, S/P SIGMOIDECTOMY WITH COLOSTOMY\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with h/o hepatic cyst, diverticulits s/p sigmoidectomy and\n colostomy now with abd pain\n REASON FOR THIS EXAMINATION:\n evaluate for AAA, intrabdominal bleed, retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMBu 4:37 PM\n dISTENDED GALLBLADDER WITH SURROUNDING STRANDING AND HIGH ATTENUATION ASCITES\n CONCERNING FOR HEMOPERITONEUM.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: History of diverticulitis status post sigmoidectomy and colostomy.\n Now with abdominal pain, hematocrit drop, white count of 25,000, and INR over\n 5. Creatinine 2.6. Assess for hemorrhage/intra-abdominal pathology. Fall.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is some patchy opacity at the\n lung bases and there is a trace right pleural effusion. The examination is\n somewhat limited by the absence of intravenous contrast. However, there is no\n hepatic cyst identified, as suggested in the provided history. This is\n confirmed when comparing with the prior CT from which demonstrated\n a normal liver. There is no obvious distortion of the liver contour, although\n a liver laceration cannot be excluded in the absence of intravenous contrast.\n The gallbladder is markedly distended and heterogeneous in appearance with\n surrounding stranding. There is a moderate amount of high-attenuation ascites\n distributed throughout the abdomen into the pelvis and centered about the\n liver, concerning for hemoperitoneum. There is no biliary ductal dilatation\n appreciated. The pancreas, spleen and adrenal glands are normal for non-\n contrast technique. The kidneys are atrophic and there is vascular\n calcification associated with the right renal hilum at the origin of the renal\n vessels. There is no abdominal aortic aneurysm. There is a prominent\n epicardial lymph node measuring 11 mm in greatest short axis dimension. This\n is larger than on the prior study. There are scattered prominent\n retroperitoneal lymph nodes in the left renal hilar area, but none of these\n reach CT criteria for pathologic enlargement.\n\n CT OF THE PELVIS WITH IV CONTRAST: Although limited by the absence of oral\n and intravenous contrast, there is no direct evidence of bowel inflammation.\n There is an ostomy in the left lower quadrant with a nonobstructing peristomal\n hernia containing bowel. The bladder conains a Foley catheter. There is a\n left hip prosthesis causing streak artifact on the lower pelvis. There is no\n evidence of retroperitoneal or thigh hematoma.\n\n IMPRESSION: Distended and heterogeneous gallbladder with surrounding\n (Over)\n\n 2:32 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABDOMINAL PAIN, ? AAA, RETROPERITONEAL BLEED, S/P SIGMOIDECTOMY WITH COLOSTOMY\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n stranding and associated high-attenuation moderate amount of ascites possibly\n hemoperitoneum or other cause of high density fluid. The appearance of the\n gallbladder is suggestive of of cholecystitis and this should be further\n investigated with ultrasound. It is unclear whether the high- attenuation\n ascites is related to this process. Since the patient reports being post fall,\n a liver laceration is not entirely excluded on this non- contrast study. These\n findings were discussed with the clinical team at the time of the exam.\n\n" }, { "category": "ECG", "chartdate": "2158-12-25 00:00:00.000", "description": "Report", "row_id": 132659, "text": "Probable atrial fibrillation\nGeneralized low QRS voltages\nLeft axis deviation\nAnterior T wave inversion, consider ischemia\nSince previous tracing, atrial fibrillation has returned\n\n" }, { "category": "ECG", "chartdate": "2158-12-24 00:00:00.000", "description": "Report", "row_id": 132660, "text": "Technically difficult study\nProbable normal sinus rhythm\nLeft axis deviation\nLate transition\nNonspecific ST-T wave changes\nSince previous tracing, atrial fibrillation is gone\n\n" }, { "category": "ECG", "chartdate": "2158-12-24 00:00:00.000", "description": "Report", "row_id": 132661, "text": "Atrial fibrillation with uncontrolled ventricular response\nLeft axis deviation\nVentricular premature complex\nNonspecific ST-T wave changes\nSince previous tracing, atrial fibrillation is new\n\n" }, { "category": "Nursing/other", "chartdate": "2158-12-24 00:00:00.000", "description": "Report", "row_id": 1293803, "text": "admit note\nPt admitted from the ER at 1745. One unit PRBC hanging and had received 2 FFP. CT abdomen showed an enlarged gall bladder. Crit is 25. Access is an issue. Since INR is 5.1 cannot put in a line at this time.\n\nneuro: Pt is axox3, follows commands. She rates pain as a and she was medicated with 1 mg IV morphine.\n\nresp: Tachypneic, RR 32-38. Crackles in r base. 3L nc.\n\ncv: Afib 76-80, rare PVC. BP currently 81/45. Levophed at .04mcg/kg/min.\n\naccess: 1 piv, 2 have blown since she was admitted to MICU. Attempting to place additional piv. Need to reverse INR before attept central access. Team will attempt a femoral line.\n\ngi/Gu: Pt has a colostomy (7 years old). Belly soft with + BS. Foley in place with purulent drainage.\n\nskin: Intact.\n\nVascular: L leg graft. No dopplerable pulses on L foot. Team is aware.\nL foot is mottled and is becoing more mottled over the past hour. Vascular is being consulted.\n\nHeme: has had 2 FFP, needs 2 more. PRBC up. Needs one after that.\n\nPlan: Line placement, blood products, antibiotics.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-12-25 00:00:00.000", "description": "Report", "row_id": 1293804, "text": "MICU-B NPN 1900-0700\nPT 79 Y/O FEMALE ADMIT FROM EW S/P FALL @ HOME WITH UROSEPSIS, HYPOTENSION REQUIRING PRESSORS, HCT 25, COAGULOPATHY WITH INITIAL INR 5.1, (L)LOWER EXTREM PULSELESS. CT OF ABD. SHOWED FLUID IN GALL BLADDER AND FREE FLUID IN ABD. PT. HAS RECEIVED TOTAL OF 4U PRBCS, 8U FFP, AND 8L FLUID FOR COAGULOPATHY AND FLUID RESUSCITATION FOR HYPOTENSION. ON ABX FOR UROSEPSIS. PT. IN ARF WITH ELEVATED BUN/CREAT. WITH EXTREMELY MINIMAL AMTS. PURULENT OUTPUT FROM FOLEY. (L) LOWER EXTREM. REMAINS PULSELESS. ? GRAFT FAILURE RELATED TO HYPOTENSION/PRESSORS CAUSING VASOCONSTRICTION. VASCULAR CONSULTED. . PT. WITH INC. METABOLIC ACIDOSIS LACTATE 9 AND BICARB. 12. ELECTIVE INTUBATION FOR AIRWAY PROTECTION @ 0600. PARALYZED AND SEDATED FOR PROCEDURE WITH ETOM. & SUCCS. FOLLOWING INTUBATION PT. DROPPING PRESSURE TO 50'S/20'S REQUIRING FLUID BOLUSES. INC. IN LEVOPHED TO MAX DOSE .25 MCG/KG/MIN AND VASOPRESSIN ADDED TO REGIME WITH IMPROVEMENT. PLAN IS FOR PT. TO HAVE COAGULOPATHY REVERSED TO GO EMERGENTLY TO HAVE PERCUTANEOUS CHOLYCYSTECTOMY TUBE PLACED IF INR <1.5.\nROS - NEURO - PT. INITIALLY AXOX3. +MAE, NOW INTUB. UNRESPONSIVE S/P SUCC. & ETOM. ALSO GIVEN X1 2MG ATIVAN, AWAITING FENT. AND ATIVAN GTTS. FOR SEDATION; HOLDING FOR HYPOTENSION INITIALLY.\n\nC/V - HR 70'S>100'S, A-FIB WITH OCCAS. PVCS NOTED. NBP 90'S-ONE-TEENS/ 70'S-80'S WITH MAP 50'S-70'S. REMAINS ON LEVOPHED GTT. @ .25MCG/KG/MIN. VASOPESSIN GTT. . FROM .04U/MIN TO .02U/MIN. (L)LOWER EXTREM. PULSELESS. RLE DOPPLERABLE. EXTREM. EXTREMELY COOL LLE MOTTLED. MPT. ALSO RI MI WITH EKG CHANGES AND ELEVATED TROP.\n\nRESP - PT. INITIALLY ON 4L NC WITH O2SATS 100%. LS CLEAR UPPER WITH BILAT. DIMIN. BASES. PRIOR TO INTUBATION PT. WITH C/O INC. WOB. SATS. DROPPING TO HIGH 80'S. CRACKLES NOTED TO BE INC. PER AUSCULTATION. AS ABOVE PT. INTUB. FOR AIRWAY PROTECTION IN LIEU OF MET. ACIDOSIS. CURRENT VENT SETTINGS ON A/C 1.00 400X20/PEEP5.\n\nHEME - AS ABOVE PT. RECEIVED TOTAL 4U PRBCS AND 8U FFP. INR POST 4UFFP 2.9 AND HCT S/P 2U PRBCS 29.8. SINCE PT. HAS RECEIVED 2 MORE UPRBCS AND 4MORE UFFP. WILL CONT. TO . COAGS. GOAL INR<1.5 FOR PERCUTANEOUS CHOLYCYSTECTOMY TUBE.\n\nGI/GU - PT. NPO. NAUSEAUS AND VOMITING X3 SM. AMTS. GUIAC POS. GREY, GASTRIC CONTENTS. ABD. OBESE, SOFT, TENDER TO TOUCH. +BS COLOSTOMY IN PLACE; PLACED 7YEARS AGO FOR DIVERTICULITIS. SM. AMT. BROWN, LOOSE STOOL IN BAG. INDWELLING FOLEY IN PLACE; WITH SCANT. AMTS. PURULENT DRAINAGE. FLUSHED X2 FOR PATENCY. BUN/CREAT. ELEVATED.\n\nACCESS - (R)FEMORAL MULTI-LUMEN LINE PLACED; PATENT. (R)HAND PIV; PATENT.\n\nSOCIAL - PT. HUSBAND CALLED IN THIS AM AND SPOKE WITH MD PER PT. STATUS AND CONT. PLAN OF CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-12-25 00:00:00.000", "description": "Report", "row_id": 1293805, "text": "transfer to OR\nPt transferred to OR at 1045.\n\nThis morning pt received a total of 6 units PRBC and 8 FFp, cryo was hung on the way to the OR. INR as high as 3.4 despite FFP and vit K.\n\nHypothermic with temp 92.2, on bair hugger and cooling blanket set at 103.0. Entire body was mottled.\n\nPt was hypotensive at times and required vasopressin and levophed to maintain a MAP greater than 70.\nSedated on propofol.\n\nAcidotic with ph 7.03 and 7.04. Was on a bicarb gtt and receiving bicarb pushes frequently.\n\nAt 1000 anaesthia at bedside to transport pt to OR. At 1010 pt with asystolic arrest. CPR started and received epi/atropine. Rhythm and pressure reestablished.\n\nPt transferred to OR at 1045.\n\nSurgical team has been i touch with family and they are in the waiting room.\n" }, { "category": "Nursing/other", "chartdate": "2158-12-25 00:00:00.000", "description": "Report", "row_id": 1293806, "text": "Patient on mechanical ventilation,esophageal balloon inserted,transpulmonary pressure measured. patient on 15 cmH20,rate could be increased to 20 due to metabolic acidosis.\n" }, { "category": "Nursing/other", "chartdate": "2158-12-25 00:00:00.000", "description": "Report", "row_id": 1293807, "text": "TRAUMA SICU NSG NOTE\n 79 Y/O FEMALE RETURNED FROM OR TO TSICU FOR POST OP CARE. ( SEE FHPA AND ADMIT NOTE BY MICU RN ) PT 1PM S/P EXP LAP, WASHOUT OF ABD CAVITY, REMOVAL OF GALLSTONES AND PLACEMENT OF 4 JP DRAINS. ABD LEFT OPEN W/ OCCLUSIVE DSG. SICU COARSE AS FOLLOWS:\n PARALYZED AND SEDATED ON CISATRA AND FENTANYL.\n HEMODYNAMICALLY UNSTABLE W/ LABILE BP ON MAXIMUM PRESSOR SUPPORT W/ LEVOPHED, EPI AND VASOPRESSIN. FP ELEVATED W/ INITIAL CO/CI 6.5/3.2, SV02 76 W/ CONTINUOUS DETERIORATION DESPITE FULL SUPPORT. SV02 DOWN TO 53. PERSISTENT ACIDOSIS W/ PH 7.12-7.09 DESPITE BICARB GTT AND Q1-2HR BOLUSES OF NA BICARB. ANURIC AND ATTEMPTED CVVH W/ POOR TOLERATION.\nCOAGULOPATHIC W/ ELEVATED COAGS AND INR 2.0 DESPITE 4UFFP. LIVER ENZYMES ELEVATED. GLUCOSE LOW W/ AMP D50 X2. PT WENT IN TO CARDIAC ARREST AT 11:30PM AND WAS SUCCESSFULLY RESUSCITATED FOR A BRIEF PERIOD. PT ARRESTED AGAIN BY 12:00 AM AND AFTER FAMILY DISCUSSION PT ORDERED CPR NOT INDICATED. PT WAS PRONOUNCED DEAD AT 12:04 PM.\nFAMILY NOTIFIED.\n" } ]

[ { "category": "Nursing", "chartdate": "2167-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342509, "text": "85M with PMH of both Hodgkins and non-Hodgkins lymphoma currently on\n chemo who presented to an OSH after a fall in his driveway, pt was\n noted to be febrile and tachycardic in ED so transferred to ICU for\n further evaluation and work-up. Patient reports that he accidentally\n tripped and fell while out on a walk. He reports that he bumped his\n head in the fall. He was found down by his neighbor and EMS was\n called. The patient states that he awoke in the ambulance. He was\n initially taken to where an EKG was performed that was\n concerning for ST-segment elevations. Patient received one dose of\n atorvastatin and cardiac enzymes were negative x1. His CBC was\n significant for a white count of 13.8 with an 18% bandemia. The patient\n was then transferred to on a nitro gtt for admission to\n cardiology for STEMI. Upon arrival in the ED, vitals were 99.6 HR\n 80-140s 130/77 22 97% on 3L. The EKGs were reviewed by cardiology and\n were not read as ST-segment elevations. Nitro gtt was stopped.\n Cardiac enzymes were cycled and negative x1. EKG was notable for sinus\n tachycardia to the 140s. Patient was reportedly asymptomatic. A head\n CT was performed at the OSH that was reported as negative. A CT scan\n of C/A/P was done in the ED that was negative for pulmonary emboli and\n intra-abdominal pathology but he was noted to have a small-moderate\n pericardial effusion. In addition to the tachycardia, the patient was\n later febrile to 102. The patient was again noted to have an elevated\n white blood cell count with a bandemia of 8%. Patient was given 4L of\n NS, blood and urine cultures were sent. UA negative. Patient was\n started on vanc and levaquin and given one dose of Tylenol.\n .\n The patient's primary oncologist is . He is scheduled to\n received Cycle 19 of Gemzar/Navelbine today. Patient has also been on\n neulasta, last received on .\n" }, { "category": "Nursing", "chartdate": "2167-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342612, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient tachycardic at 130\ns-140\ns PAT w/occasional PVC\ns. B/P\n 90-100\ns/60\ns, maintains his mental status. Denies SOB. Lower extr.\n edema. Peripheral pulses present\n Action:\n Started on esmolol 50-300/mcg/kg/hr, ECG done\n Response:\n Dropped b/p to 80\ns /40\ns, esmolol d/c IVF bolus of 1.5L given. Periods\n of SR at 80\ns. b/p at 90-100\ns/50. At 530 am run of VT (24beats).\n During the episode asymptomatic, denies CP, SOB. VSS. -> started on\n amiodarone. Repleted w/Mg ( 1.7) and K (3.8) per sliding scale.\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient febrile. Tmax\n 101 PO. WBC -12.0 s/p vanc /levoquin\n administration in ED. U/A negative, abd CT\n no abd process. Cultures\n taken and results pending, CXR benign\n Action:\n Vancomycin restarted qd, Tylenol given\n Response:\n Temp down to 98.0\n Plan:\n Continue to monitor patient status, f/u cultures, consider to culture\n line (porthacath), ID/onc consult\n Neuro: alert oriented X 3, follows commands\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. Small BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley about 100cc/hr.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit.\n" }, { "category": "Nursing", "chartdate": "2167-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342871, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is in NSR at 80\ns w/ occasional PVC\ns, b/p 120-130\ns/60. Denies\n SOB. Lower extr. edema. Peripheral pulses present\n Action:\n Continue on amiodarone drip at 0.5. At 6 am d/c and switch to PO.\n Response:\n Remains in SR at 80\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient low grade temp. Tmax\n 100.7 PO. WBC -10.7 on vancomycin. U/A\n negative, abd CT\n no abd process. Cultures taken and results pending,\n CXR benign\n Action:\n Continue Vancomycin qd, Tylenol prn\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands, unsteady gait, OOB to\n chair w/assist of 2\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. large BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley ,adequate amnt.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit\n P.S. transfused w/1 unit RBC for Hct of 23.2. HCT after transfusion\n 25.7.\n If patient is called out to the floor, please call daughter at\n to update her.\n" }, { "category": "Physician ", "chartdate": "2167-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342640, "text": "Chief Complaint: 85 year old male with Hodgkin's lymphoma currently\n undergoing chemotherapy with gemzar/navelbine, trasnferred to for\n work-up of fever and tachycardia\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 08:06 PM\n EKG - At 11:09 PM\n Patient without complaints except that hungry for breakfast. Denies\n chest pain, subjective palpitations, shortness of breath, or abdominal\n pain. Denies subjective fevers or chills, nausea, vomiting, diarrhea.\n Yesterday, thinks that patient is in SVT specifically atrial tachy\n - started on esmolol drip for atrial tachycardia, had to increase to\n titrate up however did not break rhythm and blood pressure was low\n - troponin 0.07 => 0.10, CK and CK-MB are flat and no chest pain\n - tsh 5.1 (little bit elevated), no previous tsh on record\n - need to order free t3 and t4\n - also ordered EKG for AM for computer eval\n - blood cultures and urine culture pending\n - spiked fever overnight to 101, drew culture from lines, ordered\n tyleno, restarted vanc (to get in AM)\n - off drip 1 am, now heart rate better\n - went into NSVT for 20+ beats at 5:30am, patient was asymptomatic with\n normal blood pressure\n - wrote for amio load and then amio drip\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 04:30 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: none\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 35.7\nC (96.2\n HR: 78 (78 - 151) bpm\n BP: 102/48(59) {85/25(46) - 122/78(81)} mmHg\n RR: 17 (15 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 6,805 mL\n 739 mL\n PO:\n 600 mL\n TF:\n IVF:\n 3,205 mL\n 739 mL\n Blood products:\n Total out:\n 3,305 mL\n 780 mL\n Urine:\n 2,305 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,500 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic, regular, no\n murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: warm and well perfused\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, time, place, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 245 K/uL\n 7.6 g/dL\n 116 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 135 mEq/L\n 23.2 %\n 10.7 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n WBC\n 12.8\n 12.0\n 10.7\n Hct\n 25.9\n 25.3\n 23.2\n Plt\n 265\n 272\n 245\n Cr\n 1.3\n 1.3\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n Other labs: PT / PTT / INR:26.5/37.1/2.6, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.7 mg/dL, Mg++:1.7\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n .\n Fevers/SIRS- In the setting of tachycardia, elevated WBC - meets\n criteria for SIRS. UA clean. Chest x-ray and CT chest without evidence\n of pneumonia or intraabdominal abscess. After 4 liters of NS, systolic\n BPs in 80s, asymptomatic. Per OMR, baseline BPs 120-140s on a\n BBlocker. Baseline HR 70s-80s on BBlocker. Patient last recieved\n Neulasta on . Differential includes SIRS/Sepsis v. tamponade v a\n conglomeration of lymphoma and treatment related symptoms.\n Mild-moderate pericardial effusion noted in ED. EKG somewhat low\n voltage, no electrical alternans, cards consulted. No JVD or pulsus\n paradoxus on exam but distant heart sounds. Pt does have small\n pericardial effusion noted on prior Cts. On coumadin with INR of 2.7.\n Effusion could be hemorrhagic v malignant v other. Oncologist, Dr.\n , felt that elevation of WBC count could be attributable to\n Neulasta and that fevers are not uncommon in patient's with lymphoma.\n Etiology of tachycardia uncertain, however, as per cardiology rhythm is\n atrial tachycardia with rapid onset and rapid offest. Elevation of\n lactate likely due to fall and being down for an unknown period of\n time. Dr. also noted that patients who have been on chemo for\n extended periods can develop neuropathies and cardiac conduction\n abnormalities.\n - repeat CBC and diff\n - patient has not required aggressive fluid resuscitation since arrival\n - f/u blood and urine cultures -pending\n - patient received vanc and levo in ED, originally were going to hold\n off on additional antiobiotics however patietn spiked fever again\n - recultured where portacath site is, and restarted vancomycin, will\n continue pending negative blood/line culture results and potential\n source of infection in this patient\n - CTA negative for acute PE, no PNA noted either, CT abdomen negative\n for intrabdominal process\n Tachycardia\n appears to be atrial tachycardia\n - appreciate cards consult yesterday, reccomended beta blocker to treat\n a-tach\n - tried esmolol drip without success in breaking rhythm and also\n limited by low blood pressure\n - d/c esmolol drip and patient returned to sinus rhythm\n overnight\n - subsequently patient developed run of 22 NSVT with stable blood\n pressure, asymptomatic\n checked electrolytes which were okay (gave\n repletion to optimize) and started on amio load\n - will need to reconsult cardiology regarding other options for\n treatment as IV beta blocker did not work and now with NSVT\n - as below the pericardial effusion appears circumferential without\n signs of tamponade, so would continue to dose coumadin at regular dose\n - ECHO: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is low normal (LVEF 50%).\n Right ventricular chamber size is normal. with focal hypokinesis of the\n apical free wall. The ascending aorta is mildly dilated. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. The pulmonary artery systolic pressure could not\n be determined. There is a small pericardial effusion. The effusion\n appears circumferential. There are no echocardiographic signs of\n tamponade. No right atrial or right ventricular diastolic collapse is\n seen.\n Compared with the findings of the prior report (images unavailable for\n review) of , the right ventricle is no longer dilated and\n globally hypocontractile.\n .\n Lymphoma - missed cycle of gemzar/navelbine . primary oncologist,\n , dose chemo next week\n - last dose chemo , last dose neulasta \n - continue megace for now\n .\n Hypertension - Baseline 140s\n - hold BBlocker, hold doxazosin\n - currently still hypotensive\n .\n History of PE - no acute PE on CT but remnant of past noted\n - hold coumadin for evaluation of pericardial effusion\n .\n Hyperlipidemia - Continue statin\n .\n Renal Insufficiency - baseline creatnine 1.2, 1.4 on arrival. Did\n receive contrast in ED for PE CT.\n - continue IVFs\n - avoid nephrotoxic meds\n .\n BPH - hold doxazosin for now while hypotensive\n .\n Fall - per onc attending, patient has unsteadiness of gait at baseline\n and is supposed to walk with walker but does not.\n - PT consult and eval\n .\n FEN - regular diet, replete lytes prn by onc sliding scales\n .\n Access - Right-sided portacath, peripheral IVs\n .\n Code Status - Full code\n .\n Contact - HCP, wife.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n 18 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2167-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342586, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient tachycardic at 130\ns-140\ns PAT w/occasional PVC\ns. B/P\n 90-100\ns/60\ns, maintains his mental status. Denies SOB. Lower extr.\n edema. Peripheral pulses present\n Action:\n Started on esmolol 50-300/mcg/kg/hr, ECG done\n Response:\n Dropped b/p to 80\ns /40\ns, esmolol d/c IVF bolus of 1.5L given. Periods\n of SR at 80\ns. b/p at 90-100\ns/50\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient febrile. Tmax\n 101 PO. WBC -12.0 s/p vanc /levoquin\n administration in ED. U/A negative, abd CT\n no abd process. Cultures\n taken and results pending, CXR benign\n Action:\n Vancomycin restarted qd, Tylenol given\n Response:\n Temp down to 98.0\n Plan:\n Continue to monitor patient status, f/u cultures, consider to culture\n line (porthacath), ID/onc consult\n Neuro: alert oriented X 3, follows commands\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. Small BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley about 100cc/hr.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit.\n" }, { "category": "Physician ", "chartdate": "2167-08-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342658, "text": "Chief Complaint: tachycardia , HOTN\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 85 yo man with hodgkins lymphoma. Tripped and fell, no reported . At\n OSH, not trauma at OSH (negative head CT). Was tachycardic,\n transferred here. Cardiology didn't feel that he had ACS, but with\n atrial tachycardia. Started on esmolol, but was not effective. Was\n weaned off esmolol, and flipped into sinus sinus for 5 hours. Had 22\n beat run of NSVT. Started on amio drip. Also was febrile to 101\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 08:06 PM\n EKG - At 11:09 PM\n BLOOD CULTURED - At 04:00 AM\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Metoprolol - 04:30 PM\n Other medications:\n simvastat\n asa\n allopurinol\n vanco\n amiodarone\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: Fever\n Cardiovascular: Tachycardia\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 10:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.8\nC (98.2\n HR: 128 (77 - 144) bpm\n BP: 90/59(66) {85/25(46) - 122/78(81)} mmHg\n RR: 20 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: PAT (Paroxysmal Atrial Tachycardia)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 6,805 mL\n 1,331 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 3,205 mL\n 1,211 mL\n Blood products:\n Total out:\n 3,305 mL\n 1,400 mL\n Urine:\n 2,305 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,500 mL\n -68 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3 , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 7.6 g/dL\n 245 K/uL\n 116 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 135 mEq/L\n 23.2 %\n 10.7 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n WBC\n 12.8\n 12.0\n 10.7\n Hct\n 25.9\n 25.3\n 23.2\n Plt\n 265\n 272\n 245\n Cr\n 1.3\n 1.3\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n Other labs: PT / PTT / INR:26.5/37.1/2.6, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.7 mg/dL, Mg++:1.7\n mg/dL, PO4:3.4 mg/dL\n Imaging: echo: no tamponade. Low normal EF 50%\n CT chest: No PE\n CT abdomen: no abd process.\n Assessment and Plan\n Fevers: No clear source. Await cultures. Empiric vancomycin to cover\n line source pending cultures.\n HOTN: Unclear cause. Has had decreased PO intake over past few days,\n so could be dehydration.\n PAF: In and out of AF, now in sinus. On amiodarone drip currently.\n Coumadin for AF and prior PE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n 18 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2167-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342659, "text": "Chief Complaint: 85 year old male with Hodgkin's lymphoma currently\n undergoing chemotherapy with gemzar/navelbine, trasnferred to for\n work-up of fever and tachycardia\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 08:06 PM\n EKG - At 11:09 PM\n Patient without complaints except that hungry for breakfast. Denies\n chest pain, subjective palpitations, shortness of breath, or abdominal\n pain. Denies subjective fevers or chills, nausea, vomiting, diarrhea.\n Yesterday, thinks that patient is in SVT specifically atrial tachy\n - started on esmolol drip for atrial tachycardia, had to increase to\n titrate up however did not break rhythm and blood pressure was low\n - troponin 0.07 => 0.10, CK and CK-MB are flat and no chest pain\n - tsh 5.1 (little bit elevated), no previous tsh on record\n - need to order free t3 and t4\n - also ordered EKG for AM for computer eval\n - blood cultures and urine culture pending\n - spiked fever overnight to 101, drew culture from lines, ordered\n tyleno, restarted vanc (to get in AM)\n - off drip 1 am, now heart rate better\n - went into NSVT for 20+ beats at 5:30am, patient was asymptomatic with\n normal blood pressure\n - wrote for amio load and then amio drip\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 04:30 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: none\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 35.7\nC (96.2\n HR: 78 (78 - 151) bpm\n BP: 102/48(59) {85/25(46) - 122/78(81)} mmHg\n RR: 17 (15 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 6,805 mL\n 739 mL\n PO:\n 600 mL\n TF:\n IVF:\n 3,205 mL\n 739 mL\n Blood products:\n Total out:\n 3,305 mL\n 780 mL\n Urine:\n 2,305 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,500 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic, regular, no\n murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: warm and well perfused\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, time, place, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 245 K/uL\n 7.6 g/dL\n 116 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 135 mEq/L\n 23.2 %\n 10.7 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n WBC\n 12.8\n 12.0\n 10.7\n Hct\n 25.9\n 25.3\n 23.2\n Plt\n 265\n 272\n 245\n Cr\n 1.3\n 1.3\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n Other labs: PT / PTT / INR:26.5/37.1/2.6, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.7 mg/dL, Mg++:1.7\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n .\n Fevers/SIRS- In the setting of tachycardia, elevated WBC - meets\n criteria for SIRS. UA clean. Chest x-ray and CT chest without evidence\n of pneumonia or intraabdominal abscess. After 4 liters of NS, systolic\n BPs in 80s, asymptomatic. Per OMR, baseline BPs 120-140s on a\n BBlocker. Baseline HR 70s-80s on BBlocker. Patient last recieved\n Neulasta on . Differential includes SIRS/Sepsis v. tamponade v a\n conglomeration of lymphoma and treatment related symptoms.\n Mild-moderate pericardial effusion noted in ED. EKG somewhat low\n voltage, no electrical alternans, cards consulted. No JVD or pulsus\n paradoxus on exam but distant heart sounds. Pt does have small\n pericardial effusion noted on prior Cts. On coumadin with INR of 2.7.\n Effusion could be hemorrhagic v malignant v other. Oncologist, Dr.\n , felt that elevation of WBC count could be attributable to\n Neulasta and that fevers are not uncommon in patient's with lymphoma.\n Etiology of tachycardia uncertain, however, as per cardiology rhythm is\n atrial tachycardia with rapid onset and rapid offest. Elevation of\n lactate likely due to fall and being down for an unknown period of\n time. Dr. also noted that patients who have been on chemo for\n extended periods can develop neuropathies and cardiac conduction\n abnormalities.\n - repeat CBC and diff\n - patient has not required aggressive fluid resuscitation since arrival\n - f/u blood and urine cultures -pending\n - patient received vanc and levo in ED, originally were going to hold\n off on additional antiobiotics however patietn spiked fever again\n - recultured where portacath site is, and restarted vancomycin, will\n continue pending negative blood/line culture results and potential\n source of infection in this patient\n - CTA negative for acute PE, no PNA noted either, CT abdomen negative\n for intrabdominal process\n - suspect that fever may be related to lymphoma, however until cx\n negative will treat with iv vanc\n Tachycardia\n appears to be atrial tachycardia\n - appreciate cards consult yesterday, reccomended beta blocker to treat\n a-tach\n - tried esmolol drip limited by low blood pressure, did not appear to\n break rythmn\n - d/c esmolol drip and patient returned to sinus rhythm\n overnight\n - subsequently patient developed run of 22 NSVT with stable blood\n pressure, asymptomatic\n checked electrolytes which were okay (gave\n repletion to optimize) and started on amiodarone load\n - will follow up with cardiology as think that much of presentation\n consistent with cardiac etiology\n - would consider transfer to if pressures improve\n - definitely has a CAD equivalent with PVD\n - as below the pericardial effusion appears circumferential without\n signs of tamponade, so would restart coumadin\n - ECHO: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is low normal (LVEF 50%).\n Right ventricular chamber size is normal. with focal hypokinesis of the\n apical free wall. The ascending aorta is mildly dilated. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. The pulmonary artery systolic pressure could not\n be determined. There is a small pericardial effusion. The effusion\n appears circumferential. There are no echocardiographic signs of\n tamponade. No right atrial or right ventricular diastolic collapse is\n seen.\n Compared with the findings of the prior report (images unavailable for\n review) of , the right ventricle is no longer dilated and\n globally hypocontractile.\n Lymphoma - missed cycle of gemzar/navelbine . primary oncologist,\n , dose chemo next week\n - last dose chemo , last dose neulasta \n - continue megace for now\n .\n Hypertension - Baseline 140s\n - hold BBlocker, hold doxazosin\n - currently still hypotensive\n .\n History of PE - no acute PE on CT but remnant of past noted\n - hold coumadin for evaluation of pericardial effusion\n .\n Hyperlipidemia - Continue statin\n PVD\n - history of peripheral vascular disease had fem/posterial\n tibial bypass (also stent)\n - essentially a CAD equivalent\n - on statin\n .\n Renal Insufficiency - baseline creatnine 1.2, 1.4 on arrival. Did\n receive contrast in ED for PE CT.\n - continue IVFs\n - avoid nephrotoxic meds\n .\n BPH - hold doxazosin for now while hypotensive\n .\n Fall - per onc attending, patient has unsteadiness of gait at baseline\n and is supposed to walk with walker but does not.\n - PT consult and eval\n .\n FEN - regular diet, replete lytes prn by onc sliding scales\n .\n Access - Right-sided portacath, peripheral IVs\n .\n Code Status - Full code\n .\n Contact - HCP, wife.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n 18 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2167-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342619, "text": "Chief Complaint: 85 year old male with Hodgkin's lymphoma currently\n undergoing chemotherapy with gemzar/navelbine, trasnferred to for\n work-up of fever and tachycardia\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 08:06 PM\n EKG - At 11:09 PM\n Yesterday, thinks that patient is in SVT specifically atrial tachy\n - started on esmolol drip for atrial tachycardia, had to increase to\n titrate up however did not break rhythm and blood pressure was low\n - troponin 0.07 => 0.10, CK and CK-MB are flat and no chest pain\n - tsh 5.1 (little bit elevated), no previous tsh on record\n - need to order free t3 and t4\n - also ordered EKG for AM for computer eval\n - blood cultures and urine culture pending\n - spiked fever overnight to 101, drew culture from lines, ordered\n tyleno, restarted vanc (to get in AM)\n - off drip 1 am, now heart rate better\n - went into NSVT for 20+ beats at 5:30am, patient was asymptomatic with\n normal blood pressure\n - wrote for amio load and then amio drip\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\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 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 35.7\nC (96.2\n HR: 78 (78 - 151) bpm\n BP: 102/48(59) {85/25(46) - 122/78(81)} mmHg\n RR: 17 (15 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 6,805 mL\n 739 mL\n PO:\n 600 mL\n TF:\n IVF:\n 3,205 mL\n 739 mL\n Blood products:\n Total out:\n 3,305 mL\n 780 mL\n Urine:\n 2,305 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,500 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic, no murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, 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, Oriented (to): person, time, place, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 245 K/uL\n 7.6 g/dL\n 116 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 135 mEq/L\n 23.2 %\n 10.7 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n WBC\n 12.8\n 12.0\n 10.7\n Hct\n 25.9\n 25.3\n 23.2\n Plt\n 265\n 272\n 245\n Cr\n 1.3\n 1.3\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n Other labs: PT / PTT / INR:26.5/37.1/2.6, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.7 mg/dL, Mg++:1.7\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n .\n Fevers/SIRS- In the setting of tachycardia, elevated WBC - meets\n criteria for SIRS. UA clean. Chest x-ray and CT chest without evidence\n of pneumonia or intraabdominal abscess. After 4 liters of NS, systolic\n BPs in 80s, asymptomatic. Per OMR, baseline BPs 120-140s on a\n BBlocker. Baseline HR 70s-80s on BBlocker. Patient last recieved\n Neulasta on . Differential includes SIRS/Sepsis v. tamponade v a\n conglomeration of lymphoma and treatment related symptoms.\n Mild-moderate pericardial effusion noted in ED. EKG somewhat low\n voltage, no electrical alternans, cards consulted. No JVD or pulsus\n paradoxus on exam but distant heart sounds. Pt does have small\n pericardial effusion noted on prior Cts. On coumadin with INR of 2.7.\n Effusion could be hemorrhagic v malignant v other. Oncologist, Dr.\n , felt that elevation of WBC count could be attributable to\n Neulasta and that fevers are not uncommon in patient's with lymphoma.\n Etiology of tachycardia uncertain, however, as per cardiology rhythm is\n atrial tachycardia with rapid onset and rapid offest. Elevation of\n lactate likely due to fall and being down for an unknown period of\n time. Dr. also noted that patients who have been on chemo for\n extended periods can develop neuropathies and cardiac conduction\n abnormalities.\n - repeat CBC and diff\n - patient has not required aggressive fluid resuscitation since arrival\n - f/u blood and urine cultures -pending\n - patient received vanc and levo in ED, originally were going to hold\n off on additional antiobiotics however patietn spiked fever again\n - recultured where portacath site is, and restarted vancomycin, will\n continue pending negative blood/line culture results and potential\n source of infection in this patient\n - CTA negative for acute PE, no PNA noted either, CT abdomen negative\n for intrabdominal process\n Tachycardia\n appears to be atrial tachycardia\n - appreciate cards consult yesterday, reccomended beta blocker to treat\n a-tach\n - tried esmolol drip without success in breaking rhythm and also\n limited by low blood pressure\n - d/c esmolol drip and patient returned to sinus rhythm\n overnight\n - subsequently patient developed run of 22 NSVT with stable blood\n pressure, asymptomatic\n checked electrolytes which were okay (gave\n repletion to optimize) and started on amio load\n - will need to reconsult cardiology regarding other options for\n treatment as IV beta blocker did not work and now with NSVT\n - as below the pericardial effusion appears circumferential without\n signs of tamponade, so would continue to dose coumadin at regular dose\n - ECHO: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is low normal (LVEF 50%).\n Right ventricular chamber size is normal. with focal hypokinesis of the\n apical free wall. The ascending aorta is mildly dilated. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. The pulmonary artery systolic pressure could not\n be determined. There is a small pericardial effusion. The effusion\n appears circumferential. There are no echocardiographic signs of\n tamponade. No right atrial or right ventricular diastolic collapse is\n seen.\n Compared with the findings of the prior report (images unavailable for\n review) of , the right ventricle is no longer dilated and\n globally hypocontractile.\n .\n Lymphoma - missed cycle of gemzar/navelbine . primary oncologist,\n , dose chemo next week\n - last dose chemo , last dose neulasta \n - continue megace for now\n .\n Hypertension - Baseline 140s\n - hold BBlocker, hold doxazosin\n - currently still hypotensive\n .\n History of PE - no acute PE on CT but remnant of past noted\n - hold coumadin for evaluation of pericardial effusion\n .\n Hyperlipidemia - Continue statin\n .\n Renal Insufficiency - baseline creatnine 1.2, 1.4 on arrival. Did\n receive contrast in ED for PE CT.\n - continue IVFs\n - avoid nephrotoxic meds\n .\n BPH - hold doxazosin for now while hypotensive\n .\n Fall - per onc attending, patient has unsteadiness of gait at baseline\n and is supposed to walk with walker but does not.\n - PT consult and eval\n .\n FEN - regular diet, replete lytes prn by onc sliding scales\n .\n Access - Right-sided portacath, peripheral IVs\n .\n Code Status - Full code\n .\n Contact - HCP, wife.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n 18 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2167-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342620, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is tachycardic at 130\ns-140\ns PAT w/occasional PVC\ns. B/P\n 90-100\ns/60\ns, maintains his mental status. Denies SOB. Lower extr.\n edema. Peripheral pulses present\n Action:\n Started on esmolol 50-300/mcg/kg/hr, ECG done\n Response:\n Dropped b/p to 80\ns /40\ns, esmolol d/c, IVF bolus of 1.5L given. HR at\n 80\ns w/frequent periods of PAT at 130\ns. b/p at 90-100\ns/50. At 530 am\n run of VT (24beats). During the episode asymptomatic, denies CP, SOB.\n VSS. -> started on amiodarone. Repleted w/Mg ( 1.7) and K (3.8) per\n sliding scale. Trop-0.11ck- 63 ck-mb-5\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient febrile. Tmax\n 101 PO. WBC -12.0 s/p vanc /levoquin\n administration in ED. U/A negative, abd CT\n no abd process. Cultures\n taken and results pending, CXR benign\n Action:\n Vancomycin restarted qd, Tylenol given\n Response:\n Temp down to 98.0\n Plan:\n Continue to monitor patient status, f/u cultures, consider to culture\n line (porthacath), ID/onc consult\n Neuro: alert oriented X 3, follows commands\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. Small BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley about 100cc/hr.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit.\n" }, { "category": "Nursing", "chartdate": "2167-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342625, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is tachycardic at 130\ns-140\ns PAT w/occasional PVC\ns. B/P\n 90-100\ns/60\ns, maintains his mental status. Denies SOB. Lower extr.\n edema. Peripheral pulses present\n Action:\n Started on esmolol 50-300/mcg/kg/hr, ECG done\n Response:\n Dropped b/p to 80\ns /40\ns, esmolol d/c, IVF bolus of 1.5L given. HR at\n 80\ns w/frequent periods of PAT at 130\ns. b/p at 90-100\ns/50. At 530 am\n run of VT (24beats). During the episode asymptomatic, denies CP, SOB.\n VSS. -> started on amiodarone. Repleted w/Mg ( 1.7) and K (3.8) per\n sliding scale. Trop-0.11ck- 63 ck-mb-5\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control. Repeat ECG/cycle CE???\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient febrile. Tmax\n 101 PO. WBC -12.0 s/p vanc /levoquin\n administration in ED. U/A negative, abd CT\n no abd process. Cultures\n taken and results pending, CXR benign\n Action:\n Vancomycin restarted qd, Tylenol given, blood cultures from porthacath\n sent\n Response:\n Temp down to 98.0\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. Small BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley about 100cc/hr.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit.\n" }, { "category": "Nursing", "chartdate": "2167-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342791, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is in NSR at 80\ns w/ occasional PVC\ns, b/p 120-130\ns/60. Denies\n SOB. Lower extr. edema. Peripheral pulses present\n Action:\n Continue on amiodarone drip at 0.5. At 6 am d/c and switch to PO.\n Response:\n Remains in SR at 80\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient low grade temp. Tmax\n 100.7 PO. WBC -10.7 on vancomycin. U/A\n negative, abd CT\n no abd process. Cultures taken and results pending,\n CXR benign\n Action:\n Continue Vancomycin qd, Tylenol prn\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands, unsteady gait, OOB to\n chair w/assist of 2\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. large BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley ,adequate amnt.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit\n" }, { "category": "Nursing", "chartdate": "2167-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 342792, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is in NSR at 80\ns w/ occasional PVC\ns, b/p 120-130\ns/60. Denies\n SOB. Lower extr. edema. Peripheral pulses present\n Action:\n Continue on amiodarone drip at 0.5. At 6 am d/c and switch to PO.\n Response:\n Remains in SR at 80\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient low grade temp. Tmax\n 100.7 PO. WBC -10.7 on vancomycin. U/A\n negative, abd CT\n no abd process. Cultures taken and results pending,\n CXR benign\n Action:\n Continue Vancomycin qd, Tylenol prn\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands, unsteady gait, OOB to\n chair w/assist of 2\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. large BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley ,adequate amnt.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit\n" }, { "category": "Rehab Services", "chartdate": "2167-08-27 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 342716, "text": "Attending Physician: , .\n Referral date: \n Medical Diagnosis / ICD 9: HL / 201.9\n Reason of referral: eval and tx\n History of Present Illness / Subjective Complaint: 85 yo M w/ HL with\n h/o ground-level fall without trauma to head (per CT) and with ECG\n changes at OSH. Upon admit to , had tachycardia, hypotension,\n fever. Currently on chemo w/ Gemzar/Navelbine. Pt reports hitting jaw\n on ground during fall, and \"maybe I blacked out.\"\n Past Medical / Surgical History: HL/NHL, gout, PE, DVT\n Medications: metoprolol, simvastatin, ASA, allopurinol, vancomycin,\n amiodarone\n Radiology: Chest CT negative for PE, but ECHO positive for moderate\n pericardial effusion\n Labs:\n 23.2\n 7.6\n 245\n 10.7\n [image002.jpg]\n Other labs:\n Activity Orders: OOB per MDs\n Social / Occupational History: lives w/ wife; 2 daughters who live in\n , NY; son who is a PT and lives in the area\n Living Environment: has 5 STE; 3 FOS inside (4 level house) with\n washer/dryer on bottom level, kitchen on first, bedrooms on second,\n attic on third\n Prior Functional Status / Activity Level: carries a SC while walking;\n owns RW which he doesn't use; walks every day to his neighbor's house\n (reports \"a quarter of a mile\")\n Objective Test\n Arousal / Attention / Cognition / Communication: A&Ox3; responded to\n all questions/commands appropriately\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 87\n 119/59\n 16\n 100% on RA\n Sit\n /\n Activity\n 123\n 114/63\n 22\n 100% on RA\n Stand\n /\n Recovery\n 82\n 129/58\n 23\n 100% on RA\n Total distance walked: NA\n Minutes: NA\n Pulmonary Status: increased WOB/SOB w/ activity; no cough noted\n Integumentary / Vascular: R PIV; CVL; telemetry; foley intact; 1+ edema\n in R leg (this is the leg in which pt had DVT)\n Sensory Integrity: reports uncomfortable tingling all over feet;\n sensation diminished on plantar surfaces to light touch\n Pain / Limiting Symptoms: no c/o pain\n Posture: kyphotic\n Range of Motion\n Muscle Performance\n not formally tested\n unable to lift R LE against gravity; able to lift other extremities\n against gravity\n Motor Function: + resting tremor in B UE noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: pt unable to amb \"heaviness/weakness\" in his\n legs; +shaking in B LE upon WB even while using RW for support. pt did\n sit-stand x 2 w/ mod A x 2. transferred bed-chair w/ mod A x 2 w/\n stand-pivot technique and using RW for support.\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n T\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 Balance: able to maintain static sitting balance at EOB x 1 minute;\n unable to maintain dynamic sitting position at EOB; no other positions\n tested, but no LOB during transfer to chair; pt had\n difficulty maintaining upright posture- stood with trunk flexed even\n after VC to \"stand up straight\"; was retropulsive in sitting/standing\n Education / Communication: pt education re: importance of OOB/amb; D/C\n planning; comm w/ nsg and MDs re: pt status\n Intervention:\n Other:\n Diagnosis:\n Clinical impression / Prognosis: 85 yo M w/ HL presents w/ decreased\n strength and endurance, impaired balance, poor safety awareness, and\n decreased functional mobility consistent with progressive disorders of\n the CNS. Pt is currently functioning well below his baseline as he is\n requiring A and S w/ all mobility and is unable to amb. Pt's progress\n may be limited by progression of his disease, age, and commorbidities.\n Pt can benefit from continued PT to address his impairments and\n functional limitations. Recommend rehab as pt has decreased support at\n home and has poor safety awareness.\n Goals\n Time frame: 1 week\n 1.\n able to move all extremities against gravity\n 2.\n tolerates daily PT treats w/ VSS/min SOB\n 3.\n able to maintain static standing x 20 seconds\n 4.\n uses AD appropriately 100% of the time\n 5.\n amb 20' using RW w/ CG-\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n strengthening, conditioning, balance training, pt education, functional\n tasks--amb, D/C planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2167-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342607, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient tachycardic at 130\ns-140\ns PAT w/occasional PVC\ns. B/P\n 90-100\ns/60\ns, maintains his mental status. Denies SOB. Lower extr.\n edema. Peripheral pulses present\n Action:\n Started on esmolol 50-300/mcg/kg/hr, ECG done\n Response:\n Dropped b/p to 80\ns /40\ns, esmolol d/c IVF bolus of 1.5L given. Periods\n of SR at 80\ns. b/p at 90-100\ns/50. At 530 am run of VT (24beats).\n During the episode asymptomatic, denies CP, SOB. VSS. -> started on\n amiodarone. Repleted w/Mg ( 1.7) and K (3.8) per sliding scale.\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient febrile. Tmax\n 101 PO. WBC -12.0 s/p vanc /levoquin\n administration in ED. U/A negative, abd CT\n no abd process. Cultures\n taken and results pending, CXR benign\n Action:\n Vancomycin restarted qd, Tylenol given\n Response:\n Temp down to 98.0\n Plan:\n Continue to monitor patient status, f/u cultures, consider to culture\n line (porthacath), ID/onc consult\n Neuro: alert oriented X 3, follows commands\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. Small BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley about 100cc/hr.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit.\n" }, { "category": "Nursing", "chartdate": "2167-08-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342830, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is in NSR at 80\ns w/ occasional PVC\ns, b/p 120-130\ns/60. Denies\n SOB. Lower extr. edema. Peripheral pulses present\n Action:\n Continue on amiodarone drip at 0.5. At 6 am d/c and switch to PO.\n Response:\n Remains in SR at 80\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient low grade temp. Tmax\n 100.7 PO. WBC -10.7 on vancomycin. U/A\n negative, abd CT\n no abd process. Cultures taken and results pending,\n CXR benign\n Action:\n Continue Vancomycin qd, Tylenol prn\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands, unsteady gait, OOB to\n chair w/assist of 2\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. large BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley ,adequate amnt.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit\n P.S. transfused w/1 unit RBC for Hct of 23.2.\n" }, { "category": "Nursing", "chartdate": "2167-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 342966, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is in NSR at 80\ns w/ occasional PVC\ns, b/p 120-130\ns/60. Denies\n SOB. Lower extr. edema. Peripheral pulses present\n Action:\n Continue on amiodarone drip at 0.5. At 6 am d/c and switch to PO.\n Response:\n Remains in SR at 80\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient low grade temp. Tmax\n 100.7 PO. WBC -10.7 on vancomycin. U/A\n negative, abd CT\n no abd process. Cultures taken and results pending,\n CXR benign\n Action:\n Continue Vancomycin qd, Tylenol prn\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands, unsteady gait, OOB to\n chair w/assist of 2\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. large BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley ,adequate amnt.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit\n" }, { "category": "Nursing", "chartdate": "2167-08-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 342970, "text": "85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n Tachycardia, Other\n Assessment:\n Patient is in NSR at 80\ns w/ occasional PVC\ns, b/p 120-130\ns/60. Denies\n SOB. Lower extr. edema. Peripheral pulses present\n Action:\n Continue on amiodarone drip at 0.5. At 6 am d/c , PO loprossor started\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n FEVER\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 72.1 kg\n Daily weight:\n 72.2 kg\n Allergies/Reactions:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Precautions:\n PMH:\n CV-PMH: Hypertension, PVD\n Additional history: Pulmonary Embolism, Renal Insufficiency, Hodgkins\n Lymphoma\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:55\n Temperature:\n 97.6\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 None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 768 mL\n 24h total out:\n 1,430 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:23 AM\n Potassium:\n 4.2 mEq/L\n 04:23 AM\n Chloride:\n 106 mEq/L\n 04:23 AM\n CO2:\n 20 mEq/L\n 04:23 AM\n BUN:\n 15 mg/dL\n 04:23 AM\n Creatinine:\n 1.2 mg/dL\n 04:23 AM\n Glucose:\n 130 mg/dL\n 04:23 AM\n Hematocrit:\n 25.7 %\n 04:23 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cell phone\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 7 south\n Date & time of Transfer: 12:00 AM\n .\n Response:\n Remains in SR at 80\n Plan:\n Continue to monitor patient hemodynamic status, cards consult if\n needed,???med regimen for rate control.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient low grade temp. Tmax\n 100.7 PO. WBC -10.7 on vancomycin. U/A\n negative, abd CT\n no abd process. Cultures taken and results pending,\n CXR benign\n Action:\n Continue Vancomycin qd, Tylenol prn\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u cultures), ID/onc consult\n Neuro: alert oriented X 3, follows commands, unsteady gait, OOB to\n chair w/assist of 2\n Resp: on RA sats at high 90\ns- 100. Denies SOB. Bil LS diminished.\n RRR. Unlabored breathing.\n GI: abd soft non tender, positive for BS and flatus. large BM during\n the shift. Heart healthy diet, tolerated well, denies N/V.\n GU: clear yellow urine via foley ,adequate amnt.\n Skin: no skin impairment noted.\n IV access: 2 PIV 18/20G on the RT, porthacath at the RT chest, accessed\n on .\n Social: patient is a FULL CODE. Family in to visit\n" }, { "category": "Physician ", "chartdate": "2167-08-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342609, "text": "Chief Complaint: 85 year old male with Hodgkin's lymphoma currently\n undergoing chemotherapy with gemzar/navelbine, trasnferred to for\n work-up of fever and tachycardia\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 08:06 PM\n EKG - At 11:09 PM\n Yesterday, thinks that patient is in SVT specifically atrial tachy\n - started on esmolol drip for atrial tachycardia, had to increase to\n titrate up however did not break rhythm and blood pressure was low\n - troponin 0.07 => 0.10, CK and CK-MB are flat and no chest pain\n - tsh 5.1 (little bit elevated), no previous tsh on record\n - need to order free t3 and t4\n - also ordered EKG for AM for computer eval\n - blood cultures and urine culture pending\n ECHO: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is low normal (LVEF 50%).\n Right ventricular chamber size is normal. with focal hypokinesis of the\n apical free wall. The ascending aorta is mildly dilated. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. The pulmonary artery systolic pressure could not\n be determined. There is a small pericardial effusion. The effusion\n appears circumferential. There are no echocardiographic signs of\n tamponade. No right atrial or right ventricular diastolic collapse is\n seen.\n Compared with the findings of the prior report (images unavailable for\n review) of , the right ventricle is no longer dilated and\n globally hypocontractile.\n - spiked fever overnight to 101, drew culture from lines, ordered\n tyleno, restarted vanc (to get in AM)\n - off drip 1 am, now heart rate better\n - went into NSVT for 20+ beats at 5:30am, patient was asymptomatic with\n normal blood pressure\n - wrote for amio load and then amio drip\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\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 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 35.7\nC (96.2\n HR: 78 (78 - 151) bpm\n BP: 102/48(59) {85/25(46) - 122/78(81)} mmHg\n RR: 17 (15 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 6,805 mL\n 739 mL\n PO:\n 600 mL\n TF:\n IVF:\n 3,205 mL\n 739 mL\n Blood products:\n Total out:\n 3,305 mL\n 780 mL\n Urine:\n 2,305 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,500 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic, no murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, 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, Oriented (to): person, time, place, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 245 K/uL\n 7.6 g/dL\n 116 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 135 mEq/L\n 23.2 %\n 10.7 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n WBC\n 12.8\n 12.0\n 10.7\n Hct\n 25.9\n 25.3\n 23.2\n Plt\n 265\n 272\n 245\n Cr\n 1.3\n 1.3\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n Other labs: PT / PTT / INR:26.5/37.1/2.6, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.7 mg/dL, Mg++:1.7\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n .\n Fever, hypotension, tachycardia, elevated WBC - meets criteria for\n SIRS. After 4 liters of NS, systolic BPs in 80s, asymptomatic. Per\n OMR, baseline BPs 120-140s on a BBlocker. Baseline HR 70s-80s on\n BBlocker. Patient last recieved Neulasta on . Differntial includes\n SIRS/Sepsis v. tamponade v a conglomeration of lymphoma and treatment\n related symptoms. Discussed patient with primary oncologist this am.\n Mild-moderate pericardial effusion noted in ED. EKG somewhat low\n voltage, no electrical alternans, cards consulted. No JVD or pulses on\n exam but distant heart sounds. Pt does have small pericardial effusion\n noted on prior Cts. On coumadin with INR of 2.7. Effusion could be\n hemorrhagic v malignant v other. Oncologist, Dr. , felt that\n elevation of WBC count could be attributable to Neulasta and that\n fevers are not uncommon in patient's with lymphoma. Etiology of\n tachycardia uncertain, however, patient now back at baseline with only\n fluid intervention and BBlocker held. Elevation of lactate likely due\n to fall and being down for an unknown period of time. Dr. also\n noted that patients who have been on chemo for extended periods can\n develop neuropathies and cardiac conduction abnormalities.\n - repeat CBC and diff\n - continue fluid resuscitation as needed, pt continues to make\n excellent urine and sats are 100% on RA\n - f/u blood and urine cultures\n - patient received vanc and levo in , gold on further\n antibiotics for now and observe patient\n - CTA negative for acute PE, no PNA noted either\n - CT abdomen negative for intrabdominal process\n - mild-moderate pericardial effusion also noted, could account for\n tachycardia\n - ECHO for better evaluation of pericardial effusion\n - cards consult\n - hold coumadin pending work-up of effusion\n .\n Lymphoma - due to recieve next cycle of gemzar/navelbine today. Spoke\n with primary oncologist, this am, will hold until next\n week\n - last dose chemo , last dose neulasta \n - continue megace\n .\n Hypertension - Baseline 140s\n - hold BBlocker, hold doxazosin\n .\n History of PE - no acute PE on CT but remnant of past noted\n - hold coumadin for evaluation of pericardial effusion\n .\n Hyperlipidemia - Continue statin\n .\n Renal Insufficiency - baseline creatnine 1.2, 1.4 on arrival. Did\n receive contrast in ED for PE CT.\n - continue IVFs\n - avoid nephrotoxic meds\n .\n BPH - hold doxazosin for now while hypotensive\n .\n Fall - per onc attending, patient has unsteadiness of gait at baseline\n and is supposed to walk with walker but does not.\n - PT consult and eval\n .\n FEN - regular diet, replete lytes prn by onc sliding scales, IVFs\n .\n Access - Right-sided portacath, peripheral IVs\n .\n Code Status - Full code\n .\n Contact - HCP, wife.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n 18 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2167-08-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 342479, "text": "Chief Complaint: S/P fall\n Pericardial Effusion noted in f/u exam\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient had mechanical fall yesterday witnessed by neighbor and had ECG\n changes noted at and was t-fer to \n In ED here--CT chest negative for PE but with moderate pericardial\n effusion noted on f/u ECHO\n T=99.6, BP-130/77, 97% on 3 liters\n Patient to ICU for further care with concern for pericardial effusion\n noted on CT and ultrasound exam.\n Here in ICU he has\n HR-147, BP=92/45, RR=22, 100% on RA\n Initial Rx was with 1 liter IVF and HR improved to 85 and SBP >103\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Lymphoma-Hodgkin's and non-Hodgkin's Lymphoma\n Gout\n PE-On coumadin\n DVT\n Non-contirbutory\n Occupation: Ret'd\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Wife-HCP and lives with her at home\n Review of systems:\n Flowsheet Data as of 11:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.7\nC (96.2\n HR: 140 (140 - 151) bpm\n BP: 113/43(61) {92/43(57) - 113/64(66)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 4,000 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 2,000 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,000 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Distant), 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), (Percussion: Resonant : ),\n (Breath Sounds: Diminished: )\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 18\n [image002.jpg]\n Imaging: CT Scan-\n No intra-abdominal pathology noted\n Pericardial Effusion noted\n ECG: ST-low voltage at baseline, no significant ST or PR segment\n changes\n Assessment and Plan\n 85 yo male admit to ICU with mechanical fall and an absence of\n significant prodrom. Upon evaluation he had ECG findings which were\n raised as concerning for acute myocardial ischemia which has not been\n supported upon further evaluation. What is signficiant is that patient\n did arrive with tachycardia and hypotension which is responsive to 1\n liter bolus of IVF and fever raising concern for systemic infection.\n 1)Sepsis\nthere is concern for sepsis but do not see evidence of primary\n infection at this time. He does have background treatment for Lymphoma\n in place and this may be most likely explanation given constellation of\n findings and overall reasonable clinical exam. CXR and CT scan do fail\n to show significant focus of infection.\n -IVF as needed\n -Recheck WBC count for trend down\n -Will D/C abx with cultures negative at 48 hours to retain coverage\n during evaluation\n -Bolus as needed\nhas 5 liters to date\n 2)Pericardial Effusion-This has been raised as an issue with\n tachycardia and fluid responsive hypotension. He, however, does not\n have evidence of tamponade by exam.\n -ECHO\n -Cardiology consultation\n -If effusion significant he will need transfer to for\n management\n 3)PE-\n -Hold coumadin until nature of effusion is confirmed\n -Will need long term anti-coagulation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots, Does have elevated INR related to coumadin therapy\n Stress ulcer: Not Indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2167-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342535, "text": "85M with PMH of both Hodgkins and non-Hodgkins lymphoma currently on\n chemo who presented to an OSH after a fall in his driveway, pt was\n noted to be febrile and tachycardic in ED so transferred to ICU for\n further evaluation and work-up. Patient reports that he accidentally\n tripped and fell while out on a walk. He reports that he bumped his\n head in the fall. He was found down by his neighbor and EMS was\n called. The patient states that he awoke in the ambulance. He was\n initially taken to where an EKG was performed that was\n concerning for ST-segment elevations. Patient received one dose of\n atorvastatin and cardiac enzymes were negative x1. His CBC was\n significant for a white count of 13.8 with an 18% bandemia. The patient\n was then transferred to on a nitro gtt for admission to\n cardiology for STEMI. Upon arrival in the ED, vitals were 99.6 HR\n 80-140s 130/77 22 97% on 3L. The EKGs were reviewed by cardiology and\n were not read as ST-segment elevations. Nitro gtt was stopped.\n Cardiac enzymes were cycled and negative x1. EKG was notable for sinus\n tachycardia to the 140s. Patient was reportedly asymptomatic. A head\n CT was performed at the OSH that was reported as negative. A CT scan\n of C/A/P was done in the ED that was negative for pulmonary emboli and\n intra-abdominal pathology but he was noted to have a small-moderate\n pericardial effusion. In addition to the tachycardia, the patient was\n later febrile to 102. The patient was again noted to have an elevated\n white blood cell count with a bandemia of 8%. Patient was given 4L of\n NS, blood and urine cultures were sent. UA negative. Patient was\n started on vanc and levaquin and given one dose of Tylenol.\n .\n The patient's primary oncologist is . He is scheduled to\n received Cycle 19 of Gemzar/Navelbine today. Patient has also been on\n neulasta, last received on .\n" }, { "category": "Physician ", "chartdate": "2167-08-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 342481, "text": "Chief Complaint: Fall\n HPI:\n 85M with PMH of both Hodgkins and non-Hodgkins lymphoma currently on\n chemo who presented to an OSH after a fall in his driveway, pt was\n noted to be febrile and tachycardic in ED so transferred to ICU for\n further evaluation and work-up. Patient reports that he accidentally\n tripped and fell while out on a walk. He reports that he bumped his\n head in the fall. He was found down by his neighbor and EMS was\n called. The patient states that he awoke in the ambulance. He was\n initially taken to where an EKG was performed that was\n concerning for ST-segment elevations. Patient received one dose of\n atorvastatin and cardiac enzymes were negative x1. His CBC was\n significant for a white count of 13.8 with an 18% bandemia. The patient\n was then transferred to on a nitro gtt for admission to\n cardiology for STEMI. Upon arrival in the ED, vitals were 99.6 HR\n 80-140s 130/77 22 97% on 3L. The EKGs were reviewed by cardiology and\n were not read as ST-segment elevations. Nitro gtt was stopped.\n Cardiac enzymes were cycled and negative x1. EKG was notable for sinus\n tachycardia to the 140s. Patient was reportedly asymptomatic. A head\n CT was performed at the OSH that was reported as negative. A CT scan\n of C/A/P was done in the ED that was negative for pulmonary emboli and\n intra-abdominal pathology but he was noted to have a small-moderate\n pericardial effusion. In addition to the tachycardia, the patient was\n later febrile to 102. The patient was again noted to have an elevated\n white blood cell count with a bandemia of 8%. Patient was given 4L of\n NS, blood and urine cultures were sent. UA negative. Patient was\n started on vanc and levaquin and given one dose of Tylenol.\n .\n The patient's primary oncologist is . He is scheduled to\n received Cycle 19 of Gemzar/Navelbine today. Patient has also been on\n neulasta, last received on .\n .\n On arrival to the , the patients vitals were 96.2 147 92/45 22 100%\n RA. Patient was asymptomatic. ROS positive for left-sided jaw pain\n that he has at baseline.\n Patient admitted from: ER\n History obtained from Medical records, ED resident\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hodgkins Lymphoma\n Non-Hodgkins Lymphoma\n Renal Insufficiency\n Hypertension\n Gout\n Peripheral Vascular Disease s/p right tibial femoral to tibial artery\n bypass\n H/O Pulmonary Embolism and Right DVT\n Non-contributory\n Occupation:\n Drugs: None\n Tobacco: Remote use, 1ppd x 15y\n Alcohol: Minimal\n Other: Lives in with wife of 59 years. Has three daughters\n and one son. Daughter, Julies, lives next door. Patient states that\n his wife is his HCP through he notes that she now suffers from memory\n problems. Is supposed to walk with a cane.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Pain: Minimal\n Pain location: left jaw\n Flowsheet Data as of 12:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.2\n Tcurrent: 35.7\nC (96.2\n HR: 140 (140 - 151) bpm\n BP: 113/43(61) {92/43(57) - 113/64(66)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 4,000 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 2,000 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,000 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, 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, abrasions on lower lip\n and chin\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Distant), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic), Distant heart sounds\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 265 K/uL\n 8.5 g/dL\n 25.9 %\n 12.8 K/uL\n [image002.jpg]\n \n 2:33 A9/17/ 10:57 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 12.8\n Hct\n 25.9\n Plt\n 265\n Other labs: PT / PTT / INR:29.3/120.6/3.0, Differential-Neuts:86.0 %,\n Band:2.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0 %\n Assessment and Plan\n 85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n .\n Fever, hypotension, tachycardia, elevated WBC - meets criteria for\n SIRS. After 4 liters of NS, systolic BPs in 80s, asymptomatic. Per\n OMR, baseline BPs 120-140s on a BBlocker. Baseline HR 70s-80s on\n BBlocker. Patient last recieved Neulasta on . Differntial includes\n SIRS/Sepsis v. tamponade v a conglomeration of lymphoma and\n treatment-related symptoms. Mild-moderate pericardial effusion noted\n in ED. EKG somewhat low voltage, no electrical alternans, cards\n consulted. No JVD or pulses on exam but distant heart sounds. Pt does\n have small pericardial effusion noted on prior Cts. On coumadin with\n INR of 2.7. Effusion could be hemorrhagic v malignant v other.\n Discussed patient with primary oncologist this am, Dr. , felt\n that elevation of WBC count could be attributable to Neulasta and that\n fevers are not uncommon in patient's with lymphoma. Dr. also\n noted that patients who have been on chemo for extended periods can\n develop neuropathies and cardiac conduction abnormalities. Etiology of\n tachycardia uncertain, however, patient now back at baseline with only\n fluid intervention and BBlocker held. Elevation of lactate likely due\n to fall and being down for an unknown period of time.\n - repeat CBC and diff\n - continue fluid resuscitation as needed, pt continues to make\n excellent urine and sats are 100% on RA\n - consider central line if pt become hemodynamically unstable\n - f/u blood and urine cultures\n - patient received vanc and levo in , hold on further\n antibiotics for now and observe patient, low threshold to restart\n - CTA negative for acute PE, no evidence PNA either\n - CT abdomen negative for intrabdominal process\n - mild-moderate pericardial effusion also noted, could account for\n tachycardia\n - ECHO for better evaluation of pericardial effusion\n - cards consult\n - hold coumadin pending work-up of effusion\n .\n Lymphoma - due to receive next cycle of gemzar/navelbine today. Spoke\n with primary oncologist, this am, will hold until next\n week\n - last dose chemo , last dose neulasta \n - continue megace\n .\n Hypertension - Baseline 140s\n - hold BBlocker, hold doxazosin\n -\n .\n History of PE - no acute PE on CT but remnant of past noted\n - hold coumadin for evaluation of pericardial effusion\n .\n Hyperlipidemia - Continue statin\n .\n Renal Insufficiency - baseline creatnine 1.2, 1.4 on arrival. Did\n receive contrast in ED for PE CT.\n - continue IVFs\n - avoid nephrotoxic meds\n .\n BPH - hold doxazosin for now while hypotensive\n .\n Fall - per onc attending, patient has unsteadiness of gait at baseline\n and is supposed to walk with cane but does not.\n - PT consult and eval\n .\n FEN - regular diet, replete lytes prn by onc sliding scales, IVFs\n .\n Access - Right-sided portacath, peripheral IVs\n .\n Code Status - Full code\n .\n Contact - HCP, wife.\n ICU \n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None, on coumadin at baseline,\n holding pending ECHO)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2167-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342538, "text": "85M with PMH of both Hodgkins and non-Hodgkins lymphoma currently on\n chemo who presented to an OSH after a fall in his driveway, pt was\n noted to be febrile and tachycardic in ED so transferred to ICU for\n further evaluation and work-up. Patient reports that he accidentally\n tripped and fell while out on a walk. He reports that he bumped his\n head in the fall. He was found down by his neighbor and EMS was\n called. The patient states that he awoke in the ambulance. He was\n initially taken to where an EKG was performed that was\n concerning for ST-segment elevations. Patient received one dose of\n atorvastatin and cardiac enzymes were negative x1. His CBC was\n significant for a white count of 13.8 with an 18% bandemia. The patient\n was then transferred to on a nitro gtt for admission to\n cardiology for STEMI. Upon arrival in the ED, vitals were 99.6 HR\n 80-140s 130/77 22 97% on 3L. The EKGs were reviewed by cardiology and\n were not read as ST-segment elevations. Nitro gtt was stopped.\n Cardiac enzymes were cycled and negative x1. EKG was notable for sinus\n tachycardia to the 140s. Patient was reportedly asymptomatic. A head\n CT was performed at the OSH that was reported as negative. A CT scan\n of C/A/P was done in the ED that was negative for pulmonary emboli and\n intra-abdominal pathology but he was noted to have a small-moderate\n pericardial effusion. In addition to the tachycardia, the patient was\n later febrile to 102. The patient was again noted to have an elevated\n white blood cell count with a bandemia of 8%. Patient was given 4L of\n NS, blood and urine cultures were sent. UA negative. Patient was\n started on vanc and levaquin and given one dose of Tylenol.\n .\n The patient's primary oncologist is . He is scheduled to\n received Cycle 19 of Gemzar/Navelbine today. Patient has also been on\n neulasta, last received on .\n Tachycardia, Other\n Assessment:\n Pt admitted with heart rate of 140-150..?st/af/aflutter. BP\n 90-123/60-70. No c/o chest discomfort.\n Action:\n EKG done, cardiology consult, echo done. Given total 2liters ns\n here\n3l in ew..\n Given 2.5mgm metoprolol x2 ,\n Response:\n Pt periodically breaks rhythm. Per cardilology..pt is in atrial\n tachycardia\n.Did not respond to last fluid bolus..u/o is excellent\n Plan:\n To start esmolol gtt. Monitor bp.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt febrile in EW\nno temp here. 96-97po\n Action:\n Pt not ordered for antibiotics at this time.\n Response:\n No action taken\n Plan:\n Follow temp curve , cultures.\n" }, { "category": "Physician ", "chartdate": "2167-08-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342679, "text": "Chief Complaint: tachycardia , HOTN\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 85 yo man with hodgkins lymphoma. Tripped and fell, no reported . At\n OSH, not trauma at OSH (negative head CT). Was tachycardic,\n transferred here. Cardiology didn't feel that he had ACS, but with\n atrial tachycardia. Started on esmolol, but was not effective. Was\n weaned off esmolol, and flipped into sinus sinus for 5 hours. Had 22\n beat run of NSVT. Started on amio drip. Also was febrile to 101\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 08:06 PM\n EKG - At 11:09 PM\n BLOOD CULTURED - At 04:00 AM\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Metoprolol - 04:30 PM\n Other medications:\n simvastat\n asa\n allopurinol\n vanco\n amiodarone\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: Fever\n Cardiovascular: Tachycardia\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 10:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.8\nC (98.2\n HR: 128 (77 - 144) bpm\n BP: 90/59(66) {85/25(46) - 122/78(81)} mmHg\n RR: 20 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: PAT (Paroxysmal Atrial Tachycardia)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 6,805 mL\n 1,331 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 3,205 mL\n 1,211 mL\n Blood products:\n Total out:\n 3,305 mL\n 1,400 mL\n Urine:\n 2,305 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,500 mL\n -68 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3 , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 7.6 g/dL\n 245 K/uL\n 116 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 108 mEq/L\n 135 mEq/L\n 23.2 %\n 10.7 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n WBC\n 12.8\n 12.0\n 10.7\n Hct\n 25.9\n 25.3\n 23.2\n Plt\n 265\n 272\n 245\n Cr\n 1.3\n 1.3\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n Other labs: PT / PTT / INR:26.5/37.1/2.6, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.7 mg/dL, Mg++:1.7\n mg/dL, PO4:3.4 mg/dL\n Imaging: echo: no tamponade. Low normal EF 50%\n CT chest: No PE\n CT abdomen: no abd process.\n Assessment and Plan\n Fevers: No clear source. Await cultures. Empiric vancomycin to cover\n line source pending cultures.\n HOTN: Unclear cause. Has had decreased PO intake over past few days,\n so could be dehydration.\n PAF: In and out of AF, now in sinus. On amiodarone drip currently.\n Coumadin for AF and prior PE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n 18 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2167-08-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 342939, "text": "Chief Complaint: Tachyardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 04:31 AM\n History obtained from Medical records\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Vancomycin - 08:24 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:38 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: 36.8\nC (98.3\n HR: 73 (68 - 121) bpm\n BP: 117/54(69) {103/50(66) - 134/87(92)} mmHg\n RR: 20 (14 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 2,607 mL\n 600 mL\n PO:\n 720 mL\n 210 mL\n TF:\n IVF:\n 1,602 mL\n 390 mL\n Blood products:\n 285 mL\n Total out:\n 2,380 mL\n 1,170 mL\n Urine:\n 2,380 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 227 mL\n -570 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 290 K/uL\n 130 mg/dL\n 1.2 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 136 mEq/L\n 25.7 %\n 11.5 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n 04:23 AM\n WBC\n 12.8\n 12.0\n 10.7\n 11.5\n Hct\n 25.9\n 25.3\n 23.2\n 25.7\n Plt\n 265\n 272\n 245\n 290\n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n 130\n Other labs: PT / PTT / INR:24.4/33.7/2.4, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.9 mg/dL, Mg++:1.8\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 85 yo male with persistent and recurrent tachycardia now with\n substantial improvement and return to sinus rhythm. This was in the\n setting of Amiodarone being given but long term plan will need to be\n clarified with cardiology consultation given difficult to control heart\n rate on Esmolol.\n 1)Atrial Tachycardia-Difficult decision, Amiodarone considered but\n patient has conversion to stabilized heart rate without significant\n load of medication\n -Will continue with beta-blocker dosing\n -Consider Amiodarone if worsening seen and symptomatic insult noted\n 2)Fever\nno bacterial source identified on cultures. Patient has been\n maintained on Vanco.\n -Will D/C if cultures negative\n 3)Malignancy-\n -Follow up treatment per Dr. \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition :Transfer to floor\n Total time spent: 40 minutes\n" }, { "category": "Nursing", "chartdate": "2167-08-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342749, "text": "85M with PMH of both Hodgkins and non-Hodgkins lymphoma currently on\n chemo who presented to an OSH after a fall in his driveway, pt was\n noted to be febrile and tachycardic in ED so transferred to ICU for\n further evaluation and work-up. Patient reports that he accidentally\n tripped and fell while out on a walk. He reports that he bumped his\n head in the fall. He was found down by his neighbor and EMS was\n called. The patient states that he awoke in the ambulance. He was\n initially taken to where an EKG was performed that was\n concerning for ST-segment elevations. Patient received one dose of\n atorvastatin and cardiac enzymes were negative x1. His CBC was\n significant for a white count of 13.8 with an 18% bandemia. The patient\n was then transferred to on a nitro gtt for admission to\n cardiology for STEMI. Upon arrival in the ED, vitals were 99.6 HR\n 80-140s 130/77 22 97% on 3L. The EKGs were reviewed by cardiology and\n were not read as ST-segment elevations. Nitro gtt was stopped.\n Cardiac enzymes were cycled and negative x1. EKG was notable for sinus\n tachycardia to the 140s. Patient was reportedly asymptomatic. A head\n CT was performed at the OSH that was reported as negative. A CT scan\n of C/A/P was done in the ED that was negative for pulmonary emboli and\n intra-abdominal pathology but he was noted to have a small-moderate\n pericardial effusion. In addition to the tachycardia, the patient was\n later febrile to 102. The patient was again noted to have an elevated\n white blood cell count with a bandemia of 8%. Patient was given 4L of\n NS, blood and urine cultures were sent. UA negative. Patient was\n started on vanc and levaquin and given one dose of Tylenol.\n Tachycardia, Other\n Assessment:\n Remains on amioderone, HR most of morning and early afternoon very\n tachycardic to 140\ns..Pt spontaneously converted to NSR early\n afternoon..\n Action:\n Currently on IV amioderone..hr #6 of 18hr infusion\n Response:\n Pt has remained in NSR\n Plan:\n Will continue to follow hr..amioderone to be dc\nd at 6am \n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp this afternoon to 100\n Action:\n Following previous cultures..\n Response:\n ??cause of fever d/t to lymphoma\n Plan:\n Currently on vanco..\n Heme:\n AM hct down to 23..to receive 1u RPC this evening.\n No obvious s/s of bleeding..\n Restarted coumadin this afternoon..\n" }, { "category": "Physician ", "chartdate": "2167-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342895, "text": "Chief Complaint: S/p fall and LOC\n 24 Hour Events:\n BLOOD CULTURED - At 04:31 AM\n - Coumadin was restarted\n - Amiodarone load was finished\n -1U PRBC at 5pm for low hct\n -urine cx negative\n -PT eval c/w significant peripheral neuropathy will need to use walker\n at home. Also renally dosed neurontin today.\n - has several runs of NSVT, asymptomatic\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Vancomycin - 08:00 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 07:27 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: 38.1\nC (100.5\n HR: 78 (78 - 132) bpm\n BP: 124/52(70) {90/50(65) - 134/87(92)} mmHg\n RR: 20 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 2,607 mL\n 209 mL\n PO:\n 720 mL\n 60 mL\n TF:\n IVF:\n 1,602 mL\n 149 mL\n Blood products:\n 285 mL\n Total out:\n 2,380 mL\n 630 mL\n Urine:\n 2,380 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 227 mL\n -421 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), Faint heart\n sounds. No S3, S4 or other sounds. JVD 7 cm, no pulsus paradoxus or\n kussmaul sign.\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: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, Patient complains of\n \"tingling\" over both legs. This started last monday (5 days ago)\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 290 K/uL\n 8.6 g/dL\n 130 mg/dL\n 1.2 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 136 mEq/L\n 25.7 %\n 11.5 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n 04:23 AM\n WBC\n 12.8\n 12.0\n 10.7\n 11.5\n Hct\n 25.9\n 25.3\n 23.2\n 25.7\n Plt\n 265\n 272\n 245\n 290\n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n 130\n Other labs: PT / PTT / INR:24.4/33.7/2.4, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.9 mg/dL, Mg++:1.8\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2167-08-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342899, "text": "Chief Complaint: S/p fall and LOC\n 24 Hour Events:\n BLOOD CULTURED - At 04:31 AM\n - Coumadin was restarted\n - Amiodarone load was finished\n -1U PRBC at 5pm for low hct\n -urine cx negative\n -PT eval c/w significant peripheral neuropathy will need to use walker\n at home. Also renally dosed neurontin today.\n - has several runs of NSVT, asymptomatic\n Allergies:\n Bleomycins\n Anaphylaxis;\n Strawberry\n facial swelling\n Pineapple\n Unknown; from a\n Last dose of Antibiotics:\n Vancomycin - 08:00 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 07:27 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: 38.1\nC (100.5\n HR: 78 (78 - 132) bpm\n BP: 124/52(70) {90/50(65) - 134/87(92)} mmHg\n RR: 20 (15 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.2 kg (admission): 72.1 kg\n Height: 67 Inch\n Total In:\n 2,607 mL\n 209 mL\n PO:\n 720 mL\n 60 mL\n TF:\n IVF:\n 1,602 mL\n 149 mL\n Blood products:\n 285 mL\n Total out:\n 2,380 mL\n 630 mL\n Urine:\n 2,380 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 227 mL\n -421 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), Faint heart\n sounds. No S3, S4 or other sounds. JVD 7 cm, no pulsus paradoxus or\n kussmaul sign.\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: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, Patient complains of\n \"tingling\" over both legs. This started last monday (5 days ago)\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 290 K/uL\n 8.6 g/dL\n 130 mg/dL\n 1.2 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 136 mEq/L\n 25.7 %\n 11.5 K/uL\n [image002.jpg]\n 10:57 AM\n 05:55 PM\n 04:06 AM\n 04:23 AM\n WBC\n 12.8\n 12.0\n 10.7\n 11.5\n Hct\n 25.9\n 25.3\n 23.2\n 25.7\n Plt\n 265\n 272\n 245\n 290\n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.10\n 0.11\n Glucose\n 141\n 116\n 130\n Other labs: PT / PTT / INR:24.4/33.7/2.4, CK / CKMB /\n Troponin-T:63/5/0.11, ALT / AST:16/18, Alk Phos / T Bili:120/0.7,\n Differential-Neuts:68.0 %, Band:13.0 %, Lymph:11.0 %, Mono:5.0 %,\n Eos:0.0 %, Albumin:3.0 g/dL, LDH:323 IU/L, Ca++:7.9 mg/dL, Mg++:1.8\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 85M with Hodgkin's Lymphoma currently undergoing chemotherapy with\n Gemzar/ transferred to for work-up of fever and\n tachycardia.\n .\n Fevers- Patient still with fever and increasing WBC with left shift,\n but hemodinamically stable. Blood cultures and urine cultures negative\n so far. Portho cath site looks ok. CXR and CT of abdomen and pelvis\n without signs of infection. Small pericardial effusion by\n echocardiogram. Oncologist, Dr. , felt that elevation of WBC\n count could be attributable to Neulasta and that fevers are not\n uncommon in patient's with lymphoma.\n - F/u CBC and diff\n - f/u blood and urine cultures -pending\n Tachycardia\n appears to be atrial tachycardia\n - appreciate cards consult yesterday, reccomended beta blocker to treat\n a-tach\n - tried esmolol drip limited by low blood pressure, did not appear to\n break rythmn\n - d/c esmolol drip and patient returned to sinus rhythm\n overnight\n - subsequently patient developed run of 22 NSVT with stable blood\n pressure, asymptomatic\n checked electrolytes which were okay (gave\n repletion to optimize) and started on amiodarone load\n - will follow up with cardiology as think that much of presentation\n consistent with cardiac etiology\n - would consider transfer to if pressures improve\n - definitely has a CAD equivalent with PVD\n - as below the pericardial effusion appears circumferential without\n signs of tamponade, so would restart coumadin\n - ECHO: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is low normal (LVEF 50%).\n Right ventricular chamber size is normal. with focal hypokinesis of the\n apical free wall. The ascending aorta is mildly dilated. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Trivial mitral\n regurgitation is seen. The pulmonary artery systolic pressure could not\n be determined. There is a small pericardial effusion. The effusion\n appears circumferential. There are no echocardiographic signs of\n tamponade. No right atrial or right ventricular diastolic collapse is\n seen.\n Compared with the findings of the prior report (images unavailable for\n review) of , the right ventricle is no longer dilated and\n globally hypocontractile.\n Lymphoma - missed cycle of gemzar/navelbine . primary oncologist,\n , dose chemo next week\n - last dose chemo , last dose neulasta \n - continue megace for now\n .\n Hypertension - Baseline 140s\n - hold BBlocker, hold doxazosin\n - currently still hypotensive\n .\n History of PE - no acute PE on CT but remnant of past noted\n - hold coumadin for evaluation of pericardial effusion\n .\n Hyperlipidemia - Continue statin\n PVD\n - history of peripheral vascular disease had fem/posterial\n tibial bypass (also stent)\n - essentially a CAD equivalent\n - on statin\n .\n Renal Insufficiency - baseline creatnine 1.2, 1.4 on arrival. Did\n receive contrast in ED for PE CT.\n - continue IVFs\n - avoid nephrotoxic meds\n .\n BPH - hold doxazosin for now while hypotensive\n .\n Fall - per onc attending, patient has unsteadiness of gait at baseline\n and is supposed to walk with walker but does not.\n - PT consult and eval\n .\n FEN - regular diet, replete lytes prn by onc sliding scales\n .\n Access - Right-sided portacath, peripheral IVs\n .\n Code Status - Full code\n .\n Contact - HCP, wife.\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n Indwelling Port (PortaCath) - 08:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Echo", "chartdate": "2167-08-26 00:00:00.000", "description": "Report", "row_id": 64559, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tachycardia\nHeight: (in) 65\nWeight (lb): 158\nBSA (m2): 1.79 m2\nBP (mm Hg): 106/67\nHR (bpm): 142\nStatus: Inpatient\nDate/Time: at 15:35\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Low normal\nLVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Focal\napical hypokinesis of RV free wall.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade. No RA or RV diastolic collapse.\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 low normal (LVEF 50%). Right ventricular chamber size is\nnormal. with focal hypokinesis of the apical free wall. The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is a small pericardial effusion. The effusion appears\ncircumferential. There are no echocardiographic signs of tamponade. No right\natrial or right ventricular diastolic collapse is seen.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , the right ventricle is no longer dilated and globally\nhypocontractile.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034439, "text": " 12:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for abnl card enlargement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo F with chest pain\n REASON FOR THIS EXAMINATION:\n please eval for abnl card enlargement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old female with chest pain, evaluate for abnormal cardiac\n enlargement.\n\n COMPARISON: .\n\n PORTABLE AP UPRIGHT CHEST, ONE VIEW: Heart is mildly enlarged in size, with a\n left ventricular configuration. Atherosclerotic aortic calcifications are\n present. Lungs are clear without consolidation or pulmonary edema. There is\n no pleural effusion or pneumothorax. A right central line tip terminates in\n low SVC. Osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Cardiomegaly with left ventricular configuration.\n\n 2. No pneumonia or pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-26 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1034475, "text": " 5:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: intrasbdominal infection. please no contrast 9got IV alread\n Admitting Diagnosis: FEVER\n Field of view: 44\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with fever, tachycardia, unclear source. also fall earlier\n today\n REASON FOR THIS EXAMINATION:\n intrasbdominal infection. please no contrast 9got IV already and will not\n tolerate PO) thanks\n CONTRAINDICATIONS for IV CONTRAST:\n received earlier\n ______________________________________________________________________________\n WET READ: JXKc WED 5:49 AM\n Moderate size pericardial effusion. Minimally displaced right 10th rib fx. No\n acute intraabdominal process. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, tachycardia and fall.\n\n TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained\n without oral or IV contrast as the patient could not tolerate fluids and had a\n recent IV contrast.\n\n COMPARISON: .\n\n CT Abdomen: There is a moderate-sized pericardial effusion. There is\n atherosclerotic calcification in the thoracic aorta. There is mild dependent\n atelectasis at the lung bases.\n Evaluation of the solid organs is somewhat limited by the lack of IV contrast:\n The liver, pancreas, and spleen are normal. The patient has had prior\n cholecystectomy. The right adrenal nodule measures 23 x 18 mm (2:20), similar\n to prior study. The left adrenal is normal. There is vascular calcification\n of the aorta, the splenic artery, the origin of the SMA and the renal arteries\n as well as the common, external and internal iliac arteries. There is no free\n fluid, free air, or adenopathy. The intra- abdominal small and large bowel is\n normal.\n\n CT PELVIS: The rectum, sigmoid, and bladder are normal. There is a Foley in\n the bladder. There is no free fluid, inguinal or pelvic adenopathy.\n\n BONE WINDOWS: There is degenerative change in the lumbar spine. The\n minimally displaced right 12th rib fracture is again noted.\n\n IMPRESSION:\n\n 1. No acute intra-abdominal process.\n\n 2. Minimally displaced right 10th rib fracture, which is chronic.\n\n 3. Diffuse vascular calcifications.\n (Over)\n\n 5:14 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: intrasbdominal infection. please no contrast 9got IV alread\n Admitting Diagnosis: FEVER\n Field of view: 44\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2167-08-26 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1034446, "text": " 1:42 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please eval for pe\n Field of view: 42 Contrast: VISAPAQUE Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with hodgkins lymphoma, s/p fall today. had head, c-spine ct at\n osh. tachy here\n REASON FOR THIS EXAMINATION:\n please eval for pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc WED 2:45 AM\n Eccentric filling defect in small subsegmental branch to left upper lobe\n unchanged from and is likely residual thrombus from prior massive PE.\n No evidence of acute PE.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old male with Hodgkin's lymphoma status post fall today, now\n with tachycardia. Evaluate for pulmonary embolism.\n\n COMPARISON: and .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n upper abdomen with the administration of IV contrast. Coronal, sagittal and\n oblique reformatted images were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: Coronary artery calcifications are present.\n A small pericardial effusion is present. The thoracic aorta demonstrates\n atherosclerotic calcifications, without evidence for dissection. There is no\n evidence of an acute segmental or large subsegmental pulmonary embolism. Again\n noted is an eccentric filling defect within a subsegmental branch to the left\n upper lobe (3:36), similar in appearance from , which likely\n reflects very minimal residual adherent thrombus from a significant massive\n pulmonary embolism from . There is a calcified right\n paratracheal node, unchanged. Additionally, there are mildly prominent right\n hilar nodes, measuring up to approximately 1 cm in short axis dimensions.\n There are calcified right hilar nodes.\n\n Regions of parenchymal calcification within the lungs, particularly within the\n right lower lobe are unchanged. The lungs are clear without consolidation or\n pulmonary edema. Minimal dependent atelectasis are present within the lung\n bases. There is no pleural effusion or pneumothorax. The airways are patent\n to the subsegmental level.\n\n Limited views of the upper abdomen reveal a right adrenal nodule, similar in\n appearance to prior study, and incompletely imaged.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is identified. A\n minimally displaced right 10th rib fracture is present.\n\n IMPRESSION:\n\n (Over)\n\n 1:42 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please eval for pe\n Field of view: 42 Contrast: VISAPAQUE Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No thoracic aortic dissection or acute pulmonary embolism within a\n segmental or large subsegmental branch. Tiny eccentric filling defect within\n a left upper lobe subsegmental branch is unchanged, likely reflecting minimal\n residual thrombus from a significant PE from .\n\n 2. Calcified mediastinal node, likely reflecting treated lymphoma with mildly\n prominent right hilar nodes, measuring up to 1 cm.\n\n 3. Stable coarse parenchymal calcifications within the right lower lobe.\n\n 4. Small pericardial effusion.\n\n 5. Minimally displaced right 10th rib fracture.\n\n 6. Right adrenal nodule, incompletely imaged.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-26 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 1034444, "text": " 12:35 AM\n PELVIS (AP ONLY); FEMUR (AP & LAT) RIGHT Clip # \n Reason: please eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 yo M s/p fall unable to move right leg\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall. Pain.\n\n These two examinations consist of five radiographs of the pelvis, right hip,\n and right femur. No fracture or other significant focal osseous abnormality.\n Extensive vascular calcifications with a partially visualized arterial stent\n just below the knee. The hips and SI joints are normal and symmetric.\n\n IMPRESSION: No fracture identified.\n\n" }, { "category": "ECG", "chartdate": "2167-08-27 00:00:00.000", "description": "Report", "row_id": 131733, "text": "Compared to the previous tracing probably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-08-26 00:00:00.000", "description": "Report", "row_id": 131734, "text": "Probable sinus tachycardia at rate 132. Left axis deviation. Borderline\nlow voltage. Anteroseptal myocardial infarction of indeterminate age,\npossibly acute. Compared to the previous tracing of no significant\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2167-08-26 00:00:00.000", "description": "Report", "row_id": 131735, "text": "Sinus tachycardia. Compared to the previous tracing of multiple\ndescribed abnormalities persist. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2167-08-26 00:00:00.000", "description": "Report", "row_id": 131736, "text": "Sinus tachycardia. Compared to the previous tracing of multiple\ndescribed abnormalities persist.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2167-08-25 00:00:00.000", "description": "Report", "row_id": 131737, "text": "Underlying rhythm is most likely sinus tachycardia. Poor R wave progression.\nCannot rule out anteroseptal myocardial infarction of indeterminate age.\nDiffuse ST-T wave changes which are non-specific. Diffuse low QRS voltage.\nCompared to the previous tracing of tachycardia is new. Diffuse\nST-T wave changes as well as diffuse low QRS voltage are new. Anterior\nST-T wave changes persist but are improved. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2167-08-31 00:00:00.000", "description": "Report", "row_id": 131732, "text": "Sinus tachycardia versus atrial tachycardia. Anteroseptal myocardial\ninfarction of undetermined age. Compared to the previous tracing of \nthe findings are similar.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2129-03-05 00:00:00.000", "description": "T-SPINE", "row_id": 1003566, "text": " 10:05 AM\n T-SPINE Clip # \n Reason: 34 year old man s/p thoracic fusion, please check AP/lat sta\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man s/p thoracic fusion, please check AP/lat standing thoracic\n films - please make sure can see both ends of hardware\n REASON FOR THIS EXAMINATION:\n 34 year old man s/p thoracic fusion, please check AP/lat standing thoracic\n films - please make sure can see both ends of hardware\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Thoracic spine three views .\n\n HISTORY: 34-year-old man status post thoracic fusion.\n\n FINDINGS: There is a compression deformity seen of T11 which has a cage\n device. There is a posterior fixation spanning T9 to L1. There is no signs\n for hardware-related complications. Surgical skin staples are seen\n posteriorly.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-03-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1003328, "text": " 4:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: R/O structural cause for seizures\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with with Potts disease s/p large spine surgery for\n stabilization now with mental status changes question seizing\n REASON FOR THIS EXAMINATION:\n R/O structural cause for seizures\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 34-year-old male with Potts' disease, status post large spine\n surgery for stabilization, now with mental status changes, possible seizures.\n Please evaluate for structural cause of seizures.\n\n COMPARISON: Spine MRI from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or\n infarction. The ventricles and sulci are normal in size and configuration.\n There is no fracture. Visualized paranasal sinuses are normally aerated.\n\n IMPRESSION: Unremarkable head CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-03-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002902, "text": " 11:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man s/p or for spine now unable to extubate with inc\n secretions\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post bone surgery.\n\n FINDINGS: In comparison with the study of , extensive spinal surgery is\n again seen in the lower thoracic region. Endotracheal tube is in place with\n its tip approximately 7 cm above the carina. Nasogastric tube extends to the\n upper stomach. There is some suggested opacification in the right infrahilar\n region consistent with atelectasis or even developing pneumonia. This area\n should be closely watched on subsequent studies.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-23 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 1001964, "text": " 10:41 AM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: FALL OFF BIKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with 34 year old man with with hx of fall off bike 2 mos ago,\n with worsening pain, T11 compression fx per OSH films\n REASON FOR THIS EXAMINATION:\n Pls do w & w/o contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture of T11.\n\n Comparison is made with .\n\n Again noted is a pathologic fracture of T11 with approximately 50%\n loss of height. There is extension of the fracture into the left pedicle. No\n significant increase in the compression at this level has occurred since the\n prior study. There is mild kyphotic angulation at the fracture level,\n unchanged from prior examination. Permeative destruction of T11 is again seen\n with a large pre- and para-vertebral component extending from approximately T8\n to T12.\n\n\n Biopsy tracts are again seen within the left T11 and T10 pedicles. Again noted\n is permeative destruction in the T5 and T7 corners.\n\n On the soft tissue windows, there is suggestion of an epidural process at T10\n through T11 extendig to the foramina which could represent an epidural\n phlegmon/abscess.I would recommend correlation with MRI.\n\n There is atelectasis and pleural fluid in the right and to a lesser extent in\n the left lung.\n\n IMPRESSION:\n\n Stable pathologic compression fracture of T11 vertebral body and bony\n destruction at T5 and T7 compatible with history of TB spondylodiscitis. There\n has been no further progression of kyphosis or compression of T11. There is a\n stable pre- and para-vertebral phlegmon/abscess. There is suggestion of an\n epidural process at T10 and T11 for which I would recommend correlation with\n MRI. Findings were conveyed to , PA, for Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-24 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1002123, "text": " 9:39 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: SPINAL INSTABILITY\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with Pott's disease\n REASON FOR THIS EXAMINATION:\n r/o active disease pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old man with Potts' disease, for pre-op examination.\n\n COMPARISON: Chest AP and lateral from .\n\n CHEST AP AND LATERAL: The bottom AP view is severely compromised by\n overexposure in the area of the lumbar spine. The cardiac silhouette is\n normal. The lungs are clear. There is no pleural effusion or pneumothorax.\n Again seen is a paraspinal opacity extending along the inferior aspect of the\n thoracic spine. The poor quality of the lateral view prevents visualization\n of the previously visualized anterior wedging of the T11 vertebral body.\n\n IMPRESSION:\n\n 1) Previously detected paraspinal density along the inferior thoracic spine\n consistent with patient's diagnosis of Potts' disease.\n 2) The previously detected T11 compression fracture is not well visualized in\n this poor quality study.\n 3) No evidence of pneumonia or CHF. Overall unchanged study.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-02-28 00:00:00.000", "description": "O LUMBAR SP,SINGLE FILM IN O.R.", "row_id": 1002760, "text": " 2:15 PM\n LUMBAR SP,SINGLE FILM IN O.R. Clip # \n Reason: FUSION\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE\n\n CLINICAL HISTORY: Fusion.\n\n Four intraoperative films are submitted.\n\n The first film shows the compression of the T11 vertebral body, shown on the\n thoracic spine MRI. The six non-rib-bearing lumbar vertebral bodies\n are again noted. The clamps are present at the L2 and L4 levels. On the\n second film from one of the clamps lies at the T11 level, and the other at the\n L1 level. The last two films or AP and lateral film showing a cage at the T11\n level with pedicle screws bilaterally at T9, T12 and L1, right-sided pedicle\n screw at T11, and laminectomy defects at T10-T11 and T12. On the frontal\n view, the cage is canted somewhat with the left superiorly.\n\n IMPRESSION: Intraoperative films as described above. Please see operative\n notes for full details.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1003684, "text": " 10:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infx process\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with cough post op\n REASON FOR THIS EXAMINATION:\n r/o infx process\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 34-year-old male with cough, postop. Evaluate for infectious\n process.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a cage device in T11. There is fixation hardware spanning T9 to L1.\n The lungs are clear. Atelectasis and mild pulmonary congestion seen\n previously have resolved.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2129-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1003217, "text": " 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SPINAL INSTABILITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with Pott's disease\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n Compared to prior study performed .\n\n REASON FOR EXAM: Pott's disease.\n\n Bibasilar atelectases have increased, greater on the right side. Small\n bilateral pleural effusions, greater on the right side, have also increased.\n Mild fluid overload is stable. Cardiac size is top normal. Postoperative\n changes in the lower thoracic region and upper lumbar spine are noted,\n unchanged.\n\n jr\n\n DR. \n" }, { "category": "Nursing/other", "chartdate": "2129-03-03 00:00:00.000", "description": "Report", "row_id": 1656780, "text": "NPN 1900-0700\nPLEASE SEE CAREVUE FOR EXACT DATA\n\n\nNEURO: Alert, able to state name after much coaxing, but non-verbal when asked place/date. occasionally nods yes/no to questions-rarely verbalizes answers/ Pt very sensitive to tactile stimuli in all extremities(much more noteable than yesterday) screaming \"no\" when catheter manipulated or turned in bed. Lifts and holds RUE-fair strength, LUE Lifts/falls back, lifts both knees up on bed-unable to lift legs off bed though. Blank stare/focuses on speaker. PERRLA 4-5mm and brisk. Medicated with Dilaudid IV PRn with adeqaute pain control.\n\nCV/HEME: HR 100's-125, no ectopic beats. BP 100's-150's systolic. Hct 25.8. Coags resent his am as PTT came back as 70-recheck 61.2, INR 1.3. Pedal pulses strong. SQ Heparin as ordered.\n\nRESP: Lungs clear/diminshed, sats 98-100% on 2L NC. Strong cough-coughing frequently though appears to be swallowing sputum. ABG sent this am, (O2=70) WNL.\n\nGI: Abd soft, BS+. No BM. Attempted NGT placement x1, however pt was uncoop. and began thrashing in bed. Remains NPO (due to pt's lack of ability to follow commands). Pepcid.\n\nGU:Foley draining adequate amts of clear urine/Q hr. K+ 2.9 this am-repleted with 30meq IV thus far, calcium also repleted. LR at 80cc/hr.\n\nSKIN: Incision site-staples WNL, dsg clean/intact. Jp drain with approx 70cc serosang. drainage overnoc. Skin unremarkable otherwise.\n\nID: WBC 9.9. T-max 101.4 overnoc-treated with PR tylenol, temp down to 97.6 this am. Needs final sputum spec to r/o TB.\n\nPOC: pain management\n continue to assess for any changes in neuro status\n obtain sputum spec- f/u pending cxs\n reassess pt's ability to take POs\n update family\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-03-03 00:00:00.000", "description": "Report", "row_id": 1656781, "text": "Nursing Progress Note\nSee Carevue For Specific Data.\n\nSignificant Events: Pt to CT for suspicion of seizures. Pt occasionally alert/oriented, usually difficult to ellicit verbal answers. JP drain in back removed by neuro- d/t minimal output.\n\nNeuro: Pt rarely A & O x3-usually A & O x1-2 (name, date). Pt follows commands, MAE's. Q4hr neuro checks. Pupils 3mm/3mm, equal, brisk. Pt occasionally staring into space and does not respond to questions. Pt also has twitching in right cheek and makes clicking sound (clicking may be personal/cultural practice meaning something negative according to pt's cousin.) Pt occasionally seems to choose not to answer questions vs. unresponsive as evidenced by fluid, coherent speech to cousin. Pt speaks English clearly/well according to family.\n\nPain: Pt gets oxycodone at home for back pain, continues in hospital. Has dilaudid for pain PRN. Pt c/o pain during repositioning, needs time to move at own comfort level.\n\nCV: Hemodynamically stable-has arterial line. Systolic BP 110-140's. HR 90-110, NSR-ST, no ectopy. Easily palpable pedal pulses, heparin sc.\n\nResp: Lung sounds clear in upper lobes, slightly diminished at bases. Third sputum culture sent to lab to test for TB today-pt expectorated clear sputum by coughing. (Pt currently on TB/droplet precautions/negative pressure room). Pt maintaining O2 sats >97% on 2L nc. Continues on tb meds PO per orders.\n\nGI: Abdomen soft, not distended, nontender. +BS, last BM unknown. Pt NPO except for meds, tolerated sips/meds without issues. Maintenance fluid: LR at 80cc/hr.\n\nGU: Adequate amounts of clear, urine through foley qhour. d/t rifampin.\n\nID: afebrile, WBCs 9.9.\n\nSkin: Back incisions (2): no drainage, stapled, open to air. JP drain which was in back was removed by neuro- d/t minimal serosanguinous output and site was sutured, no drainage.\n\nSocial: Pt had multiple family members in to visit for brief periods of time throughout the day. wife visited, answered questions as needed. father visited but was too emotional to enter the room-observed son from outside the door, wept. This RN spoke to father and consoled him, but father had limited English.\n\nPlan: Transfer pt to SDU for further management? EEG as ordered. Advance diet as tolerated? Monitor neuro status/changes. Monitor for signs of seizures. Continue to support pt and family. d/c arterial line? wean O2 as tolerated. Continue TB meds as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2129-03-04 00:00:00.000", "description": "Report", "row_id": 1656782, "text": "Nursing (1900-present)\nSee flowsheet for details. See Nursing transfer note written by this RN.\n\nPt. A&O. Has \"blank stare\", blinks often, and is slow to answer all questions and follow all commands. No focal deficits or seizure activity noted. MAE equally and slowly. Pain treated as noted.\n\nVS as documented. Skin warm, dry, color wnl. A.m. labs noted and reported to H.O. K repletion in progress. Incision dry.\n\nNo resp. distress noted with normal abg on 2L.\n\nAbd. benign. No dysphagia. Pt. is \"starving\". Autodiuresing.\n\nNo family contact overnight.\n\nPlan: To be transfered to cc6, time unknown at present. Monitor hemodynamcis, follow temp curve, optimize comfort and mobility.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-03-02 00:00:00.000", "description": "Report", "row_id": 1656777, "text": "NPN 1900-0700\nPLEASE SEE CAREVUE FOR EXACT INFO\n\nNEURO: Sedation changed to Propofol>lightly sedated, following all commands. Lifts both UE's approx 6 inches off bed and lifts both knees up. Pt nods \"yes\" to indicate same/normal sensation in all extremities. PERRLA 3mm brisk. Strong cough/gag. Medicated with PRN Fentanyl and Oxycodone for pain>fair pain control (standing Oxycontin SR dose held due to inability to crush). Tremors/? muscle spasms noted in LE's with prolonged tactile stimuli.\n\nCV: HR 100's-125 ST, no ectopy. ABP 90's-140 systolic (correlates with cuff). Pt requiring (3) LR boluses overnight>hypotensive to 80's-good response to. Skin warm, pedal pulses palpable. Hct 26 (33).\n\nRESP: Weaned to 15/5 this am>ABG prior to this change on CMV WNL. Lungs clear and diminished bilaterally at bases. Sm amts thick yellow secretions sxnd from ETT.\n\nGI: Abd soft, non-distended, +BS. Protonix for prophlaxis and full bowel regimine ordered. No Bm. NGT clamped.\n\nGU: Foley patently draining marginal amts of cloudy urine. (3) 500cc LR boluses given. Pt is approx +4L for LOS and +1500 for past 24hrs. K+ and Mag repleted. LR cont. at 80cc/hr for maint.\n\nENDO: No RISS ordered. Blood glucoses 83-92.\n\nID: Pt remains in neg. pressure room on droplet/TB prec. WBC 16. T-max 100.6=>tylenol given. Continues on TB tx.\n\nSKIN: Backside midline incision with primary DSD-clean and intact, sm amt of serosang. drainge at bottom of dsg>reinforced. JP drain with a total of 90cc serosang. drainage overnoc. New #20 PIV placed in L AC.\n\nSOCIAL\r: No inquiries overnoc.\n\nPOC: Wean to extubate\n sputum spec for (TB r/o)\n fluid recessitation for hypotension/low u/o\n Recheck Hct\n ? PCA\n update and support family\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-03-02 00:00:00.000", "description": "Report", "row_id": 1656778, "text": "RESP CARE NOTE\nPT REMAINED ON AC OVERNIGHT. BREATH SOUNDS DIMINISHED AT BASES. SUCTIONED SMALL AMTS OF THICK YELLOW SECRETIONS AND LARGE AMTS OF ORAL SECRETIONS. OETT PATENT AND SECURE. ATTEMPTED TO WEAN TO PSV AND PT BECAME ANXIOUS WITH RR IN 50'S. AFTER TWO MORE ATTEMPS WAS ABLE TO START AT 20/5. ONCE PT SETTLED SLOWLY WEANED TO 15/5 WITH VT 350-400 AND RR 20-25. RSBI 196. SPOKE TO PHYSICIAN ABOUT ANXIETY INTERFERING WITH WEAN AND THEY TRY ATIVAN.\nPLAN: WEAN TO EXTUBATE AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2129-03-02 00:00:00.000", "description": "Report", "row_id": 1656779, "text": "nursing progress note\n\nevents: pt extubated this am, o2 sats stable, able to wean supplemental o2 throughout day. remains very tachypneic, although does not appear distressed or labored. rr 30s-40s most of day w/ only few episodes of slowing to mid 20s, abg wnl as result. pt shakes head no to question of breathing difficulty.\n\nneuro: once extubated, pt confused, very little verbalized. some improvement this afternoon, occas answering questions. following commands only after much repeating. perrla, 4mm. strength to ble , able to bend knees while feet on bed, unable to lift entire leg off bed. bue w/ weak grasp bilat. per family, pt able to speak english well, upon exam pt only staring at speaker, little to no speaking, clearly disoriented. pain an issue this am post extub., given mult doses fentanyl w/ little effect. dilaudid given x1 w/ much better effect, orders adjusted. pain better this pm, note pt w/ chronic pain med regimen, likely to have higher tolerance for meds.\n\nresp: as above, tachypneic, in no distress. abg wnl. ls clear, dimin to bases, occas coarse sounds cleared w/ strong cough. o2 weaned to 3L NC.\n\ncv: tachycardic for shift, given lopressor x1 w/ transient effect. hypertensive w/ pain/stimulus, bp stable at rest. autodiuresing large amts clear urine today.\n\ngi: ogt d/c'd this am, remains npo d/t mental status. belly soft/nt/nd. bs present.\n\nendo: glucose levels stable.\n\nid: tmax 102.2 this am, blood cx x2, urine cx obtained. given tylenol for temp, await effect.\n\nskin: large back incision w/ staples, dsg changed by neuro team this am. bottom of incision, to iliac donor site w/ sm amt serosang drainage, rest of incision dry. jp w/ mod amts serosang output.\n\nsocial: pt's wife and friend in for visit today, updated. confirm pt's confusion when visiting w/ pt., explanation given as to possibility of reintubation if pt tires from breathing standpoint.\n\na/p: s/p T9-L1 fusion, abscess drainage w/ known dx Pott's tuberculosis to spinal canal. s/p 3+ weeks on antiviral regimen, #2 of 3 AFB cx completed as of this am.\nconfused mental status: cont to monitor, minimize pain meds?\ntachypneic: cont to closely follow resp pattern/effort.\nfebrile: follow pending pan cx, AFB smears. tylenol for comfort.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656773, "text": "npn 21:00-07:00 addendum at 06:20\n\nPt's T 102.4 at 04:00, however notable was pt's card rate/rhythm of ST to be up to 131 at approx 05:00, T checked again at 05:00, found to be 103.8;\nPt again received tylenol liquid 650 mg via ngt; 1 set blood cultures sent at that time from a-line;\nPt received anti-TB meds at 06:00 via ngt; urine also noted to be newly cloudy at that time, speciment obtained from foley, sent for u/a and culture;\n\nvery small amt of sero-sang drainage noted on bed pad under lower pole of back incision at 05:45, pt received new pad.\n\nOral cares re intubated and VAP prevention received at that time.\n\nHOB 30-45 degrees all night, to assist decreasing of head/neck swelling (from prone positioning during surgery) and per VAP prevention protocol.\n\nFurther plans for care at a.m. rounds.\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656774, "text": "Nursing Progress Note\nEvents: temp spike to 102.8. Pt failed SBTx2 with resp rate climbing to 50's. Propofol switched to fentanyl and midaz. Pt received two 1L LR bolus for hypotension with good effect.\n\nNeuro: pt lightly sedated on propofol and midaz. arouses easily to voice. MAE, sensation intact. Pt communicates with nodding. Follows all commands. PERRLA, 3mm, brisk. Denies pain.\n\nCV: ST, no ectopy. HR 100-130's when febrile. SBP 90-120's. Pt had episode of hypotension around 1200. SBP down to 70-80's with MAP's 30's. Pt received 2L LR boluses with good effect. +PP.\n\nResp: pt currently on CMV. most recent abg wnl. Sats 98-100%, RR 15-20. Pt had one short self limiting episode of desaturation to 93% this am. LSCTAB, dim in bilat bases. Pt sx'd several times for copious amts thick yellow sputum. TB cx sent.\n\nto be cont.....\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656775, "text": "Resp Care\nPt remains intubated currently on CMV. Attempted SBT X2, did not tolerate RR^40-50. Sx for mod amts yellow. Required to switch to CMV, plan to continue to wean goal of extubation.\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656776, "text": "cont from above....\nGI: Abd soft, nt, nd. +BS. Sm smear of loose brown stool. OGT clamped.\n\nGU: Foley draining adequate amts cloudy-->clear urine, responding well to fluid boluses.\n\nID: Tm 102.8. Tylenol given with good effect. Pt cont on anti-TB meds.\n\nSkin: Incision to back covered with original OR dsg, reinforced x2. Draining sm amts s/s fluid. JP drain to back drained approx 350ml since midnight.\n\nSocial: Pt family visiting today, supportive, updated on plan of care.\n\nPlan: Wean sedation for planned extubation tomorrow morning, ?7am. pulm toilet. fever control. send 2nd TB cx. monitor drainage from back incision.\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656770, "text": "npn 21:00-07:00\n\nNrsing post-op admit note to T-SICU\n\nBrought over from OR to T-SICU, admitted to , d/t plan for remaining intubated post-op overnight, d/t concern for head/ swelling. Reportedly pt was face and head down for several hours intra-op, also received much intra-op IVF; pt w/ visible scleral edema, therefor w/ presumed neck edema as well.\n\nPt's primary dx is spinal TB/Pott's dz, w/ progressing neurological symptoms of back pain and bil thigh numbness, w/u showed compression of T11. Pt had been having fevers at home and night sweats, which were improved w/ abx x 3 weeks.\n\nPt underwent planned posterior fusion Mon , and is planned for anterior fusion Thursday . Received 4 L crystalloid, had 1.5 L EBL and 1.5 L urinary output, received 2 units PRBC's in OR as well as calcium.\n\nTBC\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656771, "text": "npn 21:00-07:00 continued\n\nPaged and talked to covering Inf DZ nurse, to clarify what kind of precautions pt needed; room #1 has neg pressure capability for TB precautions, neg pressure functioning, however alarm system not--\nID nurse stated pt did not require neg pressure room at this point, only in OR d/t potential aerosolization of spinal fluid during the surgery process, which has the TB for this pt; also asked about JP drain to incisional area, ID nurse stated contact precautions of mask/eye shield/glove protection needed to prevent contact TB lesions.\n\nPt's family present at pt's admission to T-SICU.\n\nPropofol turned off briefly at approx 01:15, so neurology could come and perform a neuro exam on pt. PT appropriately responsive w/ nods and following commands/requests--see neuro post-op note.\n\nPt febrile to 103.8 at midnight 00:00, reported to MD who stated to go ahead and give pt Tylenol, pt received 650 mg liquid tylenol via ngt, 1 hr later T down to 102.6 again (o). Pt w/ hx of being in ST with elevated T's, however pt received lopressor 2.5 mg IV x2 in attempt to decrease tachycardia, possible mild effect.\n\npt on ps5/peep5 for vent assistance, plan is to obtain ABG, rep thrpy to obtain RSBI in a.m., and pt likely extubated in the morning; suctioned for small amts yellwo thick return.\n\nJP drain patent to back/incisional site, initially draining sanguinous return, lightening to sero-sanguinous, output volume decreasing.\n\nPt on propofol 75-80 mcg/k/min overnight until extubation, team aware of elevated LFT's, stated short term use of propofol Ok for this patient, as well as conservative use of tylenol.\n\nMD notified of serum mag level of 1.7, no repletion desired or ordered at this time.\n\nUrine output adequate, due to med Rifampin.\n\nPLAN:\n1) ABG approx 02:00\n2) keep intubated overnight w/ plan of extubation in a.m.\n3) post-op admit labs obtained 22:00 as ordered, therefore a.m. labs dc'd by team covering MD\n4) cont to follow T's, urine output\n5) return to OR Thurs for anterior fusion\n6) provide explainations to patient and family\n" }, { "category": "Nursing/other", "chartdate": "2129-03-01 00:00:00.000", "description": "Report", "row_id": 1656772, "text": "RESP CARE NOTE\nRECEIVED PT FROM OR AND PLACED ON PSV 5/5/50% INITIALLY. RR ^'D AND VT DROPPED TO 200'S, PSV ^'D TO 8. PT WAS IN PRONE POSITION FOR HOURS DURING SPINAL SURGERY AND THERE WAS CONCERN ABOUT AIRWAY SWELLING, REMAINED INTUBATED OVERNIGHT. CUFF LEAK PRESENT. BREATH SOUNDS DIMINISHED BILATERALLY. SUCTIONING SMALL TO MOD AMTS OF THICK TAN SECRETIONS. RECEIVING PROPOFOL FOR SEDATION. RSBI 83. ABG ON 50%: 7.43/36/187/25. CURRENT VENT SETTINGS 8/5/40%.\nPLAN: EXTUBATE ON DAYS\n" }, { "category": "Radiology", "chartdate": "2129-02-25 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 1002266, "text": " 2:22 AM\n MR W &W/O CONTRAST Clip # \n Reason: Pls re-assess\n Admitting Diagnosis: SPINAL INSTABILITY\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with with T11 compression fx\n REASON FOR THIS EXAMINATION:\n Pls re-assess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD FRI 4:14 AM\n POSITIVE for fracture of T11, with soft tissue extending posteriorly into the\n anterior epidural space and then superiorly along the anterior epidural space\n of T10. This causes moderate compression of the R side of the cord at T10-T11.\n Abnormal soft tissue can be seen anterior to Vertebral bodies # 8 through 12\n There is also generalized abnormal signal scattered in the cervical and\n thoracic vertebral osseosus structures The above is highly suggestive of\n metastatic disease MD\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic spine.\n\n CLINICAL INFORMATION: Patient with TB spondylitis, for further evaluation.\n\n TECHNIQUE: T1, T2, and inversion-recovery sagittal and T2 axial images were\n obtained before gadolinium. T1 sagittal images were obtained following\n gadolinium.\n\n FINDINGS: Again identified are changes of TB spondylitis and discitis at\n T10-11 and T11-12 level with compression of T11 vertebral body. There is a\n large pre- and paraspinal abscess identified which extends from T7-L1 level\n and has increased in size and extent since the previous study. In addition,\n there is now increased epidural soft tissue phlegmon is identified with small\n area of low signal in enhancing tissue indicating epidural abscess. There is\n more than 50% narrowing of the spinal canal seen with moderate compression on\n the spinal cord. There is no abnormal signal seen within the spinal cord at\n this level.\n\n Again noted are intraosseous changes within C6, T1, T5, T7, and L1 vertebral\n bodies indicative of intraosseous tuberculosis. No evidence of compression of\n spinal cord seen in the remaining levels in the thoracic region.\n\n IMPRESSION: Since the previous MRI of , there is increase in pre- and\n paravertebral abscess identified in the lower thoracic region with increased\n epidural phlegmon and epidural abscess with more than 50% narrowing of the\n spinal canal at T11 level. There is now moderate compression of the spinal\n cord seen. Findings were discussed with the neurosurgery resident at the time\n of interpretation of this study on .\n\n (Over)\n\n 2:22 AM\n MR W &W/O CONTRAST Clip # \n Reason: Pls re-assess\n Admitting Diagnosis: SPINAL INSTABILITY\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2129-02-24 00:00:00.000", "description": "Report", "row_id": 213540, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nsinus tachycardia is no longer present. Other findings are similar.\n\n" } ]

[ { "category": "ECG", "chartdate": "2164-08-20 00:00:00.000", "description": "Report", "row_id": 124750, "text": "Probable ectopiv atrial rhythm\nQT long for rate\nNonspecific inferior T wave abnormalities\nConsider anteroseptal myocardial infarct\nPossible Left ventricular hypertrophy\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2164-08-21 00:00:00.000", "description": "Report", "row_id": 124751, "text": "Ectopic atrial rhythm. Q-T interval prolongation, more marked as compared to\nthe previous tracing of . In addition, junctional rhythm has appeared.\nClinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2164-08-18 00:00:00.000", "description": "Report", "row_id": 124754, "text": "Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\nof the ectopic atrial rhythm and atrial tachycardia have resolved.\nThere are occasional junctional escapes The ST segment abnormalities have\nimproved. Followup and clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 124755, "text": "Ectopic atrial rhythm with A-V conduction delay, P-R interval 0.26, and atrial\ntachycardia, rate 100. Compared to the previous tracing of ectopic\natrial rhythm and atrial tachycardia have appeared. There is left ventricular\nhypertrophy. The precordial T waves, in the context of the tachycardia, appear\nhyperacute. In addition, there is more prominent ST segment depression in\nleads V4-V6 and new ST segment depression in leads II, III and aVF, with\nbiphasic T waves, consistent with active inferolateral ischemic process.\nRule out infarction. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 124752, "text": "Normal sinus rhythm, rate 57\nLate transition\nProbable left ventricular hypertrophy\nConsider anteroseptal myocardial infarct\nNondiagnostic lateral ST-T abnormalities\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2164-08-19 00:00:00.000", "description": "Report", "row_id": 124753, "text": "Sinus rhythm. Compared to the previous tracing of the rate is\nincreased. The Q-T interval remains prolonged. The ST segment abnormalities\nhave mostly resolved. Junctional escape rhythm is no longer recorded. Clinical\ncorrelation is suggested.\nTRACING #3\n\n" }, { "category": "Radiology", "chartdate": "2164-08-21 00:00:00.000", "description": "ART DUP EXT LO UNI;F/U", "row_id": 740149, "text": " 2:48 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: POST CATH RIGHT THRILL\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: duplex evaluation demonstrates no evidence of pseudoaneurysm or\n arterial venous fistula in the right femoral region.\n\n" } ]

[ { "category": "ECG", "chartdate": "2154-10-19 00:00:00.000", "description": "Report", "row_id": 117352, "text": "Atrial fibrillation. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2154-10-10 00:00:00.000", "description": "Report", "row_id": 117353, "text": "Atrial fibrillation with rapid ventricular response. ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. Otherwise,\nunchanged.\n\n" }, { "category": "ECG", "chartdate": "2154-10-07 00:00:00.000", "description": "Report", "row_id": 117354, "text": "Atrial fibrillation. Since the previous tracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2154-10-07 00:00:00.000", "description": "Report", "row_id": 117355, "text": "Atrial fibrillation with a controlled ventricular response. ST-T wave\nabnormalities. Since the previous tracing of the rate is somewhat\nfaster. Otherwise, no change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2154-10-15 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1255890, "text": " 8:55 PM\n CT ABD & PELVIS W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for expanding hemaperitoneum causing bladder/foley \n Admitting Diagnosis: ANEMIA\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with GIST, admitted with anemia and likely hemoperitoneum,\n now with urinary retenion with PVR on bladder scan showing >900ml, but after\n Foley placement, only 30ml of urine.\n REASON FOR THIS EXAMINATION:\n eval for expanding hemaperitoneum causing bladder/foley obstruction. also eval\n bladder to see if PVR on bladder scan is incorrect.\n CONTRAINDICATIONS for IV CONTRAST:\n /ARF\n ______________________________________________________________________________\n WET READ: MJMgb TUE 11:27 PM\n Comparison is made to CT-Abdomen/Pelvis from 9 hours prior:\n\n 1. Slight increase in size of hemoperitoneum in left paracolic gutter.\n Hyperdensities in this region are indeterminate for hemorrhage (2:52,53). In\n both CTs, there is direct mass effect on the bladder, which is collapsed.\n 2. Mild increase in large right hemorrhagic pleural effusion, though\n incompletely imaged.\n 3. No hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST.\n\n COMPARISON: CT done 9 hours prior from .\n\n INDICATION: 79-year-old woman with GIST, admitted with anemia and likely\n hemoperitoneum, now with urinary retention with post-void residual on bladder\n scan showing greater than 900 cc, but after Foley placement, only 30 mL of\n urine output was noted. Evaluate for hemoperitoneum causing bladder/Foley\n obstruction.\n\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis was obtained without IV\n or oral contrast. Multiplanar reformatted images were obtained and reviewed.\n\n DLP: 981.45 mGy-cm.\n\n FINDINGS:\n\n CT ABDOMEN: Stable moderate-sized right-sided pleural perfusion with\n persistent higher density and resulting basilar atelectasis. Segmental\n atelectasis in the inferior portion of the remaining visualized lung, which is\n otherwise clear.\n\n No evidence of left-sided pleural effusion. The visualized heart is prominent\n in size without pericardial effusion. Coronary artery disease and aortic\n annular calcification is noted.\n\n (Over)\n\n 8:55 PM\n CT ABD & PELVIS W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for expanding hemaperitoneum causing bladder/foley \n Admitting Diagnosis: ANEMIA\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Low density blood pool in the heart likely represents underlying anemia.\n\n Redemonstration of moderate-to-large amounts of hemoperitoneum involving the\n perihepatic region and extending into both paracolic gutters, with extension\n into the pelvis. Overall stable intra-abdominal/ pelvic hemoperitoneum. The\n attenuation in differed pockets measures similar to the CT from 9 hours prior.\n Two foci of hyperdensity within the anterior aspect of the left paracolic\n gutter most likely represent foci of contrast within adjacent coursing bowel\n through the left paracolic gutter hemoperitoneum (2:52 and 2:54); these were\n not previously seen.\n\n Redemonstration of multiple hypodense lesions within the liver, the largest\n likely representing hepatic cysts, the smaller difficult to characterize due\n to size.\n\n The spleen, pancreas, bilateral adrenal glands and both kidneys are grossly\n stable, although limited evaluation without IV contrast.\n\n Redemonstration of diffuse mesenteric and peritoneal implants as previously\n seen. Redemonstration of mass abutting the distal stomach is again seen.\n Visualized bowel is normal. No free air is noted. Midline abdominal incision\n is noted.\n\n CT PELVIS:\n\n Stable subtle amorphous hyperdensity within the lower pelvis, as previously\n seen (2:68). Stable since , this likely represents a uterine\n fibroid rather than active extravasation.\n\n Relatively stable attenuation of the moderate hemoperitoneum layering within\n the pelvis. No significant pelvic lymphadenopathy is identified. No inguinal\n lymphadenopathy is noted.\n\n Foley catheter is noted with the completely decompressed urinary bladder\n noted. The pelvic hemoperitoneum resides above the urinary bladder results in\n mass effect.\n\n BONES AND SOFT TISSUES: Degenerative disc disease and facet arthropathy is\n most prominent in the lower thoracic and lower lumbar spine.\n\n IMPRESSION:\n 1. Stable intra-abdominal and pelvic hemoperitoneum, overall unchanged since\n CT from 9 hours prior.\n 2. Foci of hyperdensity within the anterior aspect of the left side of the\n hemoperitoneum may represent residual contrast within bowel. Overall, no\n (Over)\n\n 8:55 PM\n CT ABD & PELVIS W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for expanding hemaperitoneum causing bladder/foley \n Admitting Diagnosis: ANEMIA\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n significant change in attenuation of the hemoperitoneum to suggest\n accumulating acute blood product.\n 3. Stable moderate right basilar high density pleural effusion and basilar\n atelectasis.\n 4. Completely decompressed urinary bladder with Foley catheter in place and\n no residual urine noted within the bladder. Large amount of pelvic\n hemoperitoneum overlies the urinary bladder superiorly. No evidence of\n hydronephrosis. On review of the prior CT, no distended bladder is identified\n - it is possible that the post void residual seen was due to above loculated\n hemoperitoneum given the extent of fluid as described.\n\n Preliminary findings were discussed with Dr. at 11:27 p.m. by Dr.\n .\n\n The final report findings were discussed with Dr. at 6:15 pm on .\n\n" }, { "category": "Radiology", "chartdate": "2154-10-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1255241, "text": " 11:15 AM\n CHEST (PA & LAT) Clip # \n Reason: ?pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 79F with chest pain\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison with a CT torso from as well as a chest radiograph from\n .\n\n CLINICAL HISTORY: Chest pain, question pneumonia.\n\n FINDINGS: PA and lateral views of the chest were provided. Since the prior\n exam, there is increased opacity at the right lung base which could represent\n a combination of atelectasis and effusion, though underlying pneumonia is\n difficult to exclude in the correct clinical setting. Lung volumes and\n evaluation for mild pulmonary edema is limited. There is no overt edema. No\n pneumothorax is seen. Bony structures appear intact.\n\n IMPRESSION: Increased opacity at the right lung base, likely a combination of\n effusion and atelectasis, though underlying pneumonia difficult to exclude.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1255431, "text": " 11:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion/pulmonary edema\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with SOB, diastolic heart failure\n REASON FOR THIS EXAMINATION:\n effusion/pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:57 A.M. ON \n\n HISTORY: 79-year-old woman with shortness of breath and diastolic heart\n failure, pleural effusion and possible pulmonary edema.\n\n IMPRESSION: AP chest compared to :\n\n There is greater consolidation at the right lung base today, which could be\n atelectasis worsening in the setting of persistent moderate right pleural\n effusion or worsening pneumonia. Improvement in perihilar opacification in\n the left mid lung may be a function of difference in radiographic technique.\n The area is not clear, whether it is edema or a second focus of pneumonia, is\n radiographically indeterminate. Moderate enlargement of the cardiac\n silhouette is longstanding.\n\n Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1255582, "text": " 4:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: enlarging effusion\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with wheezing, pleural effusion\n REASON FOR THIS EXAMINATION:\n enlarging effusion\n ______________________________________________________________________________\n WET READ: 7:32 PM\n Persistent moderate right pleural effusion and underlying consolidation.\n Possible mild interstitial edema, slightly increased compared to prior. Low\n lung volumes with bilateral perihilar atelectasis. Discussed with Dr. \n Hessner by phone at 7:30 p.m. on at time of initial review of the\n study.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable AP chest radiograph.\n\n COMPARISON EXAM: Portable AP chest x-ray , PA and lateral\n chest x-ray .\n\n INDICATION: 79-year-old with wheezing and pleural effusions.\n\n FINDINGS: There is stable moderate cardiomegaly. The mediastinal contour is\n stable. There is a persistent right pleural effusion with associated\n atelectasis. There is also some mild left base atelectasis as well as mild\n interstitial edema.\n\n IMPRESSION: Persistent right pleural effusion and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2154-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1255970, "text": " 5:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with right effusion s/p right chest tube placement\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n WET READ: MJMgb WED 5:49 PM\n New right pigtail pleural drain. No PTX. Similar size of moderate right\n pleural effusion. Low lung volumes with bibasilar atelectasis. Stable\n cardiomediastinal silhouette.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, patient has received a\n right pigtail catheter in the pleural space. There is no pneumothorax.\n Pre-existing effusion on the right has mildly decreased. Signs of mild\n pulmonary edema persist. Mild cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-10-15 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1255849, "text": " 12:25 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evaluate for worse or new abd bleed\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with GIST, initially admitted with anemia, found to have\n hemoperiotneum, was transfused PRBC and stable, now with new drop in Hct.\n Please eval for .d\n REASON FOR THIS EXAMINATION:\n evaluate for worse or new abd bleed\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with history of metastatic GIST, admitted with\n anemia, hemoperitoneum and was given packed RBC transfusions, now with new\n drop in hematocrit, to assess for interval bleeding.\n\n COMPARISON: CT of the abdomen and pelvis, .\n\n TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained\n without intravenous contrast. Sagittal and coronal reformations were\n performed and reviewed.\n\n DLP: 891.36 mGy-cm.\n\n FINDINGS: Partially imaged moderate-to-large hemorrhagic right pleural\n effusion, is slightly larger compared to the prior study. Mild increase in\n the compressive atelectasis of the right lung base. There is no left pleural\n effusion. Trace pericardial fluid is noted. The heart is normal in size.\n The large-volume complex ascites with attenuation values of 33-36 indicating\n internal hemorrhage or proteinaceous contents, has mildly increased in size\n since the earlier study of . Again seen are diffuse mesenteric and\n peritoneal implants with nodular implants and complex fluid extending from the\n right hemidiaphragm inferiorly into the pelvis, along the right paracolic\n gutter. Additional peritoneal deposits are seen in the perisplenic region.\n There is stable peritoneal metastasis surrounding the liver, stomach, head of\n the pancreas, right hemicolon and portions of small bowel. A 4.7 cm hypodense\n mass abutting the distal stomach has not significantly changed since the prior\n study. Two hypodense liver lesions, consistent with simple hepatic cysts are\n redemonstrated. An additional hypodense lesion in segment VII of the liver\n (2:34) measuring 13 mm is not characterized in this study. The adrenal glands,\n spleen, pancreas and kidneys are unremarkable. The small and large bowel\n loops are unremarkable. There is no intra-abdominal free air.\n\n CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The urinary bladder is empty. The\n rectum and sigmoid colon are normal. Mild increase in complex abdomino-pelvic\n ascites, as described above.\n\n BONES AND SOFT TISSUES: Mild degenerative changes are seen in the lumbar\n spine. No suspicious sclerotic or lytic bone lesion is detected. Mild\n anasarca is present.\n (Over)\n\n 12:25 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evaluate for worse or new abd bleed\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Mild interval increase in the complex abdominal fluid, likely\n hemoperitoneum, compared to . Multiple stable peritoneal and\n mesenteric metastasis.\n\n 2. Mild interval increase in the hemorrhagic moderate-to-large right pleural\n effusion.\n\n The findings were discussed with Dr. at 3:30 P.M on .\n\n" }, { "category": "Radiology", "chartdate": "2154-10-20 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1256117, "text": " 12:08 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evidence of increase fluid collection or increase intraabdom\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with increasing abdominal girth, pain, , elevated bladder\n pressure. Please evaluate for growth in intraabdominal blood, renal vein\n compression (if able to see), hydronephrosis\n REASON FOR THIS EXAMINATION:\n evidence of increase fluid collection or increase intraabdominal pressures\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing abdominal girth with history of known metastatic GIST\n to the omentum with hemoperitoneum and expanding abdominal girth. Also, had a\n chest tube recently placed for drainage. Evaluation for interval change.\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases to the pelvic\n outlet without oral or intravenous contrast. Coronal and sagittal\n reformations were acquired.\n\n COMPARISON: Two prior CTs from .\n\n FINDINGS: Again seen is large volume high-density ascites consistent with\n hemoperitoneum. As noted on previous CT of , there now appears to be\n slight increase in the left paracolic gutter component again consistent with\n increasing hemoperitoneum (2:54). Additionally, in the interim, a right\n pleural pigtail catheter has been placed, with a small amount of expected\n intrapleural air and a significant decrease in the size of pleural effusion.\n There is bibasilar atelectasis, particularly at the left lung base. The heart\n is enlarged but otherwise unremarkable except for aortic and coronary\n calcifications. Evaluation of the liver is limited in the absence of\n intravenous contrast and multiple cystic lesions again noted most consistent\n with hepatic cysts. The gallbladder is distended but otherwise unchanged.\n The pancreas, spleen, adrenals are unremarkable. There is no nephrolithiasis\n or hydronephrosis. There is no free intraperitoneal air. Diffuse mesenteric\n and peritoneal implants consistent with metastases are again demonstrated.\n The stomach and small bowel are grossly unremarkable.\n\n CT PELVIS: Again noted is pelvic hemoperitoneum. The urinary bladder is\n collapsed and contains a Foley catheter. The colon and rectum are\n unremarkable. There is no pelvic lymphadenopathy.\n\n OSSEOUS STRUCTURES: Again seen is degenerative disc disease without lytic or\n blastic lesion worrisome for malignancy. Again seen are posterior osteophytes\n and disc osteophyte complexes at L3-L4 and L4-L5.\n\n IMPRESSION:\n 1. Mild interval increase in high density ascites along the left paracolic\n gutter, representing mild progression of hemoperitoneum compared to .\n 2. Interval drainage of right pleural effusion with pleural catheter in place\n (Over)\n\n 12:08 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evidence of increase fluid collection or increase intraabdom\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and hydropneumothorax.\n 3. Redemonstration of the diffuse omental and peritoneal metastases.\n 4. No evidence of renal vein compression in particular (as queried) given the\n limitations of this non-contrast study.\n\n" }, { "category": "Radiology", "chartdate": "2154-10-10 00:00:00.000", "description": "CTA ABD & PELVIS", "row_id": 1255566, "text": " 2:42 PM\n CTA ABD & PELVIS Clip # \n Reason: Intraabdominal bleeding\n Admitting Diagnosis: ANEMIA\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with GIST tumor with history of RP bleeding from tumor. Now\n with acute anemia.\n REASON FOR THIS EXAMINATION:\n Intraabdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:34 PM\n Increased large-volume hemoperitoneum concerning for bleeding\n peritoneal/omental tumor. No active extravasation.\n\n Inc large R pleural effusion with intermediate density that could represent\n blood, possibly from diaphragmatic rent with tracking into the thorax.\n\n Volume overload.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Malignant GIST with omental metastasis, post-local resection.\n History of retroperitoneal bleeding, now with acute anemia.\n\n COMPARISON: .\n\n TECHNIQUE: Helical MDCT images were acquired from the lung bases through the\n greater trochanters before and after the uneventful administration of 150 cc\n of intravenous Omnipaque, scanning in non-contrast, late arterial, and venous\n phases. 5-and 2.5-mm axial, 5-mm coronal and sagittal multiplanar reformats\n were generated.\n\n FINDINGS: Geographic ground-glass opacities have developed at the lung bases,\n compatible with pulmonary edema. Interval increase in the right pleural\n effusion, now large, with intermediate attenuation contents measuring 30-40\n . There is associated compressive atelectasis, with consolidation and air\n bronchograms in the posterior basal segment of the right lower lobe. A trace\n left simple pleural effusion has also developed.\n\n The heart is normal in size, with minimal leftward bowing of the inferior\n interventricular septum (3a:37) suggesting right heart strain. Relative\n hypoattenuation of the blood pool is compatible with anemia. Mild\n calcifications in the aortic root and left anterior descending coronary\n artery. No pericardial effusion.\n\n ABDOMEN: Interval increase in large-volume hemoperitoneum throughout the\n abdomen, measuring 30-40 in attenuation. Several prominent mesenteric\n vessel branches course through this region, but there is no active arterial\n extravasation. Similar appearance of diffuse peritoneal metastases, with\n mixed solid/cystic appearance and nodular enhancement. Metastases involve the\n (Over)\n\n 2:42 PM\n CTA ABD & PELVIS Clip # \n Reason: Intraabdominal bleeding\n Admitting Diagnosis: ANEMIA\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n entirety of the anterior peritoneum, but are most confluent along the right\n subdiaphragmatic/perihepatic region and paracolic gutter. This infiltrates\n the porta hepatis and gallbladder fossa, and abuts the lateral pancreatic\n head, proximal duodenum, and ascending colon. There is also extension into\n the lesser omentum abutting the lesser curvature of the stomach.\n\n Multiple well-defined, hypodense non-enhancing lesions throughout the liver,\n measuring up to 3.8 x 3.5 cm in segment II/, are compatible with cysts.\n There is mild periportal edema. The gallbladder is contracted. Pancreas is\n normal. No intra- or extra-hepatic biliary ductal dilation. The spleen is\n normal in size.\n\n The adrenals are normal. Kidneys enhance and excrete contrast promptly and\n symmetrically, without stones or hydronephrosis. Bilateral tiny hypodensities\n are too small to characterize, but likely represent cysts.\n\n Fat stranding and fascial thickening in the anterior abdominal wall from prior\n surgery. No imaging signs of bowel obstruction or inflammation.\n\n PELVIS: There is a large amount of retained fecal material in the ascending\n colon, which is medially displaced by the omental mass.\n\n The bladder is inferiorly deviated and compressed by fluid. There is descent\n of the bladder below the pubococcygeal line, compatible with pelvic floor\n dysfunction.\n\n Scattered calcifications throughout the aorta and branch vessels. There is\n mild right renal artery stenosis.\n\n Diffuse body wall edema has developed. Minimal anterolisthesis at L3-L4.\n Multilevel degenerative disease with bridging anterior osteophytes throughout\n the thoracolumbar spine. Diffuse disc-osteophyte complexes in the lower\n lumbar spine, with effacement of the ventral thecal sac. Facet hypertrophy is\n also present at these levels.\n\n IMPRESSION:\n 1. Large-volume hemoperitoneum concerning for bleeding from diffuse\n peritoneal metastases, though there is no active extravasation.\n\n 2. Increased right pleural effusion with possibly hemorrhagic contents,\n raising the question of thoracoabdominal communication through a diaphragmatic\n rent.\n\n 3. Volume overload.\n (Over)\n\n 2:42 PM\n CTA ABD & PELVIS Clip # \n Reason: Intraabdominal bleeding\n Admitting Diagnosis: ANEMIA\n Contrast: OMNIPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2154-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256130, "text": " 11:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, pulm edema\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with metastatic cancer, significant abdominal pressure,\n pleural effusion, p/w shortness of breath and tachypnea.\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic cancer, abdominal pressure, pleural effusion, shortness\n of breath, tachypnea.\n\n CHEST, SINGLE AP VIEW. Low inspiratory volumes.\n\n Compared with at 17:32 p.m., there has been an increase in the\n effusion at the right lung base, now small-to-moderate, with underlying\n collapse and/or consolidation. A right-sided chest tube is again seen. No\n pneumothorax is detected.\n\n The cardiomediastinal silhouette is enlarged, but unchanged. There is patchy\n retrocardiac opacity consistent with left lower lobe collapse and/or\n consolidation, possibly slightly worse. There is upper zone redistribution,\n but no definite CHF.\n\n IMPRESSION:\n 1. Increased right effusion with underlying collapse and/or consolidation.\n 2. Slight worsening of left lower lobe collapse and/or consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2154-10-17 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1255997, "text": " 10:08 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate right pleural effusion\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with metastatic GIST, c/b hemoperitoneum, and also with right\n pleural effusion, bloody, now s/p chest tube.\n REASON FOR THIS EXAMINATION:\n please evaluate right pleural effusion\n CONTRAINDICATIONS for IV CONTRAST:\n / ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with metastatic GIST complicated by\n hemoperitoneum with right pleural effusion bloody, now with chest tube.\n Assess pleural effusion.\n\n COMPARISONS: .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest without\n intravenous contrast. Coronal and sagittal reformations were prepared.\n\n FINDINGS: Thyroid gland, aorta, major branches, and cardiac contour are\n unremarkable without pericardial effusion. Minimal aortic valvular and\n coronary vascular calcifications are identified. The esophagus is somewhat\n patulous. Assessment for lymphadenopathy is somewhat limited but the upper\n right hilar contours are enlarged which could reflect engorged mediastinal\n veins or intervally developed lymphadenopathy. Left 10mm hilar node (3a:24) is\n increased from 8mm previously. A 23 x 13 mm right diaphragmatic lymph node\n (2a:32) was 19 x 7mm previously.\n\n Though this study is not tailored for subdiaphragmatic evaluation, imaged\n upper abdomen demonstrates moderate volume ascites which is complex in\n attenuation and hepatic hypodensities which are better assessed on recent CT\n torso.\n\n Tracheal AP diameter is reduced suggesting a component of tracheomalacia with\n endoluminal, material noted (3a:9). The bronchial tree is patent to the\n segmental level. Right basal chest tube is seen without significant residual\n pleural fluid collection. Bibasilar opacities are likely atelectasis, and\n less likely could be due to aspiration. Linear right middle lobe atelectasis\n is also noted. Minimal right upper lobe atelectasis or tracking pleural fluid\n is seen along the fissure.\n\n OSSEOUS STRUCTURES: Multilevel degenerative changes are seen in the spine.\n There is no lytic or sclerotic bony lesion to suggest osseous malignancy.\n\n IMPRESSION:\n 1. Complete drainage of right pleural fluid collection after placement of\n right basal pleural catheter. Bibasilar opacities are more likely atelectasis\n than aspiration. Status of the effusion can be monitored with serial\n radiographs if clinically relevant.\n (Over)\n\n 10:08 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate right pleural effusion\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Intervally enlarged epicardial lymph node with possibly enlarging right\n hilar lymph nodes are not fully assessed on this non-contrast study. These\n findings should be reassessed in weeks (or per continuing surveillance\n plans for intraabdominal malignancy) with a contrast CT study.\n\n 3. Complex ascites and other findings of known intra-abdominal malignancy are\n incompletely assessed on this study.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2168-08-29 00:00:00.000", "description": "Report", "row_id": 1304277, "text": "T/SICU Nursing 19-00\nAddendum:\nPatient remained in T/SICU overnight for logistical reasons. There were no major changes or events overnight. He required dilaudid x2 for pain related to the HALO vest and his right knee, with excellent effect. He is NPO and to go to the OR for bilateral wrist surgery, then PACU, then floor.\n" }, { "category": "Radiology", "chartdate": "2168-08-30 00:00:00.000", "description": "BO WRIST, AP & LAT VIEWS BILAT IN O.R.", "row_id": 922313, "text": " 10:49 AM\n WRIST, AP & LAT VIEWS BILAT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILATClip # \n Reason: BILATERAL DISTAL RADIUS ORIF\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral distal radius ORIF.\n\n FINDINGS: Six intraoperative spot fluoroscopic radiographs are taken of the\n right and left wrists by the surgeon without a radiologist present. There has\n been interval placement of 2 volar fracture plates with multiple cortical\n screws fixating the previously described distal radial fractures of the right\n and left upper extremities. A small mildly displaced fracture of the right\n ulnar styloid is unchanged in appearance. No immediate surgical hardware\n complications are identified. For further information, please consult the\n intraoperative report.\n\n" }, { "category": "Radiology", "chartdate": "2168-09-02 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 922747, "text": " 5:24 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: IVC filter placemntAM PLEASE! By 6am on please\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with mult ext fractures c2 fracture s/p IVC filter placemnet\n REASON FOR THIS EXAMINATION:\n IVC filter placemntAM PLEASE! By 6am on please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old male with cervical spine fracture status post IVC\n placement. Check IVC filter.\n\n COMPARISONS: Comparison is made to intraoperative picture.\n\n AP SINGLE VIEW OF THE ABDOMEN: There is an IVC filter in place centered at\n the level of T12. It is slightly angulated towards the left side with a 5-\n degree angle in relation to the spinous process. There is air in small and\n large bowel, which could be related to ileus.\n\n IMPRESSION: IVC filter in place as described above.\n\n" }, { "category": "Radiology", "chartdate": "2168-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 922273, "text": " 6:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: temp. spikes, r/o pulmonary source, please take CXR this AM\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p fall with C2 fracture now intubated\n\n REASON FOR THIS EXAMINATION:\n temp. spikes, r/o pulmonary source, please take CXR this AM\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:27 A.M. \n\n HISTORY: Fever.\n\n IMPRESSION: AP chest compared to and 29:\n\n Following extubation, low lung volumes have decreased further and there is new\n perihilar opacification symmetrically distributed in both lungs, previously\n limited to the right lower lung. Heart size is mildly enlarged and the azygos\n vein is distended. The new pulmonary findings are likely due to edema,\n cardiogenic or otherwise. Pleural effusion, if any, is minimal. There is no\n pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-08-28 00:00:00.000", "description": "Report", "row_id": 1304273, "text": "T/SICU NPN\nBrief ROS-\nNeuro- Intact. MAE on command and spontaneously. Halo traction maintained, he is just understanding plan(halo) of care and finding halo slightly uncomfortable. PERL. Cooperative and appropriate all shift. Fentanyl gtt continues, to switch to po percocet.\n\nCV- Stable vs. Skin warm and dry. Palpable pulses.\n\nResp- No issues. Cont. with NC 2L. Gd sats. Bilat breath sounds are reletively clear. Pt. has a gd strong productive cough, thick green secretions.\n\nGI- Taking po's well. Abd soft, scantly distended. +BS. No BM's.\n\nGU- Adequate u/o via foley. IVF decreased to KVO, flushing fentanyl.\n\nHeme/ID- Pneumoboot to left leg. SQ heparin.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-27 00:00:00.000", "description": "Report", "row_id": 1304269, "text": "T/SICU NPN\nBrief ROS:\n Pt. appears to be intact. He nods head appropriatly to question of pain or in response to command. Opens eyes to speech. Moves fingers and toes to command. Has moved arms around on bed during day. Difficult to assess location of pain but he has signaled he's had pain. Continues on fent drip. PERL. Calm. J collar removed this am as Dr. placed halo traction on pt.\n\n Pt. has been essentially stable all shift with a couple of episodes of sagging BP which responds well to fluid. Got 1600cc LR through procedure and with BP decrease. BP 120's now with maint. fluid running. HR has been rapid all shift, 107-120's. Probably remains dry, has a brisk u/o when fld given. Skin warm and dry. Palpable pulses to all 4 extremities.\n\nResp- Remains vented but is ready to extubate with gd abg's on and 40% O2. Breath sounds clear bilaterally. Thick yellow secretions this am but scant amts this afternoon. Spont. rr 20's.\n\nGI- Abd soft. OGT in place for mod amt of drg, bilious. NPO, except for potassium supplement. No bowel sounds heard on auscultation.\n\nGU- Adequate u/o via foley, brisk output with fluid boluses.\n\nEndo- No issues.\n\nHeme/ID- Temp presently 102. Cefazolin x 3 doses in progress. Last hct, down to 28.2(from 30). Pneumoboot to left leg. SQ heparin.\n\nSkin- Generally intact. Pins to HALO to head. thighs bilat have sml dsd to OR spots. Rt continues to be larger than left, measured without change over shift.\n\nSocial- Have not heard from family today, did not call girlfriend as planned while interpretor present.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-27 00:00:00.000", "description": "Report", "row_id": 1304270, "text": "Patient weaned from A/C to PSV 5/5 with good ABG.BS clear,CXR normal.Plan to extubate soon then to go to CT scan for wrist films.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-27 00:00:00.000", "description": "Report", "row_id": 1304271, "text": "Patient now extubated on 100% cool-mist via aerosol mask,gone to ct scan on venturi mask 50%.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-27 00:00:00.000", "description": "Report", "row_id": 1304267, "text": "Resp: pt via OR intubated ett # 7.5 taped 23 @ lip on A/C 12/800/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. Bs are rs clear with coarse sounds on ls. ABG's (see careview) Vent changes to ^ rr to 18 with decrease TV to 650.AM ABG 7.38/41/125/25. Fio2 decreased to 40%. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-27 00:00:00.000", "description": "Report", "row_id": 1304268, "text": "Admit Note\n Pt is a 35 yo male transferred from hospital s/p fall from open box on truck. Injuries sustained include bilateral femur fractures, bilateral distal radial shaft fx and communited C2 transverse body fx of dens extending into vetebral foramen, minimally displaced and C2-3 anterolisthesis Grade 1.\n Pt directly to OR from EW for ORIF and rodding of bilateraly femurs. Bilateral wrists splinted. In OR ortho noted blood collection in R knee, knee immobilizer on. Transferred to T/SICU post op.\n pt was intubated fiberoptically with stabilization of neck maintained. Required some neo on induction but BP stable during case. Recieved 2450cc crystalloid, 830cc UO and 250cc blood. Arrived to unit sedated on propofol gtt at 100mcg/kg/min, having been reversed from paralytic.\n\nPMHx- Reflux disease, takes prilosec PRN.\n\nSHx- Occ ETOH use and marijuana. Tox screen neg in EW. Denies tobacco use. is pt girlfriend and had been notified of accident by Hospital.\n\n\n Pt arrived sedated, unresponsive. Propofol off and pt HR in 130s and rigors. Restarted and given demerol for rigors. Fent given PRN and gtt to be started. Pupils 2-3mm and reactive. No movement of extremeties noted however in EW able to move fingers and toes, + sensation and + rectal tone. J collar on. Logroll maintained, TLS films per intial read (-). to place Halo today.\n\nResp- Vented post op with good ABGs on present settings. Lungs clear throughout. Scant secretions. Adeq sats. CXR done post-op.\n\nCV- ST off sedation, however HR climbing when resedated. SBP into 80s. Given fluid bolus with response. Cont in low 100s, no ectopy. BP into 120s. PIV x 2. R axillary Aline. Strong pedal and radial pulses. Afebrile. On ancef x 3 doses. KCL repleted. HCT drop from 38 to 30.1 postop. Skin w/d/i. Contusion on forehead. Small surigcal incision with staples bil upper thigh. R with some amt sanginous drainage, R thigh markedly swollen compared to L.\n\nGI/GU- Abd soft, hypo BS. Pt + flatus. OGT placed and scant output. Foley patent with good UO.\n\nSocial- No visitors or contact overnight.\n\nPlan- Most likely will need halo today. Close monitoring of CV and resp status. Recheck HCT later this morning.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-08-28 00:00:00.000", "description": "Report", "row_id": 1304272, "text": "NPN 00-0700\n Pt slept all night. Easily arousable for exam and nursing care. Calm and cooperative. Spanish speaking only but able to communicate basic needs with gestures and simple spanish words. Moves all extremities. Wiggles toes and turns legs side to side, wiggle fingers and lifts off bed. Unable to accurately assess sensation due to language barrier but pt feels pain in all limbs. Remains on fent gtt with ativan ATC. Halo in place, no pressure points noted from vest. Pin care done.\n\n When pt asleep has loud snore which sounds like obstuctive sleep apnea. RR and sats all wnl. ABGs while asleep had slightly elevated pCO2 of 46, normal pH. Lungs coarse when asleep, clear when awake. On 3lNC.\n\nCV- ST in 110-120s. BP 120-130s/80s. Temp 101.1 and WBCs 11.2 (from 7.7) blood and urine cx sent, unable to get sputum. Magnesium repleted. HCt stable in 26 range. IVF cont at 125cc/h. Brisk UO. R thigh remains swollen but unchanged in size.\n\nGI/GU- Abd soft, + BS. NPO at this time. Foley patent.\n\nSocial- No contact from family overnight.\n\n Pt needs bowel regimen. ? change NPO status. OT/PT consult on Monday. Tentative plan for OR early next week for both wrists.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-29 00:00:00.000", "description": "Report", "row_id": 1304274, "text": "ASSESSMENT AS NOTED\n\nHCT DOWN TO 22+, HO AWARE, CONT TO MONITOR HEME, R.HIP IS SWOLLEN WITH KNEE IMMOBILIZER ON, HALO TRACTION ON/INTACT, C/O SOME ITCHING UNDER THE TRACTION. SCELETO-MUSCULAR PAIN TREATED WITH DILODID AND PERCOCET PO, FENTANYL GTT WAS OFF LAST NIGHT. REMAINS IN S/TACH 110-120, BP STABLE, RES STABLE, +BS AND FLATUS, MOVES IN BED WITH HELP , SLEPT MOST OF THE NIGHT.PLANNING TO BE OPERATED ON BOTH LOWER ARMS/WRISTS TODAY:PT AWARE AND REMAINS NPO SINCE MIDNIGHT\n" }, { "category": "Nursing/other", "chartdate": "2168-08-29 00:00:00.000", "description": "Report", "row_id": 1304275, "text": "TSICU NPN 0700-1900\nREVIEW OF SYSTEMS:\n\nNEURO: A&OX3, per spanish interpreter. Speaks little english. Moves all extremities on bed, follows commands. Pupils 3mm, briskly reactive. Halo intact. Sensation to all extremities.\n\nCV: ST 100-120's, no ectopy noted. Arterial line DC'd. SBP ranging 110-120's. HCT trending down to 21.3 this afternoon, currently recieving 1 unit PRBC's. + radial and pedal pulses. Extremities warm.\n\nRESP: 2L NC with SATS >95%. LS clear throughout. No respiratory distress noted.\n\nID: TMAX 101.5 - pan cultured this afternoon.\n\nGI: Abd soft, non-distended. Regular diet tolerated. NPO after midnight for OR in am. +flatus.\n\nGU: Foley draining clear yellow urine.\n\nSKIN: BLE swollen. Backside intact.\n\nSOCIAL: No contact from family/friends this shift.\n\nPLAN: Tx to floor when bed available. OR in am.\n\nACTIVITY: OOB to chair X 4 hours today. PT c/s. BUE with splints intact, will go to OR tomorrow for wrist repair. BLE with knee immoblizers intact.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-29 00:00:00.000", "description": "Report", "row_id": 1304276, "text": "T/SICU Nursing 19-00\nSee CareVue for specific data.\n\nNeuro: A&Ox3, MAE purposefully, follows commands. PERRL.\n\nPain: Denies / resolves with position changes only.\n\nResp: Lung sounds clear, SPO2 99-100%, on 2LNC for comfort. Using IS appropriately.\n\nCV: Sinus tachycardia with rate 90's-110's. Latest BP 133/59. All ext warm and well perfused with strong palpable pulses. F/U Hct post-transfusion appropriate bump.\n\nGI: Abd soft, non-tender. Tolerated house meal. NPO after midnight.\n\nGU: Foley to gravity, slight autodiuresis noted. Clear yellow output.\n\nEndo: RISS, no coverage required.\n\nSkin: Intact, splints to all 4 extremities (bilat wrists, knee immobilizers).\n\nID: Temp 99.8. Cultures are pending.\n\nSocial: 2 family visitors tonight, helped explain to patient need to stay in HALO and probable rehab/home nursing assistance due to limited mobility.\n\nPlan:\nMaintain safety\nPain management\nIS/pulmonary toileting\nHALO\nOR in AM for wrist repair\nTransfer to floor for further management\n" }, { "category": "Radiology", "chartdate": "2168-08-29 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 922216, "text": " 3:56 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: TRAUMA,EVAL FOR DVTS\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with bilateral femur fractures\n REASON FOR THIS EXAMINATION:\n evaluate for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral femur fractures. Evaluate for DVT.\n\n FINDINGS: -scale and Doppler son of the right common femoral and\n superficial femoral veins were performed. The popliteal veins were not\n evaluated due to the patient's bilateral leg fractures. Normal flow,\n augmentation, compressibility and waveforms were demonstrated within the\n vessels examined. No intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of DVT in the right or left common femoral or\n superficial femoral veins. Please note that the popliteal veins were not\n examined.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 921908, "text": " 8:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval head bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n eval head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb FRI 8:47 PM\n No intracranial hemorrhage or mass effect. No cranial fractures.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 35-year-old man, status post fall. Evaluate for intracranial\n hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage identified. The\n ventricles are symmetric, and there is no shift of normally midline\n structures. The -white matter differentiation is preserved. The density\n of the brain parenchyma is within normal limits. There is a small amount of\n fluid within the left maxillary sinus, which demonstrates low attenuation.\n There is no evidence of definite hemorrhage. No facial fractures are\n identified. There is a small retention cyst within the sphenoid sinus.\n\n IMPRESSION: No intracranial hemorrhage or mass effect is identified.\n Air fluid level is noted in the left maxillary sinus, of low attentuation,\n mopst probably due to sinusitis. However given the history of trauma, a CT of\n the sinuses/facial bones may be performed as clinically warranted.\n\n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 921909, "text": " 8:24 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: C2 fracture from OSH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n C2 fracture from OSH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb FRI 8:55 PM\n Fractures extending through the C2 transverse foramen bilaterally. Grade 1\n anterolisthesis of C2/C3. Given the location of the fractures, there may be\n an associated vertebral artery injury, and further evaluation with a CTA\n should be obtained.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of trauma, status post fall. History of C2 fracture seen\n on study from an outside hospital.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images of the cervical spine were obtained with\n coronal and sagittal reconstructions.\n\n CT C-SPINE: There are fractures extending through the transverse foramen of\n C2 bilaterally. The left fracture demonstrates several millimeters of\n distraction of the fracture fragments. Additionally, there is associated 3-mm\n grade I anterolisthesis of C2 on C3. No other fractures are identified. The\n dens articulates normally with the anterior aspect of C1. The atlantoaxial\n space is preserved. The lateral masses of C1 articulate normally with the\n dens. No other fractures are identified. The spinal canal is widely patent.\n There is limited evaluation of intrathecal contents; however, the contour of\n the thecal sac is within normal limits.\n\n IMPRESSION: There are fractures extending through the transverse foramen of\n C2 bilaterally. There is associated grade I anterolisthesis of C2 on C3.\n Given the location of the fractures, there is concern for associated vertebral\n artery injury, and further evaluation with a CTA is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "B FOOT AP,LAT & OBL BILAT", "row_id": 921915, "text": " 8:44 PM\n FOOT AP,LAT & OBL BILAT; TIB/FIB (AP & LAT) BILAT Clip # \n FEMUR (AP & LAT) BILAT; KNEE (3 VIEWS) BILAT\n T-SPINE; L-SPINE (AP & LAT)\n Reason: eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with fall\n REASON FOR THIS EXAMINATION:\n eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n ELEVEN VIEWS OF THE SPINE, HIPS, AND LOWER EXTREMITIES:\n\n There is no evidence of fracture or malalignment within the thoracic and\n lumbosacral spine. There is no fracture or dislocation within the hips.\n There are bilateral transverse overriding medially displaced femoral shaft\n fractures with fracture fragments. The knees and ankles demonstrate no\n evidence of fracture. Joint spaces of the knees and ankles are preserved.\n\n IMPRESSION:\n\n Bilateral displaced overriding femoral shaft fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 921927, "text": " 10:08 PM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: Please do CT-angiogram of the neck to assess the vertebro-ba\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p 15-foot fall and C2 fracture\n REASON FOR THIS EXAMINATION:\n Please do CT-angiogram of the neck to assess the vertebro-basilar arterial\n system. Requested by radiology due to C2 fracture.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old man with status post fall and C2 fracture, CT\n angiogram to evaluate for vertebrobasilar arterial system.\n\n No prior studies for comparison.\n\n TECHNIQUE: CT angiogram of the neck with IV contrast.\n\n FINDINGS: Both vertebral arteries are patent and normal in caliber throughout\n their length. Bilateral common carotid, external and internal carotid\n arteries are patent and normal. However, the sensitivity of CT angiography\n for evaluation of intramural hematoma is unknown. Hence, intramural\n hematoma/dissection cannot be completely excluded based on this study alone.\n\n Again noted are C2 transverse foraminal fractures noted bilaterally. There is\n mild mucosal thickening noted in the left maxillary sinus.\n\n IMPRESSION:\n\n Bilateral C2 transverse foraminal fractures, as before.\n\n Normal-appearing vertebral artery and bilateral common carotid internal and\n external carotid arteries. However, the sensitivity of CT angiography for\n intramural hematoma is unknown. Hence dissection cannot be excluded based on\n this study alone.\n\n\n\n Findings discussed with trauma team . At the time of review, only sagittal\n reconstructions were available.\n\n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "OB LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILAT", "row_id": 921932, "text": " 11:24 PM\n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILAT; FEMUR (AP & LAT) BILAT IN O.R.Clip # \n Reason: S/P FALL /ROOF ORIF RT FEMUR FX\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture.\n\n Twelve intraoperative fluoroscopic views of the right femur were obtained\n without a radiologist present. These demonstrate successive ORIF of right\n femur diaphysial fracture. For additional details, please consult the\n operative report.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 921906, "text": " 8:16 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n CHEST: Detail is obscured by the underlying trauma board. Heart size is\n within normal limits. The descending aortic interface is relatively well\n defined. No definite pneumothorax is seen. There are low lung volumes. No\n rib fractures are seen.\n\n PELVIS: Detail is obscured by the underlying trauma board. There appears to\n be a Foley catheter with possible contrast material seen within the bladder.\n No definite fractures are seen. The lateral portion of the left greater\n trochanter is not imaged.\n\n" }, { "category": "Radiology", "chartdate": "2168-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 921946, "text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p fall with C2 fracture now intubated\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n CHEST, ONE VIEW: There are no comparisons. The endotracheal tube is\n approximately 3 cm above the carina. An NG tube terminates coiled within the\n stomach. The lungs are clear without consolidation, effusion, or pulmonary\n edema. There is no pneumothorax. The cardiac contour is at the upper limits\n of normal in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-27 00:00:00.000", "description": "R CT LOW EXT W/O C RIGHT", "row_id": 922005, "text": " 6:49 PM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: r/o tib plateau fx\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n hemarthrosis\n REASON FOR THIS EXAMINATION:\n r/o tib plateau fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT scan of the right knee was performed without intravenous contrast. Images\n were acquired in the axial plane. Coronal and sagittal reformats were created\n and reviewed. No comparisons.\n\n FINDINGS:\n\n OSSEOUS: There is a minimally displaced fracture of the tibial plateau and\n involves the posterior and central aspect of the proximal tibia. Approximately\n 1 mm of displacement is noted. The fracture fragment is located posterior to\n the tibial spine. No significant anteroposterior displacement is noted. The\n distal aspect of an intramedullary rod fixing a femoral diaphysis fracture is\n seen with two distal interlocking screws. No hardware-related complication is\n seen.\n\n SOFT TISSUES: There is a joint effusion. Skin clips are noted anteriorly.\n Diffuse reticular edema of the subcutaneous soft tissues reflects recent\n injury.\n\n IMPRESSION:\n\n 1. Minimally displaced fracture of the proximal tibia located at the\n posterior and central aspect of the tibial plateau. The fracture fragment is\n displaced by less than 1 mm and is located posterior to the tibial spine.\n\n 2. Incomplete visualization of the distal aspect of intramedullary rod in the\n right femur, with no evidence of hardware-related complication.\n\n 3. Right knee joint effusion. Diffuse reticular edema of the subcutaneous\n soft tissues.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2168-08-26 00:00:00.000", "description": "B FOREARM (AP & LAT) BILAT", "row_id": 921916, "text": " 8:44 PM\n FOREARM (AP & LAT) BILAT; WRIST(3 + VIEWS) BILAT Clip # \n ELBOW (AP, LAT & OBLIQUE) BILAT\n Reason: eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with fall\n REASON FOR THIS EXAMINATION:\n eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall.\n\n Fourteen radiographs of the bilateral hands, bilateral elbows, and right\n forearm are submitted.\n\n RIGHT HAND AND FOREARM: There is a minimally displaced, intra-articular\n fracture involving the distal radius. There is a 2 mm gap involving the\n fracture fragments at the articular surface. Fracture line involves the\n distal radial ulnar joint. There is a minimally displaced avulsion fracture\n of the ulnar styloid. The remaining osseous structures are unremarkable.\n Mineralization is normal. Soft tissues are unremarkable.\n\n LEFT HAND: There is a comminuted, intra-articular, distal radius fracture.\n The ulna is unremarkable. Remaining osseous structures are unremarkable.\n Regional soft tissues are normal. Assessment is limited by overlying casting\n material.\n\n LEFT ELBOW: Assessment for effusion is precluded by absence of a lateral\n view. No fracture identified. The regional soft tissues are unremarkable.\n\n RIGHT ELBOW: No effusion. No fracture. The soft tissues are unremarkable.\n\n IMPRESSION:\n\n Bilateral, intra-articular, distal radius fractures.\n\n Unremarkable elbow radiographs, although assessment for effusion on the left\n is limited by the absence of a lateral view.\n\n CareWeb notes indicate the clinical service caring for the patient is aware of\n these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-27 00:00:00.000", "description": "C-SPINE (PORTABLE)", "row_id": 921974, "text": " 11:40 AM\n C-SPINE (PORTABLE) Clip # \n Reason: C spine alignement\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with known B/L C2 transverse process fx now s/p halo placement\n REASON FOR THIS EXAMINATION:\n C spine alignement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known C2 transverse process fractures, question alignment.\n\n FINDINGS: This a single lateral view of the C-spine from C2 through C5\n demonstrating normal alignment at these levels. The transverse process\n fractures are visible on this film but are better seen on the CT performed the\n prior day. The endotracheal tube and NG tube proximal portions are\n visualized.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-09-01 00:00:00.000", "description": "OO ABDOMEN (SUPINE ONLY) IN O.R. IN O.R.", "row_id": 922649, "text": " 1:03 PM\n ABDOMEN (SUPINE ONLY) IN O.R. IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGISTClip # \n Reason: IVC FILTER\n Admitting Diagnosis: S/P FALL WITH C2 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: IVC filter placement.\n\n Single spot image performed in the operating room without radiologist present\n is available demonstrates an IVC filter at the level of T12. A sheath is\n noted in the bottom part of the image and the overlying hardware is okay.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2140-02-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1007135, "text": " 12:26 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: CVA evolution\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with CVA\n REASON FOR THIS EXAMINATION:\n CVA evolution\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with occlusion of the tip of the basilar artery and\n associated infarction, now status post cerebral angiogram and intervention.\n\n COMPARISON: Non-contrast head CT with CT angiogram head at 21:13,\n conventional cerebral angiogram at 22:16.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: New hyperdensity is noted throughout the basilar cisterns and\n layering within the bilateral sylvian fissures. Discrete foci of relatively\n greater hyperdensity are noted within the interpeduncular cistern and right\n quadrigeminal cistern which measures 6 and 16 mm in size, respectively. The\n lateral ventricles have slightly increased in size compared to the prior study\n at 21:13. There is no shift of midline structures. The cerebral sulci are\n slightly less well defined. Redemonstrated is the area of old right\n frontoparietal infarction and ex vacuo dilatation of the occipital of the\n right lateral ventricle. An old small lacunar infarct near the genu of the\n left internal capsule is again seen. Subtle thalamic hypodensity seen on the\n prior study is less apparent. There are small fluid levels in the sphenoid\n sinus air cells. Maxillary sinus mucosal thickening is worse on the right.\n There is mucosal thickening of the ethmoid air cells. Mastoid air cells\n remain clear.\n\n IMPRESSION:\n 1. Extravasated contrast and hemorrhage within the subarachnoid space as\n described.\n 2. Slight increase in size of the lateral ventricles.\n 3. Old right frontoparietal infarction.\n 4. Old lacunar infarct of the genu of the left internal capsule.\n 5. Possible acute infarct of the thalamus.\n 6. Paranasal sinus disease as described.\n\n These findings were immediately discussed with the ordering physician, .\n , at 00:55 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2140-02-22 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 1007126, "text": " 10:02 PM\n CAROT/CEREB Clip # \n Reason: ? MERCI clot retreival\n Contrast: OPTIRAY Amt: 215\n ********************************* CPT Codes ********************************\n * PRIMARY MECH THROMBECTOMY ART/ SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY PRIMARY MECH THROMBECTOMY ART/ *\n * ADD'L 2ND/3RD ORDER VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with unresponsiveness, bithalamic infarcts on MRI,\n top of the basilar occlusion on CTA\n REASON FOR THIS EXAMINATION:\n ? MERCI clot retreival\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF PROCEDURE: .\n\n DIAGNOSIS: Distal basilar occlusion.\n\n PROCEDURE PERFORMED: Left vertebral artery arteriogram, mechanical and\n intra-arterial thrombolysis of distal basilar artery and posterior cerebral\n artery.\n\n ATTENDING:\n ASSISTANT: .\n\n INDICATIONS: The patient is a 73-year-old male with a top-of-the-basilar\n occlusion with a poor neurological examination including nonreactive pupils. I\n discussed with his daughter the risks and benefits of the procedure including\n the possibility of wire perforation and death .\n\n TECHNIQUE: Both groins were prepped and draped in a sterile fashion.\n Following this, access was gained into the right common femoral artery using a\n Seldinger technique, and an 8 French guiding sheath was placed into the right\n common femoral artery and into the distal aorta. Following this, the left\n vertebral artery was catheterized with 2 catheter. AP, lateral\n filming was done which demonstrated distal basilar occlusion. Based on the\n diagnostic findings, it was decided to perform mechanical and chemical\n thrombectomy. Therefore, this was now exchanged out for an 8 French MERCI\n catheter. Following this, SL-10 microcatheter and a Synchro soft wire were\n guided out into the distal basilar artery and eight units of TPA was given in\n the distal basilar area. Following this, both posterior cerebral arteries and\n the basilar apex were still occluded by clot. Therefore, we now guided the\n SL-10 catheter into the distal left PCA. Following this, this was exchanged\n out for an 18L MERCI microcatheter and a MERCI L4 device was used under\n constant suction to do mechanical thrombolysis of this area. Following this,\n left vertebral arteriogram demonstrated open left PCA. There was still clot in\n the basilar apex and the right PCA and SCA was not visualized. We now did the\n same mechanical thrombolysis in the right PCA . Following this, the patient\n (Over)\n\n 10:02 PM\n CAROT/CEREB Clip # \n Reason: ? MERCI clot retreival\n Contrast: OPTIRAY Amt: 215\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n was noted to suddenly become hypertensive. Followup runs demonstrated that\n there was significant pressure in the posterior fossa and there was poor\n opacification of the distal vertebral artery and basilar artery. At this\n point, the procedure was stopped and the patient was taken for a CT scan,\n which demonstrated massive subarachnoid hemorrhage and emergent\n ventriculostomy was placed.\n\n FINDINGS: Left vertebral artery arteriogram shows normal filling of the\n vertebral artery. The basilar artery fills well up to the superior cerebellar\n artery, however, there is thrombus in the distal basilar artery with thrombus\n extending into the left PCA and occlusion of the right PCA.\n\n Left vertebral artery arteriogram post-mechanical thrombolysis runs\n demonstrate contrast extravasation and poor opacification of the distal\n basilar area consistent with increased pressure effects.\n\n IMPRESSION: underwent emergent mechanical and chemical thrombolysis of\n distal basilar occlusion. The patient had an intraoperative perforation with\n significant mass effect in the posterior fossa and emergent ventriculostomy\n was done and the patient was taken back to the ICU. The poor prognosis was\n discussed with the family.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-22 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1007118, "text": " 8:53 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: repeat eval of CVA for potential lysis\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with CVA\n REASON FOR THIS EXAMINATION:\n repeat eval of CVA for potential lysis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 10:16 PM\n Tip of basilar artery does not opacify consistent with occlusion. The PCAs do\n opacify however, probably from collaterals given no PCOMs identified.\n Dominant left vert.\n\n Hypodensity of bilateral thalamus possible acute infarcts. No ICH. Old right\n parietal infarct with ex vacuo dilataton of right occipital . old infarct\n of genu of left internal capsule. Paranasal sinus disease.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the head with and without contrast.\n\n CLINICAL INDICATION: 73-year-old man with history of CVA, evaluation for\n potential lysis.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial images were performed from the\n aortic arch through the brain during the infusion of nonionic intravenous\n contrast material. The images were processed on a separate workstation and\n multiple reformatted images as well as maximum intensity projection\n reconstructions were submitted for interpretation.\n\n COMPARISON: No prior examinations of the head are available at the time of\n this interpretation.\n\n FINDINGS:\n\n CT HEAD. Demonstrated no evidence of hemorrhage or mass effect. Subtle low\n attenuation areas are noted in both thalamic regions. Multiple low densities\n in the basal ganglia are noted consistent with chronic lacunar ischemic\n changes. The ventricles and sulci are prominent, likely involutional in\n nature and age related. In the brain parenchyma at the right parietal\n convexity, there is evidence of sequelae of old chronic infarction producing\n mild asymmetry and retraction of the ventricular occipital . Dense\n atherosclerotic calcifications are noted in the basilar artery which is\n tortuous as well as in the carotid siphons.\n\n There is evidence of patchy ethmoidal mucosal thickening as well as bilateral\n mucosal thickening in the maxillary sinuses, more evident on the right. NG\n and endotracheal tubes are in place, the distal tip of these tubes are not\n visualized.\n\n (Over)\n\n 8:53 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: repeat eval of CVA for potential lysis\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Sequelae of multiple chronic lacunar ischemic events noted in the\n basal ganglia as well as in the right parietal lobe as described above.\n Several low attenuation areas are noted in the thalamic regions bilaterally,\n which also may represent chronic ischemic changes, please correlate\n clinically. Dense arteriosclerotic calcifications noted in the basilar artery\n as well as in the carotid siphons.\n\n There is evidence of patchy ethmoidal mucosal thickening as well as bilateral\n mucosal thickening in the maxillary sinuses, more evident on the right. NG\n and endotracheal tubes are in place, the distal tip of these tubes are not\n visualized.\n\n CTA. The tip of the basilar artery is not clearly visualized, this finding is\n suspicious for vascular occlusion, the superior cerebellar arteries apparently\n are patent, there are filling defects in the origin of both P1 segments\n bilaterally at the level of the tip of the basilar artery (images #249, 250,\n 251, and 252, series #3), bilateral dense arteriosclerotic calcifications are\n visualized in the carotid siphons as well as in the basilar artery. The left\n vertebral artery is dominant, no significant stenosis or atherosclerotic\n plaques are noted in the carotid bifurcations. Severe multilevel degenerative\n changes are noted in the cervical spine with large osteophytic formations at\n C4, C5, and C6. Enlargement of the left side of the thyroid gland with\n heterogeneous enhancement and calcifications measuring approximately 4 x 4 cm\n in the maximum dimensions, correlation with ultrasound is recommended if\n clinically warranted. Mild fibrotic changes are noted on the right lung apex.\n\n IMPRESSION: The tip of the basilar artery does not opacify, likely consistent\n with occlusion as described in detail above. There is no evidence of\n opacification of the P1 segments bilaterally. Low attenuation areas are\n detected in the thalamic regions bilaterally. Significant atherosclerotic\n changes noted in the carotid siphons as well as in the basilar artery.\n Enlargement of the thyroid gland with heterogeneous enhancement and\n calcifications with extension into the mediastinum, correlation with thyroid\n ultrasound is recommended if clinically warranted. Multilevel degenerative\n changes of the cervical spine as described above. NG and ET tubes are in\n place.\n\n" }, { "category": "Radiology", "chartdate": "2140-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007113, "text": " 8:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with intubation, transfer from osh\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: transferred from outside hospital.\n\n COMPARISONS: None.\n\n SINGLE VIEW CHEST, AP SUPINE: The ET tube is approximately 3.3 cm above the\n carina. The NG tube tip extends below the diaphragm in to the stomach. There\n is accentuation of pulmonary vasculature, which is likely within normal limits\n allowing for the supine nature of the study. No focal pulmonary opacities are\n identified. There is a rounded, apparently calcified nodule at the left lung\n base which likely represents a granuloma versus a nipple shadow.\n\n IMPRESSION: Appropriate placement of NG and ET tubes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-02-23 00:00:00.000", "description": "Report", "row_id": 1629211, "text": "Resp Care\n\nPt remains intubated and currently vented on full support overbreathing set rate with MV 16-18L. BS essentially clear no sxing required. Last ABG with resp alkalosis and acceptable pao2. Fio2 weaned accordingly. WIll cont with vent support. Awaiting family members to arrive from out of state and to make CMO.\n" }, { "category": "Nursing/other", "chartdate": "2140-02-23 00:00:00.000", "description": "Report", "row_id": 1629212, "text": "Focus: Status Update\nData:\nPatient unresponsive with no spontaneous movement. Slight posturing all four extremities noted this afternoon when nailbed pressure applied. Neurology resident asked to assess and agrees. Also fine muscle tremors bilat inner thighs and right cheek noted this am and afternoon, negative Chvostek's sign, although Calcium was repleted and Dilantin started. Pupils are unequal, right at 7mm and irregular/cloudy and left 8mm and round, both are unreactive. Negative corneals. Temp spike to 106.7 rectally which was treated with Tylenol, cold NGT lavage, cool foley irrigation, ice packs and cooling blanket. Temperature quickly came down to 101 and all ice and cooling was removed with continued decrease to 94F at which time warming blanket was placed on pt and discontinued at 97f. Ventriculostomy clogged this am, all tubing was sterily flushed and Dr. asked to flush drain into pt. as well with very small results. Very viscous bloody drainage early, now clear. ICP remains 40's-50's with decrease to 23 after Mannitol dose. CPP remains poor<60.\n\nHypertensive to 170's in am decreasing to 100sys this afternoon, Neo gtt started with goal 130's sys and improved CPP. HR down to 50-60's after initiating Neo. No episode of further bradycardia.\n\nLungs bilaterally clear. Continues on AC vent now at 40%, pt has positive small gag and impaired cough reaction at times, he is also overbreathing vent.\n\nDr. and Neurology updated family regarding poor prognosis and family expressed desire to continue full support until daughter arrives from at midnight. from social work asked to offer family support. Organ Bank updated x2 on pt. condition.\n\nPlan;\nContinue Neo gtt for BP support, Mannitol as needed, Q1hr neuro assessments. Support family. Possible DNR when daughter arrives from .\n" }, { "category": "Nursing/other", "chartdate": "2140-02-23 00:00:00.000", "description": "Report", "row_id": 1629209, "text": "Resp Care Note\nReceived pt from angio and placed on AC 12/500/+5/100%. ABG 7.36/40/331/24, FiO2 decreased to 50%. Oett patent and secure at 22cms. ICP 90's and BP/HR unstable. Family at bedside.\nPlan: full code, cont full vent support\n" }, { "category": "Nursing/other", "chartdate": "2140-02-23 00:00:00.000", "description": "Report", "row_id": 1629210, "text": "Admission Note\nPt arrived from IR S/P bithalmic infarct. attempted Procedure, angioplasty and TPA. Pt having bleed at this time. Ct confirmed bleed and pt back to IR for ventriculostomy drain placed. Med with mannitol 50GM X1 with little effect.\n\nNeuro;Pt unresponsive, pupils fixed and dilated. no gag/cough reflex. no response to nailbed pressure. no posturing noted since admission.\n\nCV: hypothermic on arrival bear hugger in place. HR 50 with several episodes of bradycardia 20's resolved without intervention. ABP very labile 80-200/40-100. extremities warm with +pp. lytes pending.\n\nRESP: lung clear throughout. Remains on Ac with no changes this am. ABG acceplable.\n\nGI: NGT to clws. ABD soft with +BS.\n\nGU: foley draining adequate clear yellow urine\n\nPLAN: monitor VS, neuro exam for any changes. emotional support to family and pt.\n" }, { "category": "Nursing/other", "chartdate": "2140-02-24 00:00:00.000", "description": "Report", "row_id": 1629213, "text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR SPECIFICS\n\nNEURO: OVER COURSE OF EVENING PT INCREASINGLY UNRESPONSIVE TO NAILBED PRESSURE AND STERNAL RUB, NO MOVEMENTS. NO POSTURING NOTED. TREMORS SUBSIDED. PUPILS UNEQUAL, RIGHT IRREGULAR, NR AT 7MM, LEFT ROUND, NR AT 8MM. CONT DILANTIN.\nICP 7-98. BLD IN VENT DRAIN TUBING, ? CLOT D/T WAVEFORM BECOMING MORE DAMPENED AND DRAINAGE. NEURO MADE AWARE, FLUSHED STERILY W/5CC H20 PER NEURO REQUEST BY DR >> WAVEFORM BETTER (STILL REMAINS SLIGHTLY DAMPENED) W/DRAINAGE (CLR CSF). LEVEL DROPPED TO 5CM H20 AT TRAGUS. MANNITOL GIVEN X2.\n\nID: WBC 13.7. CONT CEF. TENUOUS BODY TEMP RANGING FROM 95.8 TO 101.7 APPLYING WARM/COLD BLANKETS W/TYLENOL AS NEEDED.\n\nCV: TITRATING NEO TO MAINTAIN SBP AROUND 130. HR 70-90, 1ST DEGREE AV BLOCK. RARE BURSTS TO 130S X2. EKG OBTAINED. DR AWARE.\n\nRESP: NO VENT CHANGES MADE. ABG 7.30/52/122/-. LCTAB. MIN ORAL SECRETIONS. NO EPISODES NOTED OF PT OVERBREATHING VENT. NO COUGH OR GAG PRESENT.\n\nGI/ENDO: ABD SOFT. NON DISTENDED. OGT TO LCWS W/FAIR AMT BILIOUS OUTPUT. + BS. NO BM. FBS TX PER RISS, NO COVERAGE REQUIRED.\n\nGU: FOLEY W/INC CYU, >100CC/HR.\n\nSKIN: INTACT. STAPLES ON HEAD AROUND VENT DRAIN. SMALL BLISTERS NOTED ON LEFT SIDE, FLD FILLED, NOT OPENED.\n\nSOCIAL: DTR (HCP) IN FROM . , WIFE AND YOUNGEST DTR AT BS. DR SPOKE W/FAMILY REGARDING PTS CURRENT CONDITION AND PERCIEVED OUTCOME/POC. CURRENTLY REMAINS FULL CODE, WILL RE-EVALUATE CODE STATUS IN MORNING.\n\nOTHER: ORGAN BANK CONTACT AND UPDATED ABOUT PT'S ABSENT COUGH/GAG AND RESPONSE TO PAIN. WILL CONT TO UPDATE AS NEEDED.\n\nPOC: FOLLOW AND TX LABS AS NEEDED. MONITOR ICP, RECIEVING PRN MANNITOL, CSF DRAINAGE. TITRATE NEO. CLOSELY MONITOR TEMP. Q1 HR NEURO ASSESSMENTS. ? BRAIN DEATH TEST IN AM PRIOR TO READRESSING CODE STATUS W/FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2140-02-24 00:00:00.000", "description": "Report", "row_id": 1629214, "text": "RESP CARE NOTE\nRECEIVED PT ON AC 12/500/+5/40%. ABG 7.30/52/122/27 AND RR ^ TO 16. BREATH SOUNDS CLEAR BILATERALLY, NO SX REQUIRED OR DONE DUE TO HIGH ICP'S.\nPLAN: ? APNEA TEST, SPEAK WITH FAMILY TO DETERMINE PLAN OF CARE, CONT ON CURRENT VENT SETTINGS.\n" }, { "category": "Nursing/other", "chartdate": "2140-02-24 00:00:00.000", "description": "Report", "row_id": 1629215, "text": "resp care\npt received on ac mode. apnea test positive with full team present. awaiting further family members arrival, then will likely extubate. refer to flow sheet.\n" }, { "category": "Nursing/other", "chartdate": "2140-02-24 00:00:00.000", "description": "Report", "row_id": 1629216, "text": "Focus: Brain Death\nData:\nPt. non-responsive, pupils fixed and dialated, cold calorics performed per neurology with negative eye movement. No gag or cough present. Apnea test performed per Dr. per protocol with increase in PCo2 to 61 from 40 and no spontaneous effort of breathing noted. Family meeting post apnea test with whole family and Dr. . Organ Bank notified also met with family. Family declined organ donation and autopsy. Family asked to wait for one more family member to arrive before pronouncing and expressed wishes to dress pt. themselves to observe cultural customs, post bathing of pt. per nursing staff. Family wishes honored and pt. to be officially pronounced by Neurology service.\n" }, { "category": "ECG", "chartdate": "2140-02-22 00:00:00.000", "description": "Report", "row_id": 213660, "text": "Probable sinus rhythm with atrial premature beats. Low limb lead voltage.\nIncreased precordial voltage. Left ventricular hypertrophy with ST-T wave\nabnormalities. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2140-02-23 00:00:00.000", "description": "Report", "row_id": 213878, "text": "Sinus rhythm. Atrial ectopy. Low normal voltage in the limb leads.\nNon-specific T wave inversions in lead aVL. Junctional ST segment depression\nin leads V2-V3. Non-specific ST segment depressions in leads V4-V6 with\nhorizontal component and in lead I suggestive of ischemia. Consider clinical\ncorrelation. Compared to the previous tracing of left ventricular\nhypertrophy is no longer present. ST segment depressions persist.\n\n" } ]

[ { "category": "Echo", "chartdate": "2142-12-03 00:00:00.000", "description": "Report", "row_id": 74415, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion.\nHeight: (in) 70\nWeight (lb): 128\nBSA (m2): 1.73 m2\nBP (mm Hg): 130/80\nHR (bpm): 126\nStatus: Inpatient\nDate/Time: at 15:39\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. Severely depressed LVEF. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function\ndepressed.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis moderately dilated. There is severe global left ventricular hypokinesis.\nOverall left ventricular systolic function is severely depressed. No masses or\nthrombi are seen in the left ventricle.\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction appears depressed.\n4.The aortic root is mildly dilated. The ascending aorta is mildly dilated.\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen.\n6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n7.The pulmonary artery systolic pressure could not be determined.\n8.There is a moderate sized pericardial effusion. The effusion appears\ncircumferential. There are no echocardiographic signs of tamponade.\n\nCompared to the previous report of , no change with regards to LV\nfunction or size of pericardial effusion present.\n\n\n" }, { "category": "ECG", "chartdate": "2142-12-18 00:00:00.000", "description": "Report", "row_id": 181520, "text": "Sinus tachycardia\nPoor R wave progression\nDiffuse ST-T wave changes are nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2142-12-11 00:00:00.000", "description": "Report", "row_id": 181521, "text": "Baseline artifact in leads V5-V6\nProbable sinus tachycardia although atrial tachycardia also possible\nBorderline left axis deviation - is nonspecific\nLeft ventricular hypertrophy by voltage\nModest diffuse nonspecific T wave changes\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2142-12-10 00:00:00.000", "description": "Report", "row_id": 181522, "text": "Sinus tachycardia. Borderline left atrial abnormality. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of \nmultiple abnormalities as previously noted persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2142-12-03 00:00:00.000", "description": "Report", "row_id": 177882, "text": "Baseline artifact\nSinus tachycardia\nBorderline left axis deviation - is nonspecific\nRSR' pattern in leads V1 and V2 - probable normal variant\nProbable left ventricular hypertrophy with ST-T wave changes\nThe ST-T changes are diffuse - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia rate slower\n\n" }, { "category": "Radiology", "chartdate": "2142-12-04 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 893767, "text": " 1:08 PM\n CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # \n Reason: infection, pulmonary edema\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CLL s/p BMT with neutropenia. Hypoxia, new b/l infiltrates\n on CXR suggesting fungal infection. Also has cardiomyopathy with CHF on\n clinical exam.\n REASON FOR THIS EXAMINATION:\n infection, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL status post bone marrow transplantation with neutropenia.\n Cardiomyopathy with CHF on clinical examination.\n\n TECHNIQUE: Axial CT imaging of the chest without and with intravenous\n contrast. Comparison made to CT of the chest from .\n\n FINDINGS: Multiple enlarged mediastinal lymph nodes are present (up to 3.1 x\n 1.2 cm in the right paratracheal station). A large pericardial effusion has\n increased compared to . Polychamber cardiomyopathy is present. A\n dilated esophagus with distal mural thickening is filled with debris.\n\n A 5.3 x 3.5 cm (5:37) rim-enhancing fluid collection along the anterior medial\n margin of the right chest abuts pleura and pericardium and crosses the plane\n of the minor fissure, adjacent to a previous pneumonia; whether is a lung or\n pleural abscess is uncertain. Enlarging, moderate volume, nonhemorrhagic,\n layering pleural effusions have some pleural enhancement suggesting exudation\n (5:35).\n\n New multiple foci of ground-glass opacity and parenchymal consolidation occur\n in both upper lobes and the superior segment of the right lower lobe.\n\n No bone lesions worrisome for malignancy are seen.\n\n In the imaged upper abdomen, marked splenomegaly and enlargement of a patent\n portal vein are unchanged compared to . The imaged liver, kidneys,\n and pancreas are normal. Enlarged lymph nodes are present adjacent to the\n renal vessels and the celiac axis.\n\n IMPRESSION:\n\n 1. A new 5.3 x 3.5 cm abscess in the anteromedial right chest could be\n pleural or pulmonary, abutting an enlarging pericardial effusion.\n\n 2. Multifocal consolidation and ground-glass opacity suggest pneumonia.\n Alternative diagnostic considerations include pulmonary hemorrhage or\n unexplained pulmonary edema.\n\n 4. Polychamber cardiomegaly.\n\n (Over)\n\n 1:08 PM\n CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # \n Reason: infection, pulmonary edema\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Dilated debris-filled esophagus with wall thickening.\n\n 6. Mediastinal adenopathy.\n\n 7. Enlarging pericardial and bilateral pleural effusion (right greater than\n left), likely exudative.\n\n 8. Stable splenomegaly and enlargement of the patent portal vein.\n\n These findings were discussed at length with Dr. at 2 p.m. on\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2142-12-05 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 893936, "text": " 1:20 PM\n CT FINE NEEDLE ASP; CT GUIDED NEEDLE PLACTMENT Clip # \n CT CHEST W/O CONTRAST\n Reason: Please perform CT guided diagnostic sampling/drainage of rig\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CLL, s/p transplant; now neutropenic and febrile. Chest CT\n demonstrates bilateral infiltrates, large right pleural effusion, and right\n antero-medial (near pericardium) fluid collection/suspect abscess.\n REASON FOR THIS EXAMINATION:\n Please perform CT guided diagnostic sampling/drainage of right antero-medial\n fluid collection and send for gram stain, cultures, and cytology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right anteromedial lesion on chest CT dated .\n\n PROCEDURE/FINDINGS: Prior to the procedure, the risks and benefits of the\n procedure were discussed with the patient and the patient's wife. Signed\n informed consent was then obtained. A pre-procedure time-out was performed\n with Dr. , the attending radiologist, present and supervising\n throughout. The patient was placed supine on the CT table. Non-contrast\n images with grid in place were then obtained for localization. An adequate\n spot was marked on the patient's skin for the procedure. The patient was then\n prepped and draped in standard sterile fashion. The skin and subcutaneous\n tissues were anesthetized with 1% lidocaine. Multiple passes, under CT\n guidance, were then enacted with a 25-gauge needle with aspiration. Several\n small aliquots of dark substance were obtained and collected for analysis.\n\n Postprocedure images of the lower chest demonstrate bilateral pleural\n effusions, and multifocal patchy opacities in the lungs with right\n anteromedial lesion unchanged in appearance. There is no post-procedural\n pneumothorax demonstrated on the postprocedural CT images.\n\n Note is made of a hyperdense liver, diffusely unchanged compared to the\n previous exam. The spleen is enlarged.\n\n IMPRESSION:\n\n 1. Technically successful fine needle aspiration of right anteromedial\n intrathoracic lesion.\n\n 2. Diffuse hyperdensity of the liver parenchyma again demonstrated.\n Differential considerations include hemochromatosis, glycogen storage disease\n and amiodarone toxicity.\n\n\n\n (Over)\n\n 1:20 PM\n CT FINE NEEDLE ASP; CT GUIDED NEEDLE PLACTMENT Clip # \n CT CHEST W/O CONTRAST\n Reason: Please perform CT guided diagnostic sampling/drainage of rig\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2142-12-10 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 894526, "text": " 2:07 PM\n CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # \n Reason: re-assess multiple findings on last CT, interval change\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CLL s/p BMT with neutropenia. Hypoxia, new b/l\n infiltrates on CXR suggesting fungal infection. Has resolving CHF on exam and\n is s/p right thoracentesis. now w/ recurrent fevers.\n REASON FOR THIS EXAMINATION:\n re-assess multiple findings on last CT, interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old man with CLL status post BMT with neutropenia. He has\n hypoxia and new bilateral infiltrates. Resolving CHF on exam and is status\n post right thoracentesis. Now with recurrent fevers.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the chest were obtained without and\n with IV contrast. 100 cc Optiray.\n\n FINDINGS: Again seen is a rim-enhancing fluid collection along the right\n anteromedial chest. It has not significantly changed in size. There\n continues to be patchy opacities predominantly involving both upper lobes.\n They appear slightly worsened compared to prior exam in the left upper lobe\n and apical portion of the left lower lobe. Multiple enlarged mediastinal lymph\n nodes are again identified and stable.\n\n The large pericardial effusion is stable. The moderate-to-large right pleural\n effusion appears slightly increased in size. There is no evidence of\n pneumothorax. The small left pleural effusion is unchanged. The heart size\n is stablely enlarged. Again noted is a somewhat dilated distal esophagus\n which is filled with debris. The liver remains hyperintense on the non-\n contrast sequence. The spleen is enlarged. There are no suspicious lytic or\n sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Slight increase in multifocal ground glass opacities and consolidations\n suggestive of pneumonia. As stated previously, pulmonary hemorrhage and\n pulmonary edema are the other possibilities.\n 2. Stable rim-enhancing right anteromedial chest collection consistent with\n an abscess.\n 3. Stable large pericardial effusion and small left pleural effusion. Slight\n increase in size of moderate-to-large right pleural effusion.\n 4. Stable mediastinal adenopathy.\n\n (Over)\n\n 2:07 PM\n CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # \n Reason: re-assess multiple findings on last CT, interval change\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2142-12-13 00:00:00.000", "description": "Report", "row_id": 1402566, "text": "PROGRESS NOTE 7P-7A\nEvents: At start of shift pt. complaining of lg. amount of mucous in \"esophagus\". He stated that he wasn't nauseated and that he didn't feel as though it was coming from his lungs. Anzemet given along with Maalox. Pt. continued x2h \"gagging\" up large amounts of extremely thick clear/sometimes green mucous. (Basin emptied 17 times) At approx 2130 pt. requested something to help him sleep. He was unable to swallow the ambien pills and stated that he was taking ativan up on the floor. MDs wrote one time order for ativan and 1mg given. Approx. 15 minutes later pt. found unresponsive with audible wheezes/crackles throughout lung fields. Pt. appeared to have labored breathing at this time. Pt. suctioned for a lg. amount of pinkish tinged frothy sputum x2. Blood gas done. (WNL) and CXR and EKG received. Also, an additional 60mg lasix given IVP (total 80mg). Pt. placed on face mask 50% O2 and appeared to be resting comfortably. Breath sounds improved over the next couple of hours and work of breathing lessened. Pt. became more awake as the shift continued stating that he felt much better. K repleted with 20MEQ and 2gm calcium gluconate given.\n\nNeuro: Pt. alert and oriented x3. MAE Pupils equal and reactive. No pain issues at this time.\n\nResp: Pt. back on 3-4L NC with sats >97%. Breath sounds remain diminished with crackles in lower lobes at this time.\n\nCVS: Pt. SR/ST with no ectopy. SBP high 90's to low 100's. Skin W+D. + pulses. TMax 102.3 orally. Tylenol 650 given at 1900 and 0200.\n\nGI: Pt. remains on TPN via Picc line. Abd. soft. BS present. Fecal incontinence bag remains on draining liquid green stool. Pt. not swallowing his pills at this time for fear \"they won't go down\"\n\nGU: Foley with approx. 80cc/hr. Diuresed approx. 1000cc after given the 60mg lasix.\n\nSkin: Intact\n\nPlan: Pt. to have new PICC line placed today. Monitor respiratory status closely. At this time please continue with current plan of care. AM labs pending\n" }, { "category": "Nursing/other", "chartdate": "2142-12-12 00:00:00.000", "description": "Report", "row_id": 1402564, "text": "NPN 1900-0700\n\nNEURO:AXOX3, DENIES PAIN .\n\nRESP:TACHPNEIC IN 30'S ABG 7.57/27/69.LUNG SOUNDS DIM W/ CRACKLES 2/3 UP BILAT . MAINTAINING SATS 95-99% ON 3L.\n\nC/V: ST UP INTO 130'S, ? R/T TEMP. BP 90-100'S, CAPTOPRIL AND LOPRESSOR HELD.\n\nF/E/N:UO ~100CC HR, LASIX HELD ,WILL BE DOSED ACCORDINGLY, TPN INFUSING, INCT OF LOOSE STOOLS.AM LYTES PENDING.\n\nI&D: T MAX 102 W/ ACCOMPANYING TACHYCARDIA. BROAD SPECTRUM AB TX COVERAGE.\n\nPLAN:CONT CLOSELY MONITOR RESP STATUS, HEMODYNAMICS, AB TXEMOTIONAL SUPPORT FOR FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2142-12-12 00:00:00.000", "description": "Report", "row_id": 1402565, "text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details...\n\nA&Ox3. Pleasant and cooperative. Denies painb.\n\nMaintaining gd O2sats on 3L N/C. RR 30s. Still w/ some DOE.\n\nOOB-chair x ~2hrs. Tol well.\n\nSl hypotensive this am and captopril held but given later in day and is tol it well.\n\nU.O. ~ 100cc/hr though fluid status positive since midnight. No Lasix this shift. Passing sm amt of liq stool via rectal bag.\n\nT max 101.3 po w/assoc. tachycardia 120s. Both improve with Tylenol. Continues on broad spectrum antibiotics.\n\nWife in all day but has gone home for the night.\n" }, { "category": "Radiology", "chartdate": "2142-12-06 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 894091, "text": " 1:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p thoracentesis. evaluate interval change in R effusion an\n Admitting Diagnosis: CHRONIC LYMPHOCYTIC LEUKEMIA;FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CLL and progressive infiltrates seen on chest CT with\n likely abscess/fluid collection. Increased SOB. Today is s/p CT-guided\n drainage of this collection.\n REASON FOR THIS EXAMINATION:\n s/p thoracentesis. evaluate interval change in R effusion and rule out\n pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old with CLL, increased shortness of breath and status\n post thoracentesis.\n\n COMPARISON: , at 3:45 a.m.\n\n AP UPRIGHT CHEST RADIOGRAPH: Right-sided PICC line terminates within the\n distal SVC. There has been interval decrease in the previously seen right\n pleural effusion. There is a small left pleural effusion. Multifocal\n parenchymal opacities are again seen which may be consistent with pneumonia.\n\n IMPRESSION:\n 1. Decrease in size of right pleural effusion.\n 2. Small left pleural effusion.\n 3. Multifocal parenchymal opacities which may be consistent with pneumonia.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2189-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 877977, "text": " 4:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube removal, r/o pneumo\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p OPCABG x2\n\n REASON FOR THIS EXAMINATION:\n chest tube removal, r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: \n\n INDICATION: Chest tube removal. Evaluate for pneumothorax.\n\n There has been interval removal of various lines and tubes, with a residual\n right internal jugular vascular sheath remaining in place. There is no\n pneumothorax. The heart size is normal. There are patchy atelectatic changes\n at the lung bases, slightly worse in the left retrocardiac area than before.\n There is otherwise no significant change.\n\n\n" }, { "category": "ECG", "chartdate": "2189-07-09 00:00:00.000", "description": "Report", "row_id": 152002, "text": "Sinus bradycardia. Diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of no diagnostic change.\n\n" }, { "category": "Radiology", "chartdate": "2189-07-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 878235, "text": " 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf., eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with cad\n REASON FOR THIS EXAMINATION:\n r/o inf., eff\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST X-RAY, \n\n COMPARISON: .\n\n INDICATION: Coronary artery disease. Status post coronary artery bypass\n surgery.\n\n The patient is status post recent median sternotomy and coronary artery bypass\n surgery. There has been interval removal of a right internal jugular vascular\n sheath, with no pneumothorax. The heart is upper limits of normal in size.\n Pulmonary vascularity is normal. Previously present bibasilar atelectatic\n changes have nearly resolved in the interval and there are small bilateral\n pleural effusions present, which were probably present previously but\n difficult to visualize due to the supine positioning of the patient at that\n time.\n\n IMPRESSION: Small bilateral pleural effusions and minor bibasilar\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-07-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 877815, "text": " 12:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p OPCABG x2\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post coronary artery bypass surgery.\n\n Patient is status post interval median sternotomy and coronary artery bypass\n surgery. An endotracheal tube is in satisfactory position. The side port of\n nasogastric tube is proximal to GE junction, although the tip terminates\n within the stomach. Bilateral chest tubes are present as well as mediastinal\n drains. Heart size and mediastinal contours are within normal limits for\n technique and postoperative status of the patient. Minor atelectatic changes\n are noted in both lower lobes as well as a small left pleural effusion. Note\n is also made of a small apical left pneumothorax. No right pneumothorax is\n evident.\n\n IMPRESSION:\n 1. Small left apical pneumothorax with chest tube in place.\n 2. Side port of nasogastric tube proximal to GE junction level and could be\n advanced for more optimal placement. Findings communicated to \n on the date of the study.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-07-09 00:00:00.000", "description": "Report", "row_id": 1435633, "text": "ARRIVED FROM OR TO CSRU S/P CABG X2 (OFF PUMP DUE TO CALCIFIED AORTA) PT IN OR RECEIVED 5UPRBS/2 FFP (FOR INR 2.5) AND 1 PLT (PLT 50'S) AMICAR THROUGH CASE. PRESERVED EF POST OP. ARRIVED ON EPI/NEO/INS/PROP. SB 50'S. MINIMAL CT DRNG. CCO SWAN\nNEURO: PROPOFOL SHUT OFF 1400, NO REVERSALS GIVEN FOR SINUS BRADY. SLOW TO WAKE. AT 1730 PT MOVING TOES TO STIMULI, MOUTH MOVING. OVERBREATHING. TEAM AWARE. SLOW TO WAKE. PERRLA. NO PAIN MED YET DUET TO SB AND SEDATION\nCV: HR 47-67 SB/SR RARE PAC. PT WITH BRIEF EPISODE OF JUNC RHYTHM 48 WITH DECREASE BP BUT TRANSIENT. BOTH A AND V WIRES WORK BUT WHEN A PACING PT HAS CHANGE IN VENT COMPLEX (DIFFERENT FROM V PACING) WITH DROP IN BP. DOES NOT TOLERATE WELL. TEAM AWARE AND INTO SEE. ? A WIRE CLOSE TO RT VENTRICLE. ATROPINE AT BEDSIDE FOR PRECAUTION. PT SB PER DR. AND PT LOPRESSOR 5MG IV IN OR FOR HTN. PT BP TOLERATE SB VERY WELL WITH LOW DOSE NEO (SEE FLOWSHEET). WIDE PULSE PRESSURE SO MAP REQUIRE SBP ~120 FOR MAPS>60, SVO2 68-78 (CCO RECALED) CI BY CCO LOW AT TIMES BUT BY FICK >3---FOLLOWING FICKS. PT 2UPRBS IN CSRU FOR HCT 25 (REPEAT 34) DOPPLERALB EPEDAL PULSES. B/L FEET EDEMA LT >RT. MINIMAL CT DRNG. JP IN RT LEG.\nRESP: LUNGS COARSE SOUNDING THROUGHOUT. SX THICK YELLOW. EXCELLENT OXYGENATION. ABG ADEQUATE. CONT IMV UNTIL MORE AWAKE. OVERBREATHING AT PRESENT. MDI'S ORDERED.\nGI: OGT TO LCWS WITH MOD BILIOUS DRNG. OGT PLACEMENT CONFIRMED BY AUSCULTATION. ABD SOFT. NO BS\nGU: UOP GD. FOLEY PATENT. URINE CLEAR YELLOW.\nENDO: ARRIVED ON INSULIN GTT RECEIVED 20 UNITS INSULIN IVP IN OR AND RAN GTT. BS UPA 87 1UNIT/HR CONT TO DROP TO 70'S GTT OFF, 2HRS LATER BS 105. NO TX.\nSOCIAL: SONS AND SISTERS INTO VISIT. ICU PACKET GIVEN TO SON AND VISITING HOURS EXPLAINED.\nPLAN: WEAN EPI TO OFF AFTER 8HRS. CONT ASSESS CARDIO/RESP STATUS. WEAN TO EXUTBATE WHEN MORE AWAKE. CONT CURRENT PLAN OF CARE AND ADVANCE PER CSRU PROTOCOL.\n" }, { "category": "Nursing/other", "chartdate": "2189-07-09 00:00:00.000", "description": "Report", "row_id": 1435634, "text": "Respiratory Care Note\nPt received from the OR intubated and ventilated. Pt placed on SIMV as noted. BS coarse with good aeration bilaterally. Pt suctioned for small amt thick yellow secretions. IMV and FiO2 weaned according to ABG's. Pt slowly waking. Plan to wean as tolerated toward extubation as pt becomes more responsive.\n" }, { "category": "Nursing/other", "chartdate": "2189-07-10 00:00:00.000", "description": "Report", "row_id": 1435635, "text": "Pt hemodynamics stable on 0.2mcg/kg/min NEO. Continues with vent support d/t slow to wake. Pt assessed as follows:\nNEURO: Intact. No noted deficits. Pt MAE equally bilaterally, but continues to be very sleepy.\n\nCARDIAC: SB-SR overnight with PACs which resolved with mag repletion. MAPs maintained >60 with NEO gtt. PA pressures WNL. CVP 6-8. CI>2. SVO2s 66-68. Last Mixed Venous 66. S1S2 with rub. Bilat pedal edema(L>R). Minimal serosangenous CT drainage overnight. CTs to LWS without airleak/creptus noted. Continues with 4 epicardial wires which are all attached to pacer in the off position.\n\nRESP: LS currently clear ant & decreased post bilat. Pt continues to be slow to wake. Attempted CPAP trial @ 0530 this am with no success. Continues on SIMV with rate decreased to 4 per team following rounds. ABG to be drawn. O2 SATs 99% on FIO2 35%. Minimal secretions upon suctioning.\n\nGI: ABD round/soft. OGT to LWS. Very hypoactive BS. Denies N/V.\n\nGU: F/C to gravity & patent. U/O adequate/clear/yellow urine.\n\nSKIN: Intact. No noted areas of breakdown. All DSGs currently D/I. Bilat ace wraps taken down this am. Underlying DSGs intact. Ace wraps reapplied.\n\nENDO: Pt received RISS coverage overnight. Last BS level 114. Levels are controlled at this point.\n\nPLAN: Continue to wean NEO as pt tolerates. Continue to wean ventilator as pt tolerates & facilitate extubation.\n" }, { "category": "Nursing/other", "chartdate": "2189-07-10 00:00:00.000", "description": "Report", "row_id": 1435636, "text": "CV: SR 60's-80's with no VEA noted; SBP generally 110-130's, rarely 150's, neo gtt dc'd and pt has tol well maintaining MAP >60; CO by TD >3 CI>2->post extubation CO >4/CI >2, PA line dc'd with cordis remaining in place; 2a/2v wires with pacer off as a wires sense but pace inappropriately, although v wires function; bil pedal pulses by doppler; bil LE 3+ edema; CTs dc'ed with post CXR completed; JP drain to RLE dc'd without difficulty; K+ repleated\n\nNeuro: Pt still very lethargic, oriented to person and place only, follows commands, MAE; PERLA; no deficits noted\n\nResp: Pt weaned and extubated by noon with adequate post ABGs and later ABGs better yet; sats mid-high 90's-100% initially on OFM and now on 4L NC; LS coarse and diminished in bil bases; loose productive cough but pt unable to expectorate->suctioned for mod amt thick, blood-tinged secretions\n\nGI/GU: Abd soft with normoactive bowel sounds, pt remains NPO at this time r/to lethargy, no bowel mvt this shift; adequate clear yellow HUO per foley catheter to gravity, pt has good diuresis with lasix iv\n\nEndo: BS covered by SS and is controlled (see flowsheet)\n\nID: TMax 100.0, cont course ABX\n\nPain: Pt denies pain and has required no pain medication this shift, however, pt cont lethargic and team has requested no narcotics\n\nPlan: Pulmonary hygiene, monitor hemodynamics, increase activity to counter lethargy, monitor lytes and replace prn, monitor pain control as pt becomes more alert\n" }, { "category": "Nursing/other", "chartdate": "2189-07-10 00:00:00.000", "description": "Report", "row_id": 1435637, "text": "Addendum:\n\nCV: Pt has had a few MAPs drifting down to mid-high 50's.\n\nActivity: Pt >chair with 2 assists (minimal!) and tol well.\n\nPlan: If MAPs cont to drift, restart neo , NP; recheck HCT and if <30, will need PCs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-07-11 00:00:00.000", "description": "Report", "row_id": 1435638, "text": "CSRU NSG:\n\nNEURO: A&OX3, appropriate, speech thick. Follows commands, +MAE, PERRL.\n\nCV: RSR, no ectopy. Pedal pulses per doppler, radial pulses palpable. Generalized edema. Hands & feet warm, dry. NTG drip started per Dr. for hypertension.\n\nPULM: LSCTAB. Compliant w/C/DB & IS. SpO2 96 - 100% on 4L/NC. No SOB.\n\nGU: Urine clr, yellow, output QS. Diureses well from scheduled lasix.\n\nGI: Abdomen soft, NT. I am unable to hear bowel sounds until 0400 assessment, when they are faint and hypoactive. No stool or flatus. Swallows pills with water without problem.\n\nINTEG: Skin intact, no breakdown noted. Patient move about in bed ad lib, relieves pressure without assistance at times.\n\nCOMFORT: Denies pain, no objective s/sx discomfort observed.\n\nASSESS: 2d postop, requiring NTG drip for HTN, HR currently 80's.\n\nPLAN: ?Start po lopressor in am, wean NTG drip as tolerated. Advance diet. Encourage C/DB/IS.\n" } ]

[ { "category": "Physician ", "chartdate": "2144-01-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 716212, "text": "Chief Complaint: fever\n HPI:\n Mr. is a 44 year old male with quadriplegia following a\n MVC in who presents for with a fever of 102. Events are unclear\n but it seems that pt was d/c to , checked himself out because\n he was unhappy with how they turned him/took care of him there and he\n could feel his \"ulcers were getting bigger.\" He went home and then\n re-presented to for wound care. At , his temp was\n found to be high (T 102) with BP of 87/54, so he was sent to .\n .\n .\n He was recently treated at (admitted at transferred to ). He was recently\n admitted to from .\n .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given\n that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it\n is unlikely he has acute osteomyelitis and there is no\n superinfection of ulcers. He was not started on chronic\n suppressive therapy, both because no appropriate oral regimen\n exists that would cover his known microbiology, and oral\n suppression could more resistant microorganisms in the\n future.\n .\n Pt has abdominal pain, unclear if worse than his chronic pain. No BM in\n a few days. On heavy pain regimen. SBP dropped to 87, but responded to\n fluids. Still dropping SBP to low 90s (baseline high 90s-100s). concern\n for urosepsis.\n .\n In the ED, initial vs were: T 97.8 HR 99 BP 95/56 RR 16 O2 97%. Patient\n complained of abdominal pain, though it was unclear if this was worse\n than his chronic pain. No BM for a few days. SBP dropped to 87, but\n responded to IV fluids. Continued to drop SBP to low 90s.\n Patient was given IV fluids, one dose of Vancomycin and Zosyn. UA was\n positive, but patient has a history of chronic colonization with ESBL\n Ecoli. Urine culture was sent. CT Abdomen and pelvis was performed\n which showed osteomyelitis chronic vs. acute. Surgery was consulted to\n evaluate large decubitus ulcers. They had not evaluated the patient\n yet on sign out. VS at transfer: T 99.5 BP 92/54 P94 R11 96% RA.\n .\n .\n On the floor, he mentions that he had fevers multiple times at home for\n the days prior. Complains of back pain and leg pain, though these\n aren't new for him. He has a cough productive of some white sputum.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies night sweats, recent weight loss or gain. Denies headache,\n sinus tenderness, rhinorrhea or congestion. Denies shortness of breath,\n or wheezing. Denies chest pain, chest pressure, palpitations, or\n weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal\n pain, or changes in bowel habits. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications (per d/c summary on )\n 1. Fentanyl 100 mcg/hr Patch q72 hr\n 2. Fentanyl 25 mcg/hr Patch q72 hr\n 3. Diazepam 10-20 mg po q6h\n 4. Ascorbic Acid 500 mg po bid\n 5. Docusate Sodium 100 mg po bid\n 6. Bisacodyl 10mg po daily\n 7. Ferrous Sulfate 325 mg (65 mg Iron) po bid\n 8. Baclofen 20 mg po qid\n 9. Senna 8.6 mg po bid\n 10. Tizanidine 2 mg po qhs\n 11. Calcium 500 + D 500 mg(1,250mg) -200 unit po bid\n 12. Capsaicin 0.1 % Cream Topical three times a day: Please apply to\n neck and shoulders.\n 13. Morphine 15-30 mg PO Q4H PRN for breakthrough pain\n 14. Oxybutynin Chloride 5 mg po q8h\n 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two\n (2) Drop Ophthalmic QID (4 times a day).\n 16. Multivitamin po daily\n 17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\n ML PO DAILY\n 18. Omeprazole 20 mg po daily\n 19. Morphine 100 mg po q12h\n 20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet\n Sustained Release PO twice a day\n 21. Metformin 500 mg po daily\n 22. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal\n three times a day.\n Past medical history:\n Family history:\n Social History:\n 1. Quadriplegia following a MVC in or ; Injury at C4-C5\n level. Pt was driving from police at high speed (up to 160mph)\n and car flipped.\n 2. History of decubitus ulcers and osteomyelitis of the sacrum\n and ischial tuberosity- followed by Dr. (ID) at \n ()\n 3. s/p flap repair of ischial and sacral decubitus ulcers\n 4. - Sacral decubitus ulcer debridement at \n 5. - Creation of diverting transverse loop colostomy to\n divert stool away from sacral ulcers at (Dr. ,\n ); colonic obstruction and colostomy revised\n ; ex-lap with revision of ostomy on \n 6. Neurogenic bladder with suprapubic catheter and history of\n frequent UTIs\n 7. Depression\n 8. Anemia\n 9. DM type II on metformin\n 10. HTN\n 11. History of intubation secondary to narcotic overuse -\n approximately / per pt but records\n suggest it may have occurred more recently (possibly as\n there is Head CT done for \"overdose\"), no documents of this\n hospitalization available\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: (per OMR):\n Lives at home with family (sister, brother-in-law, brother, and\n their children). No tobacco, alcohol, or illicit drugs per\n patient. OSH indicates prior history of marijuana and cocaine\n use. Per discussion with PCP, is concern amongst some of\n his prior PCP's in the area that he has sold some of his\n narcotics.\n Review of systems:\n Flowsheet Data as of 09:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 99 (99 - 113) bpm\n BP: 85/50(58) {85/48(55) - 139/104(108)} mmHg\n RR: 19 (13 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,622 mL\n PO:\n TF:\n IVF:\n 522 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,822 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Vitals: T:99.2 BP:85/50 P:90 R: 14 O2: 95% on RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Dentures in place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: UA >50 WBCs\n Lactate 2.0\n Imaging: CT Abdomen\n consolidation RLL likely rounded atelectasis. no acute intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n Microbiology: Blood culture pending\n Urine culture pending\n ECG: EKG: NSR @ 101. Nl Axis. No ST segment changes.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent\n decubitus ulcers who presents with fevers in the setting of chronic\n bilateral ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Abdominal exam is benign, and no obvious source\n of infection seen on CT. Patient also has positive UA, though\n asymptomatic, with history of colonization with ESBL Ecoli. No cough or\n increasing oxygen requirement currently. No indwelling lines or drains.\n Patient has a long history of chronic infection, however given relative\n hypotension, fever, and leukocytosis, would favor antibiotic\n treatment.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin and Meropenem given most recent sensitivities from\n ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -attempt to place CVL for access\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis.\n -obtain LFTs and lipase\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain, MS\n contin 115mg po q12h\n -continue outpatient bowel regimen\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Iron studies from last admission suggest anemia of\n chronic disease. He required no transfusions. He was continued on iron\n .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\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 18 Gauge - 06:45 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": "2144-01-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 716216, "text": "Chief Complaint: fever\n HPI:\n Mr. is a 44 year old male with quadriplegia following a\n MVC in , history of chronic ischial decubitus ulcers who presents\n for with a fever of 102. Events are unclear but it seems that pt was\n d/c to , checked himself out because he was unhappy with how\n they turned him/took care of him there and he could feel his \"ulcers\n were getting bigger.\" He went home and then re-presented to \n for wound care. At , his temp was found to be high (T 102)\n with BP of 87/54, so he was sent to .\n .\n .\n He was recently treated at (admitted at transferred to ). He was recently\n admitted to from .\n .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given\n that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it\n is unlikely he has acute osteomyelitis and there is no\n superinfection of ulcers. He was not started on chronic\n suppressive therapy, both because no appropriate oral regimen\n exists that would cover his known microbiology, and oral\n suppression could more resistant microorganisms in the\n future.\n .\n .\n In the ED, initial vs were: T 97.8 HR 99 BP 95/56 RR 16 O2 97%. Patient\n complained of abdominal pain, though it was unclear if this was worse\n than his chronic pain. No BM for a few days. SBP dropped to 87, but\n responded to IV fluids. Continued to drop SBP to low 90s.\n Patient was given IV fluids, one dose of Vancomycin and Zosyn. UA was\n positive, but patient has a history of chronic colonization with ESBL\n Ecoli. Urine culture was sent. CT Abdomen and pelvis was performed\n which showed osteomyelitis chronic vs. acute. Surgery was consulted to\n evaluate large decubitus ulcers. They had not evaluated the patient\n yet on sign out. VS at transfer: T 99.5 BP 92/54 P94 R11 96% RA.\n .\n .\n On the floor, he mentions that he had fevers multiple times at home for\n the days prior. Complains of back pain and leg pain, though these\n aren't new for him. He has a cough productive of some white sputum.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies night sweats, recent weight loss or gain. Denies headache,\n sinus tenderness, rhinorrhea or congestion. Denies shortness of breath,\n or wheezing. Denies chest pain, chest pressure, palpitations, or\n weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal\n pain, or changes in bowel habits. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications (per d/c summary on )\n 1. Fentanyl 100 mcg/hr Patch q72 hr\n 2. Fentanyl 25 mcg/hr Patch q72 hr\n 3. Diazepam 10-20 mg po q6h\n 4. Ascorbic Acid 500 mg po bid\n 5. Docusate Sodium 100 mg po bid\n 6. Bisacodyl 10mg po daily\n 7. Ferrous Sulfate 325 mg (65 mg Iron) po bid\n 8. Baclofen 20 mg po qid\n 9. Senna 8.6 mg po bid\n 10. Tizanidine 2 mg po qhs\n 11. Calcium 500 + D 500 mg(1,250mg) -200 unit po bid\n 12. Capsaicin 0.1 % Cream Topical three times a day: Please apply to\n neck and shoulders.\n 13. Morphine 15-30 mg PO Q4H PRN for breakthrough pain\n 14. Oxybutynin Chloride 5 mg po q8h\n 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two\n (2) Drop Ophthalmic QID (4 times a day).\n 16. Multivitamin po daily\n 17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\n ML PO DAILY\n 18. Omeprazole 20 mg po daily\n 19. Morphine 100 mg po q12h\n 20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet\n Sustained Release PO twice a day\n 21. Metformin 500 mg po daily\n 22. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal\n three times a day.\n Past medical history:\n Family history:\n Social History:\n 1. Quadriplegia following a MVC in or ; Injury at C4-C5\n level. Pt was driving from police at high speed (up to 160mph)\n and car flipped.\n 2. History of decubitus ulcers and osteomyelitis of the sacrum\n and ischial tuberosity- followed by Dr. (ID) at \n ()\n 3. s/p flap repair of ischial and sacral decubitus ulcers\n 4. - Sacral decubitus ulcer debridement at \n 5. - Creation of diverting transverse loop colostomy to\n divert stool away from sacral ulcers at (Dr. ,\n ); colonic obstruction and colostomy revised\n ; ex-lap with revision of ostomy on \n 6. Neurogenic bladder with suprapubic catheter and history of\n frequent UTIs\n 7. Depression\n 8. Anemia\n 9. DM type II on metformin\n 10. HTN\n 11. History of intubation secondary to narcotic overuse -\n approximately / per pt but records\n suggest it may have occurred more recently (possibly as\n there is Head CT done for \"overdose\"), no documents of this\n hospitalization available\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: (per OMR):\n Lives at home with family (sister, brother-in-law, brother, and\n their children). No tobacco, alcohol, or illicit drugs per\n patient. OSH indicates prior history of marijuana and cocaine\n use. Per discussion with PCP, is concern amongst some of\n his prior PCP's in the area that he has sold some of his\n narcotics.\n Review of systems:\n Flowsheet Data as of 09:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 99 (99 - 113) bpm\n BP: 85/50(58) {85/48(55) - 139/104(108)} mmHg\n RR: 19 (13 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,622 mL\n PO:\n TF:\n IVF:\n 522 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,822 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Vitals: T:99.2 BP:85/50 P:90 R: 14 O2: 95% on RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Dentures in place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: UA >50 WBCs\n Lactate 2.0\n Imaging: CT Abdomen\n consolidation RLL likely rounded atelectasis. no acute intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n Microbiology: Blood culture pending\n Urine culture pending\n ECG: EKG: NSR @ 101. Nl Axis. No ST segment changes.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent\n decubitus ulcers who presents with fevers in the setting of chronic\n bilateral ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Endocarditis is also a possibility. Abdominal\n exam is benign, and no obvious source of infection seen on CT. Patient\n also has positive UA, though asymptomatic, with history of colonization\n with ESBL Ecoli. No cough or increasing oxygen requirement currently.\n No indwelling lines or drains. Patient has a long history of chronic\n infection, however given relative hypotension, fever, and leukocytosis,\n would favor antibiotic treatment.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -attempt to place CVL for access\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc, Cipro, and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis.\n -obtain LFTs and lipase\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain, MS\n contin 115mg po q12h\n -continue outpatient bowel regimen\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\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 18 Gauge - 06:45 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": "2144-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 716270, "text": "TITLE:\n Chief Complaint: Fever\n 24 Hour Events:\n - Failed Femoral Line Placement secondary to positioning\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 10:02 PM\n Ciprofloxacin - 03:01 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 06:22 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: 35.6\nC (96\n HR: 63 (57 - 117) bpm\n BP: 83/50(58) {78/42(51) - 139/104(108)} mmHg\n RR: 7 (7 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 93.1 kg (admission): 87 kg\n Height: 74 Inch\n Total In:\n 5,750 mL\n 2,319 mL\n PO:\n 950 mL\n TF:\n IVF:\n 2,650 mL\n 1,369 mL\n Blood products:\n Total out:\n 1,105 mL\n 1,440 mL\n Urine:\n 555 mL\n 1,440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,645 mL\n 879 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 293 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.2 %\n 8.5 K/uL\n [image002.jpg]\n 08:47 PM\n 04:26 AM\n WBC\n 10.6\n 8.5\n Hct\n 25.9\n 24.2\n Plt\n 288\n 293\n Cr\n 0.8\n 0.7\n Glucose\n 108\n 114\n Other labs: PT / PTT / INR:14.8/27.5/1.3, ALT / AST:, Alk Phos / T\n Bili:119/0.6, Amylase / Lipase:/16, LDH:287 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Micro:\n Urine: Pending\n Blood: Pending\n Suprapubic Catheter Discharge: Culture\n Imaging:\n CT ABD/PELVIS: consolidation RLL likely rounded atelectasis. no acute\n intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n CXR: Right middle lobe subsegmental atelectasis. No acute process\n identified.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent decubitus\n ulcers who presents with fevers in the setting of chronic bilateral\n ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Endocarditis is also a possibility. Abdominal\n exam is benign, and no obvious source of infection seen on CT. Patient\n also has positive UA, though asymptomatic, with history of colonization\n with ESBL Ecoli. No cough or increasing oxygen requirement currently.\n No indwelling lines or drains. Patient has a long history of chronic\n infection, however given relative hypotension, fever, and leukocytosis,\n would favor antibiotic treatment.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -attempt to place CVL for access\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc, Cipro, and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis.\n -obtain LFTs and lipase\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain, MS\n contin 115mg po q12h\n -continue outpatient bowel regimen\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: None\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for Now\n" }, { "category": "Physician ", "chartdate": "2144-01-13 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 716346, "text": "TITLE:\n Chief Complaint: Fever\n 24 Hour Events:\n - Failed Femoral Line Placement secondary to positioning\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 10:02 PM\n Ciprofloxacin - 03:01 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 06:22 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: 35.6\nC (96\n HR: 63 (57 - 117) bpm\n BP: 83/50(58) {78/42(51) - 139/104(108)} mmHg\n RR: 7 (7 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 93.1 kg (admission): 87 kg\n Height: 74 Inch\n Total In:\n 5,750 mL\n 2,319 mL\n PO:\n 950 mL\n TF:\n IVF:\n 2,650 mL\n 1,369 mL\n Blood products:\n Total out:\n 1,105 mL\n 1,440 mL\n Urine:\n 555 mL\n 1,440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,645 mL\n 879 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Upper Dentures in\n place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: minimally distended, bowel sounds present, no rebound\n tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n ****Will assess back ulceration when dressings are changed.\n Labs / Radiology\n 293 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.2 %\n 8.5 K/uL\n [image002.jpg]\n 08:47 PM\n 04:26 AM\n WBC\n 10.6\n 8.5\n Hct\n 25.9\n 24.2\n Plt\n 288\n 293\n Cr\n 0.8\n 0.7\n Glucose\n 108\n 114\n Other labs: PT / PTT / INR:14.8/27.5/1.3, ALT / AST:, Alk Phos / T\n Bili:119/0.6, Amylase / Lipase:/16, LDH:287 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Micro:\n Urine: Pending\n Blood: Pending\n Suprapubic Catheter Discharge: Culture\n Imaging:\n CT ABD/PELVIS: consolidation RLL likely rounded atelectasis. no acute\n intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n CXR: Right middle lobe subsegmental atelectasis. No acute process\n identified.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent decubitus\n ulcers who presents with fevers in the setting of chronic bilateral\n ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Endocarditis is also a possibility. Abdominal\n exam is benign, and no obvious source of infection seen on CT. Patient\n also has positive UA, though asymptomatic, with history of colonization\n with ESBL Ecoli. No cough or increasing oxygen requirement currently.\n No indwelling lines or drains. Patient has a long history of chronic\n infection, however given relative hypotension, fever, and leukocytosis,\n would favor antibiotic treatment. Of note, it is unclear as to the\n degree of hypotension from patient\ns baseline. With low blood pressure\n patient without tachycardia and maintains excellent urine output. \n be related secondary to drugs.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -PICC for access today.\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc, Cipro, and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis. Normal\n LFTS/Lipase.\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain,\n -continue outpatient bowel regimen\n - Will hold MS contin 115mg po q12h for now and provide prn morphine.\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: None\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for Now\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 44M C4-5 quadraplegia s/p MVA c/b\n ischial ulcers p/w fever and hypotension. Treated with IVF, vanco /\n zosyn and sent to MICU. CT notable for chronic osteo.\n Exam notable for Tm 99.8 BP 90/40 HR 63 RR 14 with sat 96 on RA. WD\n man, reports pain LLE c/w muscle spasm. CTA B, JVD mid neck at 30 deg.\n RRR s1s2. Distended, +BS, ostomy c/d/i. No edema. Labs notable for WBC\n 8K, HCT 24, K+ 4.4, Cr 0.7, lactate 2.0 s AG. CXR with clear lungs.\n Agree with plan to manage recurrent nosocomial sepsis with broad abx\n coverage (vanco / ) while awaiting cx data. Ulcers / osteo likely\n source but urine, blood, stool are also possible contributors. Will\n check stool for c. diff, attempt PICC placement, and change SPT.\n Hypotension may be chronic, no bump in creatinine, excellent UOP - will\n hold off on art line for now, recheck lactate, and check CvO2 off PICC\n once placed. Will also hold tizanidine and cipro for now given risk of\n hypotension and drug-drug interaction. Will try to resume home pain\n meds, but will hold MS contin until pressure improves. For severe\n decubes / osteo - appreciate input re wounds, wound care team to\n see today. Case management for SRH screening today. Remainder of plan\n as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:39 PM ------\n" }, { "category": "Nursing", "chartdate": "2144-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716423, "text": "Events: BP stable 85-104/40-50\ns MAP 52-60. IV ABX administered-\n a-febrile. Refusing to turn Q2- multiple small positioning for pt\n comfort. Wound care done. Taking Po\ns well.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain- requesting and given baclofen, multiple position changed\n Action:\n Baclofen QID, PRN IR oxycodone, emotional support, repositioning\n Response:\n Post positing pt falling asleep, can use adapted callbell for\n additional pain regimen and repositioning\n Plan:\n Cont PRN pain control, likely resume SR Morphine if BP stable in AM,\n emotional support, repositioning\n Decubitus ulcer (Present At Admission)\n Assessment:\n 2 large decube stage III (left) and IV (right) ischial ulcers,\n * left ulcer: s/p debredment by plastics 1 / 4- multicolored wound bed\n in various stages of healing- some granulation tissue, slough, purple\n and necrotic areas- peri-wound purple and macerated\n * right ulcer: s/p debredment 1 /4\n deep with multiple tunneling and\n likely fistula- multicolored wound bed in various states of healing\n some granulation tissue, yellow slough, large amount purple areas with\n black necrotic tissue, peri-wound purple and mascerated\n Action:\n Both ulcers cleaned wound wound spray, gentle pat dry, thin layer of\n duoderm gel, very lightly moistened antimicrobial kerlex, dry 4x4\n abd, and covered with soft sorb\n Response:\n No acute change\n Plan:\n Support nutrition, turn as pt allows- encourage frequent turning, wound\n care as ordered by surgery and wound care\n" }, { "category": "Nursing", "chartdate": "2144-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716424, "text": "Mr. is a 44 year old male with quadriplegia following a MVC in\n , history of chronic ischial decubitus ulcers who presents for with\n a fever of 102. Events are unclear but it seems that pt was d/c to\n , checked himself out because he was unhappy with how they\n turned him/took care of him there and he could feel his \"ulcers were\n getting bigger.\" He went home and then re-presented to for\n wound care. At , his temp was found to be high (T 102) with BP\n of 87/54, so he was sent to .\n He was recently treated at (admitted at \n transferred to ). He was recently admitted to\n from .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it is\n unlikely he has acute osteomyelitis and there is no superinfection of\n ulcers. He was not started on chronic suppressive therapy, both\n because no appropriate oral regimen exists that would cover his known\n microbiology, and oral suppression could more resistant\n microorganisms in the\n future.\n Events: BP stable 85-104/40-50\ns MAP 52-60. IV ABX administered-\n a-febrile. Refusing to turn Q2- multiple small positioning for pt\n comfort. Wound care done. Taking Po\ns well.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain- requesting and given baclofen, multiple position changed\n Action:\n Baclofen QID, PRN IR oxycodone, emotional support, repositioning\n Response:\n Post positing pt falling asleep, can use adapted callbell for\n additional pain regimen and repositioning\n Plan:\n Cont PRN pain control, likely resume SR Morphine if BP stable in AM,\n emotional support, repositioning\n Decubitus ulcer (Present At Admission)\n Assessment:\n 2 large decube stage III (left) and IV (right) ischial ulcers,\n * left ulcer: s/p debredment by plastics 1 / 4- multicolored wound bed\n in various stages of healing- some granulation tissue, slough, purple\n and necrotic areas- peri-wound purple and macerated\n * right ulcer: s/p debredment 1 /4\n deep with multiple tunneling and\n likely fistula- multicolored wound bed in various states of healing\n some granulation tissue, yellow slough, large amount purple areas with\n black necrotic tissue, peri-wound purple and mascerated\n Action:\n Both ulcers cleaned wound wound spray, gentle pat dry, thin layer of\n duoderm gel, very lightly moistened antimicrobial kerlex, dry 4x4\n abd, and covered with soft sorb\n Response:\n No acute change\n Plan:\n Support nutrition, turn as pt allows- encourage frequent turning, wound\n care as ordered by surgery and wound care\n" }, { "category": "Physician ", "chartdate": "2144-01-14 00:00:00.000", "description": "MICU - Resident/Attending Progress Note", "row_id": 716532, "text": "TITLE:\n Chief Complaint: Fever\n 24 Hour Events:\n - Difficulty placing PICC - IR PICC placement ordered.\n - Patient requested regular diet\n - Patient requested no fingersticks (order changed to patient may\n refuse and A1c ordered = 5.8).\n - Wound consulted and left recs\n - Surgery came to evaluate and produced specimen for culture\n - Urology replaced suprapubic catheter.\n - Asked for lactulose (although stooling fine this was PRN in his\n previous regimen) and Maalox\n - be returned directly to rehab from ICU - will see\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 03:01 AM\n Vancomycin - 08:00 PM\n Meropenem - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 76 (57 - 94) bpm\n BP: 94/54(63) {78/41(50) - 141/109(113)} mmHg\n RR: 20 (10 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 93.1 kg (admission): 87 kg\n Height: 74 Inch\n Total In:\n 5,790 mL\n 647 mL\n PO:\n 2,580 mL\n 380 mL\n TF:\n IVF:\n 3,210 mL\n 267 mL\n Blood products:\n Total out:\n 3,350 mL\n 1,490 mL\n Urine:\n 3,350 mL\n 1,490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,440 mL\n -844 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Upper dentures in\n place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Minimally distended, + Bowel Sounds.. No organomegaly.\n Colostomy bag in place. Site looks clean. With small amount of brown\n stool present.\n GU: suprapubic catheter in place.\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n 293 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.2 %\n 8.5 K/uL\n [image002.jpg]\n 08:47 PM\n 04:26 AM\n WBC\n 10.6\n 8.5\n Hct\n 25.9\n 24.2\n Plt\n 288\n 293\n Cr\n 0.8\n 0.7\n Glucose\n 108\n 114\n Other labs: PT / PTT / INR:14.8/27.5/1.3, ALT / AST:, Alk Phos / T\n Bili:119/0.6, Amylase / Lipase:/16, Lactic Acid:1.5 mmol/L, LDH:287\n IU/L, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Imaging: No New Imaging\n Microbiology: Urine: GNR (Preliminary)\n Sacral Decubitus:\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n Culture Pending\n Subrapubic Catheter: Culture pending\n Blood 1/03: Culture Pending\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent decubitus\n ulcers who presents with fevers in the setting of chronic bilateral\n ischial and heel ulcers.\n # Fever & hypotension: Afebrile since admission to the ICU. Pressures\n low stable while in the ICU with stable heart rate and urine\n outputSources of fever include large decubitus and heel ulcers and with\n secondary chronic osteomyelitis. UA positive with GNR growing in urine,\n however this appear to be chronic. CT without intrabdominal pathology.\n -Empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture, blood, wound cultures\n -culture if spikes\n -f/u surgery and wound care recs\n -PICC with IR today\n - FU daily labs\n .\n # Abdominal pain: Without pain this AM. Had intermittent abdominal\n pain on last admission also. Normal LFTS/Lipase.\n -continue PPI\n -bowel regimen, lactulose added as above, however patient moving bowels\n .\n # Chronic pain: Stable.\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain,\n -continue outpatient bowel regimen\n - Will hold MS contin 115mg po q12h for now and provide prn morphine.\n .\n # DM2: Hold metformin.\n -qid fingersticks\n pt refused fingersticks, allowed to refuse\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Regular Diet.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Comments:\n Communication: Patient\n Code status: Full code\n Disposition:ICU, back to rehab.\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 44M C4-5 quadraplegia s/p MVA c/b\n ischial ulcers p/w fever and hypotension. Treated with IVF, vanco /\n zosyn and sent to MICU. CT notable for chronic osteo. SPT replaced,\n PICC placed in IR this AM.\n Exam notable for Tm 98.8 BP 100/40 HR 63 RR 14 with sat 92-96 on RA. WD\n man, reports abd pain c/w constipation. CTA B, JVD mid neck at 30 deg.\n RRR s1s2. Distended, +BS, ostomy c/d/i. No edema. Labs pending.\n Agree with plan to manage recurrent nosocomial sepsis (bone / skin /\n urine) with broad abx coverage (vanco / ) while awaiting cx data;\n PICC placed for durable access, bcx negative so far. For severe decubes\n / osteo - appreciate input re wounds, wound care team to see again\n today. BP improved with IVF, lactate flat, excellent UOP and no signs\n of shock. Will increrase bowel regimen for constipation. Will also call\n case management for return to SRH today, PT eval. Remainder of plan as\n outlined above.\n Total time: 25 min\n" }, { "category": "Nursing", "chartdate": "2144-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716411, "text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with bilateral ischial decubs and bilateral heel decubs (see\n metavision for specifics).\n Action:\n Pt on kinair bed, turned as frequently as pt will allow, wound care RN\n did consult, surgery debrided ischial ulcers, BLE with multipodos boots\n on.\n Response:\n Pt with no further breakdown in skin.\n Plan:\n Continue to reposition as pt will allow, maintain kinair mattress and\n multipodos boots, change heel dressings daily and change ischial ulcers\n per wound care recommendations.\n Sepsis without organ dysfunction\n Assessment:\n Pt with WBC 8.5, lactate 1.5, afebrile. Systolic BP 70s-140s, pt always\n mentating and urinating even with low BP.\n Action:\n Given 500cc NS bolus for low BP, meds per order, labs and temp trended,\n suprapubic tube change by urology.\n Response:\n BP stable, when hypotensive he has never been tachycardic. Afebrile\n all shift.\n Plan:\n Continue with meds per order, trend labs and temp, monitor vitals. Pt\n will need PICC placed in IR prior to DC to rehab.\n Diabetes Mellitus (DM), Type II\n Assessment:\n History of DM per chart and 10 AM fingerstick 168.\n Action:\n Pt medicated for 10AM fingerstick but pt now stating he is not diabetic\n and refusing fingersticks.\n Response:\n N/A\n Plan:\n N/A\n ------ Protected Section ------\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with chronic pain problems and muscle spasms. Pt on\n large doses of pain medications at baseline.\n Action:\n Pt given PO valium and PO IR morphine PRN, baclofen ATC, fentanyl patch\n intact. Pt\ns 115mg SR morphine held due to low BP.\n Response:\n Pt still with spasms periodically and some c/o pain however it is\n tolerable.\n Plan:\n Continue to assess for pain. Attempt to maintain PRN dosing routinely\n to avoid insufficient pain control.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:00 ------\n" }, { "category": "Physician ", "chartdate": "2144-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 716320, "text": "TITLE:\n Chief Complaint: Fever\n 24 Hour Events:\n - Failed Femoral Line Placement secondary to positioning\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 10:02 PM\n Ciprofloxacin - 03:01 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 06:22 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: 35.6\nC (96\n HR: 63 (57 - 117) bpm\n BP: 83/50(58) {78/42(51) - 139/104(108)} mmHg\n RR: 7 (7 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 93.1 kg (admission): 87 kg\n Height: 74 Inch\n Total In:\n 5,750 mL\n 2,319 mL\n PO:\n 950 mL\n TF:\n IVF:\n 2,650 mL\n 1,369 mL\n Blood products:\n Total out:\n 1,105 mL\n 1,440 mL\n Urine:\n 555 mL\n 1,440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,645 mL\n 879 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Upper Dentures in\n place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: minimally distended, bowel sounds present, no rebound\n tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n ****Will assess back ulceration when dressings are changed.\n Labs / Radiology\n 293 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.2 %\n 8.5 K/uL\n [image002.jpg]\n 08:47 PM\n 04:26 AM\n WBC\n 10.6\n 8.5\n Hct\n 25.9\n 24.2\n Plt\n 288\n 293\n Cr\n 0.8\n 0.7\n Glucose\n 108\n 114\n Other labs: PT / PTT / INR:14.8/27.5/1.3, ALT / AST:, Alk Phos / T\n Bili:119/0.6, Amylase / Lipase:/16, LDH:287 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Micro:\n Urine: Pending\n Blood: Pending\n Suprapubic Catheter Discharge: Culture\n Imaging:\n CT ABD/PELVIS: consolidation RLL likely rounded atelectasis. no acute\n intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n CXR: Right middle lobe subsegmental atelectasis. No acute process\n identified.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent decubitus\n ulcers who presents with fevers in the setting of chronic bilateral\n ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Endocarditis is also a possibility. Abdominal\n exam is benign, and no obvious source of infection seen on CT. Patient\n also has positive UA, though asymptomatic, with history of colonization\n with ESBL Ecoli. No cough or increasing oxygen requirement currently.\n No indwelling lines or drains. Patient has a long history of chronic\n infection, however given relative hypotension, fever, and leukocytosis,\n would favor antibiotic treatment. Of note, it is unclear as to the\n degree of hypotension from patient\ns baseline. With low blood pressure\n patient without tachycardia and maintains excellent urine output. \n be related secondary to drugs.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -PICC for access today.\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc, Cipro, and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis. Normal\n LFTS/Lipase.\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain,\n -continue outpatient bowel regimen\n - Will hold MS contin 115mg po q12h for now and provide prn morphine.\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: None\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for Now\n" }, { "category": "Nursing", "chartdate": "2144-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716377, "text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\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": "2144-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716382, "text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with bilateral ischial decubs and bilateral heel decubs (see\n metavision for specifics).\n Action:\n Pt on kinair bed, turned as frequently as pt will allow, wound care RN\n did consult, surgery debrided ischial ulcers, BLE with multipodos boots\n on.\n Response:\n Pt with no further breakdown in skin.\n Plan:\n Continue to reposition as pt will allow, maintain kinair mattress and\n multipodos boots, change heel dressings daily and change ischial ulcers\n per wound care recommendations.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n History of DM per chart and 10 AM fingerstick 168.\n Action:\n Pt medicated for 10AM fingerstick but pt now stating he is not diabetic\n and refusing fingersticks.\n Response:\n N/A\n Plan:\n N/A\n" }, { "category": "Nursing", "chartdate": "2144-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716443, "text": "Mr. is a 44 year old male with quadriplegia following a MVC in\n , history of chronic ischial decubitus ulcers who presents for with\n a fever of 102. Events are unclear but it seems that pt was d/c to\n , checked himself out because he was unhappy with how they\n turned him/took care of him there and he could feel his \"ulcers were\n getting bigger.\" He went home and then re-presented to for\n wound care. At , his temp was found to be high (T 102) with BP\n of 87/54, so he was sent to .\n He was recently treated at (admitted at \n transferred to ). He was recently admitted to\n from .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it is\n unlikely he has acute osteomyelitis and there is no superinfection of\n ulcers. He was not started on chronic suppressive therapy, both\n because no appropriate oral regimen exists that would cover his known\n microbiology, and oral suppression could more resistant\n microorganisms in the\n future.\n Events: BP stable 85-104/40-50\ns MAP 52-60. IV ABX administered-\n a-febrile. Refusing to turn Q2- multiple small positioning for pt\n comfort. Wound care done. Taking Po\ns well. Refusing AM by RN and\n anyone except phlebotomy. Social work consult placed for my hx\n depression with prolonged illness and support.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain- requesting and given baclofen, multiple position changed\n Action:\n Baclofen QID, PRN IR oxycodone, emotional support, repositioning\n Response:\n Post positing pt falling asleep, can use adapted callbell for\n additional pain regimen and repositioning\n Plan:\n Cont PRN pain control, likely resume SR Morphine if BP stable in AM,\n emotional support, repositioning\n Decubitus ulcer (Present At Admission)\n Assessment:\n 2 large decube stage III (left) and IV (right) ischial ulcers,\n * left ulcer: s/p debredment by plastics 1 / 4- multicolored wound bed\n in various stages of healing- some granulation tissue, slough, purple\n and necrotic areas- peri-wound purple and macerated\n * right ulcer: s/p debredment 1 /4\n deep with multiple tunneling and\n likely fistula- multicolored wound bed in various states of healing\n some granulation tissue, yellow slough, large amount purple areas with\n black necrotic tissue, peri-wound purple and mascerated\n Action:\n Both ulcers cleaned wound wound spray, gentle pat dry, thin layer of\n duoderm gel, very lightly moistened antimicrobial kerlex, dry 4x4\n abd, and covered with soft sorb\n Response:\n No acute change\n Plan:\n Support nutrition, turn as pt allows- encourage frequent turning, wound\n care as ordered by surgery and wound care\n" }, { "category": "Nursing", "chartdate": "2144-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716444, "text": "Mr. is a 44 year old male with quadriplegia following a MVC in\n , history of chronic ischial decubitus ulcers who presents for with\n a fever of 102. Events are unclear but it seems that pt was d/c to\n , checked himself out because he was unhappy with how they\n turned him/took care of him there and he could feel his \"ulcers were\n getting bigger.\" He went home and then re-presented to for\n wound care. At , his temp was found to be high (T 102) with BP\n of 87/54, so he was sent to .\n He was recently treated at (admitted at \n transferred to ). He was recently admitted to\n from .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it is\n unlikely he has acute osteomyelitis and there is no superinfection of\n ulcers. He was not started on chronic suppressive therapy, both\n because no appropriate oral regimen exists that would cover his known\n microbiology, and oral suppression could more resistant\n microorganisms in the\n future.\n Events: BP stable 85-104/40-50\ns MAP 52-60. IV ABX administered-\n a-febrile. Refusing to turn Q2- multiple small positioning for pt\n comfort. Wound care done. Taking Po\ns well. Refusing AM by RN and\n anyone except phlebotomy. Social work consult placed for my hx\n depression with prolonged illness and support. Pt to go to IR today\n for PICC placement\n then ? D/C back to rehab or possibly C/O to floor.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain- requesting and given baclofen, multiple position changed\n Action:\n Baclofen QID, PRN IR oxycodone, emotional support, repositioning\n Response:\n Post positing pt falling asleep, can use adapted callbell for\n additional pain regimen and repositioning\n Plan:\n Cont PRN pain control, likely resume SR Morphine if BP stable in AM,\n emotional support, repositioning\n Decubitus ulcer (Present At Admission)\n Assessment:\n 2 large decube stage III (left) and IV (right) ischial ulcers,\n * left ulcer: s/p debredment by plastics 1 / 4- multicolored wound bed\n in various stages of healing- some granulation tissue, slough, purple\n and necrotic areas- peri-wound purple and macerated\n * right ulcer: s/p debredment 1 /4\n deep with multiple tunneling and\n likely fistula- multicolored wound bed in various states of healing\n some granulation tissue, yellow slough, large amount purple areas with\n black necrotic tissue, peri-wound purple and mascerated\n Action:\n Both ulcers cleaned wound wound spray, gentle pat dry, thin layer of\n duoderm gel, very lightly moistened antimicrobial kerlex, dry 4x4\n abd, and covered with soft sorb\n Response:\n No acute change\n Plan:\n Support nutrition, turn as pt allows- encourage frequent turning, wound\n care as ordered by surgery and wound care\n" }, { "category": "Physician ", "chartdate": "2144-01-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 716213, "text": "Chief Complaint: fever\n HPI:\n Mr. is a 44 year old male with quadriplegia following a\n MVC in who presents for with a fever of 102. Events are unclear\n but it seems that pt was d/c to , checked himself out because\n he was unhappy with how they turned him/took care of him there and he\n could feel his \"ulcers were getting bigger.\" He went home and then\n re-presented to for wound care. At , his temp was\n found to be high (T 102) with BP of 87/54, so he was sent to .\n .\n .\n He was recently treated at (admitted at transferred to ). He was recently\n admitted to from .\n .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given\n that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it\n is unlikely he has acute osteomyelitis and there is no\n superinfection of ulcers. He was not started on chronic\n suppressive therapy, both because no appropriate oral regimen\n exists that would cover his known microbiology, and oral\n suppression could more resistant microorganisms in the\n future.\n .\n .\n In the ED, initial vs were: T 97.8 HR 99 BP 95/56 RR 16 O2 97%. Patient\n complained of abdominal pain, though it was unclear if this was worse\n than his chronic pain. No BM for a few days. SBP dropped to 87, but\n responded to IV fluids. Continued to drop SBP to low 90s.\n Patient was given IV fluids, one dose of Vancomycin and Zosyn. UA was\n positive, but patient has a history of chronic colonization with ESBL\n Ecoli. Urine culture was sent. CT Abdomen and pelvis was performed\n which showed osteomyelitis chronic vs. acute. Surgery was consulted to\n evaluate large decubitus ulcers. They had not evaluated the patient\n yet on sign out. VS at transfer: T 99.5 BP 92/54 P94 R11 96% RA.\n .\n .\n On the floor, he mentions that he had fevers multiple times at home for\n the days prior. Complains of back pain and leg pain, though these\n aren't new for him. He has a cough productive of some white sputum.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies night sweats, recent weight loss or gain. Denies headache,\n sinus tenderness, rhinorrhea or congestion. Denies shortness of breath,\n or wheezing. Denies chest pain, chest pressure, palpitations, or\n weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal\n pain, or changes in bowel habits. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications (per d/c summary on )\n 1. Fentanyl 100 mcg/hr Patch q72 hr\n 2. Fentanyl 25 mcg/hr Patch q72 hr\n 3. Diazepam 10-20 mg po q6h\n 4. Ascorbic Acid 500 mg po bid\n 5. Docusate Sodium 100 mg po bid\n 6. Bisacodyl 10mg po daily\n 7. Ferrous Sulfate 325 mg (65 mg Iron) po bid\n 8. Baclofen 20 mg po qid\n 9. Senna 8.6 mg po bid\n 10. Tizanidine 2 mg po qhs\n 11. Calcium 500 + D 500 mg(1,250mg) -200 unit po bid\n 12. Capsaicin 0.1 % Cream Topical three times a day: Please apply to\n neck and shoulders.\n 13. Morphine 15-30 mg PO Q4H PRN for breakthrough pain\n 14. Oxybutynin Chloride 5 mg po q8h\n 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two\n (2) Drop Ophthalmic QID (4 times a day).\n 16. Multivitamin po daily\n 17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\n ML PO DAILY\n 18. Omeprazole 20 mg po daily\n 19. Morphine 100 mg po q12h\n 20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet\n Sustained Release PO twice a day\n 21. Metformin 500 mg po daily\n 22. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal\n three times a day.\n Past medical history:\n Family history:\n Social History:\n 1. Quadriplegia following a MVC in or ; Injury at C4-C5\n level. Pt was driving from police at high speed (up to 160mph)\n and car flipped.\n 2. History of decubitus ulcers and osteomyelitis of the sacrum\n and ischial tuberosity- followed by Dr. (ID) at \n ()\n 3. s/p flap repair of ischial and sacral decubitus ulcers\n 4. - Sacral decubitus ulcer debridement at \n 5. - Creation of diverting transverse loop colostomy to\n divert stool away from sacral ulcers at (Dr. ,\n ); colonic obstruction and colostomy revised\n ; ex-lap with revision of ostomy on \n 6. Neurogenic bladder with suprapubic catheter and history of\n frequent UTIs\n 7. Depression\n 8. Anemia\n 9. DM type II on metformin\n 10. HTN\n 11. History of intubation secondary to narcotic overuse -\n approximately / per pt but records\n suggest it may have occurred more recently (possibly as\n there is Head CT done for \"overdose\"), no documents of this\n hospitalization available\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: (per OMR):\n Lives at home with family (sister, brother-in-law, brother, and\n their children). No tobacco, alcohol, or illicit drugs per\n patient. OSH indicates prior history of marijuana and cocaine\n use. Per discussion with PCP, is concern amongst some of\n his prior PCP's in the area that he has sold some of his\n narcotics.\n Review of systems:\n Flowsheet Data as of 09:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 99 (99 - 113) bpm\n BP: 85/50(58) {85/48(55) - 139/104(108)} mmHg\n RR: 19 (13 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,622 mL\n PO:\n TF:\n IVF:\n 522 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,822 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Vitals: T:99.2 BP:85/50 P:90 R: 14 O2: 95% on RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Dentures in place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: UA >50 WBCs\n Lactate 2.0\n Imaging: CT Abdomen\n consolidation RLL likely rounded atelectasis. no acute intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n Microbiology: Blood culture pending\n Urine culture pending\n ECG: EKG: NSR @ 101. Nl Axis. No ST segment changes.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent\n decubitus ulcers who presents with fevers in the setting of chronic\n bilateral ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Abdominal exam is benign, and no obvious source\n of infection seen on CT. Patient also has positive UA, though\n asymptomatic, with history of colonization with ESBL Ecoli. No cough or\n increasing oxygen requirement currently. No indwelling lines or drains.\n Patient has a long history of chronic infection, however given relative\n hypotension, fever, and leukocytosis, would favor antibiotic\n treatment.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin and Meropenem given most recent sensitivities from\n ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -attempt to place CVL for access\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis.\n -obtain LFTs and lipase\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain, MS\n contin 115mg po q12h\n -continue outpatient bowel regimen\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Iron studies from last admission suggest anemia of\n chronic disease. He required no transfusions. He was continued on iron\n .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\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 18 Gauge - 06:45 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": "2144-01-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 716221, "text": "Chief Complaint: fever\n HPI:\n Mr. is a 44 year old male with quadriplegia following a\n MVC in , history of chronic ischial decubitus ulcers who presents\n for with a fever of 102. Events are unclear but it seems that pt was\n d/c to , checked himself out because he was unhappy with how\n they turned him/took care of him there and he could feel his \"ulcers\n were getting bigger.\" He went home and then re-presented to \n for wound care. At , his temp was found to be high (T 102)\n with BP of 87/54, so he was sent to .\n .\n .\n He was recently treated at (admitted at transferred to ). He was recently\n admitted to from .\n .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given\n that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it\n is unlikely he has acute osteomyelitis and there is no\n superinfection of ulcers. He was not started on chronic\n suppressive therapy, both because no appropriate oral regimen\n exists that would cover his known microbiology, and oral\n suppression could more resistant microorganisms in the\n future.\n .\n .\n In the ED, initial vs were: T 97.8 HR 99 BP 95/56 RR 16 O2 97%. Patient\n complained of abdominal pain, though it was unclear if this was worse\n than his chronic pain. No BM for a few days. SBP dropped to 87, but\n responded to IV fluids. Continued to drop SBP to low 90s.\n Patient was given IV fluids, one dose of Vancomycin and Zosyn. UA was\n positive, but patient has a history of chronic colonization with ESBL\n Ecoli. Urine culture was sent. CT Abdomen and pelvis was performed\n which showed osteomyelitis chronic vs. acute. Surgery was consulted to\n evaluate large decubitus ulcers. They had not evaluated the patient\n yet on sign out. VS at transfer: T 99.5 BP 92/54 P94 R11 96% RA.\n .\n .\n On the floor, he mentions that he had fevers multiple times at home for\n the days prior. Complains of back pain and leg pain, though these\n aren't new for him. He has a cough productive of some white sputum.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies night sweats, recent weight loss or gain. Denies headache,\n sinus tenderness, rhinorrhea or congestion. Denies shortness of breath,\n or wheezing. Denies chest pain, chest pressure, palpitations, or\n weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal\n pain, or changes in bowel habits. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications (per d/c summary on )\n 1. Fentanyl 100 mcg/hr Patch q72 hr\n 2. Fentanyl 25 mcg/hr Patch q72 hr\n 3. Diazepam 10-20 mg po q6h\n 4. Ascorbic Acid 500 mg po bid\n 5. Docusate Sodium 100 mg po bid\n 6. Bisacodyl 10mg po daily\n 7. Ferrous Sulfate 325 mg (65 mg Iron) po bid\n 8. Baclofen 20 mg po qid\n 9. Senna 8.6 mg po bid\n 10. Tizanidine 2 mg po qhs\n 11. Calcium 500 + D 500 mg(1,250mg) -200 unit po bid\n 12. Capsaicin 0.1 % Cream Topical three times a day: Please apply to\n neck and shoulders.\n 13. Morphine 15-30 mg PO Q4H PRN for breakthrough pain\n 14. Oxybutynin Chloride 5 mg po q8h\n 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two\n (2) Drop Ophthalmic QID (4 times a day).\n 16. Multivitamin po daily\n 17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)\n ML PO DAILY\n 18. Omeprazole 20 mg po daily\n 19. Morphine 100 mg po q12h\n 20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet\n Sustained Release PO twice a day\n 21. Metformin 500 mg po daily\n 22. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal\n three times a day.\n Past medical history:\n Family history:\n Social History:\n 1. Quadriplegia following a MVC in or ; Injury at C4-C5\n level. Pt was driving from police at high speed (up to 160mph)\n and car flipped.\n 2. History of decubitus ulcers and osteomyelitis of the sacrum\n and ischial tuberosity- followed by Dr. (ID) at \n ()\n 3. s/p flap repair of ischial and sacral decubitus ulcers\n 4. - Sacral decubitus ulcer debridement at \n 5. - Creation of diverting transverse loop colostomy to\n divert stool away from sacral ulcers at (Dr. ,\n ); colonic obstruction and colostomy revised\n ; ex-lap with revision of ostomy on \n 6. Neurogenic bladder with suprapubic catheter and history of\n frequent UTIs\n 7. Depression\n 8. Anemia\n 9. DM type II on metformin\n 10. HTN\n 11. History of intubation secondary to narcotic overuse -\n approximately / per pt but records\n suggest it may have occurred more recently (possibly as\n there is Head CT done for \"overdose\"), no documents of this\n hospitalization available\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: (per OMR):\n Lives at home with family (sister, brother-in-law, brother, and\n their children). No tobacco, alcohol, or illicit drugs per\n patient. OSH indicates prior history of marijuana and cocaine\n use. Per discussion with PCP, is concern amongst some of\n his prior PCP's in the area that he has sold some of his\n narcotics.\n Review of systems:\n Flowsheet Data as of 09:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 99 (99 - 113) bpm\n BP: 85/50(58) {85/48(55) - 139/104(108)} mmHg\n RR: 19 (13 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,622 mL\n PO:\n TF:\n IVF:\n 522 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,822 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Vitals: T:99.2 BP:85/50 P:90 R: 14 O2: 95% on RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Dentures in place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: UA >50 WBCs\n Lactate 2.0\n Imaging: CT Abdomen\n consolidation RLL likely rounded atelectasis. no acute intraabdominal\n findings, including no free fluid or free air. there are bilateral\n decub\n ulcers over the ischial tuberosities, extending to bone. underlying\n bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no\n definite\n focal fluid collection within this, though complex fluid/phlegmon is\n not\n excluded.\n Microbiology: Blood culture pending\n Urine culture pending\n ECG: EKG: NSR @ 101. Nl Axis. No ST segment changes.\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent\n decubitus ulcers who presents with fevers in the setting of chronic\n bilateral ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Endocarditis is also a possibility. Abdominal\n exam is benign, and no obvious source of infection seen on CT. Patient\n also has positive UA, though asymptomatic, with history of colonization\n with ESBL Ecoli. No cough or increasing oxygen requirement currently.\n No indwelling lines or drains. Patient has a long history of chronic\n infection, however given relative hypotension, fever, and leukocytosis,\n would favor antibiotic treatment.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -attempt to place CVL for access\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc, Cipro, and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis.\n -obtain LFTs and lipase\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain, MS\n contin 115mg po q12h\n -continue outpatient bowel regimen\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\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 18 Gauge - 06:45 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 MICU ATTENDING ADDENDUM\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 44M quadreplegic p MVA , decubits ulcers\n and chronic osteo, suprapubic catheter with freq UTIs, Recent\n admissions in . Decubiti evaluated by surgery / plastics/ ID at\n that time, with no evidence of superinfection and no role for\n debridement or flap closure, suppressive antibx were not\n initiated. D/c to rehab, checked out and represented there for wound\n care, febrile and hypotensive --> brought to ED. AF 95/56 --> 87\n systolic, 99 97% RA. U/a pos (hx of colonization with esbl e coli),\n CTAP with ulcer/osteo ischial tuberosity. Surgery consulted. Received\n IVFs, vanco/zosyn and transferred to ICU.\n Exam: T 99.5 BP 92/54 HR 94 RR 14 sat 95% RA\n obese, NAD, alert M, diaphoretic\n decreased bb, CTA ant\n RR, distant, no m\n colostomy, mild diffuse tenderness, ND, + BS, soft\n muscle atrophy, decubitus ulcers at sacral, heel\n Labs notable for WBC 12.2--> 10.6 K, HCT 31--> 26, K+ 4.8, Cr 1.0,\n bicarb 30, lactate 2.0, U/a > 50 wbc, mod le,\n CXR with out focal process, CTAP reviewed\n Agree with plan to manage sepsis with aggressive IVFs, following lacate\n and urine outpt, pan cxs, broad empiric antibx with cipro//vanco,\n trend lactate. Decubitus ulcers/osteo and urine most likely sources,\n unimpressive lfts, a/l, abd ct and cxr. SBE also in ddx, though w/o\n indwelling lines. Hypotension has responded to IVFs. Will c/s wound\n care. Surgery following for possible bone bx/debridement. In terms of\n abd pain, this has been chronic, possibly from gerd and\n constipation. CT abd unimpressive and labs unrevealing. Will continue\n bowel regimen, PPI, and follow abd exam. For chronic pain and muscles\n spasms will continue morphine/ patch per home regimen, as BP\n tolerates, as pt has high chronic narcotic use and is at risk for\n withdrawal. For DM, will hold metformin and use SSI. Resp\n status appears stable with minimal O2 by NC. Follow stas and check abg.\n Full code. Attempt CVL placement but pt unable to lie flat. Attempt\n groin line. A-line if BP declines.\n Remainder of plan as outlined in resident note.\n Patient is critically ill\n Total time: 50 min\n Addendum: Pt unable to lie flat to safely place IJ or sq line.\n Difficult to position pt for fem line. Could not place bed in reverse\n trendelenberg. Attempted L fem line under sterile conditions but\n unable to get adequate return to thred wire. As pt hemodynamically\n stable, held on further line attempts at this time.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:56 ------\n" }, { "category": "Nursing", "chartdate": "2144-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716243, "text": "Chief Complaint: fever\n HPI:\n Mr. is a 44 year old male with quadriplegia following a MVC in\n , history of chronic ischial decubitus ulcers who presents for with\n a fever of 102. Events are unclear but it seems that pt was d/c to\n , checked himself out because he was unhappy with how they\n turned him/took care of him there and he could feel his \"ulcers were\n getting bigger.\" He went home and then re-presented to for\n wound care. At , his temp was found to be high (T 102) with BP\n of 87/54, so he was sent to .\n .\n He was recently treated at (admitted at \n transferred to ). He was recently admitted to\n from .\n .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down.\n .\n In the ED, initial vs were: T 97.8 HR 99 BP 95/56 RR 16 O2 97%. Patient\n complained of abdominal pain, though it was unclear if this was worse\n than his chronic pain. No BM for a few days. SBP dropped to 87, but\n responded to IV fluids. Continued to drop SBP to low 90s.\n Patient was given IV fluids, one dose of Vancomycin and Zosyn. UA was\n positive, but patient has a history of chronic colonization with ESBL\n Ecoli. Urine culture was sent. CT Abdomen and pelvis was performed\n which showed osteomyelitis chronic vs. acute. Surgery was consulted to\n evaluate large decubitus ulcers. They had not evaluated the patient\n yet on sign out. VS at transfer: T 99.5 BP 92/54 P94 R11 96% RA.\n Shift Events:\n Mrsa nasal culture\n Culture sp insertion site\n Drsg on , ischial and heels bil.\n Attempted line insertion groin site unsuccessful\n 4-5 liters ns bolus\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt. with chronic stage 4 pressure ulcers bilateral ischial and heels,\n drsg , clean non purulent , large serous sang\n Action:\n Kinair bed, wound consult, consult, redressed all wounds to\n wet/dry following last wound rec. on dc plan\n Response:\n unchanged\n Plan:\n Follow up with consults, establish wound plan\n Quadriplegia\n Assessment:\n Freq. leg spasm, unable to tol. Lying less than 30 degress due to\n diaphragmatic spasm, desats to 80\ns, increased anxiety cough prod. Pt\n able to manage airway/secretions, thin liquids, sensation limited\n below shoulders, mg+ 1.7 noted to HO\n Action:\n Po meds for spasm, pain patches only at this time, hob above 30%\n Response:\n Less spasm after medications and positioning\n Plan:\n Reassurance, meds po tol well, turning\n Sepsis without organ dysfunction\n Assessment:\n Tmax 99.4, maps under 60 requiring freq bolus to maintain maps at 60\n and above, urine light color and clear, one peripheral line with failed\n attempted at fem. Central line\n Action:\n Bolus and maintainence fluids, vanco, zosyn, merepenem and cipro\n started\n Response:\n Cont. to need fluid support, urine output increased to 400-600 hr\n Plan:\n Cont. to bolus as needed, follow resp. status carefully, oxygen for\n support further study\n" }, { "category": "Case Management ", "chartdate": "2144-01-13 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 716340, "text": "Planned Discharge Date: \n Narrative / Plan (Patient):\n Case discussed w/ team today, pt could be ready for dc to rehab\n tomorrow. CM met w/ pt who states he was at SRH and would\n like to return there. CM has asked SRH on-site liaison to screen. CM\n will follow.\n" }, { "category": "Nursing", "chartdate": "2144-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716236, "text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n Quadriplegia\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2144-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716408, "text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with bilateral ischial decubs and bilateral heel decubs (see\n metavision for specifics).\n Action:\n Pt on kinair bed, turned as frequently as pt will allow, wound care RN\n did consult, surgery debrided ischial ulcers, BLE with multipodos boots\n on.\n Response:\n Pt with no further breakdown in skin.\n Plan:\n Continue to reposition as pt will allow, maintain kinair mattress and\n multipodos boots, change heel dressings daily and change ischial ulcers\n per wound care recommendations.\n Sepsis without organ dysfunction\n Assessment:\n Pt with WBC 8.5, lactate 1.5, afebrile. Systolic BP 70s-140s, pt always\n mentating and urinating even with low BP.\n Action:\n Given 500cc NS bolus for low BP, meds per order, labs and temp trended,\n suprapubic tube change by urology.\n Response:\n BP stable, when hypotensive he has never been tachycardic. Afebrile\n all shift.\n Plan:\n Continue with meds per order, trend labs and temp, monitor vitals. Pt\n will need PICC placed in IR prior to DC to rehab.\n Diabetes Mellitus (DM), Type II\n Assessment:\n History of DM per chart and 10 AM fingerstick 168.\n Action:\n Pt medicated for 10AM fingerstick but pt now stating he is not diabetic\n and refusing fingersticks.\n Response:\n N/A\n Plan:\n N/A\n" }, { "category": "Nursing", "chartdate": "2144-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 716471, "text": "Mr. is a 44 year old male with quadriplegia following a MVC in\n , history of chronic ischial decubitus ulcers who presents for with\n a fever of 102. Events are unclear but it seems that pt was d/c to\n , checked himself out because he was unhappy with how they\n turned him/took care of him there and he could feel his \"ulcers were\n getting bigger.\" He went home and then re-presented to for\n wound care. At , his temp was found to be high (T 102) with BP\n of 87/54, so he was sent to .\n He was recently treated at (admitted at \n transferred to ). He was recently admitted to\n from .\n During his most recent admission, his ischial decubitus ulcers\n with chronic osteomyelitis were evaluated by general surgery who\n determined pt did not need debridement at that time. Plastic surgery\n will not do flap closure as pt is not ambulatory and flap will break\n down. Given that he remained afebrile, without leukocytosis, without\n purulent drainage, was not bacteremic, and he was treated with\n antibiotics for 4 months from - , ID felt that it is\n unlikely he has acute osteomyelitis and there is no superinfection of\n ulcers. He was not started on chronic suppressive therapy, both\n because no appropriate oral regimen exists that would cover his known\n microbiology, and oral suppression could more resistant\n microorganisms in the\n future.\n Events: BP stable 85-104/40-50\ns MAP 52-60. IV ABX administered-\n a-febrile. Refusing to turn Q2- multiple small positioning for pt\n comfort. Wound care done. Taking Po\ns well. Refusing AM by RN and\n anyone except phlebotomy. Social work consult placed for my hx\n depression with prolonged illness and support. Pt to go to IR today\n for PICC placement\n then ? D/C back to rehab or possibly C/O to floor.\n Pain control (acute pain, chronic pain)\n Assessment:\n pain- requesting and given baclofen, multiple position changed\n Action:\n Baclofen QID, PRN IR oxycodone, emotional support, repositioning\n Response:\n Post positing pt falling asleep, can use adapted callbell for\n additional pain regimen and repositioning\n Plan:\n Cont PRN pain control, likely resume SR Morphine if BP stable in AM,\n emotional support, repositioning\n Decubitus ulcer (Present At Admission)\n Assessment:\n 2 large decube stage III (left) and IV (right) ischial ulcers,\n * left ulcer: s/p debredment by plastics 1 / 4- multicolored wound bed\n in various stages of healing- some granulation tissue, slough, purple\n and necrotic areas- peri-wound purple and macerated\n * right ulcer: s/p debredment 1 /4\n deep with multiple tunneling and\n likely fistula- multicolored wound bed in various states of healing\n some granulation tissue, yellow slough, large amount purple areas with\n black necrotic tissue, peri-wound purple and mascerated\n Action:\n Both ulcers cleaned wound wound spray, gentle pat dry, thin layer of\n duoderm gel, very lightly moistened antimicrobial kerlex, dry 4x4\n abd, and covered with soft sorb\n Response:\n No acute change\n Plan:\n Support nutrition, turn as pt allows- encourage frequent turning, wound\n care as ordered by surgery and wound care, remain on kinair bed, ? need\n to change to turning bed if pt ref to turn in bed\n" }, { "category": "Physician ", "chartdate": "2144-01-14 00:00:00.000", "description": "Resident Progress Note", "row_id": 716462, "text": "TITLE:\n Chief Complaint: Fever\n 24 Hour Events:\n - Difficulty placing PICC - IR PICC placement ordered.\n - Patient requested regular diet\n - Patient requested no fingersticks (order changed to patient may\n refuse and A1c ordered = 5.8).\n - Wound consulted and left recs\n - Surgery came to evaluate and produced specimen for culture\n - Urology replaced suprapubic catheter.\n - Asked for lactulose (although stooling fine this was PRN in his\n previous regimen) and Maalox\n - be returned directly to rehab from ICU - will see\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 03:01 AM\n Vancomycin - 08:00 PM\n Meropenem - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 76 (57 - 94) bpm\n BP: 94/54(63) {78/41(50) - 141/109(113)} mmHg\n RR: 20 (10 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 93.1 kg (admission): 87 kg\n Height: 74 Inch\n Total In:\n 5,790 mL\n 647 mL\n PO:\n 2,580 mL\n 380 mL\n TF:\n IVF:\n 3,210 mL\n 267 mL\n Blood products:\n Total out:\n 3,350 mL\n 1,490 mL\n Urine:\n 3,350 mL\n 1,490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,440 mL\n -844 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Dentures in place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness. Patient has intermittent voluntary guarding. No\n organomegaly. Colostomy bag in place. Site looks clean. With small\n amount of brown stool present.\n GU: foley in place\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n 293 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.2 %\n 8.5 K/uL\n [image002.jpg]\n 08:47 PM\n 04:26 AM\n WBC\n 10.6\n 8.5\n Hct\n 25.9\n 24.2\n Plt\n 288\n 293\n Cr\n 0.8\n 0.7\n Glucose\n 108\n 114\n Other labs: PT / PTT / INR:14.8/27.5/1.3, ALT / AST:, Alk Phos / T\n Bili:119/0.6, Amylase / Lipase:/16, Lactic Acid:1.5 mmol/L, LDH:287\n IU/L, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Imaging: No New Imaging\n Microbiology: Urine: GNR (Preliminary)\n Sacral Decubitus:\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n Culture Pending\n Subrapubic Catheter: Culture pending\n Blood 1/03: Culture Pending\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent decubitus\n ulcers who presents with fevers in the setting of chronic bilateral\n ischial and heel ulcers.\n # Fever & hypotension: Patient with relative leukocytosis with WBC of\n 12 (8.4 on discharge), and hypotension, responsive to fluids. Sources\n of fever include large decubitus and heel ulcers and with secondary\n chronic osteomyelitis. Endocarditis is also a possibility. Abdominal\n exam is benign, and no obvious source of infection seen on CT. Patient\n also has positive UA, though asymptomatic, with history of colonization\n with ESBL Ecoli. No cough or increasing oxygen requirement currently.\n No indwelling lines or drains. Patient has a long history of chronic\n infection, however given relative hypotension, fever, and leukocytosis,\n would favor antibiotic treatment. Of note, it is unclear as to the\n degree of hypotension from patient\ns baseline. With low blood pressure\n patient without tachycardia and maintains excellent urine output. \n be related secondary to drugs.\n -IV fluid boluses to keep MAP>60\n -empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture and blood culture\n -culture if spikes\n -wound care consult for decubitus ulcers\n -f/u surgery recs\n -PICC for access today.\n .\n # +UA - > 50 WBC. Patient likely chronically colonized due to\n suprapubic catheter and neurogenic bladder. However given fever,\n leukocytosis, and hypotension will treat while waiting for UCx.\n -Vanc, Cipro, and Meropenem\n -f/u UCx\n .\n # Abdominal pain: Pt complained of abdominal pain, currently with\n intermittent pain. Had intermittent abdominal pain on last admission\n also. PPI was restarted for possible PUD/gastritis. Normal\n LFTS/Lipase.\n -continue PPI\n -bowel regimen\n -consider KUB if pain recurs\n .\n # Chronic pain:\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain,\n -continue outpatient bowel regimen\n - Will hold MS contin 115mg po q12h for now and provide prn morphine.\n .\n # DM2: Hold metformin.\n -qid fingersticks\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU, back to rehab.\n" }, { "category": "Physician ", "chartdate": "2144-01-14 00:00:00.000", "description": "Resident Progress Note", "row_id": 716487, "text": "TITLE:\n Chief Complaint: Fever\n 24 Hour Events:\n - Difficulty placing PICC - IR PICC placement ordered.\n - Patient requested regular diet\n - Patient requested no fingersticks (order changed to patient may\n refuse and A1c ordered = 5.8).\n - Wound consulted and left recs\n - Surgery came to evaluate and produced specimen for culture\n - Urology replaced suprapubic catheter.\n - Asked for lactulose (although stooling fine this was PRN in his\n previous regimen) and Maalox\n - be returned directly to rehab from ICU - will see\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 03:01 AM\n Vancomycin - 08:00 PM\n Meropenem - 02:00 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 76 (57 - 94) bpm\n BP: 94/54(63) {78/41(50) - 141/109(113)} mmHg\n RR: 20 (10 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 93.1 kg (admission): 87 kg\n Height: 74 Inch\n Total In:\n 5,790 mL\n 647 mL\n PO:\n 2,580 mL\n 380 mL\n TF:\n IVF:\n 3,210 mL\n 267 mL\n Blood products:\n Total out:\n 3,350 mL\n 1,490 mL\n Urine:\n 3,350 mL\n 1,490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,440 mL\n -844 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ////\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. Upper dentures in\n place.\n Neck: supple, unable to assess JVP given body habitus, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Minimally distended, + Bowel Sounds.. No organomegaly.\n Colostomy bag in place. Site looks clean. With small amount of brown\n stool present.\n GU: suprapubic catheter in place.\n Ext: warm, 2+ CP pulses. No edema. Bandages over heels.\n Labs / Radiology\n 293 K/uL\n 7.7 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.2 %\n 8.5 K/uL\n [image002.jpg]\n 08:47 PM\n 04:26 AM\n WBC\n 10.6\n 8.5\n Hct\n 25.9\n 24.2\n Plt\n 288\n 293\n Cr\n 0.8\n 0.7\n Glucose\n 108\n 114\n Other labs: PT / PTT / INR:14.8/27.5/1.3, ALT / AST:, Alk Phos / T\n Bili:119/0.6, Amylase / Lipase:/16, Lactic Acid:1.5 mmol/L, LDH:287\n IU/L, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Imaging: No New Imaging\n Microbiology: Urine: GNR (Preliminary)\n Sacral Decubitus:\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS.\n Culture Pending\n Subrapubic Catheter: Culture pending\n Blood 1/03: Culture Pending\n Assessment and Plan\n 44 year old male with history of quadriplegia and recurrent decubitus\n ulcers who presents with fevers in the setting of chronic bilateral\n ischial and heel ulcers.\n # Fever & hypotension: Afebrile since admission to the ICU. Pressures\n low stable while in the ICU with stable heart rate and urine\n outputSources of fever include large decubitus and heel ulcers and with\n secondary chronic osteomyelitis. UA positive with GNR growing in urine,\n however this appear to be chronic. CT without intrabdominal pathology.\n -Empiric Vancomycin, Ciprofloxacin and Meropenem given most recent\n sensitivities from ESBL UTI on \n -f/u Urine culture, blood, wound cultures\n -culture if spikes\n -f/u surgery and wound care recs\n -PICC with IR today\n - FU daily labs\n .\n # Abdominal pain: Without pain this AM. Had intermittent abdominal\n pain on last admission also. Normal LFTS/Lipase.\n -continue PPI\n -bowel regimen, lactulose added as above, however patient moving bowels\n .\n # Chronic pain: Stable.\n -continue outpatient regimen of Fentanyl patch 125mcg/hour, Diazepam\n 10mg po q6h PRN muscle spasms, Morphine 15-30mg po q4h PRN pain,\n -continue outpatient bowel regimen\n - Will hold MS contin 115mg po q12h for now and provide prn morphine.\n .\n # DM2: Hold metformin.\n -qid fingersticks\n pt refused fingersticks, allowed to refuse\n -SSI\n .\n # Microcytic anemia: Baseline HCT 27. Iron studies from last admission\n suggest anemia of chronic disease. He required no transfusions. He was\n continued on iron .\n -continue to monitor\n .\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripheral x1. Will attempt CVL tonight.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Regular Diet.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Comments:\n Communication: Patient\n Code status: Full code\n Disposition:ICU, back to rehab.\n" }, { "category": "ECG", "chartdate": "2144-01-12 00:00:00.000", "description": "Report", "row_id": 177690, "text": "Normal sinus rhythm. Tracing is within normal limits except for T wave\nflattening laterally. Compared to the previous tracing of no\ndiagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2144-01-14 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1115097, "text": " 9:23 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC for antibiotic administration\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with near-complete quadroplegia, purulent discharge from site\n of suprapubic catheter.\n REASON FOR THIS EXAMINATION:\n Please place PICC for antibiotic administration\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy 11:20 AM\n Successful placement of a double-lumen PICC in the right cephalic vein,\n terminating in the lower SVC. There were no complications. The line is ready\n for use.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old male with history of quadriplegia, with purulent\n discharge at the site of a suprapubic catheter. The patient requires PICC\n placement for administration of intravenous antibiotics.\n\n OPERATORS: Dr. (resident) and Dr. . Dr. , the\n radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: The procedure was explained to the patient. A timeout was\n performed.\n\n Using sterile technique and local anesthesia, the right cephalic vein was\n punctured under direct ultrasound guidance using a micropuncture set. Hard\n 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 48 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: Successful ultrasound and fluoroscopic-guided placement of a\n double-lumen PICC in the right cephalic vein. Final length is 48 cm. Tip is\n positioned in the distal SVC. The line is ready for use.\n (Over)\n\n 9:23 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC for antibiotic administration\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2144-01-14 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1115098, "text": ", F. MED MICU 9:23 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC for antibiotic administration\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with near-complete quadroplegia, purulent discharge from site\n of suprapubic catheter.\n REASON FOR THIS EXAMINATION:\n Please place PICC for antibiotic administration\n ______________________________________________________________________________\n PFI REPORT\n Successful placement of a double-lumen PICC in the right cephalic vein,\n terminating in the lower SVC. There were no complications. The line is ready\n for use.\n\n" }, { "category": "Radiology", "chartdate": "2144-01-12 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1114865, "text": " 2:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for osteomyelitis, intraabdominal infection\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with fever, worsening decub ulcer\n REASON FOR THIS EXAMINATION:\n eval for osteomyelitis, intraabdominal infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy 4:05 PM\n consolidation RLL likely rounded atelectasis. no acute intraabdominal\n findings, including no free fluid or free air. there are bilateral decub\n ulcers over the ischial tuberosities, extending to bone. underlying bony\n sclerosis suggests osteomyelitis, likely chronic. soft tissue density\n interposed between the right ulcer and the rectum is again noted. no definite\n focal fluid collection within this, though complex fluid/phlegmon is not\n excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male with fever and worsening decubitus ulcers.\n Evaluate for osteomyelitis or intra-abdominal infection.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed following the\n administration of 120 cc of Optiray intravenous contrast. No oral contrast\n was administered. Multiplanar reformats were compared and reviewed.\n\n FINDINGS:\n\n CT ABDOMEN: There is pleural-based opacity posteriorly within the right lower\n lobe. Its appearance suggests a chronic consolidation or atelectasis, such as\n round atelectasis, and its configuration is the same as on the prior study.\n There is no pleural effusion. There is no pericardial effusion.\n\n The liver is unremarkable in appearance with no focal lesions identified.\n There is no intra- or extra-hepatic biliary ductal dilatation. The spleen,\n pancreas, and adrenal glands are again normal. There is mild perinephric\n stranding, with no perinephric fluid collection. The kidneys enhance\n symmetrically with symmetric contrast excretion. There are no renal mass\n lesions identified. There is no hydronephrosis.\n\n The stomach, duodenum, and intra-abdominal loops of small bowel are normal.\n There is moderate retained fecal material within the colon. The colon\n terminates in the left lower quadrant colostomy.\n\n There are no mesenteric or retroperitoneal lymph nodes identified. There is\n no free fluid or free air. The aorta and major mesenteric vessels are widely\n patent. There is atherosclerotic calcification without aneurysmal dilatation\n of the aorta.\n\n (Over)\n\n 2:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for osteomyelitis, intraabdominal infection\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS: There is a suprapubic catheter seen entering the decompressed\n bladder, which is thickened, suggesting chronic inflammation. The prostate is\n unremarkable. The residual sigmoid colon is decompressed, with residual\n barium within.\n\n Bilateral large soft tissue defects overlying each ischial tuberosity appear\n to probe to the bone bilaterally. There is adjacent soft tissue stranding and\n inflammation. In particular, there is a soft tissue density interposed\n between the right ulcer and the pelvic floor musculature with a similar\n extensive soft tissue abnormality extending from the posterior aspect of the\n anus and pelvic floor musculature to the overlying midline skin surface. No\n discrete fluid collection is identified.\n\n There is trace free fluid in the cul-de-sac. There are small inguinal lymph\n nodes, measuring up to 1.5 cm. These may be reactive, and are unchanged\n compared to .\n\n There are dystrophic calcifications in the gluteal muscles adjacent to the\n greater trochanters bilaterally.\n\n BONE WINDOWS: There are no fractures identified. Extensive sclerosis of the\n ischial tuberosities noted bilaterally, compatible with chronic osteomyelitis.\n\n IMPRESSION:\n\n 1. Unchanged right basilar opacity, which may be a chronic abnormality.\n Correlation with more remote prior imaging, if available, is recommended.\n Otherwise CT follow-up is recommended in 3 months to assess further.\n\n 2. Similar large ulcerations extending to each ischial tuberosity. The\n sclerotic appearance of each tuberosity is essentially diagnostic of chronic\n osteomyelitis. No discrete fluid collection is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-01-12 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1114858, "text": " 1:28 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: 1340\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with fever, qyadriparesis\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old man with fever, quadriparesis.\n\n COMPARISON: .\n\n FINDINGS: A single upright AP portable view of the chest was obtained. The\n cardiomediastinal silhouette is stable in appearance. There is an\n oblong-shaped hazy opacity in the region of the right middle lobe which likely\n represents subsegmental atelectasis. No additional focal opacities are\n identified. There are no pleural effusions or pneumothorax. No acute osseous\n abnormalities are identified.\n\n IMPRESSION:\n Right middle lobe subsegmental atelectasis. No acute process identified.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-06-19 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 826675, "text": " 10:52 AM\n FOOT AP,LAT & OBL RIGHT Clip # \n Reason: post-op evaluation\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p right foot reconstruction with external fixation\n REASON FOR THIS EXAMINATION:\n post-op evaluation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right foot reconstruction with external fixation,\n postop evaluation.\n\n THREE VIEWS OF RIGHT FOOT: There is interval placement of extensive external\n fixation hardware, wich limits evaluation of the underlying osseous\n structures. There is diffuse osteopenia as well. Allowing for this, again\n seen is extensive destruction of the mid- foot. Stable appearance of\n degenerative changes at the first metatarsophalangeal joint, with sclerotic\n changes of the first metatarsal head. The base of the first metatarsal is not\n well evaluated. Interval resection of the distal third of the fibula. Marked\n overlying soft tissue swelling.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 826193, "text": " 3:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ett placement\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p foot surgery- still intubated\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubated.\n\n AP CHEST: Comparison was made with one day prior. The patient is status post\n CABG. The endotracheal tube is approximately 2 cm above the carina. The NG-\n tube is within the stomach. There is a layering right pleural effusion and\n left lower lobe atelectasis/consolidation. There is cardiomegaly. There is\n mild perihilar haziness, but likely due to supine positioning. No\n pneumothorax.\n\n IMPRESSION: Right pleural effusion. Left lower lobe atelectasis or\n consolidation. Satisfactory ETT and NG-tube.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-06-17 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 826398, "text": " 11:25 AM\n ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: post-op evaluation\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p right foot/ankle reconstruction with external fixation\n REASON FOR THIS EXAMINATION:\n post-op evaluation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right foot and ankle reconstruction with external\n fixation, post-op.\n\n THREE VIEWS OF RIGHT ANKLE: Comparison is made with three views of right\n ankle dated (preoperative films). There is interval placement of\n multiple external fixation hardware components, with marked limitation of\n visualization of the underlying osseous structures. Status post transverse\n osteotomy of the right distal fibula. The right ankle is not visualized due\n to overlying metallic artifact.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-14 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 826107, "text": " 6:42 PM\n ANKLE (AP, MORTISE & LAT) RIGHT; FOOT AP,LAT & OBL RIGHT Clip # \n Reason: pre-op evaluation\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with right foot/ankle charcot deformity\n REASON FOR THIS EXAMINATION:\n pre-op evaluation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right foot/ankle Charcot deformity, preop evaluation.\n\n ANKLE, 3 VWS, FOOT VWS\n\n There is marked Charcot neuroarthropathy about the right hindfoot and midfoot,\n with complete erosion/destruction of the distal tibia, much of the talus and\n talar dome, and upper portion of the calcaneus. The cuneiforms and cuboid\n bone are also in great part destroyed. There is severe diffuse osteopenia in\n the remaining portion of the foot, with hyprextension of the digits at the MTP\n joints. There is severe diffuse osteopenia. There is prominent periosteal new\n bone formation along the lateral border of the fifth metatarsal. Possible\n nondisplaced fracture base of first metatarsal. There is marked soft tissue\n edema. Lucency deep to the bandage along themedial aspect of the ankle could\n represent a site of ulceration or subcutaneous emphysema.\n\n IMPRESSION: Severe bone destruction involving the tibiotalar joint and\n midfoot. Differential diagnosis includes both neuroarthropathic change and\n infection.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-06-14 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 826106, "text": " 6:42 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHARCOT RIGHT ANKLE\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with right foot/ankle charcot deformity\n REASON FOR THIS EXAMINATION:\n r/o acute cardiopulmonary processes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of Charcot Foot.\n\n PA AND LATERAL CHEST: Status post CABG. There is cardiomegaly. No definite\n CHF. The lungs are clear and there are no pleural effusions. Calcification in\n upper abdomen in lateral view possibly gallstone, but cannot confirm on the film.\n\n IMPRESSION: No evidence for CHF or pneumonia. Cardiomegaly. Status post\n CABG.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 826521, "text": " 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o preumonia or atelectasis\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with new onset SOB following surgery with general anesthesia\n and overnight intubation.\n REASON FOR THIS EXAMINATION:\n r/o preumonia or atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n AP CHEST: Comparison is made with . There is bibasilar atelectasis\n and small bilateral pleural effusions, unchanged. There is persistent mild\n upper zone redistribution of the pulmonary vessels and cardiomegaly. Median-\n sternotomy wires are seen. No pneumothorax. The endotracheal and NG tube are\n not visualized.\n\n IMPRESSION: Findings consistent with mild CHF.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-23 00:00:00.000", "description": "PICC W/O PORT", "row_id": 827049, "text": " 12:31 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC PLACEMENT PLEASE, SINGLE ONLY FOR ONE ANTIBIOTIC, CHARCOT RIGHT ANKLE, DM TYPE I\n Admitting Diagnosis: CHARCOT RIGHT ANKLE\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 64 year old woman s/p LE reconstruction with exfix\n REASON FOR THIS EXAMINATION:\n PICC placement please, single only for one antibiotic. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple lower extremity fractures with external fixation, needs\n PICC line for IV antibiotics.\n\n RADIOLOGISTS: The procedure was performed by Drs. (resident), with Dr.\n , the attending radiologist, supervising the procedure.\n\n PROCEDURE/FINDINGS: The patient was placed supine on the angiography table.\n Ultrasound was used to document patent left brachial veins as no vein could be\n found clinically suitable for access. Hard copy ultrasound images of the vein\n were taken before and during venipuncture. The patient's left arm was prepped\n and draped in standard sterile fashion. The skin and subcutaneous tissues\n overlying the left brachial vein were anesthetized using 3 cc of 1% Lidocaine.\n Under continuous son guidance, a micropuncture needle was then\n advanced into the left brachial vein. A 0.018 calibrated guidewire was then\n advanced into the distal superior vena cava (SVC) using fluoroscopic guidance.\n The needle was removed and exchanged for a micropuncture sheath set. The\n correct catheter length was measured to be 45 cm, and the PICC was trimmed\n appropriately. The inner portion of the sheath was removed, and the PICC was\n advanced into the distal SVC, under direct fluoroscopic guidance over the\n wire. The wire and peel-away sheath were then removed. The catheter was\n secured to the skin using a Stat- Lock and Op-Site. The catheter was flushed,\n then hep-locked. There were no immediate post-procedural complications.\n\n IMPRESSION: Successful placement of a 45 cm-long, 4-French single-lumen Vaxcel\n PICC in the left brachial vein. The tip is in the distal SVC. The catheter is\n ready for immediate use.\n\n" }, { "category": "ECG", "chartdate": "2161-06-14 00:00:00.000", "description": "Report", "row_id": 137979, "text": "Sinus rhythm. No diagnostic change compared to the previous tracing\nof . There continues to show borderline left ventricular hypertrophy by\nvoltage in lead aVL and non-specific ST-T wave abnormalities which may be due\nin part, to left ventricular hypertrophy.\n\n" } ]

[ { "category": "ECG", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 151991, "text": "Normal sinus rhythm, rate 59\nBifascicular Block: Right bundle branch block and left anterior fascicular\nblock\nSince last ECG, Slight increased lateral T wave abnormalities\n\n" }, { "category": "ECG", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 151994, "text": "Normal sinus rhythm, rate 76\nBifascicular Block: Right bundle branch block and left anterior fascicular\nblock\n\n" }, { "category": "Radiology", "chartdate": "2164-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 743804, "text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AAA, RIJ swan placed, check placement and r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n s/p AAA\n RIJ swan placed\n check placement and r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AAA repair with line placement.\n\n FINDINGS: Single portable view of the chest. The film is under penetrated,\n which limits evaluation. A nasogastric tube tip terminates below the\n diaphragm. There is a right approach pulmonary artery catheter whose tip is\n in the right interlobar artery . No pneumothorax is seen.\n\n IMPRESSION: The pulmonary artery catheter tip is in the right interlobar\n artery\n\n" }, { "category": "Radiology", "chartdate": "2164-08-28 00:00:00.000", "description": "O ABDOMEN, SINGLE VIEW IN O.R.", "row_id": 743802, "text": " 4:52 PM\n ABDOMEN, SINGLE VIEW IN O.R. Clip # \n Reason: INCORRECT INSTRUMENT COUNT\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE VIEW IN THE O.R.:\n\n No foreign body demonstrated.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 743749, "text": " 7:51 PM\n CT ABDOMEN W/CONTRAST; CT CHEST W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Pt w/ symptomatic AAA, please r/o rupture w/ non contrast ab\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n Pt w/ symptomatic AAA\n please r/o rupture w/ non contrast abd CT\n Page resident #/ \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of AAA, now with back pain.\n\n TECHNIQUE: Multiple axial images were obtained from the aortic arch to the\n bifurcation with and without intravenous contrast.\n\n CONTRAST: 150 cc of Optiray was administered due to the study requirement of\n a fast rate of injection. There were no complications.\n\n CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The lungs are free of\n focal opacities. Prominent pretracheal and AP window lymph nodes are seen\n which do not meet strict CT criteria for enlargement. There are multiple\n coronary arterial calcifications. A small hiatal hernia is present. There\n are no pleural effusions. The heart is normal in size. The thoracic aorta is\n without focal enlargement and no intimal flap can be identified.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Multiple stones are seen within\n the gallbladder. The pancreas is slightly atrophic. The spleen and kidneys\n are normal in appearance. There are multiple calcifications of the abdominal\n aorta and focal dilatation of the infrarenal portion is present to a maximum\n AP diameter of 4.7 cm. Partial thrombosis of the lumen is evident,\n particularly on the posterior and right walls. Several small ulcerations are\n seen within the thrombus/plaque. There is smooth tapering of the aneurysmal\n portion prior to bifurcation. There is no evidence of extravasation of\n contrast.\n\n The lower thoracic and upper lumbar spine demonstrate multiple anterior\n osteophytes. Soft tissue is unremarkable.\n\n IMPRESSION:\n\n 1) Infrarenal abdominal aortic aneurysm with mural thrombus. There is no\n evidence of dissection, rupture or leak.\n\n 2) Small hiatal hernia.\n\n 3) Multiple gallstones. Findings were communicated to the ordering physician\n at the time of study.\n (Over)\n\n 7:51 PM\n CT ABDOMEN W/CONTRAST; CT CHEST W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Pt w/ symptomatic AAA, please r/o rupture w/ non contrast ab\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 743909, "text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CVP attemp\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p AAA repair, with fever, s/p CVP attempt, R/O PTX\n REASON FOR THIS EXAMINATION:\n s/p CVP attemp\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AAA repair, fever, s/p line placement attempt.\n\n CHEST, SINGLE VIEW: Direct comparison is made to a prior exam performed 07:33\n hours. There is no pneumothorax. There is interval appearance of atelectasis\n at the right lung base. No lines are identified within the body on this exam.\n The heart and mediastinal silhouettes are within normal limits. No pleural\n effusions and no areas of consolidation.\n\n IMPRESSION: Interval appearance of atelectasis at the right lung base. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 743899, "text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: AAA REPAIR/FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p AAA repair, with fever, r/o pneumonia\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post abdominal aortic aneursym repair.\n\n CHEST, SINGLE VIEW: Comparison study dated . Over the interval the NG\n tube has been removed. Tip of swan ganz catheter is in the region of the right\n pulmonary artery and is somewhat more centrally located than on the prior\n study. There is no pneumothorax. Heart and mediastinal silhouettes are within\n normal limits. There are no pleural effusions and no focal pulmonary\n opacities.\n\n IMPRESSION: Interval change in right swan ganz catheter as described above.\n No pneumothorax.\n\n" } ]

[ { "category": "Echo", "chartdate": "2199-04-13 00:00:00.000", "description": "Report", "row_id": 86613, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 70\nWeight (lb): 149\nBSA (m2): 1.84 m2\nBP (mm Hg): 111/57\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 00:35\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV cavity size. Severely depressed LVEF.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views.\n\nConclusions:\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is severely depressed. RV with global free wall hypokinesis. No\naortic regurgitation is seen. Trivial mitral regurgitation is seen. There is\nno pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241336, "text": " 9:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: PLEURAL EFFUSION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with recent pleurodesis and chest tube placement\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 81-year-old man with recent pleurodesis and chest tube\n placement. Evaluate interval changes.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is a dual-lead pacemaker, right IJ central venous line which are\n unchanged in position. There is also a left-sided chest tube. No\n pneumothoraces are seen. There is a marked cardiomegaly, moderate pulmonary\n edema and a left retrocardiac opacity. The opacities of the right base have\n improved since the prior study. No pneumothoraces are present.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-04-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1241189, "text": " 12:11 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Rt IJ central line placement.\n Admitting Diagnosis: PLEURAL EFFUSION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with pulm edema.\n REASON FOR THIS EXAMINATION:\n Rt IJ central line placement.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 81-year-old man with pulmonary edema.\n\n FINDINGS: There is a right-sided pacemaker which is unchanged in position\n from the prior study. There is a right IJ central venous line whose distal\n lead tip is in the cavoatrial junction. There is again seen prominence of\n pulmonary markings suggestive of pulmonary edema which is unchanged. There is\n a left-sided chest tube which is stable. There are no pneumothoraces.\n Subcutaneous gas is seen within the right lower chest wall. There is\n unchanged cardiomegaly. Overall, these findings are all stable since the\n prior study.\n\n" }, { "category": "Radiology", "chartdate": "2199-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241141, "text": " 2:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: upright please eval pneumothorax\n Admitting Diagnosis: PLEURAL EFFUSION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with hypotension, air leak after left pleurodesis\n REASON FOR THIS EXAMINATION:\n upright please eval pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old male with hypotension and air leak following left\n pleurodesis.\n\n COMPARISON: .\n\n CHEST, AP: Right atrial, ventricular, and coronary sinus\n pacemaker/defibrillator leads course in expected position. Following left\n pleurodesis, the left pleural effusion has conerted into a moderate left\n hydropneumothorax. There is also new subcutaneous air in the left chest wall.\n Moderate interstitial and airspace pulmonary edema have developed, and\n moderate cardiomegaly and central venous congestion persist. Probable small\n right pleural effusion is present.\n\n IMPRESSION:\n 1. Moderate left hydropneumothorax at pleurodesis site. This was paged to\n Dr. on at 3:55 p.m.\n 2. Increased pulmonary edema.\n\n" } ]

[ { "category": "Echo", "chartdate": "2184-09-27 00:00:00.000", "description": "Report", "row_id": 101870, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 71\nWeight (lb): 235\nBSA (m2): 2.26 m2\nBP (mm Hg): 91/70\nHR (bpm): 55\nStatus: Inpatient\nDate/Time: at 10:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Site of service corrected. No changes made in findings. WJM\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild-moderate\nregional LV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views. Echocardiographic results were\nreviewed by telephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. There is mild to moderate\nregional left ventricular systolic dysfunction with severe hypokinesis of the\nbasal half of the inferior and inferolateral walls. The remaining segments\ncontract normally (LVEF = 35-40 %). Right ventricular chamber size is normal\nwith mild global free wall hypokinesis. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild to moderate (+) mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic\nfunction c/w CAD (proximal RCA distribution). Right venticular free wall\nhypokinesis. Mild-moderate mitral regurgitation with probable papillary muscle\ndysfunction.\nCompared with the prior study (images reviewed) of , the left\nventricular dysfunction is more extensive, right ventricular dysfunction and\nmitral regurgitation are new c/w interim ischemia/infarction.\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": "2184-10-07 00:00:00.000", "description": "MOD SEDATION, FIRST 30 MIN.", "row_id": 1253286, "text": " 6:50 AM\n PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # MOD SEDATION, FIRST 30 MIN.\n Reason: apiration and drainage of 2 gastric wall fluid collections\n Admitting Diagnosis: HEART FAILURE;FEVER;ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PUNC ASP ABS HEM BUL CYST CT GUIDED NEEDLE PLACTMENT *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with LUQ pain and 2 fluid collections noted on CT.\n REASON FOR THIS EXAMINATION:\n apiration and drainage of 2 gastric wall fluid collections\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT interventional procedure, aspiration of gastric wall fluid\n collection.\n\n HISTORY: 67-year-old man with left upper quadrant pain, two fluid collections\n noted on CT, please aspirate and/or drain two gastric wall fluid collections.\n\n COMPARISON: CT torso, .\n\n PROCEDURE: The risks and benefits of the procedure were explained to the\n patient, and written informed consent was obtained. A preprocedure timeout\n was performed verifying three patient identifiers and the nature of the\n procedure to be performed. Patient was placed supine on the CT table, and\n initial non-contrast CT images were obtained through the abdomen, which\n reconfirmed the presence of a moderate-sized left subphrenic/hepatic fluid\n collection. The collection in the inferior anterior gastric wall appears to\n have significantly decreased in size since prior exam. The left\n subphrenic/hepatic fluid collection was targeted for CT-guided aspiration.\n The skin of the lower anterior chest was prepped and draped in standard\n sterile fashion. Local anesthesia was achieved via subcutaneous injection of\n approximately 8 cc of 1% lidocaine. Under direct CT fluoroscopic guidance, an\n 18-gauge needle was advanced into the left subphrenic/hepatic\n collection. Approximately 18 cc of pus was aspirated and sent for\n microbiology analysis. Drainage catheter was not placed due to the small size\n of the collection. Post-procedure limited CT demonstrated the collection to\n be collapsed and markedly decreased in size compared to prior CT. Dry sterile\n dressing was placed. The patient tolerated the procedure well, with no\n complications evident at the time of the procedure. The attending\n radiologist, Dr. , was present and supervising throughout the\n procedure.\n\n MODERATE SEDATION: Moderate sedation was provided by administering divided\n doses of 100 mcg of fentanyl and 1.5 mg of Versed intravenously throughout the\n total intraservice time of 30 minutes, during which time the patient's\n hemodynamic parameters were continuously monitored by radiology department\n nursing staff.\n\n (Over)\n\n 6:50 AM\n PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # MOD SEDATION, FIRST 30 MIN.\n Reason: apiration and drainage of 2 gastric wall fluid collections\n Admitting Diagnosis: HEART FAILURE;FEVER;ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Technically successful CT-guided percutaneous aspiration of left\n subphrenic/hepatic abscess. Approximately 18 cc of purulent material\n aspirated and sent to microbiology for analysis. Of note, the previously\n noted anterior gastric wall collection has significantly decreased in size\n since CT of .\n\n" }, { "category": "ECG", "chartdate": "2184-09-27 00:00:00.000", "description": "Report", "row_id": 298126, "text": "Sinus rhythm. Occasional ventricular ectopy. The previously mentioned multiple\nabnormalities recorded on persist consistent with active ischemia.\nFollowup and clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2184-09-27 00:00:00.000", "description": "Report", "row_id": 298127, "text": "Sinus rhythm and frequent ventricular ectopy. Left ventricular hypertrophy.\nCompared to the previous tracing of there is now ST segment depression\nin leads I, aVL and V3-V6 with frequent ventricular ectopy. This is in the\ncontext of evidence for prior inferior wall myocardial infarction with\ncontinued ST segment elevation as recorded in the inferior leads on \nand unchanged. The ST segment depression and increase in rate are consistent\nwith active anterolateral ischemia. Followup and clinical correlation are\nsuggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2184-09-30 00:00:00.000", "description": "Report", "row_id": 298121, "text": "Sinus rhythm. Non-specific intraventricular conduction delay. There are\nQ waves in the inferior leads with ST segment elevation consistent with acute\nor evolving myocardial infarction. Additional non-specific ST-T wave changes.\nCompared to the previous tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2184-09-29 00:00:00.000", "description": "Report", "row_id": 298122, "text": "Sinus rhythm. Consider left atrial abnormality. Intraventricular conduction\ndelay. Possible inferior myocardial infarction, age undetermined, it may be\nacute. Other ST-T wave abnormalities. Since the previous tracing of \nthe rate is faster. Anterior ST-T wave abnormalities are now less prominent\nand the QTc interval is shorter.\n\n" }, { "category": "ECG", "chartdate": "2184-09-27 00:00:00.000", "description": "Report", "row_id": 298123, "text": "Sinus rhythm. ST-T wave changes in the anterolateral leads. No change\ncompared to earlier tracing of . Probable left ventricular hypertrophy.\n\n" }, { "category": "ECG", "chartdate": "2184-09-27 00:00:00.000", "description": "Report", "row_id": 298124, "text": "\n\n\n" }, { "category": "ECG", "chartdate": "2184-09-27 00:00:00.000", "description": "Report", "row_id": 298125, "text": "Sinus rhythm with slowing of the rate as compared with prior tracing\nof . The ischemic appearing lateral ST segment changes are less\nprominent while there is now right precordial ST segment depression consistent\nwith posterior ischemia, in the context of some variation in precordial lead\nplacement. Rule out infarction. Followup and clinical correlation are\nsuggested.\nTRACING #3\n\n" } ]

[ { "category": "Echo", "chartdate": "2161-05-16 00:00:00.000", "description": "Report", "row_id": 63497, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 186\nBSA (m2): 2.05 m2\nBP (mm Hg): 150/72\nHR (bpm): 44\nStatus: Inpatient\nDate/Time: at 15:16\nTest: TTE (Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Overall\nleft ventricular systolic function is low normal (LVEF 50-55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: A mechanical aortic valve prosthesis is present. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: The patient is bradycardic (HR<60bpm). Emergency study\nperformed by the cardiology fellow on call.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). Right ventricular chamber size\nand free wall motion are normal. A mechanical aortic valve prosthesis is\npresent.Aortic gradients were not assessed. Mild (1+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is a trivial/physiologic pericardial effusion.\n\nCompared to the report of , there is no significant change\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 827460, "text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf vs infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with c/o's sob with 10 lb wt gain over past 3days\n REASON FOR THIS EXAMINATION:\n eval for chf vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Short of breath with 10-pound weight gain. Evaluate for CHF vs.\n infiltrate.\n\n SINGLE AP PORTABLE UPRIGHT CHEST:\n\n FINDINGS: Comparison is made to prior AP portable chest dated .\n The heart size and mediastinal contours are unchanged. Slight unfolding of\n the thoracic aorta, unchanged. In comparison with the previous examination,\n there is interval increased prominence of the pulmonary vasculature and\n perihilar and and bibasilar hazy opacity. No pleural effusions. No\n pneumothorax. The surrounding osseous structures appear unchanged. Sternal\n suture wires and mediastinal clips in unchanged configuration.\n\n IMPRESSION:\n\n Mild congestive heart failure. No pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-19 00:00:00.000", "description": "EXERCISE MIBI", "row_id": 827687, "text": "EXERCISE MIBI Clip # \n Reason: CAD EVALUATION.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sixty-five year old man with CAD, s/p CABG and AVR, who presents with\n chest pain and shortness of breath. CAD Evaluation.\n\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Exercise protocol: Modified .\n Exercise duration: 7 minutes.\n Percent maximum predicted heart rate obtained: 70%.\n Symptoms during exercise: no anginal symptoms.\n Reason exercise terminated: fatigue.\n ECG findings: no ST changes.\n\n INTERPRETATION:\n Imaging Protocol: gated SPECT.\n Resting perfusion images were obtained with Tl-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n Exercise images were obtained with Tc-m sestamibi.\n\n Stress images show a mild perfusion defect of the inferior wall.\n Resting perfusion images show resolution of this defect.\n\n Ejection fraction calculated from gated wall motion images obtained after\n exercise is 50%. There is lack of septal translation, consistent with the prior\n history of CABG.\n\n IMPRESSION: Mild, reversible inferior defect with EF 50%.\n /nkg\n\n\n , M.D.\n , M.D. Approved: 11:34 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Nursing/other", "chartdate": "2161-05-17 00:00:00.000", "description": "Report", "row_id": 1356303, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I HAD A PRETTY GOOD SLEEP\"\n\nO: NEURO: SEE CAREVUE FOR CIWA. GIVEN ATIVAN LAST NOC WITH GOOD EFFECT. SLEPT IN LONG NAPS OVERNIGHT AFTER RECEIVING AMBIEN. MOVING ALL EXTREMITIES WELL. DENIES C/O PAIN.\n\nCV: HR 45-50 SB WITH OCC MISSED BEATS. CONT ON NTG IV AT .7 MCG/KG/MIN. DENIES CHEST PAIN WHEN ASKED. SEE CAREVUE FOR VS DATA.\n\nRESP: CONGESTED COUGH, RAISING TO BACK OF THROAT AND SWALLOWING. GIVEN COUGH MED WITH FAIR EFFECT. EXP WHEEZE NOTED. WILL BENEFIT FROM ATROVENT MDI. (HEAVY SMOKER UNTIL 1 WEEK AGO) O2 SAT ON 2L 98%. DENIES C/O SOB.\n\nGI: ABD SOFT, + BOWEL SOUNDS. NO BM OVERNIGHT. TAKING SIPS OF JUICE THIS AM.\n\nGU: VOIDING IN LARGE AMTS USING URINAL. NO ADDITIONAL LASIX GIVEN.\n\nSKIN: INTACT.\n\nA: STABLE NOC, S/P MI\n\nP: CONT TO FOLLOW CK, TROP, LYTES. ? CATH NEXT WEEK\n" }, { "category": "Nursing/other", "chartdate": "2161-05-17 00:00:00.000", "description": "Report", "row_id": 1356304, "text": "Nsg Progress Note\n\nS: \"Am I going home today?\"\n\nO: Please see flow sheet for objective data. Tele remains in sinus brady 40's-50's. Beta Blockers remain on hold. To remain on Coumadin 5mg qd. INR 3.8 this am. Lisinopril increased to 40mg qd and IV nitro weaned off. BP stable.\n\nResp: Lungs with scattered rales and occ exp wheezes. Conts to have dry nonproductive cough. Given cough med with little effect. O2 sat 94-96%.\n\nNeuro: Pt is alert and oriented. Given ativan 1mg po x's2. Sleeping off and on. No evidence of tremors or withdrawal see CIWA scale. OOB to chair tolerated well.\n\nEndo: BS remain elevated today. Started on NPH and SS doses increased. BS remain > 280.\n\nGU/GI: Tolerating diet well. Abd is soft with bowel sounds present. Given Lasix 40mg iv this am with good diuresis. Creat 1.2\n\nA&P: CHF resolving with lasix. BS remain elevated with increase in insulin cont to monitor and adjust doses as needed. Transfer to floor when bed available. Possible stress test early next week.\n" }, { "category": "Nursing/other", "chartdate": "2161-05-16 00:00:00.000", "description": "Report", "row_id": 1356302, "text": "Nursing Progress Note\n\n65 yo man with IDDM & known CAD s/p AVR CABG x's 2 in . Has had recent CV for AF c/b hypotension requiring fluid boluses pt discharged and has gradually felt more short of breath and says his weight is up approx 10 lbs. Presented to the ED today ECG with ST elevation V1&V2. CK bump. Tx'd with Lasix and IV Nitro with good diuresis and relief of symptoms. Pt transferred for R/O and further observation.\n\nCV: Tele sinus brady. Atenolol being held. Started on Plavix received 300mg today. Pt is to remain on Coumadin. INR 3.4 on admit.\n\nResp: Lungs with rales throughout the bases. O2 sat 96-98% on 2lnp. Denies shortness of breath.\n\nNeuro: Pt is alert and oriented. Able to move all extremities. Pt states that until recently he would have up to 10 beers a day. States that he now has /day. Please see CIWA scale. Given ativan 1mg po.\n\nGU/GI: Tolerating diet well. Abd is soft with bowel sounds present. Voiding good amts of clear yellow urine. Creat 1.2\n\nA&P: Cont to r/o MI. Plan is to treat pt medically at this time pt will not be cathed. Lasix prn. coumadin as per orders.\n" }, { "category": "ECG", "chartdate": "2161-05-21 00:00:00.000", "description": "Report", "row_id": 126722, "text": "Sinus bradycardia\nFirst degree AV block\nIntraventricular conduction defect\nLeft ventricular hypertrophy\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2161-05-17 00:00:00.000", "description": "Report", "row_id": 126723, "text": "Sinus bradycardia\nFirst degree A-V block\nIntraventricular conduction defect\nLeft ventricular hypertrophy\nSince previous tracing, Q waves in leads V4-V6 are gone\n\n" }, { "category": "ECG", "chartdate": "2161-05-16 00:00:00.000", "description": "Report", "row_id": 126724, "text": "Sinus bradycardia\nFirst degree A-V block\nLeft axis deviation\nIntraventricular conduction defect\nLeft ventricular hypertrophy\nAnterolateral myocardial infarct\nSince previous tracing, anterolateral myocardial infarct is new\n\n" }, { "category": "ECG", "chartdate": "2161-05-16 00:00:00.000", "description": "Report", "row_id": 126772, "text": "Sinus bradycardia with 1st degree A-V block\nIV conduction defect\nPossible left ventricular hypertrophy\nDiffuse ST-T wave changes - consider ischemia\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2161-05-16 00:00:00.000", "description": "Report", "row_id": 126773, "text": "Regular rhythm\nLeft ventricular hypertrophy\nIntraventricular conduction delay\nDiffuse ST-T wave changes - consider ischemia\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2161-05-14 00:00:00.000", "description": "Report", "row_id": 126774, "text": "Sinus bradycardia with first degree A-V block. Since earlier this date the\nrhythm has reverted to sinus mechanism and the rate has slowed. Inferior\nST-T wave abnormalities are increased and the Q-T interval is prolonged\nconsistent with ischemia.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2161-05-14 00:00:00.000", "description": "Report", "row_id": 126775, "text": "Atrial fibrillation. Since the previous tracing of atrial fibrillation\nhas reappeared and the rate has increased. ST-T wave abnormalities persist.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2136-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1201612, "text": " 4:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NG and ETT placement\n Admitting Diagnosis: DIVERTING COLOSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p colectomy\n REASON FOR THIS EXAMINATION:\n NG and ETT placement\n ______________________________________________________________________________\n WET READ: ENYa FRI 11:33 PM\n ETT tip at 4.7 above the carina. NGT tip in the stoamch. Improved aeration\n of the LLL. Persistent diffuse opacities compatible with mild-to-moderate\n pulmonary edema/congestion. Bilateral pleural effusions. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Status post colectomy, NG and ETT placement.\n\n COMPARISON: Earlier same day, 1439 hours.\n\n ETT is 4.7 cm above the carina, NG tube shows the tip in the stomach.\n Bilateral pleural effusions and bilateral infiltrates left greater than right\n are unchanged. Moderate perihilar edema is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1201589, "text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema\n Admitting Diagnosis: DIVERTING COLOSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p colostomy takedown with decreased O2 sat\n REASON FOR THIS EXAMINATION:\n pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man status post colostomy takedown with decreased O2\n sats, question pulmonary edema.\n\n COMPARISON: Multiple chest radiographs latest from .\n\n The lungs are low in volume and show a near-complete opacification of the left\n lung with mild right middle lobe opacification. The cardiac silhouette is not\n well evaluated. The mediastinal silhouette is normal. There is likely a\n large left pleural effusion. Fractured sternal wires are unchanged.\n\n IMPRESSION:\n\n Opacification of the left lung likely represents a combination of collapse,\n edema and effusion.\n\n" }, { "category": "Radiology", "chartdate": "2136-08-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1201797, "text": " 10:11 AM\n CHEST (PA & LAT) Clip # \n Reason: eval pulmonary edema\n Admitting Diagnosis: DIVERTING COLOSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p colostomy take down, post-op CHF\n REASON FOR THIS EXAMINATION:\n eval pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n HISTORY: Postop congestive heart failure.\n\n COMPARISON: at 14:55 hours.\n\n The patient is post-CABG. There are fractures through the superior sternal\n wires. The heart is upper limits of normal in size. There is no pulmonary\n vascular congestion. Lungs are generally well aerated with minimal\n peribronchial prominence in the right middle lobe area. Pleural spaces are\n clear.\n\n IMPRESSION: Near complete resolution of congestive heart failure.\n\n\n" }, { "category": "ECG", "chartdate": "2136-08-19 00:00:00.000", "description": "Report", "row_id": 236154, "text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with\nsecondary repolarization changes. Compared to tracing #1 no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2136-08-17 00:00:00.000", "description": "Report", "row_id": 236371, "text": "Sinus rhythm. Left atrial abnormality. Prior inferior myocardial infarction,\nage undetermined. Left ventricular hypertrophy with secondary repolarization\naabnormalities. Compared to the previous tracing of the findings are\nsimilar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2136-08-18 00:00:00.000", "description": "Report", "row_id": 236372, "text": "Normal sinus rhythm. Left ventricular hypertrophy with secondary ST-T wave\nabnormalities. Prior inferior myocardial infarction. Compared to the previous\ntracing of the secondary repolarization abnormalities are less\nprominent.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2145-07-14 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1201330, "text": " 10:48 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: eval for disc herniation with cord compression\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with worsening UE/LE weakness after acute onset c-spine and\n lumbar p[ain while lifting a box 4d ago\n REASON FOR THIS EXAMINATION:\n eval for disc herniation with cord compression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:08 AM\n No acute fx or malalignment. No cord signal abnl. Multilevel DJD w/ broad\n based disc-osteophyte complex at C3-C4 thru C6-C7, but most prominent at C4-C5\n where there is moderate canal stenosis and b/l neural foraminal narrowing.\n Disc bulge at L5-S1 with mild canal stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 61-year-old man with worsening upper extremity and lower\n extremity weakness after acute onset cervical and lumbar pain while lifting a\n heavy box. To rule out disc herniation with cord compression.\n\n STUDY: MRI cervical, thoracic, and lumbar spine without contrast.\n\n TECHNIQUE: Sagittal T1, T2, and STIR images an axial T2 were obtained of the\n thoracic, cervical, and lumbar spine.\n\n COMPARISON STUDY: None.\n\n FINDINGS:\n\n CERVICAL SPINE: There is loss of normal cervical lordosis. There is minimal\n anterolisthesis of C2 over C3 and retrolisthesis of C3 over C4 vertebra. The\n vertebral bodies are normal in height. The marrow of C1-C5 vertebrae appears\n hyperintense on T1- and T2-weighted images suggestive of fatty marrow. This\n is secondary to radiation treatment.\n\n At C3-C4, there is diffuse posterior disc bulge which is causing indentation\n of the thecal sac with mild spinal canal stenosis. The disc with facet and\n uncovertebral osteophytes causes mild bilateral foraminal stenosis (right more\n than left).\n\n At C4-C5, there is diffuse posterior disc bulge causing indentation of the\n anterior subarachnoid space and mild spinal canal stenosis. The disc with\n facet and uncovertebral osteophytes causes mild bilateral neural foraminal\n narrowing.\n\n At C5-C6, there is diffuse posterior disc bulge without significant spinal\n canal or neural foraminal narrowing.\n\n At C6-C7, there is diffuse posterior disc bulge without significant spinal\n canal or neural foraminal narrowing.\n (Over)\n\n 10:48 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: eval for disc herniation with cord compression\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n THORACIC SPINE: The vertebral bodies are normal in height and marrow signal\n intensity. There is no evidence of significant spinal canal or neural\n foraminal narrowing in thoracic spine.\n\n The cervical and thoracic spinal cord appears normal in signal intensity\n without any focal abnormality.\n\n LUMBAR SPINE:\n\n At L3-L4, there is diffuse posterior disc bulge without significant spinal\n canal or neural foraminal narrowing.\n\n At L4-L5, there is diffuse posterior disc bulge without significant spinal\n canal or neural foraminal narrowing.\n\n At L5-S1, there is broad-based posterior disc protrusion without spinal canal\n stenosis. The disc with facet osteophytes causes mild bilateral neural\n foraminal narrowing and contacts the traversing left S1 nerve root on the left\n side.\n\n The conus medullaris ends at L1-L2 level. The distal spinal cord appears\n normal.\n\n There is no evidence of acute fracture. The paraspinal soft tissues appear\n normal.\n\n IMPRESSION:\n Degenerative disc disease of cervical and lumbar spine which is most severe at\n C3-C4 and L5-S1 levels causing mild bilateral neural foraminal narrowing at\n these levels. No evidence of paraspinal soft tissue injury or acute fracture.\n No evidence of cord compression.\n\n The findings were discussed with Dr. on at 8:20 AM.\n\n" }, { "category": "Radiology", "chartdate": "2145-07-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1201440, "text": " 2:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 50cm iv \n Admitting Diagnosis: MUSCLE WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 50cm iv \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line placement.\n\n TECHNIQUE: AP semi-erect radiograph of the chest.\n\n IMPRESSION: The tip of the right PICC line is terminating at cavoatrial\n junction. lung volumes are low. -basal atelectasis is minimal. Otherwise,\n lungs are clear and without consolidation. Heart size is top normal.\n Mediastinal and hilar contours are normal. There is no pleural\n effusion/pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2145-07-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1201479, "text": " 7:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: movement of CXR\n Admitting Diagnosis: MUSCLE WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pain in his chest with infusion of IVF's into the PICC\n REASON FOR THIS EXAMINATION:\n movement of CXR\n ______________________________________________________________________________\n WET READ: 10:10 PM\n Minimal interval change. Right PICC ends in the lower SVC\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Chest pain during PICC line usage.\n\n Portable AP chest radiograph was reviewed in comparison to \n obtained at 2:16 p.m.\n\n The tip of the PICC line is not clearly seen beyond the cavoatrial junction.\n Consider repeat chest radiograph with lateral view.\n\n Heart size is normal. Mediastinum is normal. Minimal bibasilar opacities are\n unchanged. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-07-18 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1201831, "text": " 3:48 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: PT WITH RUE SWELLING, R/O DVT\n Admitting Diagnosis: MUSCLE WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with PICC in the rue, please eval for dvt?\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n WET READ: SPfc SUN 4:32 PM\n MINIMAL RIGHT AXILLARY VEIN NON-OCCLUSIVE THROMBUS ADJACENT TO THE PICC.\n DISCUSSED VIA TELEPHONE BY DR. WITH DR. AT 16:32 ON -11\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Peripherally inserted central catheter in the right upper\n extremity with swelling and question of deep venous thrombosis.\n\n COMPARISON: None available.\n\n FINDINGS: Waveforms in the subclavian veins are symmetric bilaterally. The\n right internal jugular, paired right brachials, right basilic, and right\n cephalic veins all compress appropriately and show normal wall-to-wall flow on\n color Doppler analysis and appropriate venous waveforms. The right axillary\n vein is notable for a small amount of isoechoic material within the lumen of\n the vessel adjacent to the peripherally inserted central catheter, consistent\n with a small amount of non-occlusive thrombus. A peripherally inserted\n central catheter is visualized through the right basilic, axillary, and\n subclavian veins.\n\n IMPRESSION: Non-occlusive thrombus in the right axillary vein.\n\n These results were discussed over the telephone by Dr. with Dr. \n at 16:34 on .\n\n\n" }, { "category": "ECG", "chartdate": "2145-07-19 00:00:00.000", "description": "Report", "row_id": 249022, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthe Q-T interval has normalized.\n\n" }, { "category": "ECG", "chartdate": "2145-07-16 00:00:00.000", "description": "Report", "row_id": 249023, "text": "Sinus rhythm. The tracing is marred by baseline artifact. The Q-T interval\nremains prolonged as compared with previous tracing of . Otherwise,\nno diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-07-15 00:00:00.000", "description": "Report", "row_id": 249243, "text": "Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\nof the T wave abnormalities have improved. The Q-T interval remains\nprolonged. Otherwise, no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-07-15 00:00:00.000", "description": "Report", "row_id": 249244, "text": "Normal sinus rhythm. Prolonged Q-T interval. Extensive ST-T wave changes.\nCompared to tracing #2 no diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2145-07-15 00:00:00.000", "description": "Report", "row_id": 249245, "text": "Normal sinus rhythm. Left atrial abnormality. Marked Q-T interval prolongation.\nCompared to tracing #1 there is no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-07-15 00:00:00.000", "description": "Report", "row_id": 249246, "text": "Normal sinus rhythm. Left atrial abnormality. Q-T interval prolongation.\nNon-specific ST-T wave abnormalities. No previous tracing available for\ncomparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793020, "text": "Progress Note 1900-0700\n\n\n1. RESP: O: Infant on RA, breathing 40-60s, sats >95%. No\nretractions noted. LS clr/=. No apnea or spells so far this\nshift. A: Tolerating RA. P: Cont to monitor.\n\n2. FEN: O: TF min 40cc/kg/d of E20. All feeds po. BF x2 this\nshift for up to 20 minutes; pc'ing with up to 20cc E20. Abd\nexam benign, +BS. Voiding and stooling well. No spits.\nWeight loss of 10g. A: Tolerating feeds. P: Cont to montior.\n\n3. DEV: O: is sleepy for most cares. Quietly looks\naround and at mother during feeds. Temps stable swaddled in\nopen crib. L hand PIV appears c/d/i. A: AGA. P: Cont to\nsupport needs.\n\n4. PARENTS: O: Mom in to visit with father and other family\nmembers for cares tonight. Mom very independent with\ncares/feeds. Attempting to BF both twins. FOB involved.\nActing appropriate. Mom still in-house, due to D/C Monday.\nA: Attentive, loving mother with good support system. P:\nCont to support family's needs.\n\n5. SEPSIS: O: Blood cx pending; sent Sat AM. CBC benign. Mom\nGBS+. Infant afebrile. Receiving ampi/gent for 48hour r/o.\nA: No s/s infx noted. P: Cont to monitor, refer to bcx\nresults.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793021, "text": "Agree with above co-worker note by . To add Dstix=59 prior to feeds, took 35cc E20 this am, mom getting rest-did not come to BF.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793022, "text": "Co-worker note 7a-7p\n\n\nRES: Infant remains in RA, RR 50-70's. No retractions noted\nduring cares. LS cl/=. Sats >96%.\n\nFEN: BW 2495, current wt 2485, down 10g. TF: min 40cc/k/d pf\nE20/BM =17cc q4hr. Infant PO's >35cc very well at each\nfeed.Mom BF 10min at 1300 and supplemented with PO feed\nafter BF. D/S at 0900 was 65. Infant has had 2small spits\nafter Po feeds. AG=24.5-25cm. Abd benign, no loops, +BS.\nVoiding and passing mec stool. IV heplocked in L hand.\n\nG&D: Infant remains swaddled in an OAC with stable temps.\nQuietly active and alert with cares. Wakes for feeds. Mom\ngave today.\n\nPAR:Mom in for 1300cares and given Hep B information and\nconsent form today by RN. Rn discussed PKU with Mom. She is\nvery good with the boys, very loving and independent with\ncares, temp, and diaper change.Mom will be dc'ed tomorrow.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793023, "text": "Co-worker note 7a-7p\nAddendum:\n\nFEN: TF: increased to 80cc/k/d= 33cc/k/d.\n\nG&D: Hep B needs to be given (Mom signed the consent), carseat test needs to be done, VNA referral to be started, and PKU needs to be done. Possible discharge tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793024, "text": "NICU Attending Note\n\nDOL # 1, born at 34 5/7 weeks, approaching readiness for d/c to home\n\nCVR/RESP: RA, no A/B, will continue to monitor.\n\nFEN: Weight today 2485 gm, donw 10 gm from BW. On ad lib feeds, taking E20/MM20, taking adequate volume, breast feeding well. D stick 100. WIll continue current diet.\n\nBILI: bili this am 5.0/0.4, will monitor clinically.\n\nENV't: Stable temp in open crib, will continue to follow temps.\n\nDISPO: If no A/B, continues to feed well, temp remains stable, anticipate d/c to home tomorrow. D/c planning/teaching ongoing.\n\nPEx to follow.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793025, "text": "NICU Attending Note\nPEx: AFSOF, lungs clear, BSE, no G/F/R, RRR without murmur, abd benign, skin warm and well perfused, alert and responsive with appropriate tone and strength.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-19 00:00:00.000", "description": "Report", "row_id": 1793017, "text": "Nsg admission note\n 34 5/7wk infant born at 0428 to a 22yo G3 now P3 woman. See Dr and NNP Buck's notes for hx and delivery. He is adm to the NICU for R/O sepsis and prematurity.\n Resp: Rec brief BB O2 in DR. NICU sats >97%. RR 40-50. LS cl/=. No increased WOB.\n CV: No murmur,pink,perfused. HR 150-160's. BP 83/55 65. 73/45 55.\n ID: Bl culture drawn, CBC sent WBC 8.2 dif pnd. PIV placed in L hand. Gent and Ampi started. Temp on adm 99.4R.\n FEN: BW 2495. DS 60. Has not voided or stooled. Abd soft, flat.\n DEV: Vigorous cry. MAE. AFSO, Gd tone. Temp 99.4 nested under radiant warmer.\n PARENTS: Came to NICU to visit, with MGM. Mom asking when she can BF infant. She did hold briefly in DR. end of visit felt nauseated and vomited. Has gone to room to rest. She will call later today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-19 00:00:00.000", "description": "Report", "row_id": 1793018, "text": "NEONATOLOGY ATTENDING\n\nDay 0. 34 weeker.\n\nRESP: Comfortable on RA. No spells.\n\nCV: Good HR, perfusion. BP 65/37/52.\n\nID: On ampi and genta.\n\nHEME: WBC 8.6, plt 252. Dif 29/0/59/....\n\nFEN: 2495, ad lib 20 cal HBM/PE. DS stable (56). Voiding, no stool yet.\n\nACCESS: IV to hep lock.\n\nDVLP: Got a little warm on warmer. Swaddled, mock crib.\n\nOTHER: Undescended testis noted.\n\nPARENTS: Parents have not been in yet this AM.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-19 00:00:00.000", "description": "Report", "row_id": 1793019, "text": "NPN 0700-1900\n\n1 Resp\n2 FEN\n3 G/D\n4 Parents\n5 Sepsis\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 95%. Clear/=. RR 30-50's. No retractions\nnoted. No spells this shift. P: Cont. to monitor resp.\nstatus.\n\n2. FEN: Infant remains adlib with a min of 40 cc/kg/day\nwhich is 17 cc of E20 or BM20. Infant bottled 30cc, and then\nbreastfed >15 min with good suck x2. Tolerating feedings\nwell; abd exam benign and no spits. D/S 66. Voiding qs and\nstooled mec x1. IV is heplocked. P: Cont. to support\nnutritional needs.\n\n3. G/D: Temps stable in open air crib since 0900 this am.\nAlert and active with cares. Settles well in between.\nInfant acting appropriate with cares. MAEW. AFSF. AGA.\nP: Cont. to support developmental needs.\n\n4. Parents: Mom in for 1300 and 1700 cares. Independent\nwith diapering, taking temp, bottling, and breastfeeding.\nUpdated at bedside on infant's condition and plan of care.\nAsking appropriate questions. Mother is very comfortable\nhandling infant. Father of baby and mother's other son will\nbe in to visit this evening. Loving, involved mother. P:\nCont. to support and update parents.\n\n5. Sepsis: Infant continues on ampi and gent. CBC drawn -\ndiff reassuring. BC pending. No s/s of infection: temps\nstable and infant acting appropriate with cares. P: Cont.\nto administer ampi/gent until 48 hr r/o and monitor for s/s\nof infection.\n\nREVISIONS TO PATHWAY:\n\n 1 Resp; added\n Start date: \n 2 FEN; added\n Start date: \n 3 G/D; added\n Start date: \n 4 Parents; added\n Start date: \n 5 Sepsis; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-19 00:00:00.000", "description": "Report", "row_id": 1793015, "text": "NICU ADMISSION NOTE\nAsked by Dr. to attend preterm twin delivery. This twin male # 2 admitted to NICU for prematurity.\n\n2495 gm product of a 34 week gestation pregnancy born to a 22 year old G3 P1 Living 1 black woman. EDC by 8 week ultrasound, spontaneous twins. Prenatal screens: B+/antibody negative/Rubella immune/RPR non-reactive/HepBSAg negative/GBS unknown. Prior OB history notable for 23 week loss in , SVD at term s/p circlage placement. This pregnancy with circlage placed at 21 weeks. Admitted with contractions, circlage removed and allowed to deliver. Mother initially treated with IV Penicillin due to unknown GBS status. Fever to 100.4 prompted treatment with Ampicillin and Gentamicin. ROM of twin #1 6 hours prior to delivery. Twin #1 born by SVD. This twin with ROM 2 minutes prior to delivery and born by SVD 9 minutes after twin #1. Infant emerged with spontaneous cry, dried, bulb suctioned, blowby O2 briefly. Apgars 8, 9. Admitted to NICU. O2 saturation 99% in room air, no respiratory distress. BP 83/55. CBC and blood culture obtained. Glucose=60.\n\n\nPHYSICAL EXAM wgt=2495 gm (75%ile) L=47 cm (75%ile)\n HC=34 cm ( > 90%ile)\nSee Newborn Exam Record for details of PE.\n\nIMPRESSION: well-appearing 34 week gestation male, no respiratory distress; sepsis risk factors maternal fever, prematurity, pre-term labor, mutiple birth, unknown GBS status.\n\nPLAN: Observe in NICU with ususal CVR monitoring.\nTreat with IV Ampicillin and Gentamicin pending culture results and CBC results.\nAttempt PO feeds; PG supplement as necessary.\nUsual attenion to thermal and metabolic issues.\nParent aware of our initial impressions and plan of care.\nPrimary Pediatrician Dr. , Health Center.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-19 00:00:00.000", "description": "Report", "row_id": 1793016, "text": "Neonatology Attending Admit Note\n\nInfant's history, exam and management plan reviewed with NNP staff. Patient seen and examined.\n\nHistory as stated above.\n\nCurrently on exam:\nResting comfortably on radiant warmer. +hat. Some molding. AFOF. Sutures approximated. Lungs CTA. CV RRR, no murmur, 2+FP. Abd soft, +BS. No HSM. Nl phallus. Testes down bilat. Patent anus. Ext pink and well perfused. Left arm PIV.\n\nImpression:\n1. Preterm, AGA, male twin II.\n2. r/o Sepsis, with antibiotics.\n3. HC > 90%, exam normal.\n4. Monitor for AOP.\n\nPlan:\nWill monitor. Allow to po ad lib. Continue amp and gent pending cx results and clinical course. Follow head circ and neurological exam for now.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-20 00:00:00.000", "description": "Report", "row_id": 1793026, "text": "NPN 0700-1900\n I have read and agree with above co-worker's note and assessments per flowsheet. Discharge teaching was reviewed with mother. Hep B was given. Ampi was given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-21 00:00:00.000", "description": "Report", "row_id": 1793027, "text": "Nursing progress note\n\n\n#1 O: Remains in room air with equal & clear breath sounds &\nno retractions. O2 sat monitor d/c'd. A: Stable. P: Resolve\nproblem.\n#2 O: wgt down 50gms. Cont to receive minimumof 80cc/k/d PO\nfeeds plus breast feeding. Mom up for 2 feedings. Baby\nnursed fairly well & bottled after. Abd soft with active\nbowel sounds. Voiding with diaper changes. Sm spit X's 1. A:\nTolerating feeds. P: Cont to assess.\n#3 O: Alert with cares. Temp stable in crib. Baby passed\nhearing screen & car seat test. A: AGA. P: Cont to assess.\n#4 O: Mom & Dad up to visit. Mom very independent with\ncares. A: Involved parents. P: Support.\n#5 O: Blood cultures neg to date. No S&S of sepsis. Cultures\nto be cheked at 5AM & if neg antibiotics will be d/c'd. A:\nStable. P: Cont to assess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-03-21 00:00:00.000", "description": "Report", "row_id": 1793028, "text": "Neonatology Attending Note\nDay 2\n\nRA. BS cl and =. No A&Bs. Wt down 50. Min 80 cc/k/day of E20/BF tol well. Stable temps in open crib.\n\nHas passed hearing and car seat screening. Needs Hep B and Synagis. Arrange VNA services. Prepare for discharge today. Please see dictation/bedside chart for further details.\n" }, { "category": "Nursing/other", "chartdate": "2140-03-21 00:00:00.000", "description": "Report", "row_id": 1793029, "text": "NPN Discharge note\n\n\n1. Resp: Infant remains in RA. No spells this shift. Lungs\nclear/=. Problem resolved.\n\n2. FEN: Infant TF are adlib with a min of 80 cc/kg/day.\nInfant bottled 81 cc/kg/day + breastfeeding yesterday.\nInfant breastfeeding well with vigorous suck for >15 minutes\nand bottling 20-35cc with good coordination. Tolerating\nfeedings well; abd exam benign and no spits. Voiding qs and\nstooling transitional stools. Mom aware of feeding plan to\nbreastfeed and then supplement with E20 following.\n\n3. Sepsis: Infant completed 48 hrs of ampi/gent. CBC\nbenign, bld cultures were negative. Problem resolved.\n\n4. G/D: Temps remains stable swaddled in open air crib.\nAlert and active with cares. Infant waking q 3-4 hrs for\nfeedings. AFSF. MAEW. AGA. Infant passed hearing screen\nand car seat test. Infant received Hep. B and synagis. PKU\nwas sent. Circumcision dome today by Dr. . Mom was\ninstructed on circ care. No drainage or oozing noted from\nsite.\n\n5. Parents: Mom in throughout day. Independent with cares.\nDiscahrge teaching was completed with mother, including when\nto call doctor, protecting from infection, taking temp, and\nback to sleep. Mother verbalized understanding of teaching.\nDad was in to pick up infants. VNA referral was faxed over\nto VNA - to visit tomorrow. Pedi appt is scheduled\nfor . Discharge order was written. Tags were checked\nwith mother. Infant was discharged home in carseat.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2142-06-13 00:00:00.000", "description": "Report", "row_id": 99169, "text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Atrial fibrillation.\nHeight: (in) 61\nWeight (lb): 180\nBSA (m2): 1.81 m2\nBP (mm Hg): 133/50\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 15:57\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: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\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: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction with basal to mid inferior and infero-lateral\nhypokinesis. There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2142-06-15 00:00:00.000", "description": "Report", "row_id": 279893, "text": "Sinus bradycardia. Diffuse non-diagnostic T wave flattening. Non-diagnostic\ninferior Q wave pattern. Cannot exclude prior inferior myocardial infarction.\nCompared to the previous tracing of no major change.\n\n" }, { "category": "ECG", "chartdate": "2142-06-13 00:00:00.000", "description": "Report", "row_id": 279894, "text": "Sinus rhythm. Probable prior inferior myocardial infarction. Anterior and\nlateral ST-T wave changes may be due to myocardial ischemia. Compared to\ntracing #1 the findings are similar. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2142-06-11 00:00:00.000", "description": "Report", "row_id": 279895, "text": "Sinus rhythm. Intraventricular conduction defect. Prior inferior myocardial\ninfarction. Non-specific anterior and lateral ST-T wave changes. Compared to\nthe previous tracing of the lateral ST-T wave changes are more obvious.\nThe other findings are similar.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2142-06-14 00:00:00.000", "description": "Report", "row_id": 1263287, "text": "assessment as noted in carevue\n\nwas in nsr 10am-until 0930pm last night and then went into a/fib. lopressor was increased to 50 , pt got 2 doses lopressor iv 5+5 , she is also on oral amiodorone 400bid. bp remained stable 120-140 sys and still remains in a/fib 100/110\n\nres: strong cough, IS upto 5, ls diminished mostly, maintains sat >96 on 6lnc, encouraged deep breathing and coughing, OOB to chair twice.\nct intact, drains small amnt s/s secretions,\n\ngi: no nausea, tol clears well, fair appetite\n\ndenies pain most of the time, says she feels comfortable even with activity\n\nsocial: daughter was in last ngiht to visit\n\nplan: d/c chest tube, reapeat cardiology consult, monitor HR/BP\n" }, { "category": "Nursing/other", "chartdate": "2142-06-12 00:00:00.000", "description": "Report", "row_id": 1263282, "text": "NPN: S/P L thoractomy for LLL resection\n\nNeuro: Alert and oriented X2-3. Moves all extremities with equal strength. Conversing appropriately. PERRL.\nID: Tmax 97.9 orally. WBC 9.2. Cefazolin 1gm IV given.\nCV: 70-90 SR with rare PVC's seen. Pt requiring neo to 1.0 and LR boluses for MAP>65- now weaned off. Given 1u PRBC's for hct 27.2. Palpable pedal pulses. Elevated CK's with trop .04-.06. Lopressor held r/t low BP( on neo). CVP-.\nResp: Lungs diminished in bases with crackles on R. L CT to 20cm dry suction. No airleak seen. Serosang drainage. Cough fair-productive small amts clear secretions-? usually swallows. Requiring 4l nc and 50% OFT neb to maintain sats>94%. ABG's remain with metabolic acidosis 7.27. CXR done this am.\nGU: Foley-UO initially 10-0cc. Given LR and Hespan with some improvement. Creat 1.7. Now UO-20-40cc/hr\nGI: Abdomen obese soft, NT and ND. C/O low abdomen-pubic pain early-now resolved. LR at 100cc/hr. Lactate improving 2.2. No N/V.\nEndo: Glucoses covered per sliding scale 168-148.\nActivity: Turned side to sdie q 2 hrs. Pt moves well with 2 assists.\nComfort: Dialudid 1-.5mg IV q 2 hrs with good effect for c/o Incisional and L shoulder pain with deep breaths.\nIncisions: L thoracotomy amd small L back OTA-C/D. L CT with DSD -D/I.\nA: Remains with metabolic acidosis -still requirng further fluid resuscitation.\nP: Recheck ABG this am. Follow uo-recheck hct. Pulmonary toilet. OOB to chair. Pain manageemnt. Follow CK's/troponin.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-06-12 00:00:00.000", "description": "Report", "row_id": 1263283, "text": "Nursing (0700-1900)\nEVENTS:\nOngoing attemps to increase BP and UO today with fluid boluses and colloids.\nPt. converted to RAF this afternoon, now on amiodarone gtt.\n\nSee vitals as noted. RAF at 1500 (as high as 160's) with drop in BP noted as low as 68/syst. Pt. was given lopressor 2.5mg X 2 with some decrease in HR (BP tolerated.) Amiodarone bolus given, gtt started. This eve additional amiodarone bolus given for cont'd tachycardia, though HR down to 110-120. BP within acceptable range per thoracic and ICU teams. Pt. awake, warm, dry, pink. However pt. did develop intermittent midsternal chest \"heaviness\" and difficulty taking deep breaths. She also dropped her sat on NP and required addition of FT. Crackles noted all day, but slight increase in quality this afternoon with arrythmia. CXR done, no CHF noted, however in light of elevated CVP in AF, Dr. ordered lasix dose. Small response noted. Labs drawn, fairly stable, trop (-), urine lytes sent, pt. is still appearing pre-renal. IVF KVO's at this time. Some peripheral edema becoming apparent.\n\nPulmonary assessment as above. CT to water seal without incident per Dr. this afternoon. Prior to this episode pt. got OOB and sat up for 3.5 hours. Utilizing IS independently. ABG's largely unchanged.\n\nPt. was beginning to advance diet, but this eve's cxr revealed large amt. gas, preferred now to take clears. Pt. nervous to take prednisone today, given zofran and pepcid with it without incident. Pt. ate applesauce, juice, crackers this afternoon.\n\nDilaudid PCA started today with good effect. Most pain during episode of tachycardia, otherwise pt. complains of incisional and/or back pain that is largely at an acceptable range.\n\nFamily in, emotional support given, anxious regarding new \"issue\".\n\nA/P: POD 1 s/p open thoracotomy LLL lobectomy. Pt. with strong cardiac history, fluid issues continue and pt. still appears underrescusitated although CVP is elevated while in RAF. O2 requirement increased.\nIf BP , will treat with fluid and/or colloids. ? need PAC if this continues overnight. R/O MI, next enzymes due midnight. Pt. family support. Pain control. Mobility, pulmonary hygiene.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-06-13 00:00:00.000", "description": "Report", "row_id": 1263284, "text": "assessment as noted in carevue\n\nres: of coolmist, on nc 5l since last night, maintains sat >95, po2 71\nstrong prod cough, expectorates dark/yellow sputum, uses IS well. LS clear/dim, chest tube intact, no leak or crepitus\n\ncv: in A.fib, on amiodorone gtt 0.5, converts at times into NSR rate, weak pulses, lopressor was held d/t low bp lasyt night\n\nneuro: weak, grossly intact, cooperative, using PCA for incisional pain\n\ngu: got lasix last night 5pm, the u/o pickred up up to 100/h\n\nplan: consider caredioversion, wean amiodorone, pulm toilet, advance diet\n" }, { "category": "Nursing/other", "chartdate": "2142-06-13 00:00:00.000", "description": "Report", "row_id": 1263285, "text": "Nursing (0700-1900)\nPt. converted to NSR at 1105 after multiple brief attempts in early a.m. Seen by EP/cardiology, PO amio and lopressor started, amio gtt d/c'd one hour later. Awaiting ECHO to be done. BP/UO/CVP stable. Intermittent duskiness of nailbeds unchanged, usually dependent. Pt. did complain of right fingertip numbness earlier today, but stated it was not new.\n\nNo resp. distress noted. CT as documented, to be removed tomorrow per Dr. . Pt. up in chair x 2 today, utilizing IS, expectorating dark tan to brown secretions.\n\nMinimal pain and use of PCA today. Pt. did state that last night and this a.m. she \"saw a face flash by my eyes\", admitting to visual hallucinations, ICU team notified. ?releated to dilaudid.\n\nDiet advanced without incident. Pt. ate this afternoon.\n\nNo additional clinical issues at this time. See flowsheet.\n\nA/P: Pt. with improving cardiopulmonary assessment POD 2 thoracotomy/LLL lobectomy.\nContinue to monitor overnight, CT to be d/c'd tomorrow and pt. to floor likely. Dr. would prefer pt. to be net (-) by the end of the day. Encourage pulmonary hygiene, activity and nutrition. ?begin bowel regimen, PO analgesia.\n" }, { "category": "Nursing/other", "chartdate": "2142-06-11 00:00:00.000", "description": "Report", "row_id": 1263281, "text": "Nursing Admission/Progress Note (1335-1900)\nPt. is a 68 y.o. female admitted from OR s/p open thoracotomy, LLL resection for lung nodule, likely primary CA. She has a significant cardiac history - please see FHP for specifics and med list. See flowsheet for assessment.\n\nPt. on Neo gtt for BP support, titrated to keep MAP >65. BP dips after receiving dilaudid. Fluid boluses x 2 for low UO/CVP and to help wean neo. VEA intermittent, non-perfusing, noted most significantly during pt's first 1.5hrs on unit. Lytes stable as noted. Hct stable.\n\nPt. largely complaining of diverticular cramping with very little surgical complaints. Morphine ineffective, best control with dilaudid.\n\nNo resp. distress noted, abg's revealed metabolic acidosis and hypoxemia >> pt. given LR boluses, supplemental o2. CT as noted with 160cc output since receiving from OR.\n\nAbd. soft. Pt. with complaints of cramping as noted. Pt. given zofran once for complaints of nausea with effect. Pt. did have \"wave\" of nausea this eve, self-limiting. Pt. remains NPO.\n\nA/P:\nPOD 0 thoracotomy, LLL lobectomy with significant cardiac history/comorbidities. Pt. underrescucitated.\nContinue to give volume as needed. Next set enzymes due 2200. Keep MAP>65. Goal hct>30 given history. Optimize comfort, Pain service may place epidural once pt. is weaned off neo gtt.\n" }, { "category": "Nursing/other", "chartdate": "2142-06-13 00:00:00.000", "description": "Report", "row_id": 1263286, "text": "Nursing Addendum\nPt. stated this eve that she was having visual and audio hallucinations throughout the day. \"That girl told me not to move my leg or I will have a stroke.\" \"Why is he smoking in the chair?\" HO made aware. Dilaudid PCA d/c'd and pt. given percocet for pain. Will monitor.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2160-12-23 00:00:00.000", "description": "Report", "row_id": 1713257, "text": "NPN 7p-7a\n\n\nResp: Infant remains on nasal prong cpap 6cm. Fi02 21%. RR\n30-60's. Conts on caffiene. Spell x1 so far this shift. Mild\nstim required. Ls clr/=. Mild ic/sc retractions noted. Cont\nto monitor.\n\nG&D: Temp stable in servo isolette. Alert and irritable with\ncares. Likes pacifier. Nested in sheepskin with boundries in\nplace. Settles in prone position. Head us planned for Fri.\nCont to support developmental milestones.\n\nParenting: Parents in today for 2 cares. Mom \nwith temp and diaper. Dad still nervous. but did temp on\n. Family meeting today with Dr. \nand this RN. Parents asking appropriate questions. Cont to\nsupport and update.\n\nFEn: Infant's tf increased today to 140cc/kg. Rec pn d7.5\nwith lipids infusing via dluvc at 130cc/kg. Enteral feeds of\npe 20 at 10cc/kg. Infant had 2cc aspirate out of 2cc feed.\nPartially digested formula. NNP aware. Refed and held feed.\nAbd soft. Active bs. No stool thus far. Ag 18.5cm. U.O.\n4.2cc./kg. Spit x1. Cont to monitor feeds.\n\nBili: INfant started on double phototx this am. Bili\n6.6/0.3/6.3 Eyes covered. bili to be checked in AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-24 00:00:00.000", "description": "Report", "row_id": 1713258, "text": "Respiratory Care\nBaby remains on prong cpap 6 21%.no spells documented,rr 40-60,stable night.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-24 00:00:00.000", "description": "Report", "row_id": 1713259, "text": "NPN 1900-0730\n\n\n2. Remains in prong CPAP 6, 21%. Sats 96-100%. Lungs\nclear, RR 40-60's with mild IC/SC retractions. On caffeine.\n No A&B's this shift. ABG 7.34/33/1.2/19/-6. Cont to\nmonitor need for cpap and monitor for A&B's.\n\n3. Temp stable nested in servo isolette. Infant awake,\nirritable with cares. Settles quickly after cares. Suckles\non pacifier at times. MAE. Cont to promote G&D.\n\n4. No parental contact.\n\n5. Wt down 74gm to 923gm. TF 140/k/d; D8PN and IL at\n130/k/d via DLUVC. Enteral feeds of PE20 at 10/k/d via NGT.\nAbd. full, soft, +BS, no loops. 0.2-2cc bilious aspirates\nnoted. No emesis. 24hr U/O 4.2cc/k/hr and no stool. Held\non adv. feeds at this time for bilious aspirates. Dstick\n67, see lab flowsheet for lytes. Cont to monitor tolerance\nof feeds and ability to adv. NGT feeds.\n\n7. REmains under double phototherapy with eye shields on.\nBili this am 6/0.2/5.8. Color jaundiced, no stool and on\n10/k/d feeds. Cont to monitor bili as per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-24 00:00:00.000", "description": "Report", "row_id": 1713260, "text": "Newborn Med Attending\n\nDOL#4. Cont on CPAP6, RA, occ spells. AF flat, clear BS, no murmu, abd soft, MAE. Bili=6.2, on phototherapy. WT=923 down 74 , on 140 cc/kg/d Pn and IL and trophic feeds.\nA/P: Infant with resolving RDS and As and Bs. Monitor for spells. Increase Tf to 150 cc/kg/d. Cont phototherapy. Increase feeds as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-24 00:00:00.000", "description": "Report", "row_id": 1713261, "text": "Respiratory Therapy\nContinues on prong CPAP of 6, RA. RR 30-50. On caffeine with no spells. Plan to continue with CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-23 00:00:00.000", "description": "Report", "row_id": 1713252, "text": "NICU Nursing NOte 1900-0700\n\n1 Infant with Potential Sepsis\n\n#2 RESP\nProng CPAP of 6, FiO2 21%. RR 30-50's. CLear and equal with\nmild-mod IC/SC retractions. # spells this shift. Continues\non caffeine as ordered. Occassional periods of periodic\nbreathing and apnea.\n\n#3 DEV\nMoved to isolette. Much less irritable in isolette. ALert\nand active with cares, settles easily with pacifier and\npositioning. Nested in sheepskin.\n\n#4 Parenting\nNo contact.\n\n#5 FEN\nWeight tonight 997gm (-58). Tf 120 cc/kg/day. Trophic feeds\nof PE/BM20 at 10cc/kg/day initiated at 0100. PN D7.5/IL\nremain at 110cc/kg/day infusing via DUVC. Abd is soft, +BS,\nno loops, no spits, no aspirates. 24hr u/o was 8.5cc/kg/hr,\nsmall green stool X1 tonight. Tolerating initiation of\nfeeds. Continue to follow. Lytes this AM: 143/3.5/111/16.\n\n#7 Hyperbilirubinemia\nBili this AM was 6.6/0.3. Continues under single phtx as\nordered.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-23 00:00:00.000", "description": "Report", "row_id": 1713253, "text": "RESPIRATORY CARE NOTE\nBaby girl #2 remains on Prong CPAP 6 FiO2 21%. RR 30-60's occasional period breathing. Breath sounds are clear. On caffeine stable on CPAP will cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-23 00:00:00.000", "description": "Report", "row_id": 1713254, "text": "Newborn Med Attending\n\nCont on CPAP6, RA. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=997 down 58, on 120 cc/kg/d Pn/Il and trophic feeds. Bili=6.6.\nA/P: infant with resolving RDS, hyperbili and As and Bs. Monitor for spells. cont phototherapy. Increase total fluids and advance feeds.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-23 00:00:00.000", "description": "Report", "row_id": 1713255, "text": "Clinical Nutrition:\nO:\nFormer 27 CGA, BG now on DoL #3\nMaternal history/delivery reviewed.\nBirth wt: 1115g (50-75th%ile)\nCurrent wt: 997g (-58g)\nBirth LN: 36.5cm (~50th%ile)\nBirth HC: 26.5cm (50-75th%ile)\nLabs: noted\nDsticks: 122, 127\nTF: 140 cc/kg/day\nAccess: DLUVC\nNutrition: BM20 @ 20 cc/kg/day & PN/IL (D8, 2.5g%AA & IL)\nProjected 24hr nutrition: ~76 Kcals/kg & ~3.2 g/kg of AA\nGI: +BS, grn stool o/n\n\nA/goals:\nBaby #2 presented as VLBW, started on PN on DoL #1 due to anticipated delay in initiating enteral feeds. Trophic feeds started yesterday @ 10 cc/kg/day; advancing to 20 cc/kg/day this evening & by 10cc/kg as tolerated. Dsticks & lytes have been stable. Growth goals: ~15-20 g/kg/day, ~0.5-1.0cm/wk for HC & ~1.0 cm/wk for LN. Once tolerating full volume feeds can begin to concentrate feeds to provide add'l Kcals/protein for optimal nutrition. Will cont. to follow w/team & participate in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-23 00:00:00.000", "description": "Report", "row_id": 1713256, "text": "Respiratory Care\nPt remains on nasal prong CPAP +6cm's with the fio2 21%. Pt respiratory rates 30's to 60's. Plan is to stay on CPAP at this time.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-22 00:00:00.000", "description": "Report", "row_id": 1713248, "text": "Nursing Progress Note\n\n6 Pot Alt CV:\n\n#1. O: Infant remains on ampicillin and gentamicin for r/o\nsepsis. Blood cultures remain negative thus far. A: Sepsis.\nP: Continue to monitor.\n\n#2. O: Infant electively extubated this evening to prong\nCPAP 5. ABG 7.27-49. FiO2 also increasing to 35%. CPAP\nincreased to 6. Currently FiO2 21-35%. RR 30's-40's. Infant\nnoted to have QSR apnea and desats to high 80's. STarted on\ncaffeine. Loading dose given. A: Stable on CPAP. P: Continue\nto monitor closely.\n\n#3. O: Infant remains on radiant warmer with stable temp.\nShe is alert and active with cares. MAEW. Sucking on\npacifier intermittently. A: AGA. P: Continue to inform and\nsupport.\n\n#4. O: No contact from family tonight\n\n#5. O: Infant remains NPO on TF's of 100cc/k/d. D10PN and\nD10W with elec's infusing well via DLUVC. D/S 122=137.\nVoiding 8cc/k/hr x12hrs. Med mec stools x2. Elec's at 0100 -\nNa 140-3.7-107-20. Wgt tonight is 1055gms. A: NPO P:\nContinue to monitor FEN status.\n\n#7. O: Bili this a.m. 6.5-.3. Infant placed under single\nphotothreapy. Eye shields in place. A; Hyperbili P: Continue\nwith treatment.\n\nREVISIONS TO PATHWAY:\n\n 6 Pot Alt CV:; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-22 00:00:00.000", "description": "Report", "row_id": 1713249, "text": "Newborn Med Attending\n\nCont on CPAP5, RA-30% O2. Occ spells, on caffeine. AF flat, clear BS, no murmur, abd soft, MAe. WT=1055, on 100 cc/kg/d PN and IL. Bili=6.5.\nA/P: Infant with resolving RDS, hyper bili, As and Bs, r/o infection. Wean from CPAP as tolerated. Cont phototherapy. D/C amp and gent if cx- at 48h. Consider increase in TF and starting trophic feeds.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-22 00:00:00.000", "description": "Report", "row_id": 1713250, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 21%, Bs clear, rr 30-50's, on caffeine, had one spell so far on this shift. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713240, "text": "RESPIRATORY CARE NOTE\nBaby girl #2 27 born via C/S @ 1857 hrs. Apgars received blow by O2 in the DR facial CPAP. Transported to the NICU with facial CPAP. Once in the NICU baby was intubated with a 3.0 ETT taped at 7cm. CxR taken ETT in good position. Survanta 4.4cc given at hrs. Placed on vent settings 18/5 Rate 25 FiO2 100%. Vent settings weaned to 18/5 Rate 20 FiO2 21%. At 0115 hrs 2nd dose of survanta was given. Abg PO2 61 CO2 50 PH 7.28. Rate decreased to 18. Will cont to wean as tolerated. Cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-22 00:00:00.000", "description": "Report", "row_id": 1713251, "text": "NPN 0700-1900\n\n\nSepsis: BC NGTD. No s/s of sepsis. Plan to dc antibx this\nevening.\n\nRESP: Infant continues on prong CPAP 6. FiO2 21%. O2sat\n95-100%. RR 30-50's with mild/mod IC/SC rtx. LS clear and\nequal. Sxn'd X1 for mod amt of clear oral secretions. 2\nepisode of A/B. (see flowsheet). On caffeine.\n\nG&D: AFSF. MAE. Temp stable, nested on sheepskin on open\nwarmer. Alert and active with cares. Sleeps well between\ncares. Plan for HUS on Fri.\n\nParents: Parents in to visit this afternoon. Asking\nappropriate questions. Updated at bedside by this RN and Dr.\n. Grandparents in to visit this evening. Mom is\npumping. Plan for family meeting tomorrow at 1400.\n\nFEN: bw=1115g. TF incr to 120cc/kg/d. Infant is NPO.\nCurrently receiving D10W @ 70cc/kgwith 1mEq NaCl and 0.5Uhep\nvia primary UVC, and PND10 @50cc/kg via secondary UVC.\nD-stick 127. Abdomen is soft and flat. +BS. No loops. Tr mec\nstool X1 today. UO=6.3 cc/kh/hr X12hr. Plan to check lytes\nand bili in AM.\n\nHyperbili: Continues on single phototherapy with eye shields\non. Plan to check bili in AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713241, "text": "Neonatology Attending\nDay 1\n\nRESP: s/p 2 doses of surfactant. SIMV now 15/5 x 14, RA. RR50-60s. Last gas 7.31/41/71, since weaned in both rate and PIP.\n\nCV: No murmur today. HR 130-160s. s/p 1 NS bolus, since mean BP > 30.\n\nFEN: 1115 g. TF 100 c/k/day. D10w. d/s 44 with peak 211, last 201. Abd soft, flat, min BS. No stool yet. u/o 3.5.\n\nID: On amp/gent.\n\nNest on radiant warmer.\n\nImp: RDS, r/o sepsis\nPlan:\n1. On min SIMV setting, mainatin for now. be ready for CPAP soon.\n2. Monitor for AOP, PDA, hypotension\n3. Maintain TF at 100, begin PN. Follow d/s closely, may need to reduce total dextrose\n4. Con't amp/gent\n5. Check 24 hour lytes and bili\n6. Initial HUS screening this week\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713242, "text": "Neonatology - NNP Progress Note\n\nInfant is active, responds to stim appropriately. AFOF. She is pink, well perfused, pulses normal, quiet precordium, no murmur auscultated. She remains on low vent settings with FIo2 21%. Breath sounds clear and equal. TF @ 100cc/kg/day. IV fluids infusing via UAC/DLUVC. DS in 200 range. Abd soft, hypoactive bowel sounds, no loops. UO 3.5cc/kg/hr. Remains on amp/gent. Stable temp on open warmer. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713243, "text": "Respiratory Care\nBaby on simv 15/5 x 14, fio2 21%, Bs coarse, rr 50-60's, sx mod white secretions, abg drawn 7.31/42/71/22/-4, rate decreased from 16 and pip decreased from 16cm h2o, will repeat gas later this evening and continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713244, "text": "NPN 7a-7p\n\n\n#1: Blood cultures remain negative to date. Conts on Ampi\nand Gent as ordered. Infant with appropriate behavior. A:\nstable P:Cont with antbx as ordered. Follow labs.\n\n#2: Weaned several times in vent settings today, based on\ngood ABG results, to current settings: 15/5x14. FIO2 21%.\nBBS coarse/= with good aeration. RR stable 40-60's.\nBreathing with mild IC/SC retractions. Sx'ed q4hrs for\nsm-mod white secretions from ETT and sm white PO. A:\nweaning on settings P:Cont to monitor and provide support\nas needed. Follow labs.\n\n#3: Weaning temp on open warmer. Infant has been sleeping\ncomfortably in btw cares. Is alert and active, MAE with\ncares. Nested on sheepskin within boundaries and covered\nwith tent for added comfort. Fonts soft/flat. Bruising\nnoted on soles of feet. Nml pulses to feet, warm to touch\nand toes pink. Will bring her hands to her face. A: stable\nP:Cont to support dev needs.\n\n#4: Parents in for visit x2, updates given. Asking\nappropriate questions. Mom touching infant- bonding.\nGrandparents also in to visit. A: Involved parents P:Cont\nto support and educate. Cont orienting to NICU.\n\n#5: TF: 100cc/k/d. Currently on 1/2NS infusing via patent\nUAC, and D10W infusing via both primary and secondary ports\non double lumen UVC. All fluids also have 0.5uheparin/cc.\nD/S trending down today 201, 165 respectively. Mild gen\nedema noted. Abd soft, increasing active , no loops, ag\nstable. No stool. U/O: ~6cc/k/hr thus far in shift. NNP\nRivers aware. Lytes pending. A: stable P:Cont with TF\n100cc/k/d. I&O. Follow wt and exam. Cont NPO. Will start\nPN tonight. Follow labs and D/S.\n\n#6: Hr stable 130-160's, regular. No murmur noted. BP\nstable with means 33-43. Slightly widened pulse pressures\nin low 20's. No palmar pulses noted. Brisk cap. refill and\nnml pulses noted. Blood out this shift 0.6cc. A: stable\nP:Cont to monitor.\n\n#7: Infant becoming more ruddy jaundice over the day. Bili\n4.5/0.2. A: pot hyperbili P:Monitor\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713245, "text": "6 Pot Alt CV:\n7 Pot hyperbili:\n\nREVISIONS TO PATHWAY:\n\n 6 Pot Alt CV:; added\n Start date: \n 7 Pot hyperbili:; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-22 00:00:00.000", "description": "Report", "row_id": 1713246, "text": "UAC removed, no complications.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-22 00:00:00.000", "description": "Report", "row_id": 1713247, "text": "RESPIRATORY CARE NOTE\nBaby girl #2 received intubated on vent settings 15/5 Rate 14 FiO2 21%. At 9pm baby was extubated and placed on Prong CPAP 5 FiO2 21%. FiO2 increased to 32% CPAP increased to 6 at 2am. FiO2 weaned back to 21%. Suctioned nares for sm amt of yellow secretions. Breath sounds are clear. Baby started on caffeine. Stable on Prong CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-20 00:00:00.000", "description": "Report", "row_id": 1713237, "text": "Neonatology Attending\n\nPreterm infant admitted for NICU managment.\n\nInfant born at 27 4/7 weeks to 28 yo G1P0 O+, Ab-, GBS?, HBsAg-, RPR-NR woman. Antepartum remarkable for twin gestation with cerclage placed . Admitted at 24 6/7 weeks for contractions. Received betamethasone course at that time. Treated with MgSO4 and ampicillin. Readmitted to L&D on day of admission for new onset of contractions. Treated with ampicillin 6 hours prior to delivery. Decision made to deliver for possible chorio when WBC 26k noted. C/S under spinal anesthesia. BBO2 then CPAP administered. Apgars 7, 8. Transferred to NICU with BBO2.\n\nExam remarkable for pink infant in oxygen in moderate respiratory distress with vital signs as noted, soft AF, nl facies, intact palate, mild-moderate retractions, fair air entry, no murmur, present femoral pulses, flat soft n-t abdomen without hsm, nl external genitalia, stable hips, nl perfusion, nl tone/activity for GA.\n\nPreterm infant with clinical presentation strongly suggestive of HMD. Will intubate, treat with surfactant, and obtain CXR. Will require close non-invasive and blood gas monitoring. Will obtain umbilical vessel access. At risk for hypotension. Will follow hemodynamic status closely.\n\nGiven respiratory status, will make NPO. IV dextrose to be infused. Will follow blood glucose, temperature, and bilirubin closely.\n\nSepsis risk- prematurity, suspected chorioamnionitis. Will obtain blood culture and cbc. Will start ampicillin and gentamicin. Duration of antibiotic therapy to depend on clinical course. Likely will require CSF examination.\n\nWill screen intracranium, retinae, and auditory system.\n\nPrimary pediatrician not yet identified. Transfer from .\n\nParents aware of clinical status and immediate plan of care.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-20 00:00:00.000", "description": "Report", "row_id": 1713238, "text": "NNP On-Call/Procedure notes\n#1 Intubation\n\nIndication: respiratory distress, surfactant administration\n\n#3.0 ETT passed orally and advanced through vocal cords under direct visualization, 1st pass. #0 blade. Taped at 7 cm mark with equal breath sounds. Chest x-ray shows tip in good position. Infant tolerated procedure well, no complications.\n\n\n#2 Umbilical Vessel catheterizations.\n\nInfant restrained, prepped and draped in sterile fashion. #5 fr. dual lumen catheter inserted into umbilical vein to 9 cm, draws and flushes easily. #3.5 single lumen catheter inserted into umbilical artery to 15 cm, draws and flushes easily. X-ray shows both lines needed withdrawal, UAC withdrawn 2 cm, UVC withdrawn 1 cm. Infant tolerated procedure well, no complications. Lines sutured in place.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-21 00:00:00.000", "description": "Report", "row_id": 1713239, "text": "Nursing Admit Note 1900-0730\n\n1 Infant with Potential Sepsis\n2 Alt in Resp status\n3 Alt in Growth and Development\n4 Alt in Parenting\n5 Alt in FEN\n\n MD/NNP notes for maternal history and perinatal course.\n\n#1 Infant started on Amp/Gent for suspected chorio. D/S\nmildly elevated, could be a stress response. 26Polys,\n6Bands. Blood Cx pending. VSS after transitioning to\nextrauterine life. Will cont to monitor closely for s/s\nsepsis.\n\n#2 Intubated immediately after arrival to NICU for GFR'ing\nand given Survanta with immediate improvement in resp effort\nseen. Able to wean settings over course of shift, babe now\nstable in RA after second dose of surfactant. Lungs remain\ncoarse, but well aerated bilaterally with acceptable ABG's\nin RA on 20/5 x 18. Will cont to support resp needs and\nwean as able.\n\n#3 AGA 27 infant. Sleeps unless disturbed, initially\nsome physiologic instablilty with handling, slowly\nimproving. Enjoys flexion and boundaries, no pacifier\noffered yet. Temp stable on open warmer. Active with cares.\nWill cont to support growth and development.\n\n#4 Parents in to visit during Mom's transfer to floor.\nStunned by the events of the day, able to ask some questions\nabout the twins and their condition. Oriented to the unit\nand the plan for the night, told to call anytime with\nquestions. Will cont to support this lovely family in\ncrisis.\n\n#5 BW 1115gms. TF's 100cc/k/d of D10 and .45NS via UAC.\nUAC/UVC placed without difficulty, both lines transducing\nwell. Given one NS bolus for MAP's persistently in the mid\n20's with improvement. BP stable last six hours with MAP's\n31-42 CVP up from -1 to 4. D/S 44-156, will monitor closely\nand adjust fluids if needed. Voiding well, no stool as yet.\nAbdomen is unremarkable with active bowel sounds. AG 26cms.\nWill cont to monitor and support.\n\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Alt in Resp status ; added\n Start date: \n 3 Alt in Growth and Development; added\n Start date: \n 4 Alt in Parenting; added\n Start date: \n 5 Alt in FEN; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713269, "text": "NPN 0700-1900\n\n\nRESP: Received infant on prong CPAP 6. Infant weaned to\nprong CPAP 5. FiO2 21%. O2sat 96-100%. RR 40-60 with mild\nIC/SC rtx. LS clear and equal. No spells this shift. Cont on\ncaffeine.\n\nG&D: AFSF. MAE. Temp stable, on sheepskin in\nservo-controlled isolette. Alert and active with cares.\nIrritable at times, settles with containment.\n\nParents: Mom and dad in to visit this afternoon. Updated at\nbedside. Providing cares. Plan to visit tomorrow.\n\nFEN:bw=1115g. TF increased to 160cc/kg/d. Currently\nreceiving IVF at 120cc/kg/d of PND10 and IL via double lumen\nUVC. Enteral feeds at 40cc/kg, advancing 10cc/kg .\nTolerating well. Belly is soft and round, AG stable. +BS. No\nloops, no stools this shift. UO=2.7cc/kg/hr X12hr.\n\n: added on to morning labs. 3.8/0.5. Decreased to\nsingle phototherapy. eye shields on.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-26 00:00:00.000", "description": "Report", "row_id": 1713270, "text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 5 FIO2 21%. Suctioned nares for sm amt of yellow secretions. Breath sounds are clear. RR 30-60's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-26 00:00:00.000", "description": "Report", "row_id": 1713271, "text": "Nursing progress note\n\n\n#2 O: Remains on 5cm prong CPAP in room air with equal &\nclear breath sounds & occasional mild desats. Remains on\ncaffeine. baby had 1 that was QSR. A: Stable. P: Cont\nto assess\n#3 O: Remains in servo isolette. Alert with cares.\nSucks on pacifier. A: AGA. P: Cont to assess\n#5 O: Wgt up 48 gms. Remains on 160cc/k/d. PN & IL infusing\nwell @ 110cc/k/d thru DUV. DS 110. UOP 3.3cc/k/h. No stool.\nPG feeds at 50cc/k/d. Abd soft with active bowel sounds & no\nloops. Minimal aspirates, no spits. A: Tolerating feeds &\ngainig wgt. P: Cont to assess.\n#7 O: Remains under single phototherapy with eye patches on.\nA: Mild jaundice. P: Cont to assess.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-26 00:00:00.000", "description": "Report", "row_id": 1713272, "text": "Newborn Med Attending\n\nCont on CPAP5, RA, occ spells. AF , clear BS, no murmur, abd soft, MAE. WT=933 up 48, on 160 cc/kg/d Pn/Il and PE20.\nA/P: Infant with residual RDS, As and Bs and hyper . Cont to advance feeds. Cont phototherapy, check . Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-26 00:00:00.000", "description": "Report", "row_id": 1713273, "text": "Social Work\nSW careview note in baby a's chart. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-24 00:00:00.000", "description": "Report", "row_id": 1713262, "text": "NPN 0700-1900\n\n\nRESP: Infant continues on prong CPAP 6. FiO2 21%. RR30-60's\nwith mild IC/SC rtx. LS clear and equal. No A/B's this\nshift. On caffeine.\n\nG&D: AFSF. MAE. Temp stable, nested on sheepskin in\nservo-controlled isolette. Alert and active with cares.\nIrritable at times, settles with pacifier. Plan for HUS on\nFri.\n\nParents: Mom and dad in to visit this morning. Updated at\nbedside. Providing cares with some verbal cuing. Plan to\ncall later today and to visit tomorrow.\n\nFEN: bw=1115g. Currently TF=140cc/kg/d. Receiving IVF at\n120cc/kg of PND8 via primary UVC, and PND8 and IL via\nsecondary UVC. Enteral feeds at 20cc/kg of BM/PE 20,\nincreasing 10cc/kg . Tolerating well. Abdomen soft and\nflat, +BS. no loops, minimal aspirates. No stool this shift.\nUO=4.5 cc/kg/hr X8hrs. Plan to increase TF to 150cc/kg/d\nwith new PN and IL. Plan to check lytes in AM.\n\nHyperbili: Continues with double phototherapy with eye\nshields on. Appears pink, slightly jaundiced.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713263, "text": "nursing progress note\n\n\n2 - RESP - PT REMAINS ON PRONG CPAP6 21%. BSC/=, MILD SC/IC\nRETRACTIONS NOTED. SXN X1 - CLOUDY SECRETIONS. NO A/BS, NO\nDESATS. ON CAFFEINE\n\n3 - DEV - TEMP LOW X1 - PT LYING ON PROBE, PROBE\nREPOSITIONED - TEMP STABILIZED IN SERVO MODE ISOLETTE. PT\n. ALERT W/ CARES.\n\n4 - PARENT - NO FAMILY CONTACT THUS FAR TONIGHT\n\n5 - FEN - TF=150CC/K. PT RECEIVING 120CC/K OF PND8 AND\nLIPIDS, INFUSING VIA DUVC WITHOUT DIFFICULTY. PT RECEIVING\nENTERAL FEEDS OF BM2/PE20 AT30CC/K. TOL NG FEEDS, NO SPITS,\nMIN ASPIRATES. ABD ROUND SOFT, +BS, NO LOOPS. AG=18.5-19CM.\nPT U.O.=3.9CC/KG/HR YESTERDAY. NO STOOLS.\nA; WT=885(-38) INCREASING FEEDS 10CC/K , DUE AT 0100,\n1300. LYTES=141/5.5/1109/17. BUN=13. CREATININE=0.4.\nDSTICK=65\nP: ADVANCE FEEDS AS TOL.\n\n7 - - PT REMAINS UNDER DOUBLE PHOTOTHERAPY, EYE SHIELDS\nON. PT JAUNDICE. PT VOIDING, NO STOOLS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713264, "text": "nursing progress note\naddendum: small open area on front of left ankle noted, area cleaned, nnp aware. open area <1cm in size, pink around edges.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713265, "text": "Respiratory Care Note\nPt. continues on 6cmH2O of nasal prong CPAP and 21% FIUO2. BS are clear. Maybe pt. could be weaned to 5cmH2O CPAP. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713266, "text": "Newborn Med Attending\n\nCont on CPAP6, RA. No spells overnight. AF flat, clear BS, no murmur, abd soft, MAE. Wt=885 down 38 on 150 cc/kg/d Pn/Il and Pe20.\nA/P: Infant with resolving RDS, now advancing on feeds. Cont photherapy.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713267, "text": "Rehab/OT\n\n observed today during cares. Care plan to be posted in next 1-2 days. Parents at the bedside. Reviewed the role of OT, infant stress signals, and how to maximize 's comfort during her NICU stay. Please refer to plan for care recommendations.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-25 00:00:00.000", "description": "Report", "row_id": 1713268, "text": "Respiratory Care\nPt cont on CPAP. Weaned level to +5cmH20. Fio2 .21, rr 40's, bs clear, sx for sm amt. No spells noted. Plan to support as needed. Will follow.\n" }, { "category": "Radiology", "chartdate": "2161-01-06 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 778713, "text": " 11:04 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: Murmur, inc. O2 requirement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with rematurity, Murmur\n REASON FOR THIS EXAMINATION:\n Murmur, inc. O2 requirement\n ______________________________________________________________________________\n FINAL REPORT\n\n BABYGRAM: This is a premature infant with new onset of heart murmur.\n\n Comparison with film done on , shows the patient has been extubated.\n There is an NG tube present. There mildly increased lung markings centrally.\n This could conceivably be due to ductus arteriosus; it could also be due to\n resolving hyaline membrane disease or chronic lung disease.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-01-08 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 778876, "text": " 7:08 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: f/u previous us with bilateral germial matrix bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks, now 19 days old\n REASON FOR THIS EXAMINATION:\n f/u previous us with bilateral germial matrix bleed\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE HEAD ULTRASOUND, :\n\n CLINICAL HISTORY: Born at 27 weeks, now 19 days of age.\n\n On the current examination, there is a left Grade I germinal matrix hemorrhage\n minimally increasing in size since last examination dated . Right\n germinal matrix is normal. There is no evidence of hemorrhage on the current\n examination. On review of the previous examination, in retrospect, there is\n no evidence of right germinal matrix hemorrhage. The ventricles are normal in\n size and contain no evidence of debris. The extra-axial fluid spaces are\n normal. No intraparenchymal abnormalities are identified.\n\n IMPRESSION: Unilateral left germinal matrix hemorrhage minimally increasing\n in size since last examination.\n\n" }, { "category": "Radiology", "chartdate": "2160-12-26 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 777729, "text": " 7:12 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks, now 6 do\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: R/O IVH. Twin born at 27 weeks, now day of life six.\n\n CRANIAL ULTRASOUND: The ventricles are symmetric in appearance. There are\n bilateral at least grade I germinal matrix hemorrhages. The choroid is lumpy\n bilaterally which may suggest a small amount of intraventricular hemorrhage.\n\n The extra-axial CSF spaces are unremarkable.\n\n IMPRESSION: Bilateral grade I germinal matrix hemorrhage with possible small\n amount of hemorrhage into the ventricles bilaterally as evidenced by lumpy\n appearance to the choroid plexus.\n\n" }, { "category": "Radiology", "chartdate": "2160-12-20 00:00:00.000", "description": "BABYGRAM (CHEST & ABDOMEN)", "row_id": 777313, "text": " 10:01 PM\n BABYGRAM (CHEST & ABDOMEN) Clip # \n Reason: umbilical lines repositioned, ? tip positions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with rspiratory distress at 27 weeks\n REASON FOR THIS EXAMINATION:\n umbilical lines repositioned, ? tip positions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AND ABDOMEN, :\n\n CLINICAL INDICATION: Respiratory distress at 27 weeks.\n\n FINDINGS: A single frontal portable view of the chest and abdomen was\n performed. Since the prior study, support lines and tubes have been\n repositioned. The ETT now terminates in the mid thoracic trachea. UVC tip\n now terminates at the T6 level, in satisfactory position. UAC tip terminates\n over the right atrium. There is slight improved aeration of both lungs,\n however hazy opacification diffusely persists consistent with surfactant\n deficiency. The demonstrated bowel loops are unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2160-12-20 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 777306, "text": " 8:25 PM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: check lungs, ett, umbilical lines\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with rspiratory distress at 27 weeks\n REASON FOR THIS EXAMINATION:\n check lungs, ett, umbilical lines\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM, AT 20:40 HOURS: There is no prior study for comparison.\n\n 27 week gestational age newborn. New respiratory distress.\n\n The cardiac contour is normal. There is diffuse hazy opacity of the lungs and\n low lung volumes consistent with hyaline membrane disease. The ETT is a cm\n above the carina. Umbilical venous line is probably in the SVC at the level\n of T5. The umbilical artery line is at the level of T3. The bowel gas\n pattern is normal.\n\n IMPRESSION:\n 1) Hyaline membrane disease.\n 2) The umbilical venous and arterial lines need to be repositioned.\n\n" }, { "category": "Radiology", "chartdate": "2161-01-21 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 780029, "text": " 7:28 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: 27 WEEKS PREMATURE NOW L MO OLD AT RISK FOR PVL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks, now 1 month old\n REASON FOR THIS EXAMINATION:\n at risk for pvl\n ______________________________________________________________________________\n FINAL REPORT\n Patient was born at 27 weeks gestational age and now is 1 month old.\n\n Comparison is done to the exam of . There has been resolution of the\n left grade I germinal matrix hemorrhage. There is no hydrocephalus. There is\n no evidence of periventricular leukomalacia. Grey white matter differentiation\n is normal for the patient's age.\n\n IMPRESSION: Resolution of the left grade I germinal matrix hemorrhage. No\n evidence of periventricular leukomalacia.\n\n" }, { "category": "Echo", "chartdate": "2161-01-07 00:00:00.000", "description": "Report", "row_id": 74092, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 08:39\nTest: Portable TTE(Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713341, "text": "NPN 1500-2300\n\n\n#2 RESP\nO: Infant remains on NC 100%, 13cc. RR=40-70's. O2\nsats=92-100%. LS are clr/=. Mild SC/IC retractions. 1 spell\nduring sleep/feed w/ HR=60 and O2 sat=84%, mild stim given.\nRemains on caffeine. A: Stable in NC. P: Continue to\nmonitor.\n\n#3 G&D\nO: Infant remains in off-isolette. Temp stable. Swaddled.\nA/A w/cares. Sleeps well in between cares. Sucks on\npacifier. A: AGA P: Continue to monitor and support G&D.\n\n#4 Parenting\nO: in for 1730 cares. Updated at bedside. Asking\nappropriate questions. Independent w/ diapering and temp. A:\nInvolved, loving. P: Continue to support and update.\n\n#5 FEN\nO: TF=150cc/kg/day of PE30 w/promod, 35cc q4hr gavaged over\n1hr. Weight=1.435kg, up 25grams. 1 small spit. Minimal\naspirates. V/S, heme neg. Active bowel sounds. AG=20.5cm.\nAbdomen benign. A: Tolerating feeds P: Continue to monitor.\n\n#8 Cardiac\nO: Positive murmur. HR=150-180's. Pale/pink. WP. Brisk\ncapillary refill. Normal pulses. A: Stable P: Continue to\nmonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-13 00:00:00.000", "description": "Report", "row_id": 1713342, "text": "NPN 1900-0700\n\n\nI have read and I agree with previous note by \n, coworker for 1900-2300 portion of his shift.\n\n2. RESP: O: Pt remains in low flow nasal cannula,\nrequiring 13cc. RR 30-60's. Lung sounds are clear. Pt is\non caffeine. One spell noted so far this shift. A: Stable\nin cannula. P: Monitor.\n\n3. DEV: O: Temp stable swaddled in off isolette. MAE.\nFontales are soft and flat. Active and alert during her\ncares. A: AGA. P: Continue to support infant's needs.\n\n4. PAR: No contact from so far this shift.\n\n5. F&N: O: TF remain at 150cc/k/d of PE30 with promod.\nFeeds gavaged in over 1 hour. Small spits noted. Abd\nbenign. BS+. Minimal aspirates noted. A/G stable.\nVoidign well. No stool noted so far this shift. Weight\ngain 25 grams. A: Tol feeds well. Gaining weight. P:\nMonitor.\n\n8. C/V: O: Murmur persists. HR 150-170's. Pt is pale\npink and well perfusd. BP stable. A: Alt C/V. P:\nMonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-13 00:00:00.000", "description": "Report", "row_id": 1713343, "text": "Neonataology\nDOing well. REmains on CPAP. Few spells. Plan to leave on CPAP for now given spells. COmfortable appearing.\n\nWt up. Toelarting 30cal via agavge. Abdomen bneign.\n\nTemp stable in isollette.\n\nCOntineu as at present.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-13 00:00:00.000", "description": "Report", "row_id": 1713344, "text": "Neonataology\nWritten on wrong baby\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-13 00:00:00.000", "description": "Report", "row_id": 1713345, "text": "Nursing Progress Note\n\n\n#2 RESP and #8 CV: Remains on Low flow NC 13-25cc with good\nsat. Clear equal BS. Mild retraction. Had 1 QSR spell this\nshift. Warm and well perfused. No acute distress.P/ Cont to\nmonitor CVR status. Wean O2 as tolerated.\n#3 G/D: Temp stable on unheated isolette. Alert and active\nwith good tone. Calms with bounderies. P/ Cont to support\nG/D\n#4 Parenting: No contact with family thus far.\n#5 FEN: Tolerating PE30 with PM for TF 150cc/k/d. Gavaged\nover 1hour and 10 min. Benign soft abdomen.Voiding QS. No\nBM. No spit. P/ Cont to monitor for feeding\nintolerance.Nutrition as ordered.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-13 00:00:00.000", "description": "Report", "row_id": 1713346, "text": "fellos exam note\ncomfortable\nheent: \nlungs: clr\nheart: no murmur\nabd: soft\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-20 00:00:00.000", "description": "Report", "row_id": 1713372, "text": "fellows exam note\ncomfortable on RA\nheent: \nlungs: clr\nheart: soft SEM, (echo - PFO), pulses wnl\nabd: soft\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2161-01-20 00:00:00.000", "description": "Report", "row_id": 1713373, "text": "Clinical Nutrition\nO:\n~32 wk CGA BG on DOL 31.\nWT: 1790 g (+35)(~50th to 75th %ile); birth wt: 1115 g. Average wt gain over past wk ~28 g/kg/d.\nHC: 29 cm (~25th to 50th %ile); last: 27 cm\nLN: 43 cm (~50th to 75th %ile); last: 42 cm\nMeds include Fe and Vit E\n noted.\nNutrition: 150 cc/kg/d PE 30 w/ promod, all pg over 90 min feeds. Average of past 3 d intake ~150 cc/kg/d, providing ~150 kcal/kg/d, and ~4.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Growth is meeting recommendations for LN gain. HC gain and wt gain exceeding recommended ~0.5 to 1.0 cm/wk for HC gain and ~15 to 20 g/kg/d for wt gain. Discussed w/ team possibility of decreasing feeds, but as infant is to start po feeds today and will be utilizing more kcals to feed, we have decided not to change kcal level yet and to follow on current feeds another week. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-20 00:00:00.000", "description": "Report", "row_id": 1713374, "text": "Neonatology\nCOmfortable appearing. REmains in RA. SIngle desta last noc req BBO2.\n\nWt 1790 up 35 gram. Abdomen bneign. Tolerating feeds\nGood weight gain over time.\n\nOne month HUS in am.\n\nContinue current feeding regimen.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-19 00:00:00.000", "description": "Report", "row_id": 1713367, "text": "NPNOte;\n\n\n#2.Remains in R. air, BBS clear and equal, mild intercostal/\nsubcostal retractions present, no spells thus far this\nshift, occassional sat drifts to high 80's noted QSR. On\ncaffine. A; No spells. P; continue to monitor.\n\n#3. alert and active with care, temp stable 99-99.2,\nswaddled, co-bedding with sibling. Head circumference\nincreased by 2cm =29cm. Af flat.A; AGA P; continue dev\nsupport.\n\n#4.No contacts from thus far this shift.\n\n#5. Todays weight=1755 up 45gms, TF=150cc/kg/day, PE30 with\npromod,Pg feeds given over 90mts, tolerated, BS+, no loops,\nvoided and no stool. A; feeds tolerated. p; continue currnt\nfeeding plan.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-19 00:00:00.000", "description": "Report", "row_id": 1713368, "text": "Neonatology\nDoing well. RA. No spells having few desats.. Comfortable appeairng.\nMurmur as before.\n\nWt 1755 up 45. Tolerating feeds at 150 cc/k/d of 30 cal. Abdomen benign.\n\nTemp stable (sl high) co-bedding.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-19 00:00:00.000", "description": "Report", "row_id": 1713369, "text": "fellows exam note\ncomfortable\nheent: \nlungs clr\nherat: soft HSM, pulses nl\nabd: soft\nneuro: nonfocal\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-19 00:00:00.000", "description": "Report", "row_id": 1713370, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN RA, MAINTAINS O2 SATS IN HIGH 90'S.\nOCCASIONAL PERIODIC BREATHING WITH DRIFTS IN O2 SATS.\nNEEDING BBO2 ONCE TODAY FOR DESAT. NO EPISODES OF\nBRADYCARDIA. REMAINS ON CAFFEINE. RR 24-60'S WITH MILD\nSUBCOASTAL RETRACTIONS. CONTINUE TO MONITOR RESP STATUS\nCLOSELY.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON\n150CC/K/D OF PE 30 W/PROMOD, 44CC Q4HRS VIA GAVAGE OVER\n90MINS Q4HRS. ABD EXAM BENIGN, NO LOPS, NO SPITS. GIRTH 24.\nASP. 0.6-1.4CC. VOIDING WELL, NO STOOL THUS FAR TODAY.\nCONTINUE CURRENT FEEDING PLAN. MOM WILL GIVE FIRST BOTTLE\nTOMORROW AT 5PM.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS, MAINTAINS TEMP IN OPEN CRIB.\nCO BEDDING WITH BROTHER. SWADDLED AND IN SHEEPSKIN.\nSUCKS ON PACIFER INTERMIT. EYE EXAM WEDNESDAY. KCONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 1PM. MOM TEMP\nAND CHANGED DIAPER AND DAD HELD FOR 90MINS. UPDATED AT\nBEDSIDE. CONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-20 00:00:00.000", "description": "Report", "row_id": 1713371, "text": "1900-0730 NPN\n\n\nRESP: O/A: Pt cont in RA with RR 30's-60's and O2 sats\n92-100%. Periodic breathing at times with desats to 80%'s\nthat are QSR. Desat x 1 to 70%'s that required BBO2. No\nbradycardic episodes to report at this time. LS clear/=,\nmild S/C retractions noted. P: Cont to monitor resp status.\nCont on Caffeine as ordered.\n\nFEN: O/A: Wgt tonight was 1790g, gain of 35g. TF cont at\n150cc/kg/d of PE30 with PM. No spits, max aspirate of\n4.0cc, abd girth stable at 24.0-24.5cm. Abdomen soft,\nround, pink, BS+, no loops noted. Pt is vdg, med stool x 1\n(guiac -). P: Cont to monitor feeding tolerance.\n\nG&D: O/A: Temps stable in open crib, pt is dressed and\nswaddled. Pt is cobedding with sibling, sheepskin present.\nMAE, alert and active with cares. Sleeps between cares.\nSucks pacifier and brings hands to face for comfort.\nFontanels soft/flat. P: Cont to support growth and\ndevelopment.\n\nPARENTING: O/A: No contact from as of yet this\nshift. P: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-20 00:00:00.000", "description": "Report", "row_id": 1713375, "text": "NPN 7a-7p\n\n\n#2: remains in RA, sating >/= 94%. BBS cl/=.\nBreathing with mild retractions. RR stable. Occ drofts\nnoted to high 80's with qsr. x1. Caffiene given as\nordered. A: stable in RA P:Cont to monitor resp status and\nprovide support as needed.\n\n#3: Temps stable while swaddled in an open crib. She is\nco-bedding with her brother. and active with cares.\nMAE. Fonts soft/flat. Brings hands to face. Sucks on\npacifier intermittently. A:AGA P:Cont to support dev\nneeds. HUS and eye exam tomorrow.\n\n#4: called earlier for update. In for 1730 care.\nMom planning to offer infant her 1st bottle. Updates given.\nA: Involved P:Cont to support and educate.\n\n#5: TF: 150cc/k/d. Conts on Pe30 with PM, 45cc q4hrs\ngavaged over 90mins. Med spit x1. Min benign asps. Abd\nsoft, +, no loops. Ag stable. Voiding qs. Stooled,\nheme negative. A: tol feeds well P:Cont with current\nfeeding plan. Monitor tol to feeds. Follow wt and exam.\nOffer bottle as appropriate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-22 00:00:00.000", "description": "Report", "row_id": 1713376, "text": "NPN\n\n\n#2 Resp- Remains in RA w/o2 sats 95-100%. Occ drifts to the\n80's, QSR.RR= 40-60. BS clear. Mild retractions.Remains on\nCaffeine. Occ A's +B's. See flowsheet.A= stable in RA. P=\nMonitor.\n#4 -No contact tonight.\n#5 F/N- Abd soft,+full,+BS no loops. Tolerating feeds of Pe\n30cals w/Promod W/O spits. Minimal asps.Bottled slowly x1\nfull vol.Voiding+ stooling in adeq amts.Wt up 35gms.Feeds\ngiven on a pump over 90mins.A= Tolerating feeds well.\ngaining wt.P= Monitor wt gain+ feeding tolerance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-31 00:00:00.000", "description": "Report", "row_id": 1713407, "text": "NICU Attending Transfer Note\n\nPlease see typed summary for details of pre/perinatal hx, hosptal course by system. Please see Newborn PEx form for details of discharge PEX, all reviewed, patient examined. DOL # 42 for this former 27 week gestation female, twin # 2 = 34 4/7 weeks CGA. Current active issues are completeion of A/B \"countdown,\" growth and nutrition, learning to PO feed, ROP.\n\nCVR/RESP: Soft systolic murmur, PFO by echo, remains in RA, no A/B, (last episode ), not on caffeine.\n\nFEN: Discharge Weight 2240 gm, up 65 gm c/w yesterday, on 150 cc/kg/d PE 30 with PM, alternating PO/PG, Vit E, Fe. Will continue current diet, encourage PO intake.\n\nHEME: Most recent hct 25.1 with good retic, on Vit E, Fe, will continue to follow, hope to avoid PRBC transfusion.\n\nOPHTHO: Most recent eye exam showed ROP stage 1 zone 2 OU, f/u in 2 weeks.\n\nENV'T: Stable temp co-bedding with twin brother.\n\nDISPO: Ready for transfer to SCN for ongoing recuperative care. I will accepting MD prior to transfer.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-31 00:00:00.000", "description": "Report", "row_id": 1713408, "text": "Transfer Note\n\n\n2. O: Ls clear. RR 40-70's. Mild subcostal retractions. No\nspells. A/P: Cont to monitor resp status.\n\n3. O: Temp stable swaddled in open crib. and active\nwith cares. A/P: Cont to monitor temp. Cont to cluster\ncares.\n\n5. O: TF 150cc/kg of PE30+PM via alt po/pngt. Min asp. No\nspits. Voiding. +bs. A: Tol feeds. P: Cont to monitor wt\nabd, and po intake.\n\nReport given to Rn at Wincester. signed transfer\nconsent. aware of transfer. Transfer sheet\ncompleted. A/P: To transfer to Wincester.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-07 00:00:00.000", "description": "Report", "row_id": 1713315, "text": "npn 1900-0700\n\n8 cardiac\n\n#2 resp\nO: pt remains in nc 200ccflow with fio2 21-30%. lsc and\nequal. rr 20-70's. ic/sc retractions noted. pauses in resps\nnoted with desats to 70's the qsr. occation need for\nadjusting of o2. x1 qsr. caffeine given a/o. A:\nneeding assistance of o2 flow. p: continue to monitor for\nchagnes and suppor.t\n#3 g&d\no: pt in isolette, off @ 5am after weaning several times\nthroughout night. swaddle with two blankets. alert and quiet\nwith cares. fontanelles soft and flat. sucking on binki and\nhands. maew. a: stable p: continue to monitor for changes\nand support.\n#4 paretning\nno contact thus far this shift.\n#5 fen\no: tf 150cc/kg of pe28 with promod gavaged q4hours. wt.\n1.215kg (+35gms). abd benign, full and round. ag stable\n21-22.5cm. voiding and stooling yellow guiac neg stools. lg\naspirate x1 of 11cc partially digested milk, refed back and\nsubtracted from gavage feeding. no spits. a: stable P:\ncotninue to monitor for changes and support.\n#8 cardiac\no: pt with loud murmur. hr 150-160's up to 180's with warm\ntemps. bp 78/59 with mean 65. pulses full. pink and mottles\nwith cares and stress. P: continue to assess for changes and\nsupport as needed.\n\n\nREVISIONS TO PATHWAY:\n\n 8 cardiac; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-07 00:00:00.000", "description": "Report", "row_id": 1713316, "text": "Neonatology\nDoing well. remains in RA. NO spells. Murmru c/w PDA with increased heart size noted. CV stable. Spells not problem. Echo planned for later today.\n\nWt 1215 up 35. Tolerating feeds at 150 cc/k/d of 28 cal with promod. Single aspirate over night. Abdomen benign. Will hold feeds at current regimen pedning eval for PDA.\n\n\nHUS planned for later this week.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-07 00:00:00.000", "description": "Report", "row_id": 1713317, "text": "fellow exam note\ncomfortable\n\nlungs: cta b/l, occ crackles\nheart: HSM at lft sternal border c/w PDA?, no bounding pulses\nabd: soft\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2161-01-07 00:00:00.000", "description": "Report", "row_id": 1713318, "text": "NICU nursing note\n\n\n2. Resp=O/On RA since 0900. LSC/E. RR30-70's. SC/I\nretrac. noted with care. No spells. cont on caffeine.\nA/Resp. status stable on RA. P/cont to monitor for resp\ndistress.\n\n3. G&D=O/Temp stable in off isolette. Alert and active\nwith cares. Sleeping well between feeds. A/Alt in G&D.\nP/Cont to monitor and support G&D.\n\n4. =O/ called for update x1 and both visited\nlate this afternoon. Asking questions and participating in\ncare. A/appropriate and actively involved. P/cont to\nsupport and educate .\n\n5. FEN=O/TF cont at 150cc/k of PE28 with PM. NG feeds run\nover 1hour15min. Several sm spits. max asp=3cc. Abd.\nbenign. Voiding/Stooling heme(-). A/Tolerating current\nregime. P/cont to monitor for feeding intolerance.\n\n8. Cardiac=O/murmur cont to be heard this shift. Team\naware. Echo done. (please refer to report). HR150-180s.\npink/wp. A/cardiac murmur. P/cont to monitor cardiac\nstatus.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713336, "text": "Neonatology\nWill attempt to wean out of O2. If still requires NCO2 will change hi sat alarm to < 100.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713337, "text": "Neonatology\nDoing well. NCO2 13-25 cc. No spells. COmfortable apeparing.\n\nWT 1410. Tolerating gavage feeds at 150 cc/k/d of 28 cal. Abdomen benign. Nutritional supps to be added. WIll advance to 30 cal and monitor tolerance. Good weight gain over time.\n\nTemps table in isollette\n\nContinue current nutritional and resp management.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-29 00:00:00.000", "description": "Report", "row_id": 1713400, "text": "NPN Days\n\n\n2) Resp: Remains in RA with sats >95%. No spells.\nBBS=clear. Plan: Cont to monitor.\n3) G/D: Cobedding with twin in open crib. Temp stable.\nActive and with cares. Bottle fed well x1. Plan:\nCont with current developmental plan.\n4) Parenting: No contact with the family this far this\nshift. Plan: Cont support and updates. Possible transfer\nto level 2 tomorrow.\n5) FEN: TF 150/k/d of PE30with PM. Po/pg alternating. PG\non a pump over an hour. Abd full, active bowel sounds.\nSpit x1. Voiding, no stool thus far. Tol feeds well.\nPlan: Cont with current feeding regime. Monitor for\nintolerance. Alt po/pg feeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-29 00:00:00.000", "description": "Report", "row_id": 1713401, "text": "fellows exam note\nneuro: nonfocal\nheent: \nlungs clr\nheart: no murmur\nabd soft\n" }, { "category": "Nursing/other", "chartdate": "2161-01-30 00:00:00.000", "description": "Report", "row_id": 1713402, "text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in RA. O2 sats = 96-100%.\nRR=50-70's. Mild SCR. LS clear/=. No spells.\n\n2. G&D: wakes for every feed. and active with\ncares. Sleeps well between cares. Uses pacifier to comfort\nself. Brings hands to face. Temps stable swaddled in open\ncrib. Cobedding with brother. . AGA.\n\n3. Parenting: No contact this shift.\n\n4. FEN: WT=2175gms (up 30gms). TF=150cc/k/day PE30 with\nPM. Bottled 60cc at 0130, otherwise, gavaged 54cc over 1hr.\n2 guiac neg stools. 1 small spit. Min asp. Abd is round\nand soft with active bs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-30 00:00:00.000", "description": "Report", "row_id": 1713403, "text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable appearing.\n\nWt up to 2175 . Tolerating feeds.\n\nErady for tx to WH.\nDC summary dictated.\nDR to be contact.\n need eye fu in two weeks.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-30 00:00:00.000", "description": "Report", "row_id": 1713404, "text": "2. is in RA, color pale-pink, BBS equal, clear,\nRR50-70, sc rets, no spells P: continue to monitor.\n]3. waking for some feedings, and awake with cares,\ntemps stable swaddled in open crib with brother, taking \nwell P; continue to support growth and development.\n4. Mom called, planning to visit later, aware transfer to\n postponed til tomorrow. continue to update and\noffer support.\n5. TF 150cc/k/d PE30 with PM, 54cc q4h, taking qo feeding po\nwell, abd soft, voiding and passing stool, no spits, minimal\naspirates Continue present plan, cont to enc po.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-31 00:00:00.000", "description": "Report", "row_id": 1713405, "text": "#2 RA. LS CLEAR AND EQUAL. NO 'S OR DESATS. CONT ON\nCAFF.\n# 3 TEMPS STABLE CO-BEDDING IN OPEN CRIB. AND ACTIVE\nWITH CARES. PO FEEDING FULL FEEDS OVER NIGHT.\n#4 NO CONTACT FROM FAMILY THIS SHIFT.\n#5 150CC/KG PE30C/PRO. PO FEEDING WELL. NO SPITS. ABD FULL,\nSOFT, ACTIVE. VOIDING, NO STOOL THIS SHIFT. WEIGHT INCREASE\n65GM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-31 00:00:00.000", "description": "Report", "row_id": 1713406, "text": "NICU Attending Transfer Note\nAddendum\n\nI spoke with accepting MD Pu at .\n\nPMD wil be Dr. : . I left message of twins transfer and will fax copy of d/c summary to her office.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713338, "text": "Clinical Nutrition\nO:\n~31 wk CGA BG on DOL 23.\nWt: 1410 g (+45)(~25th to 50th %ile); birth wt: 1115 g. Average wt gain over past wk ~25 g/kg/d.\nHC: 27 cm (~10th to 25th %ile); last: 26 cm\nLN: 42 cm (~50th to 75th %ile); last: 42 cm\nMeds include Fe and Vit E\n not due yet.\nNutrition: 150 cc/kg/d PE 30 w/ promod, pg over 60 min. feeding time due to hx of spits. Feeds just increased today. Projected intake for next 24 hrs ~150 cc/kcal/kg/d and ~4.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due yet. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Feeds were increased to keep feedings the same for both twins; unclear that needs this level, but will follow on current feeds for ~1 week and adjust if needed. Growth is slightly exceeding recommended ~15 to 20 g/kg/d for wt gain. Meeting recommendations for HC gain; LN shows no change since last wk, but question accuracy of measurements. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713339, "text": "fellows exam note\ncomortable on min NC o2\nheent: \nlungs: clr\nheart: no murmur\nabd soft\nneuro: nonfocal\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713340, "text": "NPN 1450\n\n\n#2 Resp: in and out of NC O2 today to keep O2sat\n92-99%. Attempted to remain in RA X 1 1/2 hrs but infant\ndrifting to the 88-90% range. Requirement is 13cc flow 100%.\nLungs clear, =. RR 30-60. Mild IC/SC retractions. No \nspells. Continues on caffeine.\nA: Trying to wean from O2, some mild drifting.\nP: Cont. to attempt to wean from O2.\n#3 G/D: in an off isolette bundled in a hat and\nblanket. Positioned prone. Boundaries in place. Temps to\n100ax, hat and top blanket removed. Awake and alert w/\ncares, moving extremities.\nA: AGA 30 wkr.\nP: Cont dev. supports.\n#4 : Mom phoned this afternoon. Asking appropriate\nquestions about babies. Plans to visit at 4pm. Tomorrow will\nkangaroo the babies.\nA: Invested .\nP: Cont parent support.\n#5 F/N: continues on 140cc/kg/d 35cc q 4 hrs. per pg\nfeed X1 hr. Tol feeds well. No spits or aspirates. AG\nstable. Bowel snds active. Voiding and stooling, stools heme\nneg. Cals increased today to PE 30 + promod.\nA: Tol. feeds.\nP: cont to monitor growth and nutrition.\n#8 CV: HR 170-190 today d/t temps >98.6ax. Murmur loud.\nColor pink.\nA: Stable w/ murmur.\nP: Cont to assess for changes in CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-17 00:00:00.000", "description": "Report", "row_id": 1713363, "text": "NICU Nursing progress Note\n\nRESP\nO: Nasal cannula removed at 1400 after 8 hrs in room air\n50cc flow. No apnea, bradycardia, or spontaneous desat\nnoted. Breath sounds, resp rate, and WOB are at baseline.\nRemains on caffeine.\nA: Trialing off cannula.\nP: Monitor and assess.\n\nNUTRITION\nO: Remains on TF 150cc/kg/day of 30PE with PM by gavage.\nFeeds instilled over 90 mins due to hx spitting and infant\nhas not spit today. Abd exam benign. Voiding.\nA: No evidence of intolerance.\nP: Assess.\n\nDEVELOPMENT\nO: Wakes for feeds every 4 hrs. Temp stable in open crib.\nOpens eyes for ' visit. Sleeps between cares.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: in for care time and are independent in temp\ntaking and diaper change. Dad held infant during feed.\nUpdated regarding infant's plan of care.\nA: Involved .\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-18 00:00:00.000", "description": "Report", "row_id": 1713364, "text": "NPNOte:\n\n\n#2. Remains in R. air, BBS clear and equal, mild\nintercostal/subcostal retractions present, no spells thus\nfar this shift. A; stable in R. air.P; continue to monitor.\n\n#3. alert and active with care, temp stable in a open crib,\nswaddled with blanket and a hat on, loves pacifier. A; AGA\nP; continue dev support.\n\n#4. No contacts from thus far this shift.\n\n#5.Todays weight=1.710 up 65gms, TF=150cc/kg/day, PE30 with\npromod, Pg feeds given over 1hr 30mts, tolerated.BS+, no\nloops, small spit x1. A; Feeds tolerated. P; continue\ncurrent feeding plan.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-18 00:00:00.000", "description": "Report", "row_id": 1713365, "text": "Neo attending\nDOL 29 for this infant who remains comfortable in RA on caffeine\n1710 grams up 65 grams\n\nRRR + m -known to be PFO\nLUngs clear\nSoft abdomen + BS\n\nA/P:\n\nWill plan to continue current feeds and follow weight gain. No new medical changes.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-18 00:00:00.000", "description": "Report", "row_id": 1713366, "text": "NPN DAYS\n\n\nALT IN RESP:REMAIS IN RA, MAINTAINS 02 SATS IN MID TO HIGH\n90'S. RR 40-60'S WITH MILD SUBCOASTAL RETRACTIONS. NO\nEPISODES OF APNEA OR BRADYCARDIA. REMAINS ON CAFFEINE.\nCONTINUE TO MONITOR FOR SPELLS.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON\n150CC/K/D OF PE30 W/PROMOD, 43CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 23-24.\nASP. 1-1.4CC. VOIDING AND STOOLING WELL. STOOL GUIAC NEG.\nCONTINUE CURRENT FEEDING PLAN. WILL START 1 BOTTLE A DAY\nTHIS WEEK WHEN SHE IS 32WEEKS.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES.SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nPLACED IN LARGE CRIB TO CO BED WITH BROTHER THIS AFTERNOON.\nSWADDLED AND IN SHEEPSKIN. CONTINUE DEVELOPMENTAL\nCARES.\n\nALT IN PARENTING: IN TO VISIT AT 9AM. UPDATED AT\nBEDSIDE. MOM TOOK TEMP AND CHANGED DIAPER, AND HELD BABY FOR\n90MINS. HAV THEIR BABY SHOWER THIS AFTERNOON.\nCONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-27 00:00:00.000", "description": "Report", "row_id": 1713393, "text": "NPN Days\n\n\n2. O: Ls clear. RR 40-60's. No spells. O2 sats>95% RA. Mild\nsubcostal retractions. A: No A&B's. P: Cont to monitor resp\nstatus.\n\n3. O: Temp stable swaddle din open crib with twin. and\nactive with cares. Sucking on pacifier. A/P: Cont to monitor\ntemp. Cont to cluster care.\n\n4. O: Mom called X1. Rn updated MOM. MOm asking appropriate\nquestions. will be in for 1730 cares.\n\n5. O: Tf 150cc/kg of PE30+PM alt po/pngt. Min asp. No spits.\nVoiding and stooling G-. VitE and Iron given as ordered.\n request to offer bottle at 1730 care. A: Tol feeds.\nP: Cont to monitor wt,abd, tol of feeds, and po intake.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-28 00:00:00.000", "description": "Report", "row_id": 1713394, "text": "NPN 7p-7a\n\n\nResp: Infant remains in RA. LS clr/=. No spells or desats so\nfar this shift. RR 30-50's. Mild sc retractions noted. Cont\nto monitor.\n\nG&D: Temp stable swaddled in open crib. and active\nwith cares. Co-bedding with brohter. Sucks on pacifier.\nWakes for most of feeds. Eye exam scheduled in AM. Cont to\nsupport developmental milestones.\n\nParenting: NO contact from so far this shift.\n\nFen: Infant's wt. tonoc 2.115kg. TF 150cc/kg pe 30 with pm.\nInfant alt po/pg feeds. PO 30cc at 0130. Gavaged remainder.\nNo spits thus far. Minimal aspirates. Ag stable 28-28.5cm.\nStool x1 lg brown. Quaic neg. Cont to encourage po feeds.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-28 00:00:00.000", "description": "Report", "row_id": 1713282, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal wiht 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": "2160-12-29 00:00:00.000", "description": "Report", "row_id": 1713283, "text": "NPN\n\n7 Pot hyperbili:\n\n#2-O: in RA RR, 40's-60's, mild ic retractions clear and\nequal. one to 79, mild stim, on caffeine as ordered.\npink , well perfused no murmur audible.\n\n#5-O; on tf 150cc/k/d , enteral feeds increased this shift\nto 110cc/k/d = 20.5cc PE20 q 4 hrs PG over 40\" tol well, no\naspirates, no spits,increasing feeds by 10cc/k/d , abd\nfull soft, active bowel sounds, voiding qs, no stool. IVF\nD10 2nacl/1 kcl at 40cc/k/d at 1.9cc/hr infusing well.\n\n#3-O; temp stable in servo isolette, awake alert and active\nat cares. , , app. for age.\n\n#4-O: no contact with this shift.\n\nREVISIONS TO PATHWAY:\n\n 7 Pot hyperbili:; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-02 00:00:00.000", "description": "Report", "row_id": 1713297, "text": "NPN 1900-0700\n\n\n2 Resp\nMaintaining sats greater than 94% in RA. RR 40-60's. Lung\nsounds cl/=. Mild inter/subcostal retractions.\n\n3 G&D\nTemp stable in servo controlled isolette. Awake and alert\nwith cares. Sleeps well between cares. Brings hands to\nface and mouth.\n\n4 Parenting\nMom and Dad in for 2100 care. Both participated in care and\nweight.\n\n5 FEN\nCurrent weight 1.075 kg, up 25 grams. TF remain at\n150cc/kg/day of PE 20. Tolerating gavage feedings well.\nAbd soft, bs +. Girth stable. No spits or asp. Voiding\nand stooling.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-02 00:00:00.000", "description": "Report", "row_id": 1713298, "text": "Neonatology\nDoing well. RA. No spells. Comfortable appearing.\n\nWT . Tolerating gavage feeds at 150 cc/k/d. Moving up to 26 cal today. Monitor tolerance. Abdomen benign.\n\nCOntinue Curernt nutritional management.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-02 00:00:00.000", "description": "Report", "row_id": 1713299, "text": "0700- NPN\n\n\nRESP: Cont in RA, RR 30's-60's and O2 sats 97-100%. LS\nclear/=, mild SC/IC retractions noted. A/B spells x 2 with\nHR to 56-67, O2 sats 68-89%, and apnea present. Pt required\nmild stim for A/B spells. A: Pt with occasional A/B spells\nat this time. P: Cont to monitor resp status. Cont on\nCaffeine as ordered.\n\nFEN: TF cont at 150cc/kg/d. PE increased to 26 cals/oz.\nNo spits, aspirates 0.4-1.2cc, abd girths stable at 20.5cm.\nAbdomen soft, round, pink, BS+, no loops. Pt is voiding,\ntrace brown stool x 1. A: Pt tolerating feeds at this time.\nFEN status stable. P: Cont to monitor FEN status and\nfeeding tolerance.\n\nG&D: Temps stable in servo-controlled isolette. MAE, alert\nand active with cares. Sleeps between cares, sucks pacifier\nor thumb and brings hands to face for comfort. Fontanels\nsoft and flat. Pt kangarooed with Mom x 1 hr, tolerated\nwell. A: AGA. P: Cont to support growth and development.\n\nPARENTING: Mom called x 1, both in to visit x 2\nhrs. updated by this RN. A: loving and\ninvested. P: Cont to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-03 00:00:00.000", "description": "Report", "row_id": 1713300, "text": "NPN 1900-0700\n\n\n2 Resp\nContinues to maintain sats greater than 95% in RA. RR\n40-60's. Lung sounds cl/=. Mild inter/subcostal\nretractions noted. Continues on caffiene. One spell, see\nflow sheet.\n\n3 G&D\nTemp stable in servo controlled isolette. Awake and alert\nwith cares. Sleeps well between cares. Sucks\nintermittently on pacifier. State screen sent.\n\n4 Parenting\nMom called for update.\n\n5 FEN\nCurrent weight 1.115 kg, up 40 grams. TF remain at\n150cc/kg/day of PE 26. Tolerating gavage feedings well.\nAbd soft, bs +. Girth stable. No spits, min asp. Voiding\nand stooling.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-03 00:00:00.000", "description": "Report", "row_id": 1713301, "text": "Neonatology Attending\n\nDay 14\n\nRemains in RA. RR 30-60s. Occasional desaturation episodes- all mild. Remains on caffeine. RR 30-60s. Has had four mild bradycardic events over last 24 hours. No murmur. HR 150-160s. Weight 1115 gms (+40). On PE 26 at 150 cc/kg/d. Servo-controlled incubator with stable temperature.\n\nMild residual breathing control immaturity. Will continue to monitor closely. Gaining weight but will advance to 28 cal feeds. Tolerating feeds well.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-28 00:00:00.000", "description": "Report", "row_id": 1713395, "text": "Neonatology\nDoing well. Remains in RA. Comfortable appe4aring . No spells.\n\nWt 2115 up 60. abdomen bneign. TF 150 cc/k/d of 30 cal. Alt po/pg. Doing well with pos.\n\n\nCOnsider tx to at end of week.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-28 00:00:00.000", "description": "Report", "row_id": 1713396, "text": "fellows exam note\ncomfortable\nsleeping\nheent: \nlungs clr\nheart: soft murmur, SEM\n" }, { "category": "Nursing/other", "chartdate": "2161-01-28 00:00:00.000", "description": "Report", "row_id": 1713397, "text": "Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Remains in RA. No resp\ndistress. No bradys. P- Cont to assess for Resp needs.\n#3-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nopen crib. Sucks on pacifier. Eye exam done today, Stg 1\nzone , f/u 1-2wks. P- Cont to assess for G&D needs.\n#4-O/ Mom called with updates given. Plans to transfer\nto when resp stable. P- Cont to enc\nparental calls and visits.\n#5-O/A- TF=150cc/kg/d of PE30w/ProMod via NGT. Abd exam\nbenign. Voiding and stooling. Spit x1 this shift. P-\nCont to assess for FEN needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-29 00:00:00.000", "description": "Report", "row_id": 1713398, "text": "#2Resp\nLungs clear. RR40-60's. Mild subcostal retractions. No\nspells. Off caffeine. Sat 95-100.\nA. Stable\nP> Cont to monitor.\n#3Dev\nTemp stable in an open crib. Awake and withcares.\nInterested in bottling.\nA. Appropriate\nP. Cont to monitor\n#4Parent\nNo contact his shift.\n#5FEN\nBaby gained 30g to 2.145. Alt po/pg. Bottled about 30cc at\n0130. Abd soft, active bowel sounds void and stooling. No\nspits so far. Cont on PE30 with promod at 150cc/kg.\nA. Tol feeds\nP. Cont to monitor tol to feeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-29 00:00:00.000", "description": "Report", "row_id": 1713399, "text": "Neonatology\nDOing well. Soft murmur due to PDA. Comfortable\n\nWt 2145 up 30. Tolerating feeds at 150 cc/k/d of 30 cal. ABdomen benign.\n\nTook tweo bottles yesterday.\n\nWill call re possibility of tx in coming days.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-29 00:00:00.000", "description": "Report", "row_id": 1713284, "text": "Newborn Med Attending\n\nCont in RA, occ spells. AF flat, clear BS, no murmur, abd soft, MAE> WT=1025 up 25, on 150 cc/kg/d IVF and PG feeds.\nA/P: Infant with As and Bs. Monitor for spells. Cont to advance feeds.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-29 00:00:00.000", "description": "Report", "row_id": 1713285, "text": "NPN 0700-1900\n\n\n1. Resp: Infant remain in RA, maintaining her O2 sats\ngreater than 96%. Lungs sounds clear/=. RR 30-50's.\nIC/SCR noted. Infant continues on IV caffeine. One spell\nnoted thus far - please see flowsheet for further details.\nP: Cont. to monitor resp. status.\n\n2. G/D: Temps stable in servo-isolette. Infant is in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. P:\nCont. to support developmental needs.\n\n3. : Mom called x 1. She was udpated on infant's\ncondition and plan of care. Asking appropriate questions.\nBoth will be in for 1700 cares. Loving, involved\n. P: Cont. to support and udpate .\n\n4. FEN: TF remain at 150 cc/kg/day. IV fluids of D10W with\n2 mEQ of NaCl and 1 mEQ of KCl is currently infusing at 30\ncc/kg/day through a patent PIV without incidence this shift.\nEnt feedings are currently at 120 cc/kg/day of PE20, and are\nbeing advanced by 10 cc/kg/ at 01/13. Tolerating NGT\nfeedings well; Abd exam benign, one sm. spit, AG stable, and\nmin asp. UO for past 8 hours has been 4.7 cc/kg/hr. Sm mec\nstool noted. P: Cont. to support nutritional needs, advance\nfeeds as tolerated, and check a D/S with next care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-30 00:00:00.000", "description": "Report", "row_id": 1713286, "text": "NPN\n\n\n#2 is stable in rm air. SaO2 >95 with no spells, cont\non caffeine. Mild ICR noted. A: stable P: monitor\n#3 doing well in servo isolette. temp stable, sleeping\nbetween feeds, calm with cares. likes pacifier. A: AGA P:\ncont to support development\n#4 in early in shift, held brother. A: happy,\ninvolved family P: cont to support and inform.\n#5 received on PO feeds 120/k/d, with IV d10W at\n30cc/k/d, advanced to full feeds by 05:00 feeding because of\nIV inf. at 01:00. Abd benign, AG stable, no loops or\ndistention, sm spit once, no asp, vdg 2.8/k/h. weight\nunchanged tonight. A: tol feeds thusfar, P: monitor, restart\nIV if needed\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-31 00:00:00.000", "description": "Report", "row_id": 1713292, "text": "NPN 7a-7p\n\n\nResp: Infant remains in RA. Ls clr/=. No bradys so far this\nshift. RR 40-60's. IC/Sc retractions. Conts on caffiene.\nCont with current plan.\n\nG&D: Temp stable in servo isolette. Alert and active with\ncares. Sleeps well between. in sheepskin with\nboundries in place. Brings hands to mouth. Kangarooing qod.\nCont to support developmental milestones.\n\nParenting: Mom and Dad in today. Mom with temp\nand diaper. Dad kangarooed infant x70 mins. Infant tol well.\nCont to support and update.\n\nFEn: Infant conts on tf 150cc/kg. All pg feeds. Increased\ntoday to pe 22. Tol feeds well gavged over 60 mins for hx of\nspits. Abd soft. Active bs. Sm stool x1. Voiding with each\ndiaper change. No spits minimal aspirates. Cont with current\nfeeding plan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-06 00:00:00.000", "description": "Report", "row_id": 1713310, "text": "npn 1900-0700\n\n\n#2 resp\nO: pt remains on nc 200ccflow with fio2 21-30%. lsc and\nequal. sc/ic retractions noted. rr 50-70's. no spells,\noccational drift qsr (mostly). a: needing assistance of o2.\np: continue to monitor for changes and support as needed.\n#3 g&d\no: pt in covered air controll isolette with warm temps as\nhigh as 100.3. weaned several times. alert and active with\ncares. fontanelles soft and flat. sucking on pacifier and\nhands. maew. a: stable p: continue to monitor for changes\nand support.\n#4 parenting\nno contact thus far this shift.\n#5 fen\nO: tf 150cc/kg of pe28 with promod gavaged q4hours. wt.\n1.180kg (+20gms). abd benign. voiding and stooling guaic neg\nstools. ag stable 21.5-22cm. small spit x1, max aspirate of\n2cc partially digested milk. a: tolerating feedings well. p:\ncontinue to monitor for changes and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-06 00:00:00.000", "description": "Report", "row_id": 1713311, "text": "Neonatology Attending\nDOL 17\n\nRemains in NC 200 cc/min of 21-30% FiO2 with mild tachypnea. No cardiorespiratory events on caffeine.\n\nMurmur persists. BP 70/38 (50). 4-ext BP normal yesterday.\n\nWt 1180 (+20) on TFI 150 cc/kg/day PE28PM, tolerating well over 45 minutes. Abdomen benign. Voiding and stooling normally. On ferinsol and vitamin E.\n\nA&P\nPreterm infant with residual surfactant deficiency, feeding immaturity, murmur.\n\nWe will obtain a cherst radiograph today to guide further investigation of murmur.\n\nOtherwise no changes in management as detailed above.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-06 00:00:00.000", "description": "Report", "row_id": 1713312, "text": "Clinical Nutrition:\nO:\n30 CGA, BG now on DoL #17\nWt: 1180g (+20g)-(~25th%ile); gained an average of 19 g/kg/day over the last week.\nLN: 42cm (40)-(~75th%ile)\nHC: 26cm (26)-(10-25th%ile)\nLabs: none recent\nMeds: iron, vit E\nNutrition: PE28 w/ promod @ 150 cc/kg/day\n2 day averge intake: ~152 Kcals/kg & ~4.8 g/kg of protein\nGI: benign\n\nA/goals:\nFormer 27 weeker, tolerating gavage feeds over 45 minutes. Voiding & stooling. Wt gain w/in goal range over the last week. Feeds are meeting recommendations to support cont'd growth. Nutrition labs are due . Continues on iron & vit E. No changes to nutrition plan today, will cont. to follow w/team.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-06 00:00:00.000", "description": "Report", "row_id": 1713313, "text": "fellows exam note\ncomfortable, no distress\nheent: \nlungs: cta b/l\nheart: soft SM at left border, equal nl pulses throughout X 4\nabd: soft\nneuro: nonfocal\n\ncxr: nl herat size, lung fields c/w evolving CLD\n" }, { "category": "Nursing/other", "chartdate": "2161-01-06 00:00:00.000", "description": "Report", "row_id": 1713314, "text": "NPN 7a-7p\n\n\nResp: Inafnt remains in NC 200cc fi02 21-25%. RR 30-70's.\nOccasional drifts in 02 sats. Recovers quickly on own. Ls\nclr/=. Mild ic/sc retractions noted. Conts on caffiene. CXR\ndone this am.Cont to wean 02 as tol.\n\nG&D: Temp stable in airmode isolette. Swaddled with tshirt\nand hat. Alert and active with cares. Sleeps well between.\nHus shceduled for Thurs. Cont to support developmental\nmilestones.\n\nParenting: Mom called x1 for update. will be in this\nevening. Cont to support and update.\n\nFen: Infant conts on tf 150cc/kg of pe28 with pm. Tol well\ngavaged over 1hr for hx of spits. Sm spit x1 so far today.\nAbd soft. Active bs. No stool thus far. Minimal aspirates.\nConts on vite and fe. Ag stable 18.5-20.5cm. Cont with\ncurrent plan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-01 00:00:00.000", "description": "Report", "row_id": 1713293, "text": "NPN\n\n\n#2 Resp- Remains in RA. RR= 30-60. BS clear. Mild\nretractions.O2 sats 95-100%.Remains on Caffeine. Occ\nA's+B's.See flowsheet.A= Stable in RA. p= monitor.\n#4 - No contact yet tonight.\n#5 F/N- Abd soft,+bs no loops. Tolerating ng feeds of Pe 22\ncals w/o spits. Minimal asps.Feeds given on a pump over 1 hr\nq 4 hrs.Voiding+ stooling in adeq amts.Wt up 5gms. Tf=\n150cc/kg/day.A= Tolerating feeds well. P= monitor wt gain+\nfeeding tolerance.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-01 00:00:00.000", "description": "Report", "row_id": 1713294, "text": "Neonatology\nComfortable appearing. Few spells on caffeine. No murmur.\n\nWt 1050 up 5. Full volume gavage feeds at 150 cc/k/d. Abdomen benign.\nWill advance to 24 cal and start iron supps. ABdomen bneign.\n\nContinue current nutirional advance whilke monitoring tolerance.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-01 00:00:00.000", "description": "Report", "row_id": 1713295, "text": "0700- NPN\n\n\nRESP: Cont in RA, RR 30's-60's and O2 sats 96-100%. LS\nclear/=, mild SC/IC retractions noted. spell x 1 this\nshift with HR to 83, apnea, and O2 sat to 88%. Spell was\nQSR. A: Pt with occasional A/B spells. P: Cont to monitor\nresp status. Cont on Caffeine as ordered.\n\nFEN: TF cont at 150cc/kg/d. PE increased to 24 cals/oz.\nNo spits, minimal aspirates, abd girth stable at 20-20.5cm.\nAbdomen soft, round, pink, BS+, no loops. Pt is voiding,\nsmall brown stool x 2 (guiac -). Pt started on Ferinsol and\nVit E. A: Pt tolerating feeds at this time. P: Cont to\nmonitor feeding tolerance. Cont on Ferinsol and Vit E as\nordered.\n\nG&D: Temps stable in servo isolette. MAE, alert and active\nwith cares. Sleeps between cares, sucks pacifier and brings\nhands to face for comfort. Fontanels soft and flat. A:\nAGA. P: Cont to support growth and development.\n\nPARENTING: Mom called x 1, updated by this RN. She plans\nto visit sometime this evening. A: loving and\ninvested. P: Cont to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-01 00:00:00.000", "description": "Report", "row_id": 1713296, "text": "Rehab/OT\n\n brought in blankets to cover isolettes. Discussed care plans with . Discussed the importance of decreased lighting for infant comfort. OT to continue to follow for developmental support.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-04 00:00:00.000", "description": "Report", "row_id": 1713306, "text": "Nursing Progress Note\n\n\n#2 O: changed to blender for nasal cannula O2; presently in\n200cc flow, 21-30% to keep sats >95. Still mainly tends to\ndrift w/feeds, most periodic breathing noted then. Lungs\nclear/equal, RR 30's-70's, baseline SC/IC retractions.\nCaffeine dose inc to maximum. bradycardia x1 this afternoon\nw/apnea/desat. A: premie breathing pattern, generally better\nw/flow, ? refluxing w/feeds. P: monitor and document\nepisodes. Wean from nasal cannula as tol.\n#3 O: Temp stable on servo/heated isolette. Out w/dad to KC\nfor 2hours this afternoon and tol well. generally sleepy,\nbriefly awake this morning.\n#4 O: in, doing cares independently w/dad getting\nsome verbal tips on diaper changing. asking about O2, baby's\nfeeds, desats, etc. Dad KC for 2hours, very pleased.\n#5 O: TF 150cc/k/d PE28 w/PM now added. Fed on pump over\n45mins. tol well but is having periodic breathing as noted\nabove ? refluxing even if no spits noted. Abd benign,vdg and\nstooling guiac neg stools. A: tol feeds as noted above P:\ninc to 30cals as tol, monitor for reflux.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-10 00:00:00.000", "description": "Report", "row_id": 1713331, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ A and b's\nO: remains in room air, RR 40-70's, sat's >94%.\nperiodic breathing pattern noted. On caffeine, drifting occ.\nin sat's then quickly returns to baseline. One drift today\nrequiring bb02 to 78%. One spell today, req. mild stim. A:\nstable. P: cont to follow.\nCV\nO: +murmur, Hr 160-170's. Pink and well perfused with cap\nrefill <2sec. A: Stable hemodynamically. P: cont to follow.\nF/N\no: Tf of 150cc/kg/d of PE 28 w/ promod. GAvaged over 1'\".\nNo spits, min. asp's. Abd. soft, pink, no loops, active bs.\nVoiding/ no stool today. A: Stable. P: cont to provide opt.\nnut., follow.\nG/D\nO: Temp stable in off isolette. Swaddled, with hat and\ntshirt. Active and alert with cares. MAE. Font soft, flat.\nMAE. Calms with containment and pacifier. Bringing hands to\nmidline with enc. A: AGA P: cont to support dev. milestones.\nParenting\nPlease see twin A note.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-11 00:00:00.000", "description": "Report", "row_id": 1713332, "text": "NPN\n\n\n#2Resp O- Infant placed in NC 13-25cc's 100% O2 for drifts\nin O2 sat to 80's. Shallow breathing noted. RR 28-60. Mild\nretractions noted. Lungs clear. murmur audible.Remains on\ncaffeine. A-Minimal O2 need P-As per team.\n#3Dev. O- Infant active and alert with cares. Temps stable\nin off isolette. Infant sucking on pacifier when offered. A-\nAGA P- As planned.\n#4Family No contact during night.\n#5F/N Remains on PE28calw/promod at 150cc/kg. Wt. up\n50gms.Voiding and stooling g-. A- Tol. feeds P-As per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-11 00:00:00.000", "description": "Report", "row_id": 1713333, "text": "Newborn Med Attending\n\nDOL#22. Cont in low flow NC, occ spells. AF flat, clear BS, soft murmur, abd soft, MAE. Wt=1365 up 50, on 150 cc/kg/d PE28 with PM.\nA/P: Growing premie with residual lung disease and As and Bs. Wean O2 as tolerated. Monitor for spells. Cont current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-11 00:00:00.000", "description": "Report", "row_id": 1713334, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ A and B's\nO: remains with NC 100% fi02, 13cc. RR 40-70's. sat's\n94-99%. IC/SC ret. BSCE bilat. On caffeine, no spells today.\nPeriodic breathing pattern. A: Stable. P: cont to provide\nopt. oxygenation.\nCV '\nO: +murmur, HR 160-180's occ. BP 72/34 (49) right arm. A:\nStable. P: Cont to follow.\nF/N\nO: TF of 150cc/kg/day of pe 28 w/ promod. Gavaged over 60\".\nNo spits. Abd. soft, pink, no loops, active bs. Voiding/\nstooling heme (-). A: Stable. p: cont to provide opt. nut.,\nfollow.\nG/D\nO: Temp stable in off isolette. Active and alert with cares.\nMAE. font soft, flat. Calms with containment and pacifier.\nBoundaries in place. A: AGA P: cont to support dev.\nmilestones.\nParenting\nPlease refer to twin # 1 note.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-12 00:00:00.000", "description": "Report", "row_id": 1713335, "text": "NPN\n\n\n#2Resp O-Infant remains in NC 13-25cc's 100% O2 with sats\nabove 92. RR 40-60's. Lungs clear mild retractions noted.\nOccassional A+B's (see flow sheet) Remains on caffeine\nA-Comfortable on minimal O2 P-Continue to follow closely.\nWean O2 as tol.\n#3Dev. O- Temps stable with isolette off. Infant active\n/alert. She will suck on pacifier. A- AGA P-Support dev.\n#4Family No contact during night.\n#5F/N O-Remains on PE28cal w/promod at 150cc/kg. Wt 1410 up\n45gms. No spits/aspirates. Voiding well. No stool. A- Good\nwt. gain Tol. feeds P- As per team.\n#8C/V No change. Murmur audible. Color pale/pink.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-05 00:00:00.000", "description": "Report", "row_id": 1713307, "text": "NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nCONTINUES TO REQUIRE NASAL CANNULA O2 AT 200CC, 30%. NO\nEPISODES OF APNEA/BRADYCARDIA TONIGHT. CAFFIENE GIVEN AS\nORDERED. BBS CLEAR, RR50-70 WITH BASELINE RETRACTIONS.\n3. G&D\nSERVO WEANED OVERNIGHT. ALERT AND ADORABLE. QUIET UNLESS\nDISTURBED.\n4. PARENTING\nDAD CALLED AND UPDATED.\n5. F/N\nTONIGHT'S WEIGHT 1.16KG, UP 15 GRAMS. TOLERATING 150CC/KG OF\nPE28 WITH PROMOD. ABD FULL, SOFT. NO SPITS OR ASPIRATES.\nNO STOOL.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-05 00:00:00.000", "description": "Report", "row_id": 1713308, "text": "Neonatology Attending\nDOL 16\n\n is in NC 200 cc/min of 30% FiO2 with no apnea/bradycardias, on caffeine.\n\nNo murmur. BP 66/32 (45).\n\nWt 1160 (+15) on TFI 150 cc/kg/day PE28PM, tolerating well by gavage. Abdomen benign. on vitamin E and ferinsol.\n\nA&P\nPreterm twin with resolving surfactant deficiency, respiratory and feeding immaturity.\n\nContinue to monitor cardiorespiratory status and wean oxygen as tolerated.\n\nCranial ultrasound to be repeated later this weekend in follow-up of previously noted germinal matrix hemorrhage.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-05 00:00:00.000", "description": "Report", "row_id": 1713309, "text": "NPN 7a-7p\n\n\nResp: Infant remains in NC 200cc 30%. RR 40-70's. Ls clr/=.\nMild ic/sc retractions. RR 40-70's. Conts on caffiene. No\nspells so far this shift. Occasional drifts in sats.\nRecovers quickly on own.\n\nDev: Temp stable in servo isolette. Alert and active with\ncares. Sleeps well between. Likes prone position and\npacifier. Cont to support deveolopmental milestones.\n\nParenting: Mom x1 for update. will be in\nthis evening.\n\nFen: TF 150cc/kg of pe 28 with pm. Tol well gavaged over\n45mins. Sm spit x1. No aspirates. Ag stable 21-22cm. No\nstool thus far. Voiding with each diaper change. Abd soft.\nActive bs. Cont with current plan.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-09 00:00:00.000", "description": "Report", "row_id": 1713324, "text": "NPN NOCS\n\n\n2. O: In RA since beginning of this shift. O2 sats 93-100%.\nOcc drifting when feeding gavaged but recovers on own. RR\n40-60's. On caffeine. No spells. A: Stable in RA. P:\nContinue to monitor.\n\n3. O: Alert and active with cares. . Temp stable in low\nair isolette. Swaddled with boundaries in place. A: AGA. P:\nContinue to support dev. needs.\n\n4. O: in for eve cares. Update given. Asking\nappropriate questions. Requesting that the twins' time\nschedule be changed. Working up to that time schedule\nthroughout this shift. Independent with cares. A: Involved\nfamily. P: Continue to update daily and offer support.\n\n5. O: Wt 1295, up 60gms. TF remains at 150cc/kg of PE28 with\nPM. Gavaged over 1hr 15min. Small spit. Abdomen benign. No\nresiduals. Voiding and stooling. A: Tol feeds. P: Continue\nwith plan.\n\n8. Continues with soft murmur. VSS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-09 00:00:00.000", "description": "Report", "row_id": 1713325, "text": "Neonatology\nRemains in RA. Did not receive Lasix yesterday as wened spontaneously. Few spells on caffeine.\n\nWt 1295 up 60. Abdomen benign Toelrating feeds at 150 cc/k/d of 28 cal. All gaveg.\n\nContinue current resp management and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-09 00:00:00.000", "description": "Report", "row_id": 1713326, "text": "fellows exam note\ncomfortable on RA\nheent: \nlung: cta (b)\nheart: soft SEM\nabd: soft\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2161-01-16 00:00:00.000", "description": "Report", "row_id": 1713357, "text": "NPN DAYS\n\n\nALT IN RESP:IN AND OUT OF NASAL CANNULA O2 TODAY. IN 100%,\n13-25CC FOR SEVERAL HOURS AROUND EACH GAVAGE FEEDING, AND IN\nRA FOR ABOUT 2HRS PRIOR TO EACH NEXT FEEDING. LUNGS CLAER,\nRR 40-70'S WITH MILD INTERCOASTAL/SUBCOASTAL RETRACTIONS. NO\nEPISODES OF BRADYCARDIA. REMAINS OM CAFFEINE. OCCASIONAL\nDRIFTS IN O2 SATS, WITH QSR. CONTINUE TO MONITOR FOR SPELLS,\nAND WEAN O2 AS TOL.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON\n150CC/K/D OF PE 30 W/PROMOD, 40CC Q4HRS VIA GAVAGE OVER 1HR\nAND 20MINS. ABD EXAM BENIGN, NO LOOPS. GIRTH 22-23. ASP.\n0-0.4CC. VOIDING WELL. NO STOOL TODAY. APPEARS TO HAVE SOME\nREFLUX, BUT ONLY 1 SMALL SPIT TODAY. CONTINUE CURRENT\nFEEDING PLAN. MONITOR FOR ANY FEEDING INTOLERANCE.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACITVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nCONTINUE DEVELOPMENTAL CARES.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-16 00:00:00.000", "description": "Report", "row_id": 1713358, "text": "fellow exam note\ncomfortable\nheent: \nlungs: clr\nheart: no murmur\nabd: soft\n" }, { "category": "Nursing/other", "chartdate": "2161-01-16 00:00:00.000", "description": "Report", "row_id": 1713359, "text": "NPN DAYS CONTINUED\nALT IN PARENTING: IN TO VISIT AT 5PM. UPDATED AT BEDSIDE. MOM TEMP AND CHANGED DIAPER AND HELD BABY FOR 90MINS. CONTINUE TO SUPPORT AND UPDATE. AGRREABLE TO TRANSFER BACK TO WINCESTER NEXT WEEK IF TWIN REMAINS OFF CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-17 00:00:00.000", "description": "Report", "row_id": 1713360, "text": "NPN\n\n\n#2 resp=Remains in NC 100cc 21%. BS clear. Mild\nretractions.RR= 40-60.Remains on caffeine.\n#4 -No contact tonight.\n#5 F/N- Abd soft,+bs, no loops.Tolerating feeds of Pe 30\ncals w/promod w/o spits.Feeds given over 1 hr+20mins.\nminimal asps.Voiding + stooling in adeq amts.A= Tolerating\nfeeds w/occ spits.P= Monitor wt gain+ feeding tolerance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-17 00:00:00.000", "description": "Report", "row_id": 1713361, "text": "NICU Attending Note\n\nDOL # 27 for this former 27+ week gestation twin, now with issues of A/B, evolving CLD, issues of growth and nutrition. No new concerns.\n\nFull PEx to follow\n\nCVR/RESP: Murmur, small PFO by echo. Mild intercostal retractions, BS clear/=. On caffeine, with no A/B in last 24 hours. RA, 50 cc/min flow, will try off flow today.\n\nFEN: Abd benign, weight today 1645 gm, up 55 gm, on TF of 150 cc/kg/d, PE 30 with PM, all PG. Will continue current diet. Nutrition ok.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-17 00:00:00.000", "description": "Report", "row_id": 1713362, "text": "NICU Attending Note\nPEx: Well appearing, sleeping comfortably, responsive when stimulated, AFSOF, minimal intercostal retractions, BS clear/=, RRR with 1/6 systolic murmur, abd benign, skin pnik and well perfused, appropriate tone and strength\n" }, { "category": "Nursing/other", "chartdate": "2161-01-26 00:00:00.000", "description": "Report", "row_id": 1713387, "text": "Neonatology\nComfortable appearing. RA. Few spells.\n\nWt up 25. Tolerating feeds at 150 cc/k/d of 30 cal. Abdomen bneign. Tolerating gavage feeds.\n\nCOntinue to await maturation of resp control and feeds.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-26 00:00:00.000", "description": "Report", "row_id": 1713274, "text": "NPN 1900-0700\n\n\n1. Resp: Rec'd infant on prong CPAP 5 this am. Placed in\nRA at 1000. No desats or bradys all shift. RR=40-60's.\nMild baseline SCR/ICR. LS clear. Suctioned nares x1 for\nsmall amount white secretions. No spells this shift. 2\nspells in past 24hrs. On caffeine.\n\n2. G&D: is alert and active with cares. Sleeps well\nbetween cares. Temps stable in sheepskin in servo\ncontrolled isolette. HUS done today. AFSF. AGA.\n\n3. Parenting: Parents in for 1300 cares. Asking\nappropriate questions. Updated at bedside. Cont to offer\nsupport and updates.\n\n4. FEN: TF=decreased to 150cc/k/day. Currently receiving\nPND10 and IL via DLUVC at 90cc/k/day. Enteral feeds of PE20\ninfusing at 60cc/k/day. Min asp/no spits. AG stable. Plan\nis to advance enteral feeds by 10cc/k/. No stool this\nshift. U/O=3.1cc/k/hr x 12hrs. Abd is soft and slightly\nfull. Active bs. Lytes to be checked in am.\n\n5. Hyperbili: remains under single phototx. Sl\njaundiced. Eye shields in place. to be checked in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-09 00:00:00.000", "description": "Report", "row_id": 1713327, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ A and b's\no: remains in room air. RR 30-70's, sat's 94-100%.\nMild IC/SC ret. On caffeine. No spells today. A: Stable. P:\ncont to follow.\nCV\nO: +murmur, HR 160-180's, Pink, cap refill <2sec's. A:\nStable. P: cont to follow.\nF/N\nO: TF of 150cc/kg/day of Pe28 w/ promod. Gavaged over\n1'\". One small spit today. Abd. soft, round, pink, no\nloops, active bs. Voiding/ no stool today. Girth 21cm. A:\nStable. p: cont to provide opt. nut., follow.\nG/d\nO: Temp stable in air isolette. Swaddled loosely. Alert and\nactive with cares. Font soft, flat. Calms with containment\nand pacifier. Boundaries in place. A: AGA P: cont to support\ndev. milestones.\nParenting\nPlease refer to twin . note.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-10 00:00:00.000", "description": "Report", "row_id": 1713328, "text": "npn nocs\n\n\n2. O: Remains in RA. No spells. On caffeine. RR 30-70's. O2\nsats>93%. A: Stable in RA. P: Continue to monitor.\n\n3. O: Alert and active with cares. . Temp stable in off\nisolette. Swaddled with boundaries in place. A: AGA. P:\nContinue to support dev. needs.\n\n4. No contact from thus far this shift.\n\n5. O: Wt 1315, up 20gms. TF remain at 150cc/kg of PE28 with\nPM. Gavaged over 1hr 15min. No spits. Abd. benign. Min\nresidual. Voiding and stooling. A: Tol feeds. P: Continue to\nmonitor.\n\n8. Soft murmur continues. VSS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-10 00:00:00.000", "description": "Report", "row_id": 1713329, "text": "Neonatology Attending\n\nDOL 21 CGA 30 4/7 weeks\n\nRemains in RA. R 40s-70s. No A/B. On caffeine.\n\nPFO murmur. BP 47/32 mean 37.\n\nOn 150 cc/kg/d PE 28 with promod pg over 75 min. No spits. Tolerating feeds. Voiding. Stooling (heme neg). Wt 1315 grams (up 20).\n\n visiting.\n\nA: Stable. Doing well in RA. Tolerating feeds. Gaining wt.\n\nP: Continue current management\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-10 00:00:00.000", "description": "Report", "row_id": 1713330, "text": "Neonatology Attending\nExam AF soft, flat, clear bs, soft murmur, benign abd, sleeping, good perfusion\n" }, { "category": "Nursing/other", "chartdate": "2161-01-15 00:00:00.000", "description": "Report", "row_id": 1713354, "text": "Nursing Progress Note\n\n\n#2-O/A- Received infant on NCO2 100% 25cc. Infant remains\non NCO2. Cont on Caffeine. No A's or B's. No resp\ndistress. P- Cont to assess for Resp needs.\n#3-O/A- cont to be awake and active with cluster\ncares. Sleeps well between cares. Temp stable in off\nisolette. P- Cont to assess for G&D needs.\n#4-O/A- in to visit with updates given. Dad held\n while Mom held brother. P- Cont to enc parental\ncalls and visits.\n#5-O/A- TF=150cc/kg/d of PE30w/ProMod via NGT. Abd exam\nbenign. Voiding and stooling. Min asp. Sm spit x1. P-\nCont to assess for FEN needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-26 00:00:00.000", "description": "Report", "row_id": 1713388, "text": "NPN Days\n\n\n2. O: Ls clear. O2 sats >97% RA. RR 50-70's. MIld subcostal\nretractions. No spells. A: No spells. P: Cont to monitor\nresp status.\n\n3. O: Temp stable swaddled in open crib with sib. and\nactive with cares. Sucking on pacifier. A/P: Cont to monitor\ntemp. Cont to cluster cares.\n\n4. O: Dad called X1. Asking appropriate questions. \nto be in at 1700 care. A/P: Cont to educate and support.\n\n5. O: TF 150cc/kg of PE30+PM po/pngt. Bottled 31cc at 0930.\nMin asp. No spits. Voiding and stooling G-. A: Tol feeds. P:\nCont to monitor wt, abd, and tol of feeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-26 00:00:00.000", "description": "Report", "row_id": 1713389, "text": "Clinical Nutrition:\nO:\n32 CGA, BG now on DoL #37\nWt: 2020g (+25g)-(50-75th%ile); gained an average of 19 g/kg/day over the last week.\nLN: 41cm (10-25th%ile)\nHC: 30cm (25-50th%ile)\n: none recent\nMeds: Iron (~4.1 mg/kg/day from feeds & supplement) & vit E\nNutrition: PE30 w/ promod @ 150 cc/kg/day\nProjected 24hr intake: ~150 Kcals/kg & ~4.4 g/kg of protein\nGI: occasional small spits\n\nA/goals:\nTolerating gavage feeds well, took x1 full volume bottle yesterday. Voiding & stooling; occasional small spits noted. Feeds are meeting needs to support adequate growth. Wt gain w/in goal range over the last week. Nutrition due at the end of the week. Continues on iron & vit E. No changes to nutrition plan today, will cont. to follow w/team.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-27 00:00:00.000", "description": "Report", "row_id": 1713390, "text": "NNP 7p-7a\n\n\nRESP: In RA. No a's and b's. O2sat 97-100. RR: 40-60's. Pt\nis pale pink and well perfused. Ls:cl/=. Continue to support\nimprovment in resp status.\n\nDEV: Temp is stable in open crib. Pt is and active\nwith cares. Settles well with containment and pacifier and\nenjoys being swaddled next to her brother. Pt can calm\nherself by holding pacifier to her mouth on her own.\n\nPARENTING: No contact from this shift.\n\nFEN: New weight-2.055g(+35g). TF: 150cc PE30PM/kg/day;\nalternating b/w PO and gavage. 51cc/kg. Pt gavaged 51cc\nduring 1st feeding. During the second, Pt 19cc, but\ntuckered out, and then gavaged the rest(35cc). minimal asp.\n1 spit. voiding with every diaper change. Pt remains on vit\nE and Fe. Continue to encourage and support PO feeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-27 00:00:00.000", "description": "Report", "row_id": 1713391, "text": "Neonatology\nDOing well. REmains in NCO2. Comfortable apeparing.\n\nWT 2055 up 35. TF at 150 cc/k/d of 30 cal. Abdomen benign. po/pg.\n\nCOntinue to await maturation of resp control, pulm and feeding.\n\nEye exam for Wed.\n\nCO-bedding with infants.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-27 00:00:00.000", "description": "Report", "row_id": 1713392, "text": "fellows exam note\nheent:\nlungs clr\nheart:no murmur\nabd:soft\n" }, { "category": "Nursing/other", "chartdate": "2160-12-27 00:00:00.000", "description": "Report", "row_id": 1713275, "text": "2. Resp: O: Infant received in RA. RR 40-60s, ls clear,\ncolor pink. She has had one so far this shift, in 8\nhours, quickly self resolved w/ no desat. She is on caffeine\nas ordered. A: Stable in RA. P: Monitor. Meds as ordered.\n\n3. G/d: O: Infant is alert and active w/ cares and sucks\nvigorously on a pacifier. She is nestled in a sheepskin w/\nbounderies in a heated isolette. A/P: Continue to support\ninfant needs.\n\n4. Parents: No contact so far this shift.\n\n5. F/N: O: Infant is on 150cc/k/d TF, working up on pg feeds\nof PE20. She has just advanced to 70cc/k/d of pg feeds, fed\nq 4 hours over 30 min. Abd is benign, she is voiding\n3.0cc/k/h so far this shift (over 8 hours), stooled a mec\nstool and had a very small spit. She gained 37g. The\nremainder of her TF is TPN and lipids infusing via a DUV. A:\nTol w/u on feeds so far. P: Labs at the next care time.\nMonitor. Continue w/ plan.\n\n7. : O: Infant is on single phototx w/ her eyes covered.\nShe is slightly jaundiced. A: Hyperbilirubinemia. P: Check\n at next care time. Continue w/ phototx as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-27 00:00:00.000", "description": "Report", "row_id": 1713276, "text": "Neonatology Attending\nDOL 7\n\nHas remained in room since yesterday. Two bradycardias, on caffeine.\n\nNo murmur.\n\nUnder single phototherapy with bilirubin 2.5 under phototherapy.\n\nWt 970 (+37) on TFI 150 cc/kg/day, including enteral feeds PE20 at 70 cc/kg/day tolerating well. 134/4.7/103/13. D-stick 66. Urine output 3 cc/kg/hr in the past 8 hours.\n\nA&P\nPreterm infant with respiratory and feeding immaturity, hyperbilirubinemia.\n\nWe will continue to advance feeds by 10 cc/kg/day as tolerated.\n\nPhototherapy will be discontinued and bilirubin rechecked in 24 hours.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-27 00:00:00.000", "description": "Report", "row_id": 1713277, "text": "NPN 7a-7p\n\n\nResp: Infant remains in RA. Ls clr/=. IC/SC retractions. RR\n40-60's. No spells or desats so far this shift. Conts on\ncaffiene. Cont to monitor.\n\nDev: Temp stable in servo isolette. Alert and irritable with\ncares. Sleeps well between. in sheepskin with\nboundries in place. Occasionally sucks on pacifier. Cont to\nsupport developmental milestones.\n\nParenting: Dad called x1 for update. Parents unable to visit\ntoday d/t illness. Cont to support and update.\n\nFen: Infant conts on tf 150cc/kg. IVF of pn d10w with lipids\ninfusing at 70cc/kg via dluvc. Enteral feeds of pe 20 at\n80cc/kg. Increasing 10cc/kg at 01&13. Tol feeds gavaged\nover 40 mins. No spits minimal aspirates. Abd round soft.\nActive bs. Sm mec stool x1 thus far. Voidng with each diaper\nchange. Ag stable 19-19.5cm. Cont to advance feeds as tol.\n\n: Single phototx dc'd this am. level to be checked\nin AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-27 00:00:00.000", "description": "Report", "row_id": 1713278, "text": "NPN\n\n\nADD:\n\nHL placed in left leg. Upon arrival of new pn dluvc will be\ndc'd.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-28 00:00:00.000", "description": "Report", "row_id": 1713279, "text": "NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nCONTINUES IN ROOM AIR WITH O2 SATS >94. NO EPISODES OF\nAPNEA OR DESAT. CAFFIENE GIVEN AS ORDERED.\n3. G&D\nTEMP STABLE ON SERVO MODE. ALERT AND ADORABLE !\n4. PARENTING\nNO CONTACT.\n5. F/N\nTONIGHT'S WEIGHT UP 25 GRAMS TO .995KG. TOLERATING\nADVANCING FEEDINGS, CURRENTLY AT 90CC/KG OF FS PE20/BM. ABD\nFULL, SOFT. PASSED HUGE STOOL AT 0500. D11PN INFUSING AT\n60CC/KG VIA PIV. ONETOUCH 94.\n7. HYPERBILI\nAM LEVEL PENDING. COLOR IS SL JAUNDICED.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-16 00:00:00.000", "description": "Report", "row_id": 1713355, "text": "1900-0730 NPN\n\n\nRESP: Received pt in NC 100%, 25cc flow. Pt weaned to 13cc\nflow at beginning of shift, then was taken off NC at 2200.\nShe has remained in RA since then, sats 97-99%. RR\n30's-70's. LS clear/=, mild SC retractions noted. No A/B\nspells or desats noted this shift. A: Resp status stable.\nP: Cont to monitor resp status.\n\nFEN: Wgt tonight 1595g, up 40g. TF cont at 150cc/kg/d of\nPE30 with PM (39cc Q4Hr gavaged over 1hr 20min). Small spit\nx 1, aspirates 0.2cc, abd girth stable at 23cm. Abdomen\nsoft, round, pink, BS+, no loops noted. Pt is voiding, no\nstool as of yet this shift. A: Pt tolerating feedings at\nthis time, not yet ready to PO feed. P: Cont to monitor\nfeeding tolerance and weight. Monitor for readiness to PO\nfeed.\n\nG&D: Received pt in an off isolette. Temps stable, pt in\noff isolette x 1 week. Pt transferred to open crib at 0130.\nPt is dressed and swaddled, sheepskin present. MAE, alert\nand active with cares. Sleeps between cares, sucks pacifier\nand brings hands to face for comfort. Fontanels soft/flat.\nA: AGA. P: Cont to support growth and development.\n\nPARENTING: No contact from as of yet this shift.\nA: Unable to assess. P: Cont to support and educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-16 00:00:00.000", "description": "Report", "row_id": 1713356, "text": "Neonatology attending Progress Note\n\n\nNow 27 days of age.\n\nBaby is now requiring O2 only for feedings.\nNo apnea and bradycardia since the 14th.\nOn caffeine.\n\nBP 61/51 55\n\nWt. up 40gm to 1595gm on PE30 with Promod 150cc/kg/d - feedings are well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nEncouraging progress with weaning of supplemental O2.\nWill continue with current management.\nWill consider possible transfer to next week with brother if both continue to do well.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-23 00:00:00.000", "description": "Report", "row_id": 1713382, "text": "#2RESP\n REMAINS IN RA. SHE HAS RARE DRIFTS THAT APPEAR TO BE\nASSOCIATED WITH REFLUX. RR40-50'S WITH MILD RETRACTIONS.\nLUNGS CLEAR. NO TRUE SPELLS\nA. TOL RA.\nP. CONT TO MONITOR.\n#3DEV\nTEMP SL WARM IN AN OPEN CRIB . OUTFIT TAKEN OFF AND T SHIRT\nAPPLIED. BOTTLED ENTIRE FEED AT 1300 WITH GOOD COORDINATION.\n#4PARENTS\n HERE AT 1600 AND MET WITH DR. .\n#5FEN\nBABY CONT TO RECEIVE PE30 WITH PROMOD AT 150CC/KG OR 48CCQ4.\nWHEN GAVAGED, RECEIVED OVER 90 MINUTES. ABD ROUND BUT SOFT,\nSTABLE GIRTH. MINIMAL ASP. VOIDED. TRACE STOOL.DSTICK 50\nPRIOR TO FEED AT 1300. FELLOW INFORMED.\nA. TOL FEEDS\nP. CONT TO MONITOR TOL TO FEED AND DSTICK\n\nADDENDUM\nHCT SENT/ AND WAS 25.1 TEAM INFORMED. NO TREATMENT FOR NOW.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-25 00:00:00.000", "description": "Report", "row_id": 1713383, "text": "Neonatology Attending\nExam AF soft, flat, clear bs, no murmur appreciated, benign abd, good perfusion, active and \n" }, { "category": "Nursing/other", "chartdate": "2161-01-25 00:00:00.000", "description": "Report", "row_id": 1713384, "text": "Neonatology Attending\n\nDOL 36 CGA 32 5/7 weeks\n\nStable in RA. Occ desats. R 64-72. No A/B. On caffeine.\n\nBP 80/39 mean 50. Murmur secondary to PFO.\n\nContinues on PE 30 with promod at 150 cc/kg/d. Feedings ~ po. Voiding. Stooling (heme neg). Wt grams (up 50).\n\nHct 25.1 with retic 10.4\n\n visiting and up to date. desire WH transfer.\n\nA: Stable. No spells. Tolerating feeds and increasing pos. Anemic but reticing well and otherwise asymptomatic.\n\nP: Monitor\n D/C caffeine\n Encourage pos as tolerated\n Monitor hct\n To WH when she and her brother are ready for Level II care\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-28 00:00:00.000", "description": "Report", "row_id": 1713280, "text": "Neonatology\nDOL #*. Remains in RA. No spells. COmfortable appearing. REmains on caffeine. No murmur.\n\nWt 995 up 25. Continues to tolerate feeds at 90 cc/k/d out of TF of 150 cc/k/d. Advancing without difficulty. Abdomen benign. On D11 PN Lytes in normal range yesterday.\n\n in 3.5 range on rebound this am. Will follow. No need for photorx at this point.\n\nMother and father not visiting at present due to their own illness.\n\nCOntinue current resp and nutritional management.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-28 00:00:00.000", "description": "Report", "row_id": 1713281, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains in RA, maintaining O2 sats 97-100&\nthroughout the day. RR 30-40s, LS clear/=. Mild baseline\nic/sc retractions noted. Three spells noted thus far today,\n(HR 50s, sats 90s, mild stim for resolve);continues on IV\ncaffeine. P: Cont to monitor for increased spells.\n\nG&D O/A: Temp stable in servo isolette. Snuggled on\nsheepskin. sleeps well between feedings, A/A with\ncares. P: Support developmental needs.\n\nPAR O/A: Parents called for update this morning; will visit\ntomorrow. P: Cont to support NICU parents.\n\nFEN O/A: TF @ 150cc/k/d. Enteral feeds currently @ 100cc/k/d\nof PE20. receives 19cc q4h pg. Plan to increase\nenteral feeds by 10cc/k @ 13 & 01. IVF of PN D11\ncurrently @ 50cc/k/d running through a PIV in the right\nfoot. DS 126. Abdomen is round & full, girth 21-21.5; pos\nBS. Voiding/no stool. Minimal aspirates/ one large spit. P:\nCont to monitor feedig tolerance while working up on feeds.\n\n O/A: Infant remains pink/slightly jaundice. Rebound\n this morning 3.5/0.2/3.3. Remains off phototherapy.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-30 00:00:00.000", "description": "Report", "row_id": 1713287, "text": "Newborn Med Attending\n\nCont in RA, no spells on caffeine. AF flat, clear BS, no murmur, abd soft, MAE. WT=1020, no change. On 150 cc/kg/d PE20.\nA/P: infant with resolved RDS and h/o As and Bs. Monitor for spells. Just advance to full volume feeds. Start to increase cals.\n" }, { "category": "Nursing/other", "chartdate": "2160-12-30 00:00:00.000", "description": "Report", "row_id": 1713288, "text": "Clinical Nutrition:\nO:\n29 CGA, BG now on DoL #10\nWt: 1020g (no change o/n)- (~25th%ile); down ~8.5% from birth wt.\nLN: 40cm (36.5cm)-(50-75th%ile)\nHC: 26cm (26.5)-(~25th%ile)\nLabs: lytes checked this am\nDsticks: 97, 108 this am\nTF: 150 cc/kg/day\nNutrition: BM/PE20 @ 150 cc/kg/day\nProjected 24hr nutrition: ~100Kcals/kg & ~1.6-3 g/kg of protein\nGI: benign\n\nA/goals:\n was advanced to full volume enteral feeds & IVFs were d/c as PIV access was lost. Tolerating advancement well thus far; voiding & stooling, minimal aspirates/spits noted. Plan is to hold @ 20Kcals/oz for ~24hrs & begin advancing Kcals/protein in the am. Lytes/dsticks are stable. Will add iron/vit E once @ 24Kcals/oz & check nutrition labs once indicated. No other changes to nutrition plan today, will cont. to follow w/team.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-25 00:00:00.000", "description": "Report", "row_id": 1713385, "text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in room air with baseline resp rate 50-70 and O2\nsats >94. Remains on continuous oximeter.\nA: Occasional quick sr drifting sats.\nP: D/C caffeine today and continue to monitor.\n\nHEMODYNAMICS\nO: Murmur audible. Cap refill slowish. Baseline HR 170-180\nat rest.\nA: Anemic. Remains on ferinsol.\nP: Monitor and assess for compromise.\n\nNUTRITION\nO: Total fluids 150cc/kg. Receiving PE30 with PM. Infant\ntaking about half daily volume po with volufeed and yellow\nnipple. Abd exam benign. No spits. Voiding and passing green\nstool.\nA: Improving po.\nP: Po as tol.\n\nDEVELOPMENT\nO: Active and with cares. Sleeps between. Temp stable\nco-bedding in crib with brother. Sucking on pacifier and her\nfingers.\nA:Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom and Dad in for 1330 cares. Independent in temp taking\nand diaper change. Dad fed infant and handles her well.\nUpdated regarding infant's status and plan of care.\nA: Involved .\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-26 00:00:00.000", "description": "Report", "row_id": 1713386, "text": "Nursing progress note\n\n\n#2 O: remains in room air with equal & clear breath sounds &\nmild SC retractions. Baby had to 72 with apnea & desat\nto 52 during feed. Mild stim given. A: Stable. P: Cont to\nassess.\n#3 O: with cares. Waking for feeds. Baby took 15cc &\n25cc . Remainder given PG. Sucks on pacifier. Temp stable\nco-bedding with twin. A: AGA. P: Cont to assess.\n#5 O: Wgt op 25gms. Remains on 150cc/k/d PE30 w/PM. Abd soft\nwith active bowel sounds & no loops. Voiding & stooling.\nSmall spit X's 1. A: Tolerating feeds & gaining wgt. P: Cont\nto asses.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-30 00:00:00.000", "description": "Report", "row_id": 1713289, "text": "Nrsg Progress Note-0700-1500\n\n\n#2O/A-Rem in ra with 02 sats maintined >96% with no desats\nor bradsy. Color pink with bbs clear and equal. Rem with\nmild baseline retractions noted. A-Resp needs wnl this shift\n.P-Cont to assess resp needs.\n#3O/A-Rem with alertness noted with cares sucking on pcifier\nwith mottling and finger splaying with cares. A-G&d needs\nwnl this shift. P-Cont to assess g&d needs.\n#4O/A-Mom and dad visit daily with phone call from Mom with\nplans for visit this eve for the 1700 cares. A-Parental\nstatus wnl with shift. P-Cont to assess parental needs.\n#5O/ARem with tf of 150 cc's/kg with pe 20 cal with no asps,\nspits, or abd distention noted this shift. No stool as of\nthis writing. A-Fen needs wnl this shift. P-COnt to assess\nfen needs.\nPlans for report at 1500.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-31 00:00:00.000", "description": "Report", "row_id": 1713290, "text": "NPN\n\n\n#2 Resp- Remains in RA w/o2 sats 95-100%. BS clear. Mild\nretractions.RR- 30-60.Remains on Caffeine.Occ\nA's+B's.A=Stable in RA. P= Monitor.\n#4 -No contact tonight.\n#5 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of Pe 20\ncals w/sm spit x1. Minimal asps.TF= 150cc/kg/day.Feeds given\non a pump over 1 hr.Voiding in adeq amts. Sm stool x1.AG\nstable.Wt up 25 gms.A= Tolerating feeds well. p= monitor wt\ngain+ feeding tolerance.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-12-31 00:00:00.000", "description": "Report", "row_id": 1713291, "text": "Neonatology\nCOmfortable apeparing RA. Spells not a problem. murmur.\nTemp stable in isollette.\n\nWt up 25 . Tolerating full volume feeds via gaavge. WIll advance to 22 cal. Abdomen bneign.\n\nCOntinue current nutritional management.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-03 00:00:00.000", "description": "Report", "row_id": 1713302, "text": "Nursing Progress Note\n\n\n#2 O: Remains in room air w/sats>95% baseline; several\ndesats to 80's this morning w/brief BBO2 needed to resolve,\nagain this afternoon but no O2 needed. RR 30's-70's w/occ\ninc to 80's noted as well as some shallow breathing.\nBaseline IC/SC retracs, no inc wob. Caffeine as ordered, no\napnea or bradycardia episodes noted this shift. P: monitor\nclosely for inc wob.\n#3 O: temp stable on servo mode, heated isolette. pacifier\nfor short periods during feeds.\n#4 O: mom called this morning and updated, will be\nin to visit at some point today.\n#5 O: TF 150cc/k/d, now PE28. all feeds on pump over 45mins\nand tol well w/o spits or asp. Abd soft, round, active bowel\nsounds. vdg qdiaper, no stools this shift. P: cont to adv\ncals as tol. for optimum growth.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-04 00:00:00.000", "description": "Report", "row_id": 1713303, "text": "NPN\n\n\n#2 Resp- Placed in NC 100% 13-50cc for freq desats to the\n80's.RR=50-80.Mild retractions. BS clear.Shallow breathing\nat times.Remains on Caffeine.See flowsheet for A's+B's.A=\nMinimal 02 needed.P= monitor.\n#4 - no contact yet tonight.\n#5 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of Pe28\ncals w/sm spit x1.Minimal asps.AG stable.Ng feeds given on a\npump over 45 mins q 4 hrs.Voiding+ stooling in adeq amts.Wt\nup 30gms.Tf= 150cc/kg/day.A= Tolerating feeds well.P=\nmonitor wt gain+ feeding tolerance.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-04 00:00:00.000", "description": "Report", "row_id": 1713304, "text": "Neonatology Attending\nAddendum-Physical Examination\n\nHEENT AFSF; NC in place; no nasal flaring\nCHEST no retractions; good bs bialt; no crackles\nCVS well-perfused; RRR; S1S2 normal; 1/6 SEM radiating to back\nABD soft, non-distended; bs active\nCNS active, resp to stim; tone AGA\nINTEG normal\n" }, { "category": "Nursing/other", "chartdate": "2161-01-04 00:00:00.000", "description": "Report", "row_id": 1713305, "text": "Neonatology Attending\nDOL 15\n\n transitioned from room air with NC (now 200 cc/min of 23% FIO2) last night after increased desaturations with periodic breathing noted. These episodes are more prominent during feeds. On caffeine with four bradycardias in the past 24 hours.\n\nNo murmur. BP normal.\n\nWt 1145 (+30) on TFI 150 cc/kg/day PE28, tolerating well. Voiding and stooling normally.\n\nA&P\nPreterm infant with respiratory immaturity.\n\nContinue to monitor cardiorespiratory status closely. The recent oxygen requirement is likely simply respiratory immaturity and fatigue. There is no evidence clinically of another process such as infection, but this will be considered if any further deterioration is noted. Caffeine will be increased to 8 mg/kg/day.\n\nWe will start Promod today.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-08 00:00:00.000", "description": "Report", "row_id": 1713319, "text": "1900-0700 NPN\n\n\n#2RESPIRATORY\nO:RESTARTED ON NC 200CC 21-30% THIS SHIFT AFTER FREQUENT\nDRIFTS AND SATS HOVERING <92%. BS CLEAR. RESP RATE 40-62\nWITH MILD RETRACTIONS. X1 OVERNIGHT; SOME DRIFTS\nW/APNEA THAT ARE QSR\nA:REQUIRING 02 FOR SAT DRIFTS\nP:02 TO KEEP SATS >92%, MONITOR RESP STATUS CLOSELY\n\n#3G&D\nO:RETURNED TO LOW AIR CONTROL TEMPERATURE ISOLETTE AFTER\nINITIAL TEMP OF 97.7 WITH COOL EXTREMITIES. TEMPERATURE\n97.9-98.2 SINCE THEN. ACTIVE/QUIETLY ALERT WITH CARES;\nSLEEPING FAIRLY WELL BETWEEN. DOES GET A LITTLE IRRITABLE AT\nTIMES AND TAKES TIME TO CALM DOWN. FONTANEL SOFT AND FLAT;\nSUTURES SMOOTH. /SWADDLED ON SHEEPSKIN W/BOUNDARIES\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#4SEE SIBLINGS CHART\n\n#5F/E/N\nO:TF AT 150CC/KG PE28 30CC Q4HR GAVAG EOVER 1HR 15\". ABDOMEN\nSOFT AND FULL WITH GOOD B.S. VOIDING WELL; SMALL GREEN HEME\nNEGATIVE STOOL X1. NO SPITS AND <1CC ASPIRATES. AG\n21.5-22CM. WT UP 20GM\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, MONITOR WT GAIN\n\n#8CV\nO:SOFT MURMUR HEARD OVERNIGHT. HR 160-180. COLOR PALE/PINK\nWITH GOOD PERFUSION\nA:STABLE\nP:CONTINUE TO MONITOR FOR S/S OF COMPROMISE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-08 00:00:00.000", "description": "Report", "row_id": 1713320, "text": "FELLOWS EXAM NOTE\nCOMFORTABLE, NC, 200 CC\nHEENT: \nHEART: SOFT HSM MURMUR, ECHO - NO PDA, +PFO\nLUNG: CLR\nABD: SOFT, ND\nNEURO: NON FOCAL\n" }, { "category": "Nursing/other", "chartdate": "2161-01-08 00:00:00.000", "description": "Report", "row_id": 1713321, "text": "Neonatology\nIncreased NCO2 flow over past 24 hours. CXR showed slightly increased heart size. Will give dose of Lasix and monitor response.\n\nWt 1235 up 20. TF at 150 cc/k/d. Abdomen bneign. Will continue at current regimen. Lytes to be checked on Saturday.\nContinue as at present.\n\nHUS shows resolvinmg Grade 1.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-08 00:00:00.000", "description": "Report", "row_id": 1713322, "text": "Social Work\nPlease refer to careview note in baby 1's chart. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-08 00:00:00.000", "description": "Report", "row_id": 1713323, "text": "NPN 1330\n\n\n#2 Resp: remains on a nasal cannula of 200cc flow,\nFIO2 of 21%, occasionally increased to 30% for Sats drifting\nto 90%. RR 30-60, lungs clear, = bilat. Mild SC/IC\nretractions. Color pink.\nA: O2sats stable, weaning FIO2 near 21%.\nP: Cont to wean O2 as tolerated.\n#3 G/D: remains in a heated isolette w/ temps\n98.7ax-99.7ax. Awake and alert w/ cares. Positioned prone\nw/i a sheepskin. Moving all extremities.\nA: AGA 30+ corrected.\nP: Cont to provide dev. supports.\n#4 : Mom phoned this AM to check on babies. Asking\nappropriate questions. Updated on weights. Plans to visit\nthis afternoon to kangaroo the babies.\nA: Invested and involved .\nP: Cont parent support.\n#5 F/N: continues on PE28+Promod, 150cc/kg/d 30cc q\n4hrs, X1hr 15 mins. Tol pg feeds well. Abd soft, bowel snds\nactive. Voiding well, no stool today. AG stable at 20cms. No\nspits or aspirates.\nA: Tol pg feeds at present.\nP: Cont to monitor for feeding intolerance.\n#8 CV: HR 150-180, (increased when ax temp 99.7.) BP 72/34\nM48. Murmur audible, soft.\nA: Stable CV status w/ murmur.\nP: cont to monitor for change.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-14 00:00:00.000", "description": "Report", "row_id": 1713347, "text": "NPN 1900-0700\n\n\n2. RESP: O: Pt remains in low flow nasal cannula,\nrequiring 13cc of 100% FiO2. RR 30-60's. baseline\nretractions noted. Lung sounds are clear. No spell snoted\nso far this shift. Pt is on caffeine. A: Stable in\ncannula. P: Monitor.\n\n3. DEV: O: is active and alert during her ccres.\nTemp stable swaddled in off isolette. Fontanels are soft\nand flat. MAE. A: AGA. P: Continue to support infant's\nneeds.\n\n4. PAR: No contact from so far this shift.\n\n5. F&N: O: TF remain at 150cc/k/d of PE 30 with promod.\nFeeds gavaged over 1 hour 20 minutes. Abd benign. BS+. No\nspits and minimal aspirates noted. Voiding and passing\nlarge green guiac negative stool X1. Weight gain 70 grams.\nA: Tol feeds well. Gaining weight. P: Monitor.\n\n8/ C/V: O: Soft murmur persists. HR 160-170's. Pt is\npale pink and well-perfused. BP stable. A: Alt C/V. P:\nMonitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-14 00:00:00.000", "description": "Report", "row_id": 1713348, "text": "Neonatology\nDoing well. Low flow NCO2. Spells not problem. COmfortable appearing. CV stable.\n\nWt 1505 up 70. Tolerating feeds at 150 ccc/k/d of 30 cal. Abdomen benign. Spitting improved over course of day.\n\nContinue current resp management and nutritional regimen. ATtempt to wean from O2 as tolerated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-14 00:00:00.000", "description": "Report", "row_id": 1713349, "text": "Nursing Progress Note\n\n\n#2-O/A- Received infant on NCO2 100%, 13cc(less than 25cc)\nflow. Infant remains on NCO2. No resp distress. Occas\ndrifting, QSR. Cont on Caffeine. P- Cont to assess for\nresp needs.\n#3-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in off\nisolette, swaddled. P- Cont to assess for G&D needs.\n#4-O/ Mom called with updates given. Plans to be in\nlater this shift. P- Cont to enc parental calls and\nvisits.\n#5-O/A- TF=150cc/kg/d of PE30w/ProMod via NGT. Abd exam\nbenign. Voiding, no stool so far this shift. P- Cont to\nassess for FEN needs.\n#8-O/A- Cont with soft murmur. No CV distress. P- Cont\nto assess for CV needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-14 00:00:00.000", "description": "Report", "row_id": 1713350, "text": "Nursing Progress Note\nIn addition, in to visit. Mom held . Dad held .\n" }, { "category": "Nursing/other", "chartdate": "2161-01-14 00:00:00.000", "description": "Report", "row_id": 1713351, "text": "fellows exam note\n\ncomfortable\nlungs clr\nheart: no murmur\nabd: soft\n" }, { "category": "Nursing/other", "chartdate": "2161-01-15 00:00:00.000", "description": "Report", "row_id": 1713352, "text": "NURSING PROGRESS NOTE\n\n8 cardiac\n\n2 - resp -pt remains on O2 nc 25cc, 100%. BSC/=, mild SC\nretractions. no desats, No A/Bs noted\n\n3 - Dev -Temp stable in off isolette. pt alert w/ cares.\n. MAEW.\n\n4 - Parent - No family contact thus far tonight\n\n5 - FEN - TF=150cc/k of PE30 w/ PM. Pt tol ng feeds over 1\nhr 20min. no spits, min aspirats. ABD soft, +bs, no loops.\nAG=23-25. Pt voiding, stooling, guiac-. wt=1.555(+50)\n\n\n\nREVISIONS TO PATHWAY:\n\n 8 cardiac; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-15 00:00:00.000", "description": "Report", "row_id": 1713353, "text": "Neonatology Attending Progress Note\n\nNow day of life 26 for this 27 week gestation twin.\n\nIn 13-25cc of 100% O2 by nasal cannula.\nNo apnea or bradycardia in past 24 hours.\nOn caffeine.\n\nHR - 150-180s\n\nWt. 1555gm up 50gm on 150cc/kg/d of PE30 with Promod\nFeedings are well tolerated by gavage.\nNormal urine and stool output.\n\nAssessment/plan:\nNow almost one month of age, doing very well with appropriate weight gain.\nWill continue with current management.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-22 00:00:00.000", "description": "Report", "row_id": 1713377, "text": "Neonatology\nDoing well. RA. Few spells. COmfortable appearing.\n\nTemp stable co-bedding with sib\n\nWT 1885 up 35 . Tolerating feeds at 150 cc/k/d of 30 cal. Took two full bottle yesterday.\n\nContinue current resp and nutritional regimen.\n\nFU eye exam next week.\n" }, { "category": "Nursing/other", "chartdate": "2161-01-22 00:00:00.000", "description": "Report", "row_id": 1713378, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN RA, MAINTAINS O2 SATS IN MID TO HIGH\n90'S. OACCSIONAL DRIFTS IN SATS, WITH QSR. RR 40-60'S WITH\nMILD SUBCOASTAL RETRACTIONS. NO EPISODES OF APNEA OR\nBRADYCARDIA THIS SHIFT. REMAINS ON CAFFEINE. CONTINUE TO\nMONITOR RESP STATUS CLOSELY FOR SPELLS.\n\nALT IN GROWTH AND DEVELOPMENT D/ : AND ACTIVE\nWITH CARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN\nCRIB. CO BEDDING WITH BROTHER. SWADDLED AND IN\nSHEEPSKIN. CONTINUE DEVELOPMENTAL CARES. REPEAT EYE EXAM\nNEXT WEEK.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON\n150CC/K/D OF PE30 W/PROMOD, 47CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN, NO LOOPS 1 SMALL SPIT. GIRTH 24.\nASP. 0.6-1CC. VOIDING AND STOOLING WELL. STOOL GUIAC NEG.\nBABY BOTTLES ONCE A SHIFT. WILL BOTTLE BABY AT\n5:30PM. CONTINUE CURRENT FEEDING PLAN.\n\nALT IN PARENTING:MOM CALLED FOR UPDATE THIS MORNING. \nWILL BE AT 4:30PM TO BOTTLE AND HOLD BABY. CONTINUE TO\nSUPPORT AND UPDATE.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-23 00:00:00.000", "description": "Report", "row_id": 1713379, "text": "NICU NSG NOTE\n\n\n#2. Resp. O/ Conts in RA. RR 50-60's. LS clear and equal.\nBaseline subC retractions. On caffeine. Occassional drifts\nin sats to mid 80's, qsr. No bradys. A/ Stable with\noccassional drifts. P/ Cont to monitor closely.\n\n#3. G&D. O/ Awake and with cares. Sleeping well in\nbetween. Temps stable in open crib. Co-bedding with sibling.\nSwaddled. A/ AGA. P/ Cont to support developmental needs of\ninfant.\n\n#4. Parenting. No contact with family thus far this shift.\n\n#5. FEN. O/ Wt up 35g. Conts on 150cc/k/d PE30 with PM.\nreceiving q4h volumes via gavage over 1' 45\" for hx spits.\nOne sm spit this shift. Abd soft and round. Voiding and\nstooling. Max asp 5cc. AG stable. Po qsift. Due to po with\nnext care. A/ Tolerating feeds. Learning to po. P/ Cont to\nmonitor for feeding intolerances. Monitor wts.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-23 00:00:00.000", "description": "Report", "row_id": 1713380, "text": "Neonatology\nRemains in RA. No spells. Comfortable appearing.\n\nWt up 35. Tolerating feeds at 150 cc/k/d of 30 cal. Abdomen benign. . STill requiring mainly gavage.\n\nHct and retic to be checked.\n\nCOntinueing to await maturation of resp control and feeding.\n\nHUS this week shows resolution of IVH.\n\nEye exam stage 1. FU next week.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-01-23 00:00:00.000", "description": "Report", "row_id": 1713381, "text": "fellows exam note\ncomfortable\n\nheent: \nlungs: clr\nheart: soft SEM\nneuro: nonfocal\nabd: soft\n" } ]

[ { "category": "Radiology", "chartdate": "2111-08-21 00:00:00.000", "description": "BABYGRAM (CHEST & ABDOMEN)", "row_id": 766588, "text": " 9:20 PM\n BABYGRAM (CHEST & ABDOMEN) Clip # \n Reason: ett, ua uvc placemnt\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 28 week triplet #1\n REASON FOR THIS EXAMINATION:\n ett, ua uvc placemnt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with 28 and week triplet #1. ET tube, umbilical arterial\n catheter and umbilical venous catheter placement.\n\n FINDINGS:\n\n A single supine view is made available for interpretation on . The\n endotracheal tube is just past the thoracic inlet. The umbilical venous\n catheter tip projects over the liver shadow at the proximal T8/9 air space\n (and does not reach the level of the IVC/RA junction). The umbilical arterial\n catheter tip projects over the T9 vertebra. The patient is somewhat rotated.\n The lung volumes are markedly low and show coalescent lung opacities\n bilaterally. The bowel gas pattern is non-obstructive.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-08-21 00:00:00.000", "description": "Report", "row_id": 1964543, "text": "Newborn Med Attending Admit/Transfer\n\n1060g IVT triplet #1 born by C/S for advanced PTL and breech presentation at 28 2/7 weeks EGA to a 38 yo G1. Pregnancy complicated by PTL since ~23 weeks . Mother rx with Mg, , indocin and nifedipine. PROM this afternoon.\n\nPNS: O+/HBSAg-/Ab-/RPRNR.\n\nDR: Infant emerged with spont resp and cry. Given BBO2. Apgars .\n\nExam: see newborn exam sheet but notable for G/F/Ring and innsp crackles.\n\nA: Preterm female infant presents with resp distress. Most likely RDS but can't R/O infection.\n\nP: PPV and surfactant rx. Obtain CBC and blood cx. Start IV amp and gent pending 48h cx results and clinical course. Monitor DS and stsrt infusion of D10W @80 cc/kg/d. Keep family informed of plans and progress. Trtansfer to TCH.\n" }, { "category": "Nursing/other", "chartdate": "2111-08-21 00:00:00.000", "description": "Report", "row_id": 1964544, "text": "Neonatology-NNP Procedure Note\n\nProcedure: Endotracheal intubation\nIndication: Respiratory distress\n\nInfant placed in supine position with cardio-respiratory monitor in place. Under direct laryngoscopy, the vocal cords were visualized using a size 0 blade. A 3.0 ETT was inserted through the vocal cords and secured at 7cm. Breaths were auscultated bilaterally and were equal. The infant tolerated the procedure without incident. A CXR was obtained to confirm placment.\n\n\nProcedure: UAC/UVC placement\nIndication: Continuous BP monitoring, IV infusion, blood sampling\n\nInfant placed in supine position with cardio-respiratory monitoring in place. Infant prepped and draped in sterile fashion. A 3.5 Fr UAC was inserted into the umbilical artery for positive blood return, was sutured at 12cm. A 3.5 Fr double lumen UVC was inserted into the umbilical vein and was sutured at 6cm. A CXR was obtained to confirm placment. The infant tolerated the procedure without incident.\n" }, { "category": "Nursing/other", "chartdate": "2111-08-21 00:00:00.000", "description": "Report", "row_id": 1964545, "text": "Neonatology-NNP Procedure Note\nA 2.5 Fr ETT was used, not 3.0 Fr\n" }, { "category": "Nursing/other", "chartdate": "2111-08-21 00:00:00.000", "description": "Report", "row_id": 1964546, "text": "Transfer Note:Infant is a 28 week triplet. MD note for further info.Infant vented and rec'd Survanta x 1.UVC and UAC placed awaiting X-ray.Presently on vent settings of/5 rate 25.Fio2 elevated 80-90%.Infant's breathing appears labile.MAP33-39.Infant appears ruddy but well perfused.Dstick initially 52 rechecked =32,rec'd a 2 cc bolus of D10.CBC,LYTES,BLOOD CX AND ABG.Awaiting results.INFANTto be transferred to TCH.\n" } ]

[ { "category": "Radiology", "chartdate": "2111-04-10 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1008740, "text": " 3:09 PM\n PORTABLE ABDOMEN Clip # \n Reason: megacolon, colitis\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with c. diff\n REASON FOR THIS EXAMINATION:\n megacolon, colitis\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE ABDOMINAL RADIOGRAPH\n\n INDICATION: C. diff. colitis and abdominal pain.\n\n FINDINGS: A gastrostomy tube overlies the expected region of the stomach.\n There is no supine evidence of free intra-abdominal air. No dilated loops of\n small or large bowel are detected to suggest obstruction. Air and stool is\n identified within the colon without evidence of pneumatosis or wall\n thickening. Osseous screws are identified within the left proximal femur.\n Degenerative changes in the lower lumbar spine are not well evaluated on this\n study.\n\n IMPRESSION: No evidence of obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009329, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltrate, ?aspiration vs mucous plugging\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ICH, aphasia, hypoxic last night\n REASON FOR THIS EXAMINATION:\n new infiltrate, ?aspiration vs mucous plugging\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP ON \n\n COMPARISON: and .\n\n HISTORY: 79-year-old woman with ICH, aphasia, hypoxic last night; evaluate\n for infiltrate.\n\n FINDINGS:\n\n In the interim, there is elevation of the left hemidiaphragm secondary to left\n lower lobe atelectasis. which is either due to aspiration or mucous plug. The\n upper portions of the lungs are clear. The heart size is within normal\n limits. No right pleural effusion is noted, and minimal, if present, left\n pleural effusion is seen.\n\n IMPRESSION: Left lower lobe atelectasis secondary to mucous plug and/or\n aspiration causing elevation of the left hemidiaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2111-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007907, "text": " 9:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with resp distress\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with respiratory distress.\n\n COMPARISON: CT of the torso from .\n\n AP UPRIGHT CHEST: There is retrocardiac opacity in the left lower lobe which\n obscures part of the left hemidiaphragm. The mediastinal contours appear\n within normal limits. There is no evidence of pulmonary congestion. No\n definite pleural effusions are identified. Thin irregular densities which\n project over both hemithoraces are probably external to the patient. Osseous\n structures demonstrate degenerative change of the spine as well as healed\n right ninth and left nine healed posterior rib fractures.\n\n IMPRESSION: New opacity in the left lower lobe retrocardiac region could\n represent atelectasis, infection however cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1008928, "text": " 1:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with c.diff, now with low grade temps & increasing WBC\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: C. diff. New low-grade temps, increasing white count, question\n pneumonia.\n\n chest, 1 vw\n\n The heart size is at the upper limits of normal or slightly enlarged. The\n aorta is tortuous. There is borderline upper zone redistribution, without\n overt CHF. There is bibasilar atelectasis. No gross effusion is identified.\n There is osteopenia and degenerative changes of the thoracic spine, with very\n mild left convex curvature in the lower thoracic spine. The pulmonary hila\n are slightly prominent with a tapered appearance, raising the question of\n underlying pulmonary hypertension. Several left-sided rib fractures are again\n noted. Some patchy densities are seen at both bases, similar to that on\n . No new focal opacity is identified.\n\n IMPRESSION:\n\n Bibasilar atelectasis and probable resolving pneumonic infiltrate. No new\n infiltrate identified.\n\n" }, { "category": "Radiology", "chartdate": "2111-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007926, "text": " 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with respiratory distress, ? evolving PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Respiratory distress.\n\n A single AP view of the chest is obtained on at 0408 hours and compared\n with the prior evening's radiograph. No significant adverse interval change\n has occurred. Patchy density in the left lower lobe may represent linear\n atelectasis or infection. Healed rib fractures are seen in the left side. No\n frank consolidation or failure. Incidental note is made of contrast in the\n colon in the area of the splenic flexure.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-04-05 00:00:00.000", "description": "Report", "row_id": 1644053, "text": "MICU NURSING ADM NOTES :\n\nDNR/DNI.\nNKDA.\n\n79 Y/O, F,S/P RECENT ADM IN TO FOR SUBDURAL HEMATOMA/INTRAPARENCHYMAL BLEED AFTER A FALL WITH HOSPITAL COURSE COMPLICATED BY ALTERED MS( NON-VERBAL, DOES NOT FOLLOW COMMANDS) REQURING INTUBATION.S/P DKA, PNA, UTI & PEG. RECENT ADM FOLLOWING THAT FOR ASPIRATION PNA, WHICH WAS TREATED WITH VANCO & CEFEPIME. PT DISCHARGED TO NH ON . IN THE PT FOUND UNRESPONSIVE ,FINGERSTICK GLUCOSE WAS 25, RECEIVED 1 AMP OF D50 & WAS AROUSABLE, HOWEVER SHE CONTINUED TO BE IN RESP DISTRESS WITH O2 SATS IN THE 60'S, TRANSFERRED TO FOR FURTHER MANAGEMENT. IN THE , PT PRESENTED WITH THE FOLLOWING VS. T- 36.2, HR 117, BP 140/66, RR 36, O2 SATS 87 % ON . SHE WAS GIVEN EMPIRIC VANCOMYCIN,ZOSYN & LEVAQUIN FOR HAP. LS WHEEZY ,WAS GIVEN SOLUMEDROL & NEBS. CXR REVEALED NO NEW INFILTRATE.\n\n\nNEURO : OPENS EYES SPONTANEOUSLY, IS APHASIC, SEEMS TO TRACK, BUT DOES NOT FOLLOW COMMANDS. MOANS OUT LOUDLY INTERMITTENTLY. HAS CONTRACTURES, IN PAIN DURING POSITIONING AS PER GRIMACE SCALE. DURING THE PREVIOUS ADMS EXTENSIVE WORKUP FOR SUBDURAL HEMATOMA DONE INCLUDING CT, MRI, LP WHICH WAS UNREVEALING EXCEPT FOR LARGE HEMATOMA OF THE RT FRONTAL LOBE WITH BIFRONTAL GLIOSIS & SMALL SDH. CONTINUED ON AMANTIDINE & KEPRA FOR SEIZURE PROPHYLAXIS. PERLA.\n\nRESP : RECEIVED PT ON 10 LITS, SPO2 100 %, CONTINUED TO MAINTAIN 100% SATS ON ROOM AIR. LS CLEAR WITH DIMINISHES BASES BILATERALLY. RR MID 20'S TO 30'S. CXR IN AM. ON ASPIRATION PRECAUTIONS.\n\nCVS : ST, HR 114 TO 120.(S/P PERSISTENT CHRONIC TACHYCARDIA WITHOUT APPARENT ETIOLOGY. RECENT CT NEGATIVE FOR PE. TSH WNL. HAD BEEN ON BETABLOCKER PRIOR TO RECENT ADMIT)). ? LOW DOSE METOPROLOL. BP WNL. HYPONATREMIC STARTED ON NS 150 MLS/HR. PEDAL PULSES WEAK/PALPABLE. AM LABS PENDING.\n\nACCESS : PIV X 2.\n\nGI/GU : ABD SOFT, BS PRESENT, PEG TUBE FEEDS STARTED WITH PROBALANCE @ 10 MLS/HR, TO INCREASE BY 10 MLS Q 6 HRLY TO ACHIEVE GOAL OF 50 MLS/HR. FOLEY DRAINING CLEAR YELLOW URINE.\n\nID : AFEBRILE, ON CONTACT PRECAUTIONS FOR H/O C-DIFF. NOT ON ANBX AT PRESENT.\n\nENDO : ON HISS & GLARGLINE FIXED DOSES, REQUIRED COVERAGE.\n\nSOCIAL : NO CONTACT FROM FAMILY.\n\nPLAN :\n\nMONITOR RESP STATUS, MS, LYTES, BLOOD GLUCOSE..\n\n? CALL OUT.\n" }, { "category": "Nursing/other", "chartdate": "2111-04-05 00:00:00.000", "description": "Report", "row_id": 1644054, "text": "ADDENDUM :\n\nRESP RATE IN 30'S,PT HAS A MODERATE COUGH REFLEX, POST OROPHARYNGEAL SUCTIONING DONE, OBTAINED MODERATE THICK TAN SECRETIONS. WBC IN AM LABS ^ TO 24. PLAN TO SEND SPUTUM FOR CULTURE WITH THE NEXT SUCTIONING. CONTINUED ON 1 LIT O2 VIA NC.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-04-05 00:00:00.000", "description": "Report", "row_id": 1644055, "text": "7a-3p MICU Nursing Progress Note\n\nPlease refer to nursing transfer note for ROS and plan. Pt has been stable throughout the day. No further episodes of hypoglycemia or resp distress noted. She is currently maintaining her O2 sats between 97-100% on RA. She remains tachy, HR one teens-120's, but with a stable BP. She is nonverbal, not obeying any commands, but does open her eyes and make spontaneous movements at times (this is her baseline mental status). She is stable for transfer to the floor. Nursing report was given to CC6 accepting RN. Pt is a DNR/DNI.\n" }, { "category": "ECG", "chartdate": "2111-04-20 00:00:00.000", "description": "Report", "row_id": 119075, "text": "Sinus tachycardia with atrial premature depolarizations. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of no\nmajor change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2151-12-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1171098, "text": " 4:08 PM\n CHEST (PA & LAT) Clip # \n Reason: infiltrate or chf\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with acute renal failure, aspiration pneumonia, now with cough\n REASON FOR THIS EXAMINATION:\n infiltrate or chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute renal failure with aspiration pneumonia.\n\n FINDINGS: In comparison with the study of , there are continued low\n lung volumes, which enhances the prominence of the transverse diameter of the\n heart. Some indistinctness of pulmonary vessels is consistent with increased\n pulmonary venous pressure. There are some areas of atelectasis at the bases.\n A small area of asymmetry in the mid zone on the right could conceivably\n represent a developing focus of consolidation, though it could merely reflect\n some crowding of engorged vessels.\n\n Central catheter is now in place that extends to the lower portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-12-14 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1170916, "text": " 1:55 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: placement of line for dialysis later today.\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with acute renal failure\n REASON FOR THIS EXAMINATION:\n placement of line for dialysis later today.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 72-year-old man with acute renal failure, for placement of\n temporary hemodialysis catheter.\n\n RADIOLOGISTS: Dr. performed the procedure. Dr. ,\n the attending radiologist, reviewed the study.\n\n ANESTHESIA: 1% lidocaine used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After explaining the risks, benefits and alternatives\n of the procedure, written informed consent was obtained. The patient was\n brought to the angiography suite and placed supine on the imaging table. The\n right side of the neck was prepped and draped in standard sterile fashion. A\n preprocedure timeout and huddle were performed per protocol.\n\n Using ultrasound guidance with hard copy images on file, the patent right\n internal jugular vein was accessed with a micropuncture needle through which a\n 0.018 nitinol guidewire was advanced into the SVC under fluoroscopic guidance.\n The micropuncture needle was exchanged for a micropuncture sheath and the wire\n was upsized to a 0.035 wire after making appropriate measurements was\n advanced into the IVC for stability. The micropuncture sheath was removed and\n soft tissue tract was dilated using 10 and 12 French dilators. A new 14\n French x 20 cm temporary hemodialysis catheter was then advanced over the\n wire and its tip positioned within the right atrium. The wire and\n plastic stiffener were then removed. Both the ports aspirated and flushed\n easily. The catheter was secured to the skin with 0 silk sutures and sterile\n dressings were applied. The catheter was capped and heplocked. The patient\n tolerated the procedure well and there were no immediate complications.\n\n IMPRESSION: Uncomplicated placement of 14 French x 20 cm temporary\n hemodialysis catheter via right internal jugular venous access. Tip of the\n catheter terminates in the right atrium and is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-12-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1171779, "text": " 9:16 AM\n CHEST (PA & LAT) Clip # \n Reason: ? infiltrate.\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with chronic kidney disease, chf, possible infiltrate\n REASON FOR THIS EXAMINATION:\n ? infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Chronic kidney disease and CHF.\n\n IMPRESSION: PA and lateral chest compared to through :\n\n Lung volumes are consistently low. Moderate cardiomegaly is stable, but\n pulmonary vascular congestion is a little more pronounced today than it was on\n , less so than on . There is no pulmonary edema or\n appreciable pleural effusion. A supraclavicular central venous catheter ends\n in the low SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-11-30 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1169110, "text": " 9:48 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Right IJ tip location.\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p right IJ placement.\n REASON FOR THIS EXAMINATION:\n Right IJ tip location.\n ______________________________________________________________________________\n WET READ: JEKh TUE 10:22 PM\n 1. LIJ line tip in L brachiocephalic vein\n 2. pulmonary edema\n 3. chronically elevated R hemidiaphragm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left IJ catheter with its tip in the brachiocephalic vein.\n Other monitoring and support devices remain in place. Continued and worsening\n pulmonary vascular congestion. Chronically elevated right hemidiaphragm is\n again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-12-21 00:00:00.000", "description": "REMOVE TUNNELED CENTRAL W/O PORT", "row_id": 1171986, "text": " 11:41 AM\n DIALYSIS REMOVE Clip # \n Reason: Please REMOVE right subclavian HD line.\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with acute renal failure s/p transient HD, now needing line\n removal.\n REASON FOR THIS EXAMINATION:\n Please REMOVE right subclavian HD line.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Removal of right subclavian venous hemodialysis catheter.\n\n TECHNIQUE: After explanation of the procedure and discussion of the risks and\n benefits with the patient, verbal informed consent was given. The site was\n prepped in the usual standard fashion, sutures released, line removed and\n hemostasis achieved by holding pressure for 10 minutes. A sterile, occlusive\n dressing was applied.\n\n IMPRESSION: Uncomplicated removal of a pre-existing right subclavian venous\n hemodialysis catheter.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169310, "text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change, increasing pulmonary edema/vascu\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with respiratory failure intubated\n REASON FOR THIS EXAMINATION:\n Assess for interval change, increasing pulmonary edema/vascular congestion,\n consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, assessment of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. The monitoring and support devices are in constant position. The\n relatively severe pulmonary edema, associated with a likely small right\n pleural effusion, cardiomegaly and a left basal atelectasis is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-12-01 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1169159, "text": " 7:44 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: any acute abd pathology, please specifically evaluate pancre\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with lipase 1200's, intubated, on pressors in FOR THIS EXAMINATION:\n any acute abd pathology, please specifically evaluate pancreas/biliary tree to\n eval for gallstone pancreatitis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj WED 6:25 PM\n PFI: Markedly limited abdominal ultrasound, no cholelithiasis. The pancreas\n is not seen due to the presence of overlying bowel gas.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated lipase.\n\n COMPARISON: .\n\n FINDINGS: This is a limited exam due to the presence of overlying bowel gas.\n Within the limitations of the exam there are no focal liver lesions\n identified. There is no intra- or extra-hepatic biliary dilatation. The main\n portal vein is patent. The common bile duct measures 5 mm which is normal.\n There are no stones within the gallbladder. There is no gallbladder\n distention, pericholecystic fluid or gallbladder wall thickening. The\n pancreas is not visualized due to the presence of overlying bowel gas. The\n right kidney measures 12 cm. The left kidney measures 9.6 cm. There is no\n ascites.\n\n IMPRESSION:\n Markedly limited abdominal ultrasound, no cholelithiasis. The pancreas is not\n seen due to the presence of overlying bowel gas.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169493, "text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ?pneumonia.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has unchanged\n monitoring and support devices. Also unchanged is the moderate cardiomegaly,\n the small lung volumes and evidence of moderate pulmonary edema. No larger\n pleural effusions. No interval appearance of focal parenchymal opacities\n suggesting pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-09 00:00:00.000", "description": "RENAL U.S.", "row_id": 1170352, "text": ", J. MED 5S 7:26 PM\n RENAL U.S. Clip # \n Reason: evaluate for hydronephrosis\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with renal failure\n REASON FOR THIS EXAMINATION:\n evaluate for hydronephrosis\n ______________________________________________________________________________\n PFI REPORT\n Normal renal son.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1170353, "text": " 8:20 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with cough, low grade temps\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 72-year-old male with cough and low-grade fevers. Evaluate for\n pneumonia.\n\n FINDINGS: Comparison is made to previous study from .\n\n Cardiac silhouette is enlarged but unchanged. There are low lung volumes with\n some elevation of the right hemidiaphragm. There is some streaky opacity at\n the left base which may represent developing infiltrate versus atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-09 00:00:00.000", "description": "RENAL U.S.", "row_id": 1170351, "text": " 7:26 PM\n RENAL U.S. Clip # \n Reason: evaluate for hydronephrosis\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with renal failure\n REASON FOR THIS EXAMINATION:\n evaluate for hydronephrosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:44 PM\n Normal renal son.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal failure.\n\n TECHNIQUE: Renal son.\n\n COMPARISON: Ultrasound dated .\n\n FINDINGS: The kidneys appear normal without hydronephrosis, stones or masses.\n The right kidney measures 11.1 cm and the left 9.6 cm.\n\n IMPRESSION: Normal renal son.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1169012, "text": " 12:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with confusion\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa TUE 1:01 PM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Confusion.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast. Axial, coronal and sagittal reformations were\n prepared.\n\n COMPARISON: None available.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, or mass effect.\n Encephalomalacia in the left parietal, posterior temporal and lateral\n occipital lobes is likely secondary to a remote infarction. Mild prominence\n of the ventricles and sulci indicates mild age-related cerebral atrophy.\n There are calcifications of the bilateral carotid siphons.\n\n No concerning osseous lesion is seen. Phthisis bulbi is noted on the left.\n The visualized portions of the paranasal sinuses are clear.\n\n IMPRESSION:\n\n No evidence of an acute intracranial process. Large chronic infarction in the\n left hemisphere.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1169013, "text": " 12:13 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension\n\n TECHNIQUE: Two views of the chest were compared to prior examinations, most\n recent dated .\n\n FINDINGS: Evaluation is limited due to low lung volumes and body habitus. As\n compared to the prior examination increased fullness of the hila and\n prominence of the vasculature could represent additional volume overload.\n Right apical opacity correlates with a distend right internal jugular vein.\n Linear and bibasilar opacities most likely reflect atelectasis. No\n pneumothorax is seen.\n\n IMPRESSION: Findings compatible with chronic congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1169087, "text": " 5:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with intubation\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n WET READ: JEKh TUE 8:40 PM\n ETT 3.5 cm above carina; NGT courses inferiorly but side port not visualized\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of an endotracheal tube with its tip approximately 3.5 cm above the\n carina. Nasogastric tube extends to the stomach where it courses below the\n lower margin of the image.\n\n Continued low lung volumes with some indistinctness of pulmonary vessels\n suggesting elevated pulmonary venous pressure and opacification at the left\n base that could represent atelectasis. Elevation of the right hemidiaphragm\n persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-12-13 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 1170697, "text": " 10:53 AM\n DUPLEX DOPP ABD/PEL; -59 DISTINCT PROCEDURAL SERVICE Clip # \n RENAL U.S.\n Reason: ? vascular etiology of ARF\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ARF\n REASON FOR THIS EXAMINATION:\n ? vascular etiology of ARF\n ______________________________________________________________________________\n FINAL REPORT\n COLOR AND SPECTRAL DOPPLER ASSESSMENT OF THE KIDNEYS.\n\n INDICATION: Acute renal failure, question vascular etiology.\n\n FINDINGS: This examination is technically limited by patient's habitus.\n Color and pulse wave Doppler demonstrate appropriate brisk upstrokes within\n both the right and left renal arteries, although diastolic flow was difficult\n to visualize due to technical factors, there is no evidence of hydronephrosis,\n and renal sizes are unchanged.\n\n IMPRESSION: Technically limited examination. Brisk upstrokes in both the\n right and left renal arteries, indicating no definite renal artery stenosis.\n However, a mild degree of stenosis cannot be excluded. Main renal arteries\n and main renal veins appear patent.\n\n Better anatomic assessment of the renal arteries, even in acute renal failure,\n might be possible using a non-contrast MRI imaging technique, if indicated.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-01 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1169160, "text": ", MED 7:44 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: any acute abd pathology, please specifically evaluate pancre\n Admitting Diagnosis: ACUTE RENAL FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with lipase 1200's, intubated, on pressors in FOR THIS EXAMINATION:\n any acute abd pathology, please specifically evaluate pancreas/biliary tree to\n eval for gallstone pancreatitis\n ______________________________________________________________________________\n PFI REPORT\n PFI: Markedly limited abdominal ultrasound, no cholelithiasis. The pancreas\n is not seen due to the presence of overlying bowel gas.\n\n" }, { "category": "Echo", "chartdate": "2151-12-01 00:00:00.000", "description": "Report", "row_id": 70676, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Pulmonary hypertension. Right ventricular function. Valvular heart disease.\nHeight: (in) 70\nWeight (lb): 287\nBSA (m2): 2.44 m2\nBP (mm Hg): 106/42\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 09:33\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. The patient is\nmechanically ventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area\n0.8-1.0cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - body habitus. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThe right ventricular cavity is mildly dilated with borderline normal free\nwall function. The aortic valve leaflets are moderately thickened. There is\nsevere aortic valve stenosis (valve area 1.0cm2). Mild to moderate (+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPRESSION: Severe aortic valve stenosis. Normal biventricular cavity sizes\nwith preserved global biventricular systolic function. Mild-moderate aortic\nregurgitation. Right ventricular cavity enlargement with borderline normal\nfree wall motion.\nCompared with the prior study (images reviewed) of , global left\nventricular systolic function is improved and the gradient across the aortic\nvalve is increased. The severity of aortic regurgitation is similar.\n\n\n" }, { "category": "ECG", "chartdate": "2151-12-16 00:00:00.000", "description": "Report", "row_id": 160058, "text": "Sinus rhythm. Ventricular ectopy. Non-specific ST-T wave changes. Compared\nto the previous tracing of the Q-T interval is shorter and ventricular\nectopy is new.\n\n" }, { "category": "ECG", "chartdate": "2151-11-30 00:00:00.000", "description": "Report", "row_id": 160059, "text": "Sinus bradycardia. Left atrial abnormality. ST-T wave changes with prolonged\nQTc interval are non-specific but cannot exclude drug/electrolyte/metabolic\neffect or possible myocardial ischemia. Since the previous tracing of same date\nsinus bradycardia has replaced borderline sinus tachycardia. ST-T wave changes\nare less prominent and the QTc interval appears longer.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2151-11-30 00:00:00.000", "description": "Report", "row_id": 160060, "text": "Sinus rhythm. Left atrial abnormality. ST-T wave abnormalities are non-specific\nbut cannot exclude myocardial ischemia or possible hyperkalemia. Clinical\ncorrelation is suggested. Since the previous tracing of same date no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-11-30 00:00:00.000", "description": "Report", "row_id": 160061, "text": "Sinus rhythm. Consider left atrial abnormality. Anterolateral lead ST-T wave\nabnormalities are non-specific but cannot exclude possible myocardial ischemia\nor possible hyperkalemia. Clinical correlation is suggested. Since the previous\ntracing of further ST-T wave changes are present.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2147-05-10 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1010301, "text": " 8:40 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: further elucidate extent of c-spine injury, eval for ligamen\n Admitting Diagnosis: C4 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16M restrained rear passenger in 110mph mvc, ejected. with C4 burst fx\n REASON FOR THIS EXAMINATION:\n further elucidate extent of c-spine injury, eval for ligamentous injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 16-year-old involved in a motor vehicle collision. Burst fracture\n of C4 to further elucidate extent of cervical spinal injury and ligamentous\n integrity.\n\n TECHNIQUE: Multiplanar and multisequence imaging of the cervical spine was\n performed without gadolinium.\n\n COMPARISON: There is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n There is a fracture through the body of C4 with loss of height of the anterior\n body of C4. There is a disc protrusion at C4-5 level which is causing mild\n spinal stenosis. There is fluid in the facet joints without subluxation.\n The posterior longitudinal ligament is torn and the anterior longitudinal\n ligament is also probably torn. The ligament flavum and the interspinous\n ligaments are intact.\n\n There is increased signal in the thecal sac immediately below C4, likely\n pulsation artifact. There are no abnormal signals within the cord itself. The\n other vertebral levels are intact and there is edema in the T3 and T4\n vertebrae, suggestive of marrow edema. The visualized spinal muscles and soft\n tissues appear unremarkable.\n\n CONCLUSION:\n\n Fracture of the body of C4 with loss of height of anterior C4 along with\n associated ligamentous injuries as described above.\n\n" }, { "category": "Radiology", "chartdate": "2147-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010286, "text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: C4 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with pulmonary contusions afterhigh speed MVC rollover\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 16-year-old man with pulmonary contusions after high speed motor\n vehicle accident and rollover. Evaluate for change.\n FINDINGS:\n\n Right upper lobe aspiration or contusion has improved. Lungs are\n otherwise clear. Cardiomediastinal silhouette is normal. There is no pleural\n effusion or pneumothorax.\n\n IMPRESSION:\n 1. Small region of right upper lobe aspiration or contusion improved since\n yesterday.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-05-10 00:00:00.000", "description": "O C-SPINE SGL 1 VIEW IN O.R.", "row_id": 1010418, "text": " 7:06 PM\n C-SPINE SGL 1 VIEW IN O.R. Clip # \n Reason: C4 CORPECTOMY W/ALLOGRAFT AND PLATE\n Admitting Diagnosis: C4 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Status post fusion C4-C7.\n\n FINDINGS: Anterior fusion is seen at what appears to be C3-C5. Prosthetic\n device is seen effectively replacing the vertebral body of C4. Endotracheal\n tube is in place.\n\n" }, { "category": "Radiology", "chartdate": "2147-05-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1010517, "text": " 1:53 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: C4 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SOB\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Shortness of breath, evaluate for infiltrates.\n\n FINDINGS: PA and lateral chest views were obtained with patient in upright\n position. The heart size is within normal limits. No typical configurational\n abnormalities are identified. The pulmonary vasculature is normal. No signs\n of acute or chronic parenchymal infiltrates are present and the lateral and\n posterior pleural sinuses are free. No evidence of pneumothorax in the apical\n area on frontal view. Skeletal structures of the thorax grossly within normal\n limits.\n\n As the patient is status post recent MVA, the preceding single chest views of\n and are reviewed. There was no conclusive evidence for any\n pulmonary contusion on this portable chest examinations. Prominent SVC\n contour were related to patient's supine position. Diffuse haze in the\n upper thoracic areas can be explained by overlying soft tissue.\n\n IMPRESSION: Normal findings on PA and lateral chest views.\n\n" }, { "category": "Radiology", "chartdate": "2147-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010258, "text": " 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16m ejected rear passenger in 100mph mvc + abrasions on both asis\n REASON FOR THIS EXAMINATION:\n r/o trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 16-year-old male ejected rear passenger at 100 MPH MVC. Rule out\n trauma.\n\n SUPINE PORTABLE CHEST ON TRAUMA BOARD: The cardiomediastinal silhouette\n appears normal. There is slightly increased density in the right upper lung.\n The lungs appear otherwise clear and no pneumothorax or large effusion is\n seen. No rib fracture is apparent. Small details are obscured by the trauma\n board.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-05-10 00:00:00.000", "description": "Report", "row_id": 1648770, "text": "NPN 0700-1900\nPLEASE SEE CAREVUE FOR SPECIFIC DATA\n\n\nNEURO: MRI of C-spine obtained this am-pt traveled without any incident. Neuro exam remains intact,no neuro deficits present, pt MAEs with good equal strength and reports equal sensation in all extremities. Denies any numbness or tingling. Fentanyl ivp with adequate pain control, pt says pain is primarily in lower back. C-collar intact and logroll precautions maintained.\n\nCV: HR 60's-80's NSR, no ectopy noted. NIBP 120's-140's systolic. SKin warm and well perfused, pedal pulses easily palpable.\n\nRESP:Lungs clear and equal, pt requesting NC for comfort, O2 sats 100%, RR 18-22. IS teaching done-pt using up to 1200.\n\nGI/GU: NPO, abd soft and non-distended, +BS. Foley patently draining 30-60cc/hr of clear yellow urine. LR at 80cc/hr for maint. K+ and Magnesium repleted.\n\nID: Afebrile. No abx ordered.\n\nSKIN: Sm unremarkable lacs to fingers, L calf, and arms OTA. Skin otherwise intact. (2) PIVs patent.\n\nSOCIAL: mother, step-father, adn aunt at bedside all day. Spoke with Trauma, N-, and T-SICU teams re: POC. Family left for the evening and will be back later after pt returns from surgery. family very cooperative and supportive.\n\nPOC: Pt to OR at 1800 for C4 corpectomy\n update and support family\n pain maangement\n\n\n\n" }, { "category": "ECG", "chartdate": "2147-05-09 00:00:00.000", "description": "Report", "row_id": 215525, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2197-01-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1219939, "text": " 11:43 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion or infiltrates please do this am tha\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with POD 4 s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for effusion or infiltrates please do this am thank you\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation for effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there are remnant\n parenchymal opacities in both lungs, notably in the right mid lung and the\n left lower lung. However, neither the frontal nor the lateral radiograph\n shows evidence of pleural effusions. Moderate cardiomegaly with\n mild-to-moderate pulmonary edema. No mediastinal abnormalities. Status post\n CABG.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219679, "text": " 4:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change- please obtain cxr at 5pm\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with large effsuions\n REASON FOR THIS EXAMINATION:\n interval change- please obtain cxr at 5pm\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 51-year-old male patient with large effusions, evaluate for\n interval change. Obtain image at 5 p.m.\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 six and a half hours earlier during the same day.\n Status post sternotomy and considerable cardiac enlargement as before. The\n pulmonary vasculature appears congested with considerable perivascular haze in\n the accessible areas. The perivascular haze has increased in comparison with\n the preceding study. Blunting of the lateral pleural sinuses is rather\n unchanged but a considerable diffuse haze exists over both lungs mostly in the\n lower areas. As the patient is in marked recumbent position assessment of\n large pleural effusion is difficult if not impossible. Consider taking of a\n lateral view to assess better the accumulation of pleural effusion in the\n posterior pleural compartments. There is no evidence of pneumothorax.\n\n IMPRESSION: Persistent considerable perivascular haze further increasing\n during the latest interval and very close to pulmonary edema pattern. Review\n of the total of four chest x-ray examinations indicates that the patient\n already prior to cardiac surgery on the pre-operative examination showed\n considerable evidence for pulmonary congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219600, "text": ", C. CSURG FA6A 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p ct removal\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n PFI REPORT\n 1. No pneumothorax.\n 2. After removal of ETT, slightly lower lung volumes exaggerate bibasilar\n atelectasis, small bilateral pleural effusions, and mild fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2197-01-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1219344, "text": " 12:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;c\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;contact NP\n # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:50 P.M., \n\n HISTORY: Recent cardiac surgery, please look for complications.\n\n IMPRESSION: AP chest compared to preoperative chest radiograph, :\n\n Lung volumes are very low, exaggerating both the extent of pulmonary edema\n which is mild or worse and widening of the cardiomediastinal silhouette which\n is mild to moderate. Very poor definition of the bronchial tree on the left\n suggests retained secretions and may explain why it looks worse in that lung.\n There is no pneumothorax or substantial pleural effusion. ET tube, Swan-Ganz\n catheter, nasogastric tube, midline drains, and left pleural tube are in\n standard placements respectively. No pneumothorax. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219827, "text": " 3:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with vol overload\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Volume overload, to assess for change.\n\n FINDINGS: In comparison with the study of , the degree of pulmonary\n vascular congestion has somewhat decreased, though there is still evidence of\n increased pulmonary venous pressure. Continued enlargement of the cardiac\n silhouette in a patient with intact midline sternal wires.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219599, "text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p ct removal\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PRib TUE 3:45 PM\n 1. No pneumothorax.\n 2. After removal of ETT, slightly lower lung volumes exaggerate bibasilar\n atelectasis, small bilateral pleural effusions, and mild fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post chest tube removal, evaluate for pneumothorax.\n\n COMPARISON: Chest radiographs on .\n\n FINDINGS: One portable AP upright view of the chest. After chest tube\n removal, there is no evidence of pneumothorax. In the setting of low lung\n volumes, there is mild fluid overload, bilateral small pleural effusions and\n bibasilar atelectasis which has slightly increased in compared to prior as\n expected status post ETT removal. No evidence of pneumonia. Sternotomy wires\n are seen.\n\n IMPRESSION:\n 1. No pneumothorax.\n 2. After removal of ETT, slightly lower lung volumes exaggerate bibasilar\n atelectasis, small bilateral pleural effusions, and mild fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2197-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219153, "text": " 5:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cad\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n WET READ: TXCf FRI 10:21 PM\n mild to moderate pulmonary edema. possible trace right pleural effusion. no\n focal consolidation.\n chadashvili \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:24 P.M. \n\n HISTORY: Coronary artery disease.\n\n IMPRESSION: AP chest reviewed in the absence of any prior chest radiographs:\n\n Heart size is normal. There is a heterogeneous quality to the radiodensity of\n the lungs, particularly the lower left where there appeared to be at least two\n discrete lung nodules, 9 to 11 mm wide projecting over the fourth and fifth\n anterior ribs. The increase in background density of the lower lungs could be\n due to interstitial edema or chronic interstitial changes. The heart is not\n particularly enlarged and the pulmonary vasculature is borderline engorged.\n Pleural effusion is minimal if any.\n\n\n" }, { "category": "Echo", "chartdate": "2197-01-08 00:00:00.000", "description": "Report", "row_id": 93632, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraop urgent CABG evaluate valves, ventricular function, wall motion and aortic contours\nHeight: (in) 63\nWeight (lb): 184\nBSA (m2): 1.87 m2\nBP (mm Hg): 120/65\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 09:42\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the\nLAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the\naortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Trivial MR. The\nMR vena contracta is <0.3cm.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nPre Bypass: The left atrium is mildly dilated. No spontaneous echo contrast is\nseen in the left atrial appendage. Left ventricular wall thicknesses are\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are complex\n(>4mm) atheroma in the aortic arch and the descending thoracic aorta. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nno pericardial effusion.\n\nPost Bypass: Patient is A paced on phenylepherine infusion. Preserved\nBiventricular function. LVEF 55%. Aortic contours intact. Remaining exam is\nunchanged. All findings discussed with surgeons at the time of the exam.\n\n\n" }, { "category": "Echo", "chartdate": "2197-01-07 00:00:00.000", "description": "Report", "row_id": 93633, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 62\nWeight (lb): 180\nBSA (m2): 1.83 m2\nBP (mm Hg): 99/59\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:09\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.\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 diameter of aorta at the sinus, ascending and arch levels. Focal\ncalcifications in aortic root.\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.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nThe pulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global and\nregional biventricular systolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2197-01-08 00:00:00.000", "description": "Report", "row_id": 249851, "text": "Sinus rhythm. Inferior T wave inversions in leads III and aVF, possibly\nnon-specific, although cannot exclude inferior non-Q wave myocardial\ninfarction. Compared to the previous tracing of there is no interval\nchange. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2197-01-07 00:00:00.000", "description": "Report", "row_id": 249852, "text": "Sinus rhythm. Non-specific inferior ST-T wave changes may be normal variants.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 254872, "text": "Sinus rhythm\nLeft axis deviation\nInferior infarct - age undetermined\nNonspecific lateral ST-T changes\nLow QRS voltages in limb leads\nPoor R wave progression\nSince previous tracing of , slower rate noted, T wave inversion slightly\nmore pronounced\n\n" }, { "category": "ECG", "chartdate": "2148-02-28 00:00:00.000", "description": "Report", "row_id": 254873, "text": "Sinus tachycardia\nPremature ventricular contractions\nInferior infarct, age indeterminate\nLow QRS voltages in limb leads\nPoor R wave progression\nNonspecific ST-T wave changes\nSince previous tracing of , ventricular premature complex, faster rate,\nQRS changes in lead V3 - ? lead placement, and ST-T wave changes are present\n\n" }, { "category": "Nursing/other", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 1438549, "text": "Respiratory Care\n78 y/o M admitted to ED from rehab for J-tube replacement. Pt vent dependent and trached with #8 cuffed Portex trach. Pt currently on full vent support. BS coarse bilaterally. Pt suctioned for moderate amounts of thick white/clear secretions. Pt transported to X-Ray for abdomenal XR and returned without complications. No RSBI completed due to vent dependence. See CareVue for details and specifics.\nPlan: Maintain vent support, wean to PSV as tolerated. Plan to travel to IR today for J-tube replacement.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 1438547, "text": "1900-0700 rn notes micu\n\n78 y.o male lives in rehab with ESRD on HD, Afibs/p AICD,s/p CVA, CHF, CAD, s/p MI, pseudomonal colonization of trach,has G tube and J tube,vent depended admitted to ED for jtube placement in IR, J tube pulled out during HD, unsuccessfull to place back by surgion. also pt has Troponin leak 0.27, but pt's renal insufficiency as well.\nblood cx sent in ED.\n\nneuro: pt awke, follows commands, nod head for yes/no MAE, opens eyes spont.\n\nresp: trach on vent AC 40%/550/14/peep5, LS coarse, sat 100%.\n\ncv: HR 90's, NSR occass , pt s/p AICD placement. SBP 97-108/60's, baseline SBP 80-90.next cardio ensymes set at 0600.\n\ngi/gu: pt HD, no urine. pt hs G/J tube d/t gastroporesis, G tube drainged billious secretion. pt NPO for guided J tube placment in IR.\n\nskin: unbroken skin on ciccyx, skin cream barrier apllied.\n\naccess: PICC line, dialysis cath.\n\nsocial: Full code, pt's niece HCP,but no contact from her.\n\nplan: J tube placemet in IR.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 1438548, "text": "pt on contact precaution for C diff and . please send cardio ensymes at 1200.\n" } ]

[ { "category": "Radiology", "chartdate": "2199-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 978024, "text": " 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube on water seal for 12hrs, look for pnx or subq air\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with R PTX, tube thoracostomy, bilat lung contusions s/p\n airplane crash. Now s/p replacement of R subclavian cordis with triple lumen\n REASON FOR THIS EXAMINATION:\n chest tube on water seal for 12hrs, look for pnx or subq air\n ______________________________________________________________________________\n WET READ: JVg TUE 8:24 PM\n No pneumothorax visualized. ETT tip 7 cm from carina. Lungs stable and clear.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:44 P.M., \n\n HISTORY: Right pneumothorax. Tube thoracostomy. Bilateral lung contusions\n after an airplane crash.\n\n IMPRESSION: AP chest compared to .\n\n Tip of the ET tube is still above the clavicles, more than 7 cm from the\n carina, 3-4 cm above optimal placement. Nasogastric tube has been removed.\n Right subclavian line ends at the superior cavoatrial junction. No\n pneumothorax or pleural effusion, right pleural tube still in place, with its\n most proximal side port at the level of the intercostal space.\n\n Left infrahilar consolidation, new since , unchanged since\n , could be atelectasis or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 977662, "text": " 11:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval line placement\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with R PTX, tube thoracostomy, bilat lung contusions s/p\n airplane crash. Now s/p replacement of R subclavian cordis with triple lumen\n REASON FOR THIS EXAMINATION:\n Eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY.\n\n COMPARISON: Previous study from earlier the same date.\n\n INDICATION: Line placement.\n\n Right subclavian vascular catheter terminates in the lower superior vena cava.\n No apical pneumothorax is identified. The right hemidiaphragm and right heart\n border remain sharply demarcated, suggesting possible basilar pneumothorax\n without change from the pre-line placement radiograph. Endotracheal tube\n remains in a proximal location, terminating approximately 9 cm above the\n carina. Patchy and linear atelectasis in the mid and lower lungs has slightly\n worsened.\n\n Position of endotracheal tube Communicated by telephone to Dr. \n on .\n\n" }, { "category": "Radiology", "chartdate": "2199-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 978141, "text": " 1:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please perform film at ~13:00 to evaluate for recurrent PTX,\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with R PTX, tube thoracostomy, bilat lung contusions s/p\n airplane crash. Now s/p removal of chest tube\n REASON FOR THIS EXAMINATION:\n Please perform film at ~13:00 to evaluate for recurrent PTX, evaluate for other\n intrathoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 13:36 HOURS.\n\n HISTORY: Right pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: In comparison to the prior examination, the endotracheal tube has\n been removed. There is stable course and position of a right subclavian\n central venous catheter. Lung volumes are diminished with prominent lingular\n linear atelectasis. There is crowding of the bronchovascular structures and\n possibly underlying vascular congestion, however, no overt interstitial edema\n is evident. There is no consolidation. No pneumothorax or pleural effusion\n is seen. Cardiomediastinal silhouette is stable, accounting for technical and\n patient differences.\n\n IMPRESSION: Status post extubation with persistent diminished lung volumes\n and left atelectasis as above. Question mild vascular congestion most evident\n in the left hilum.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-22 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 977715, "text": " 6:13 PM\n CT UP EXT W/O C Clip # \n Reason: Evaluate L elbow for operative planning.\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with L elbow fx, scheduled for surgery tomorrow\n REASON FOR THIS EXAMINATION:\n Evaluate L elbow for operative planning.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n LEFT ELBOW CT\n\n INDICATION: Elbow fracture, preoperative planning.\n\n Non-contrast CT performed. Axial, sagittal and coronal reconstructions\n reviewed.\n\n FINDINGS:\n\n There is a comminuted fracture of the distal humeral shaft. The distal larger\n fragment is displaced medially and anteriorly by approximately one shaft\n width. There is a separate butterfly fragment at the anterior aspect of the\n distal humeral shaft.\n\n There is apex posterior angulation at the humeral fracture site.\n\n There is a severely comminuted fracture dislocation of the proximal radius\n involving the proximal shaft, neck and head.\n\n There is a fracture involving the capitellum and lateral epicondyle of the\n distal humerus.\n\n There is nondisplaced fracture of the olecranon and trochlea of the proximal\n ulna. There is a fracture of the ulnar coronoid process.\n\n There is a displaced fragment of bone medial to the proximal ulna of uncertain\n origin, possibly from the severely comminuted proximal radius.\n\n IMPRESSION:\n\n 1. Comminuted humeral shaft fracture; please see detailed description above.\n\n 2. Severely comminuted fracture dislocation of proximal radius.\n\n 3. Undisplaced olecranon and trochlear fracture.\n\n 4. Coronoid fracture.\n\n (Over)\n\n 6:13 PM\n CT UP EXT W/O C Clip # \n Reason: Evaluate L elbow for operative planning.\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2199-09-22 00:00:00.000", "description": "B SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT", "row_id": 977717, "text": " 6:43 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT; HUMERUS (AP & LAT) BILATClip # \n ELBOW (AP, LAT & OBLIQUE) BILAT; WRIST(3 + VIEWS) BILAT\n Reason: Evaluate for fx, effusion\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p plane crash w/ clear open fx L humerus, L femur, c/o bilat\n UE and LE pain\n REASON FOR THIS EXAMINATION:\n Evaluate for fx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n \n\n CLINICAL INFORMATION: Plane crash with open fracture, left humerus, left\n femur, complains of bilateral upper and lower extremity pain, question\n effusion, fracture.\n\n RIGHT WRIST, TWO VIEWS:\n\n FINDINGS: Two views of the right wrist demonstrate a large degree of soft\n tissue swelling. IV lines and tubing obscure fine osseous detail. There is a\n nondisplaced fracture of the ulnar styloid. There is also a nondisplaced\n intraarticular fracture of the radial styloid, partially obscured by overlying\n intravenous line.\n\n There is a nondisplaced fracture of the distal pole of the scaphoid. There is\n additionally a suspected nondisplaced fracture of the trapezium which is\n intraarticular with the scaphotrapezium joint. There are several 2-mm ossific\n fragments at the radial aspects of the joint.\n\n On the lateral view, there is a suspected fracture of the trapezium. Further\n evaluation with CT is recommended.\n\n LEFT WRIST:\n\n Two views of the left wrist demonstrate a 5-mm ossific fragment in the dorsal\n soft tissue. There is a large amount of soft tissue swelling. The donor site\n for the fracture fragment is far too arrive from the triquetrum.\n\n The left wrist is viewed through a splint. The splint obscures much of the\n fine osseous detail and further fractures cannot be excluded. Additional\n evaluation with CT is recommended. There is suspected abnormal contour of the\n base of the fifth metatarsal which could represent a fracture.\n\n RIGHT SHOULDER, TWO VIEWS:\n\n Extremely limited view of the right shoulder demonstrates the\n acromioclavicular joint and glenohumeral joint to be congruous. Right-sided\n chest tube and right subclavian line are present. Proximal humerus appears to\n be intact. No gross abnormality identified in the scapula, although\n visualization is grossly limited.\n (Over)\n\n 6:43 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT; HUMERUS (AP & LAT) BILATClip # \n ELBOW (AP, LAT & OBLIQUE) BILAT; WRIST(3 + VIEWS) BILAT\n Reason: Evaluate for fx, effusion\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n TWO VIEWS OF THE RIGHT HUMERUS:\n\n Demonstrates the humerus to be grossly intact.\n\n Three views of the right elbow are obtained. There is a nondisplaced fracture\n of the medial epicondyle of the humerus. In addition, there are nondisplaced\n fractures of the lateral epicondyle and capitellum, suggesting injury to the\n common extensor tendon and the lateral collateral ligament proximal\n attachment. Further evaluation with CT is recommended. In addition, there\n may be a nondisplaced fracture of the proximal aspect of the olecranon. This\n may represent a small spur. It is difficult to tell on this examination.\n\n TWO VIEWS OF THE LEFT HUMERUS:\n\n Demonstrate a comminuted fracture of the distal shaft of the left humerus. The\n major distal fracture fragment is displaced medially by approximately one\n shaft width.\n\n There is only one view at the left elbow. There is a massively comminuted\n fracture at the left elbow that involves the distal humerus, proximal radius\n and ulna. This needs evaluation with CT.\n\n IMPRESSION:\n 1. Right wrist: Nondisplaced intraarticular fracture of the radial styloid.\n Distal pole of the scaphoid, trapezium, ulnar styloid. Suspected fracture of\n the triquetrum.\n 2. Left wrist: Displaced fracture of the triquetrum. Additional fractures\n suspected although obscured by overlying splint.\n 3. No fracture identified in the right shoulder or right humeral shaft.\n 4. Right elbow: Fractures identified in the medial and lateral epicondyle,\n and capitellum. Further evaluation with CT recommended. Possible fracture in\n the olecranon.\n 5. Left humerus, comminuted fracture through the distal shaft, with medial\n displacement of the distal fracture fragment by 1 shaft width.\n 6. Left elbow: Massively comminuted fracture of distal humerus, proximal\n ulna and radius.\n\n Evaluation of all of the above fractures with CT recommended. Trauma _____\n paged to transmit results.\n (Over)\n\n 6:43 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT; HUMERUS (AP & LAT) BILATClip # \n ELBOW (AP, LAT & OBLIQUE) BILAT; WRIST(3 + VIEWS) BILAT\n Reason: Evaluate for fx, effusion\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2199-09-22 00:00:00.000", "description": "B FEMUR (AP & LAT) BILAT", "row_id": 977718, "text": " 6:44 PM\n FEMUR (AP & LAT) BILAT; KNEE (AP, LAT & OBLIQUE) BILAT Clip # \n ANKLE (AP, MORTISE & LAT) BILAT\n Reason: Evaluate for fractures\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p plane crash w/ clear open fx L humerus, L femur, c/o bilat\n UE and LE pain\n REASON FOR THIS EXAMINATION:\n Evaluate for fractures\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FEMUR\n\n Four films are submitted showing placement of two proximal subtrochanteric\n screws and three distal diaphyseal screws related to an external fixator. The\n comminuted diaphyseal fracture is again seen.\n\n LEFT FEMUR\n\n Four films are submitted showing the comminuted left femoral subtrochanteric\n fracture and a transverse pin or screw at the distal diametaphyseal level.\n\n BILATERAL TIBIAS AND FIBULAS\n\n AP films of both tibias and fibulas were obtained. The left medial malleolar\n fracture is seen. No fracture of the shafts of the tibias or fibulas is seen.\n\n BILATERAL ANKLES\n\n There are well-corticated ossicles at the tip of the right medial malleolus,\n probably related to an old fracture. No acute right ankle fracture is seen.\n On the left, there is an acute transverse fracture at the superior aspect of\n the medial malleolus. There are screws in the first metatarsal and the\n calcaneus and anchors are seen in the distal fibula. There is widening of the\n superolateral joint space. Anterior and posterior osteophytes are seen.\n\n IMPRESSION:\n 1. There are well-corticated ossicles at the tip of the right medial\n malleolus, probably related to an old injury and there is some widening of the\n right superior medial joint space.\n 2. On the left, there is an acute medial malleolar fracture with evidence of\n a previously treated injury and osteoarthritic changes.\n\n PELVIS\n\n An AP view of the pelvis was obtained. A catheter overlies the left femur.\n The known left acetabular fracture is identified.\n\n\n (Over)\n\n 6:44 PM\n FEMUR (AP & LAT) BILAT; KNEE (AP, LAT & OBLIQUE) BILAT Clip # \n ANKLE (AP, MORTISE & LAT) BILAT\n Reason: Evaluate for fractures\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2199-09-23 00:00:00.000", "description": "L MR KNEE W/O CONTRAST LEFT", "row_id": 977862, "text": " 8:20 PM\n MR KNEE W/O CONTRAST LEFT Clip # \n Reason: ? patella fracture, requested by ortho\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with\n REASON FOR THIS EXAMINATION:\n ? patella fracture, requested by ortho\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE LEFT KNEE \n\n CLINICAL INFORMATION: Question patellar fracture, history of trauma.\n\n Patient has ORIF of subtrochanteric fracture.\n\n FINDINGS:\n\n MRI of the left knee was performed on a 1.5 Tesla magnet per departmental\n protocol.\n\n The patella is intact. No fracture identified. There is a significant\n artifact in the distal femur from the intermedullary rod. There is\n prepatellar edema particularly at the lateral aspect of the knee. There is\n diffuse subcutaneous edema tracking inferiorly and posteriorly. There is a\n moderate joint effusion.\n\n In the patellofemoral compartment, there is diffuse fraying of the patellar\n cartilage with focal defect both in the medial and the lateral facet. The\n trochlear cartilage is intact. There is no subchondral patellar or marrow\n edema.\n\n There is a moderate amount of edema in the vastus medialis muscle.\n\n In the medial compartment, the medial meniscus is intact. There is grossly\n normal medial compartment cartilage. There is no subchondral marrow edema.\n\n The ACL is intact. The PCL is not well seen and it appears to be partially\n torn. There is markedly increased signal within it and there is a tear of the\n PCL.\n\n In the lateral compartment, the lateral meniscus is intact. The cartilage and\n the subchondral marrow are intact. There is a focal contusion within the\n lateral tibia. There is also a contusion within the proximal fibula at the\n proximal tibiofibular joint.\n\n The iliotibial band is intact. The lateral collateral ligament and the biceps\n femoris tendon are intact as well. The popliteus tendon is torn from its\n insertion in the popliteus hiatus.\n\n There is a tear of the anterior aspect of the medial collateral ligament.\n\n (Over)\n\n 8:20 PM\n MR KNEE W/O CONTRAST LEFT Clip # \n Reason: ? patella fracture, requested by ortho\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is a moderate joint effusion.\n\n IMPRESSION:\n 1. Torn popliteus tendon.\n 2. Torn posterior cruciate ligament.\n 3. Tear of the anterior aspect of the medial collateral ligament.\n 4. Menisci and ACL intact.\n 5. Contusion of the lateral tibia and proximal fibula.\n 6. Extensive edema.\n 7. Large joint effusion. No fracture about the knee.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977556, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement?\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with chest tube placement s/p ptx\n REASON FOR THIS EXAMINATION:\n tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n INDICATION: Endotracheal tube placement.\n\n Endotracheal tube terminates above the level of the clavicles, approximately\n 6.5 cm above the carina and could be advanced several centimeters for standard\n positioning. Right-sided chest tube courses medially to project over the\n lateral aspect of the mid thoracic spine at the T6 level. No pneumothorax is\n identified. Cardiac and mediastinal contours are within normal limits\n allowing for accentuation by low lung volumes. Patchy opacities are present\n predominantly centrally in the perihilar and basilar regions and may be due to\n either atelectasis or contusion. Small amount of subcutaneous emphysema is\n present in the right chest wall.\n\n Position of endotracheal tube and chest tube had been communicated by\n telephone with Dr. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 977594, "text": " 7:41 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: tube & line placement\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p plane crash. s/p CVL\n REASON FOR THIS EXAMINATION:\n tube & line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT \n\n INDICATION: Line placement.\n\n Right subclavian vascular sheath terminates in the region of the junction of\n the right brachiocephalic vein and superior vena cava, with no pneumothorax.\n Endotracheal tube terminates above the thoracic inlet about 8 cm above the\n carina. This finding has been communicated on to Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-24 00:00:00.000", "description": "L HUMERUS (AP & LAT) LEFT", "row_id": 978007, "text": " 3:34 PM\n HUMERUS (AP & LAT) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT\n Reason: ORIF LEFT DISTAL RADIUS, ORIF LEFT HUMERUS\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Left elbow intraoperative study. .\n\n HISTORY: Patient with distal humerus and proximal radius fracture status post\n ORIF.\n\n FINDINGS: Six fluoroscopic images from the operating room demonstrates\n interval placement of a fracture plate with associated screws within the\n proximal radius. Fracture plate has also been placed within the distal\n humerus fixating a complex fracture of the distal humeral shaft. No hardware-\n related complications are seen. There is widening of the joint space between\n the radius and the capitellum. Please refer to the operative note for\n additional details.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-26 00:00:00.000", "description": "LO HIP UNILAT MIN 2 VIEWS LEFT IN O.R.", "row_id": 978276, "text": " 10:18 AM\n HIP UNILAT MIN 2 VIEWS LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: LEFT HIP ORIF\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture fixation.\n\n This examination consists of six intraoperative radiographs of the left pelvis\n and proximal femur during placement of two perforated plates and multiple\n screws across the left acetabular fracture as well as a partially visualized\n left intramedullary rod and interlocking screw extending into the femoral\n head. There is a poorly visualized fracture of the proximal left femoral\n shaft possibly involving the trochanter. Bone detail poorly assessed.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "RO FEMUR (AP & LAT) RIGHT IN O.R.", "row_id": 977591, "text": " 6:26 PM\n FEMUR (AP & LAT) RIGHT IN O.R.; KNEE (2 VIEWS) LEFT IN O.R. Clip # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST BILAT IN O.R.\n Reason: EX-FIX.RIGHT FEMUR.LEFT KNEE PINNING.\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FEMUR AND LEFT KNEE ON .\n\n A total of eight fluoroscopic images are submitted. No radiologist was\n present. Please see operative notes for full details. Placement of\n transverse right proximal femoral screws is demonstrated. A distal left\n femoral screw is seen. The comminuted right femoral fracture is visualized.\n The known left femoral fracture is less well seen.\n\n IMPRESSION: Fluoroscopic images during ORIF of bilateral femoral fractures.\n Please see operative notes for full details.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 977548, "text": " 12:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: +LOC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39M plane crash\n REASON FOR THIS EXAMINATION:\n +LOC\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SAT 12:58 PM\n No intracranial hemorrhage or fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Plane crash and loss of consciousness.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head are obtained with 5-mm\n section thickness with 2.5-mm bone algorithm reconstructions.\n\n NON-CONTRAST CT HEAD: There is no intracranial hemorrhage, shift of normally\n midline structures, or evidence of acute major vascular territorial infarcts.\n -white matter differentiation is preserved. Bone windows reveal no\n evidence of fracture. The imaged portions of the paranasal sinuses and\n mastoid air cells appear well aerated except for a small polypoidal density\n at left maxillary sinus.\n\n IMPRESSION: No intracranial hemorrhage or fracture.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 978363, "text": " 10:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval fever\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with bilat lung contusions s/p airplane crash\n REASON FOR THIS EXAMINATION:\n eval fever\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with bilateral lung contusions\n and fever.\n\n Portable AP chest radiograph compared to .\n\n The right subclavian line tip terminates in mid SVC. The lung volumes are\n low. No significant change in bibasal linear opacities are demonstrated _____\n most likely representing atelectasis. No new or growing parenchymal\n abnormalities are demonstrated. No sizable right pleural effusion is\n identified. The left costophrenic angle was not included in the field of view\n thus precise evaluation of left pleural effusion cannot be obtained although\n there is no large left pleural effusion. There is no pneumothorax identified\n on this supine radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-26 00:00:00.000", "description": "LO ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.", "row_id": 978288, "text": " 11:50 AM\n ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: LEFT ANKLE ORIF\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n FIVE FLUOROSCOPIC SPOT FILMS OF THE LEFT ANKLE \n\n HISTORY: Status post ORIF of left ankle.\n\n FINDINGS: Five intraoperative fluoroscopic spot films are provided, with no\n radiologist in attendance. These are compared with the limited single lateral\n view dated , in the acute trauma setting, and demonstrate successive\n stages in open reduction and internal fixation of transverse intra-articular\n fracture of the medial malleolus. The fracture fragments appear in\n satisfactory position with some widening of the ankle mortise, laterally on\n film labeled \"5.\" The long calcaneal screw, first metatarsal bracket plate\n with screws and paired suture anchors in the distal fibula were already\n present on the admission radiograph, and likely related to a previous repair.\n\n The fluoroscopy time is not recorded.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977630, "text": " 6:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?change\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p plane crash with multiple injuries\n REASON FOR THIS EXAMINATION:\n ?change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n INDICATION: Injuries following plane crash.\n\n Endotracheal tube terminates about 9.0 cm above the carina and should be\n advanced several centimeters through a chief standard positioning, as\n communicated by phone to Dr. on . Right chest tube\n remains in place, with increased lucency and sharpness of the right\n hemidiaphragm suggestive of a basilar pneumothorax. Minor atelectasis is\n present within both lower lobes. No pleural effusions are identified.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "B FOREARM (AP & LAT) BILAT", "row_id": 977563, "text": " 1:40 PM\n FOREARM (AP & LAT) BILAT; HUMERUS (AP & LAT) BILAT Clip # \n Reason: assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p plane crash w/ clear open fx L humerus, L femur, c/o bilat\n UE and LE pain\n REASON FOR THIS EXAMINATION:\n assess for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man status post plane crash with fractures.\n\n COMPARISON: Not available.\n\n TWO VIEWS OF THE LEFT HUMERUS: There is a comminuted fracture of the mid\n shaft of the left humeral diaphysis with varus angulation of the fracture\n fragment and slight superior displacement of the distal fragment. There is a\n large butterfly fracture fragment.\n\n LEFT FOREARM: There is an extensively comminuted fracture-dislocation of the\n proximal left radius with marked overriding of olecranon by 2.5 shaft widths.\n There are numerous fracture fragments, with two large fragments distracted\n from the elbow. Subcutaneous emphysema is present.\n\n RIGHT HUMERUS: There is no definite fracture or dislocation.\n\n IMPRESSION:\n 1. Comminuted fracture of the mid shaft of the left humerus.\n\n 2. Extensively comminuted fracture-dislocation of the left proximal radius.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "B FEMUR (AP & LAT) BILAT", "row_id": 977564, "text": " 1:40 PM\n FEMUR (AP & LAT) BILAT; TIB/FIB (AP & LAT) BILAT Clip # \n Reason: assess for femur fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p plane crash w/ clear open fx L humerus, L femur, c/o bilat\n UE and LE pain\n REASON FOR THIS EXAMINATION:\n assess for femur fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man status post plane crash with left humerus, left\n femur fractures.\n\n COMPARISON: Not available. Note made of CT torso dated .\n\n FINDINGS: This examination is limited by position and single views.\n\n Left Femur: There is a comminuted fracture of the left femur, with medial\n displacement of the fragment. There is a varus angulation of the fracture\n fragments.\n\n Right femur: There is a comminuted spiral fracture of the right mid femoral\n diaphysis, with dorsal distraction and overriding of the large butterfly\n fracture fragment.\n\n Left Tibia and Fibula: No acute fracture or abnormal alignment. There is\n plate and screws projecting over right metatarsals. Calcaneal screw is in\n place.\n\n Right Tibia and Fibula: No acute fracture or dislocation.\n\n IMPRESSION:\n 1. Comminuted fracture of the mid right femoral diaphysis.\n 2. Comminuted subtrochanteric fracture of the left femoral neck.\n\n If there is a clinical suspicion for fracture about the knee or ankle joints,\n dedicated radiographs of these joints should be obtained.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 977545, "text": " 12:10 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39M s/p plane crash\n REASON FOR THIS EXAMINATION:\n eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n TRAUMA SERIES\n\n INDICATION: 39-year-old status post plane crash.\n\n COMPARISON: Not available.\n\n FINDINGS:\n\n CHEST: Cardiomediastinal contour is probably normal, given AP technique.\n There is a pneumothorax on the right. There is no evidence of pleural\n effusion on this single supine view. Pulmonary vascularity is normal.\n\n FRONTAL VIEW OF THE PELVIS: There is complex comminuted fracture of the left\n acetabulum. There is comminuted and displaced intertrochanteric fracture of\n the left femur. The assessment of the sacrum is limited by overlying bowel\n contents. There is a vascular catheter to the left femoral access.\n\n IMPRESSION:\n\n 1. Large right-sided pneumothorax.\n\n 2. Left acetabular and proximal femoral fractures.\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 977546, "text": " 12:13 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39M plane crash\n REASON FOR THIS EXAMINATION:\n eval injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SAT 1:25 PM\n Large right pneumorthorax. Consolidation in collapsed right lung likely\n atelectasis though cant exclude foci of contusion. Bilateral comminuted\n femoral fractures. Complex left acetabular fracture. Transverse foramen\n fractures of L1,3, and 4 with linear lucency through base of L4 likely a\n fracture. Small fracture at anterosuperior border of L3.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced axial images of the chest, abdomen, and pelvis\n are obtained with multiplanar reformatted images.\n\n CT CHEST WITH CONTRAST: There is a large right-sided pneumothorax with\n consolidation in the collapsed lung which may represent atelectasis, however\n contusion cannot be completely excluded. There is no left pneumorthorax,\n though dependent atelectasis vs. consolidation is present. There is no\n mediastinal shift to suggest tension pneumothorax. The patient is intubated\n and the airways appear patent to the segmental level bilaterally. There is no\n evidence of traumatic injury to the heart or great vessels and there is no\n pericardial or pleural effusion. There are no pathologically enlarged\n axillary, mediastinal, or hilar lymph nodes.\n\n CT ABDOMEN WITH CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal\n glands, and kidneys are unremarkable and there is no evidence of traumatic\n injury to these organs. Intra-abdominal loops of large and small bowel are\n within normal limits and there is no free air, free fluid, or pathologically\n enlarged mesenteric or retroperitoneal lymph nodes.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, prostate, seminal\n vesicles are unremarkable. A Foley is present within the bladder. There is\n no free fluid in the pelvis or pathologically enlarged pelvic lymph nodes.\n\n Bone windows reveal comminuted and displaced fractures of the femurs\n bilaterally with the left-sided fracture just distal to the femoral neck. A\n complex fracture of the left acetabulum involves the roof and posterior lip. A\n linear lucency through the base of the L4 vertebral body on the right likely\n represents an acute fracture, though there is no evidence of height loss.\n There are left-sided transverse foramen fractures of L1, L3 and L4. There is\n also a small fracture at the anterosuperior corner of the L3 vertebral body\n (Over)\n\n 12:13 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n without significant height loss.\n\n IMPRESSION:\n 1. Multiple osseous traumatic injuries including bilateral femoral, left\n acetabular and lumbar vertebral fractures as described.\n\n 2. Large right pneumothorax without evidence of tension. Right pulmonary\n contusion vs. atelectasis.\n\n Findings discussed with the surgical team immediately following completion of\n the study.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-21 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 977547, "text": " 12:14 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval c spine\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39M plane crash\n REASON FOR THIS EXAMINATION:\n eval c spine\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SAT 1:27 PM\n No fracture or acute alignment abnormality. Right PTX better evaluated on\n torso CT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the cervical spine were obtained at 5\n mm section thickness with 2.5 mm bone algorithm reconstructions.\n\n CT SPINE WITHOUT CONTRAST: There is no fracture or acute alignment\n abnormality. The atlanto-occipital and atlantoaxial articulations are\n maintained. Vertebral body and disc heights are preserved.\n\n A right apical pneumothorax and associated atelectasis are partially\n visualized. Patient is status post intubation.\n\n IMPRESSION:\n 1. No fracture or acute alignment abnormality.\n\n 2. Right pneumothorax partially visualized and better evaluated on\n accompanying torso CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-22 00:00:00.000", "description": "L ELBOW, AP & LAT VIEWS LEFT", "row_id": 977684, "text": " 2:03 PM\n ELBOW, AP & LAT VIEWS LEFT; -52 REDUCED SERVICES Clip # \n Reason: L elbow lateral performed to evaluate fx placement\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with L elbow fx\n REASON FOR THIS EXAMINATION:\n L elbow lateral performed to evaluate fx placement\n ______________________________________________________________________________\n FINAL REPORT\n ELBOW RADIOGRAPH, SINGLE LATERAL VIEW.\n\n NDICATION: Left elbow fracture.\n\n Comminuted proximal radial fracture is again demonstrated with improved\n alignment compared to the preoperative radiograph. Assessment of the\n alignment of the radial head with respect to the elbow joint is difficult to\n assess due to single view and obscuration of fine bone detail by overlying\n casting material. Additional views of the radial head would be helpful to\n better demonstrate alignment in this region. Transverse fracture of the\n distal humeral shaft is again demonstrated with approximately one shaft\n anterior displacement of the distal fracture fragment with respect to the\n proximal fracture fragment.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977749, "text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change. Evaluate for persistent ptx\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with R PTX, tube thoracostomy, bilat lung contusions s/p\n airplane crash.\n REASON FOR THIS EXAMINATION:\n Evaluate interval change. Evaluate for persistent ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n CLINICAL HISTORY: Right pneumothorax, right thoracostomy, bilateral lung\n contusions status post airline crash.\n\n COMPARISON: Chest radiograph and 8, 07.\n\n TECHNIQUE: Single frontal portable supine radiograph.\n\n FINDINGS: The endotracheal tube is 8.3 cm above carina. The right subclavian\n venous catheter and right chest tube are unchanged in position. There is\n persistent sharp demarcation of the right heart border and right\n hemidiaphragm, likely representing small right basilar pneumothorax,\n unchanged.\n\n IMPRESSION:\n 1. Endotracheal tube 8.3 cm above carina. On discussion with the clinician,\n it is noted that endotracheal tube has not been advanced based on clinical\n judgment.\n 2. No significant change from prior study.\n\n The results were discussed with Dr. at 12:20 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-23 00:00:00.000", "description": "B FEMUR (AP & LAT) BILAT", "row_id": 977802, "text": " 10:34 AM\n FEMUR (AP & LAT) BILAT Clip # \n Reason: ORIF BILATERAL FEMURS\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL FEMURS\n\n CLINICAL HISTORY: ORIF.\n\n Fifteen fluoroscopic images are submitted during ORIF of comminuted femoral\n fractures. Please see operative notes for full details. On the right, a long\n intramedullary rod with two proximal and two distal interlocking screws has\n been placed across the comminuted diaphyseal fracture. On the left, a gamma\n nail intramedullary rod has been placed across the subtrochanteric fracture.\n\n IMPRESSION: ORIF of bilateral femoral fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-23 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 977846, "text": " 3:55 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: s/p im nails bilateral femurs. please assess acetabular frac\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with polytrauma\n REASON FOR THIS EXAMINATION:\n s/p im nails bilateral femurs. please assess acetabular fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Trauma.\n\n IMPRESSION: An AP view of the pelvis was obtained.\n\n The patient has a known left acetabular fracture, well seen on reformatted\n images from the torso CT of . The horizontal component of the\n fracture line is visualized. The left hip joint space is well maintained.\n Since the CT, a right-sided intramedullary rod with interlocking screws and\n left-sided gamma nail and intramedullary rod have been placed. The distal\n ends of hardware are not seen.\n\n IMPRESSION: Left acetabular fractures seen as a baseline for followup.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-29 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 978737, "text": " 4:36 PM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: eval for fx\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p plane crash w/ clear open fx L humerus, L femur, c/o\n bilat UE and LE pain\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n WET READ: JWK SUN 6:35 PM\n No fracture identified.\n If clinical concern for scaphoid fracture persists, repeat radiographs in one\n week can be performed.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Multiple views of the right wrist. There is an IV line over the\n dorsal aspect of the proximal hand. Standard views of the wrist and\n additional navicular views show the bones intact, the joint relationships\n normal, no evidence of fracture or dislocation.\n\n CONCLUSION: No evidence of fracture or dislocation.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-28 00:00:00.000", "description": "O CHEST (SINGLE VIEW) IN O.R.", "row_id": 978639, "text": " 5:50 PM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old male with intraoperative IVC filter placement.\n\n INTRAOPERATIVE FILM: A single fluoroscopic image is provided for radiologic\n interpretation. No radiologist was present during image acquisition. The\n image demonstrates an IVC filter overlying a right proximal rib in the lower\n thoracic region. Immediately distal to the IVC filter cage, a second linear\n radiopacity is of uncertain significance and may represent an additional IVC\n filter.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-01 00:00:00.000", "description": "L ELBOW (AP, LAT & OBLIQUE) LEFT", "row_id": 978960, "text": " 9:20 AM\n ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: assess for location, do not remove splint for films\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with L elbow instability\n REASON FOR THIS EXAMINATION:\n assess for location, do not remove splint for films\n ______________________________________________________________________________\n FINAL REPORT\n LEFT ELBOW AND LEFT HUMERUS, FIVE VIEWS:\n\n INDICATION: Left elbow instability. Evaluate location.\n\n FINDINGS: Post-operative changes status post ORIF of a distal humeral\n diaphyseal fracture with a long plate and multiple screws is again seen. There\n has also been ORIF of the severely comminuted fracture of the proximal left\n radius including the radial head, neck, and proximal diaphysis. No hardware-\n related complication such as loosening or hardware fracture is identified.\n Numerous clips are seen overlying the skin. As before, there is anterior\n displacement of a radial fracture fragment and widening of the radiocapitellar\n distance. There is diffuse soft tissue swelling.\n\n IMPRESSION: Post-operative changes status post ORIF of the left humerus and\n proximal left radius, with no gross change in alignment or evidence for\n hardware-related complication. Unchanged alignment of the radiocapitellar\n joint.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-07 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 979886, "text": " 3:33 PM\n PELVIS (AP ONLY); FEMUR (AP & LAT) BILAT Clip # \n ANKLE (AP, MORTISE & LAT) LEFT\n Reason: eval hradware\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with polytrauma\n\n REASON FOR THIS EXAMINATION:\n eval hradware\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS, RIGHT FEMUR AND LEFT LOWER EXTREMITY\n\n CLINICAL HISTORY: Fractures.\n\n An AP view of the pelvis was obtained.\n\n Since , fenestrated plates have been placed along the acetabular\n fractures with multiple screws. There are new skin staples overlying the left\n iliac crest. The hip joint spaces are well maintained.\n\n RIGHT FEMUR\n\n There is a long intramedullary rod crossing the comminuted spiral fracture of\n the humeral shaft with two distal and two proximal interlocking screws. The\n lucent fracture lines are still visualized and there is no obvious change in\n fracture fragment position compared to the intraoperative studies of .\n\n LEFT FEMUR.\n\n A long intramedullary rod with a proximal gamma nail and a distal interlocking\n screw have been placed across the comminuted subtrochanteric fracture. No\n definite change in hardware or fracture fragment position is seen compared to\n .\n\n LEFT ANKLE\n\n AP, lateral and oblique views were obtained.\n\n Since the study of , two screws have been placed across the medial\n malleolar fracture. There is some superior lateral widening of the ankle\n joint. Anchors are seen in the distal fibula. There is a calcaneal screw,\n present previously. Well-corticated ossicles are seen at the dorsal aspect of\n the talus.\n\n IMPRESSION:\n 1. Since the last available studies, plates and screws have been placed\n across the left acetabular fracture and across the left medial malleolar\n fracture.\n 2. There is no other change in hardware or fracture fragment position.\n (Over)\n\n 3:33 PM\n PELVIS (AP ONLY); FEMUR (AP & LAT) BILAT Clip # \n ANKLE (AP, MORTISE & LAT) LEFT\n Reason: eval hradware\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-07 00:00:00.000", "description": "L ELBOW (AP, LAT & OBLIQUE) LEFT", "row_id": 979887, "text": " 3:33 PM\n ELBOW (AP, LAT & OBLIQUE) LEFT; HUMERUS (AP & LAT) LEFT Clip # \n Reason: eval haredware\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with polytrauma\n\n REASON FOR THIS EXAMINATION:\n eval haredware\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HUMERUS\n\n CLINICAL HISTORY: Fractures.\n\n AP and lateral views were obtained.\n\n A fracture plate and multiple screws have been placed across the comminuted\n fracture of the distal humeral shaft. There is no change from the\n intraoperative films of .\n\n IMPRESSION: There is no change in fracture fragment or hardware position.\n\n LEFT ELBOW\n\n AP, lateral, and oblique views were obtained, somewhat limited by the\n overlying cast.\n\n There is lateral radial fracture plate with multiple screws. The radial head\n is held in near anatomic orientation although somewhat separated from the\n capitellum with highly comminuted fragments are again seen.\n\n IMPRESSION: There is no change in fracture fragment position compared to the\n study from .\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 978529, "text": " 8:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for cardiopulm pathology\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p trauma w/multiple injuries, now c/o chest pain\n REASON FOR THIS EXAMINATION:\n please eval for cardiopulm pathology\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Chest pain.\n\n A single AP view of the chest is obtained on at 2045 hours and is\n compared with the prior evening's radiograph. The linear atelectasis at the\n left base has improved somewhat. The right-sided subclavian line has been\n removed. There are lung low volumes persisting. There is no evidence of\n acute consolidation or large pleural effusion on the current image. No\n pneumothorax is present and no obvious rib fractures are visualized in this\n projection.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 978823, "text": " 10:39 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Confirm position of PICC line\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p trauma w/multiple injuries, now c/o chest pain\n\n REASON FOR THIS EXAMINATION:\n Confirm position of PICC line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE EXAM OF \n\n INDICATION: PICC line placement.\n\n Right PICC line terminates at the medial head of the right clavicle at the\n expected junction of the right subclavian and right brachiocephalic veins.\n Cardiomediastinal contours are unchanged. Minor areas of atelectasis are\n present at both lung bases. Right hemidiaphragm remains mildly elevated.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-03 00:00:00.000", "description": "OL ELBOW, AP & LAT VIEWS IN O.R. LEFT", "row_id": 979413, "text": " 6:42 PM\n ELBOW, AP & LAT VIEWS IN O.R. LEFT Clip # \n Reason: ORIF LEFT ELBOW FX.\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n STUDIES: Elbow two views .\n\n HISTORY: Fracture status post ORIF.\n\n FINDINGS: Complex fracture involving the distal shaft of the left humerus.\n This is fixated by a large fracture plate and an interfragmentary screw.\n Please note that the superior portion of the fracture plate is not included on\n these views of the elbow. There is a joint effusion. There is also a complex\n fracture involving the proximal radius with several interfragmentary screws\n seen within the radial head. A fracture plate bridges the proximal radial\n shaft and the radial neck gap. There is again noted widening of the\n radiocapitellar distance. Several bony densities are seen within the volar\n aspect of the joint and medially. Overall, there is no significant change.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-30 00:00:00.000", "description": "PICC W/O PORT", "row_id": 978785, "text": " 7:20 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place IR-guided PICC\n Admitting Diagnosis: MULTIPLE INJURIES\n ********************************* CPT Codes ********************************\n * PICC W/O US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with multiple orthopedic injuries s/p plane crash now with poor\n peripheral IV access\n REASON FOR THIS EXAMINATION:\n please place IR-guided PICC\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PICC line placement.\n\n INDICATION: 30-year-old male status post plane crash with multiple\n traumatic/orthopedic injuries with poor peripheral IV access. PICC placement\n requested.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. and performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a single-lumen PICC line measuring 45 cm in length was placed\n through the peel-away sheath with its tip positioned in the upper SVC.\n Position of the catheter was confirmed by a portable chest x-ray.\n\n The peel-away sheath and guidewire were removed. The catheter was secured to\n the skin, flushed and a sterile dressing was applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound-guided single-lumen PICC line placement\n via the right brachial venous approach. Final internal length is 45 cm, with\n the tip positioned in the SVC. The line is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-09-27 00:00:00.000", "description": "L ELBOW (AP, LAT & OBLIQUE) LEFT", "row_id": 978528, "text": " 8:31 PM\n ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: please eval reduction, splint needs to stay on at all times!\n Admitting Diagnosis: MULTIPLE INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man s/p L elbow closed reduction and splinting\n REASON FOR THIS EXAMINATION:\n please eval reduction, splint needs to stay on at all times!\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Left elbow\n\n INDICATION: Comminuted radial fracture, distal humeral fracture.\n\n Two films of the left elbow are obtained in a plaster cast. There has been\n internal fixation with plate and screws of a comminuted radial fracture and a\n distal humeral fracture. Allowing for technique and positional differences,\n there does not appear to have been any significant change in the appearance\n and the alignment since the study performed on . Widening of the joint\n space between the radius and the capitellum is again seen.\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-22 00:00:00.000", "description": "Report", "row_id": 1622325, "text": "TSICU Admit Note 1900-0700\n PT is a 30yo male admitted to by S/P plane crash. Pt one of four passengers, 2 of whom are deceased, 1 other passenger is at B+W ICU.\n Pt has no PMH other than sports injuries, several ankle surgeries.Takes no meds at home, no allergies.Is married and expecting 1st child.\n Prolonged extrication at scene, pt was GCS=15 at scene and on arrival at this facility. C/o extremity and chest pain,+ sensation and movement of all extremities. Intubated in ED for hemodynamic instability, further eval of injuries.\n Injuries include:\n L open humerus fx\n L subtrochanteric fx\n ? R wrist fx\n midshaft R femur fx\n R pneumothorax\n Pt taken emergently to OR for external fixation of R femur, reposition and splinting of L humerus, extension of L femur fx w/skeletal traction.\n Laceration of R ear and cheek repaired by plastics at the bedside in TSICU\n Review of Systems\n Neuro- sedated on Propofol, Fentanyl for pain management.Wake up x1, pt nods to statements/questions, obeys simple commands.Head CT-PERL at 3mm, moves extremities minimally.cspine and logroll precautions maintained- not scanned\n CV- MP sr-st 90-110, BP 90's-130 systolic. aline w/good waveform, BP to 60's with coughing,turning- no change in HR. CVP 12-13, Cordiss R subclavian, TLC L femoral. IVF at 100, mult fld boluses for ^ lactate\n+12L for LOS, +1300 today.Pulses+ palpable, pboot on LLE only d/t wound RLE\n Resp- remains intubated, on full vent support. CMV 14, 700/40%/5.Last gas=7.34-42-132. LS clear- sl. coarse RUL, CT to 20cm sxn, +air leak, scant sanguinous dge. Faint crepitus around CT dsg\nsxn via ETT, no secretions. Occ cough.\n GI- Abd soft, BS+,no stool overnight.OG to LWS,dg clear/tan dge.On PPI coverage\n GU- Foley in place, dg clear yellow urine-spec sent for myoglobin, results pending at this time\n Skin- mult abrasions all over- RX with Bacitacin\n Social- as stated, pt is married, expecting 1st child. Parents, siblings at bedside, mult friends and support in touch with family.\n Labs- Ca,Mg repleted. Lactate remains2.5 despite mult boluses.Hct 28, wbc flat\n Plan-\n Mult plain films today to diagnose occult fractures\n Scan spine- clear spine if possible\n Pain control/sedation as needed\n Continue fluid resuscitation\n Start enteral nutrition if indicated\n Monitor Hct for further drop-transfuse if indicated\n Prepare for further ortho surgeries\n VC filter\n Update pt and family as to plan of care-\n" }, { "category": "Nursing/other", "chartdate": "2199-09-22 00:00:00.000", "description": "Report", "row_id": 1622326, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. BS clr LL, clr RUL diminished RRR. Sx scant secretions Patent rt CT, ABG WNL. RSBI 53. Plan: continue ventilatory support wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2199-09-22 00:00:00.000", "description": "Report", "row_id": 1622327, "text": "NPN 7a-7p\n\nNeuro: Pt sedated on 60 mcg/kg/min propofol and 100 mcg/hr fentanyl, follws simple commands, MAE's on bed, nods yes and no appropriately, sensation intact to pain and light touch, PERRL, protective reflexes intact, logroll cleared, cervical collar remains.\n\nPain: Fentanyl increased from 75 mcg/hr to 100 mcg/hr after patient c/o pain during neruo assessment, 50 mcg IV fentanyl bolus required prior to turning and repositioning.\n\nCV: NSR to ST with rate 80-100, R radial aline with adeq waveform and systolic pressures increasing throughout shift from 90 mmHg to 130 mmHg, IVF at 100, R SC TLC placed this am, L femoral line D/C'd, R PIV remains, L pneumoboot, hold lovenox, palp L pedal pulses, weak palp R pedal pulses---> + pulses with doppler, R LE cooler than L, R sluggish capillary refill.\n\nResp: Clear upper lobes with minimal sputum via ET suction, diminished breath sounds R LL, Vent remains 14 x 700 5 peep and 40% Fio2 with adequate blood gas and dropping lactate level, ETT 23 at the lip # 7.5 tube, CT with pos fluc and air leak and minimal output.\n\nEndo: Sliding scale with no coverage required.\n\nID: last dose of cefazolin given this am, low WBC count, temperature steadily elevating Tmax 100.3 Ax this pm, MRSA swabs sent.\n\nSkin: multiple abrasions and lacerations, R posterior shoulder friction vs thermal burn with open pink skin and minimal serous drainage, please refer to careview for details.\n\nMS: Multiple fractures, L LE in skeletal in skeletal traction and 15 lbs applied, R femer with external fixation, L UE with cast and sling, potential surgery to reduce fractures and dislocations tomorrow---> surgical consent given by pt's father.\n\nHeme: slowly dropping Hct from 27 to 25 and finally 24 this shift, minimal CT output.\n\nGU: Foley with adeq urine output, no boluses required after resuscitation in the pm, lytes ordered from the am, urine remains yellow and clear.\n\nGI: abdomen with hypoactive BS, soft, NPO, OGT to LCWS and brown/yellow thin oral secreations sumped out, + placement check.\n\nSocial: Multiple family visits, updated on pt's current status.\n\nPlan: Cont to monitor and assess as ordered, plan for OR tomorrow, pain mgmt and sedate as needed, monitor vasuclat status, assess for compartment syndrom, maintain L elbow at 90 degrees per Ortho, of logroll precautions, LSO brace to be ordered when able to sit up past 30 degrees in bed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-23 00:00:00.000", "description": "Report", "row_id": 1622328, "text": "TSICU Progress Note 1900-0700\n Stable, comfortable overnight. 2uPC's for Hct of 22.8, prep for OR this am, ORIF R and L femur, L humerus\n Review of Systems-\n Neuro- Sedated on Propofol 60mcg, Fentanyl at 125mcg. Pt arouses to voice, obeys simple commands, opens eyes, nods appropriately to questions.Sensation and movement intact to all extremities.Logroll d/c'd, may be up to 30degrees, will need LSO brace for more than 30 degrees. C-collar in place, no spinal injury but ligament injury not ruled out.\n CV- MP SR 80-90, no ectopy. BP stable by Aline,pulses+ palpable. Generalized edema noted, pt is approx 15L pos over LOS.Pboot on LLE only d/t wound on RLE. Lovenox held by team pending OR today.\n Resp- remains intubated, on full support.RSBI=25, last gas 7.41-47-134, LS clear, diminished bases. L CT to 20cm sxn, scant serosang dge overnight. +air leak, no crepitus.\n GI- abd soft, bs+.OG to lws, dg bilious dge.Pepcid \n GU- Foley cath, u/o qs clear yellow\n Skin- see carevue\n ID- Last dose Cefazolin 0700 WBC=7.1, Tmax 101.2\n Labs- K,Mg repleted per scale. NA=132, repeat Hct 25.4\n Plan\n To OR today, for ORIF R and L femur, L humerus, ?filter placement\n ? Extubate postop\n Continue pain control as needed\n Monitor pneumo-\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-23 00:00:00.000", "description": "Report", "row_id": 1622329, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. Sx scant secretions. BS clear bilaterally. RSBI 25. Please see carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2199-09-23 00:00:00.000", "description": "Report", "row_id": 1622330, "text": "T/SICU Nursing \nEvents: To OR for IM nail of bilateral femurs from 0745-1345\n\nNeuro: Sedated on propofol gtt; weening off with intermittent ativan. Following commands with all extremities. PERRL.\n\nPain: Denied pain when aroused; fentanyl gtt continues at 150mcg/hr; will ween after ativan sedation regimen obtained.\n\nResp: Lungs clear, equal bilaterally, diminished at the bases. Right chest tube to 20cm wall suction with air leak present, scan amounts of serosanguenous drainage. Ventilated on AC 600x14(overbreathes)x5 PEEPx40%.\n\nCV: Sinus tachy rhythm without ectopics. Palpable or dopplerable distal pulses. Follow hct; currently 24. Right radial arterial line, right triple lumen CVL in place and both transducing sharply.\n\nGI: Abdomen soft, non-tender, bowel sounds hypoactive. OGT to wall suction sumping thick bilios liquid.\n\nEndo: RISS with no coverage required post-op.\n\nLytes: Repleting calcium & potassium.\n\nSocial: Multiple family/friend visitors this shift.\n\nPlan: Maintain safety. Pain management. Transition to ativan for bolus sedation. Ween ventilator as tolerated. Notify team of acute changes. To OR again tomorrow for further orthopedics. Needs MRI c-spine and knees.\n" }, { "category": "Nursing/other", "chartdate": "2199-09-23 00:00:00.000", "description": "Report", "row_id": 1622331, "text": "Patient on mechanical ventilation went to OR for both femurs repair.Will go back in AM for more orthopedic works (Humerus,left ankle and right wrist)ABG normal;plan to go to MRI @ 8PM.\n" }, { "category": "Nursing/other", "chartdate": "2199-09-24 00:00:00.000", "description": "Report", "row_id": 1622332, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout. Patient to MRI. Returned to room. Latest abg results determined a respiratory alkalosais with good oxygenation.\n\nRSBI = 54 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2199-09-24 00:00:00.000", "description": "Report", "row_id": 1622333, "text": "NPN, 1900-0700\nevents: MRI of left knee, unable to MRI CS (unable to fit in scanner)\n Self-extubated 0545, stable w/ face tent.\n\nNeuro: after extubation, pt asking ?s re accident; oriented to self only. Follows commands, wiggles all digits x 4 exts. PERRLA. Fentanyl gtt off w/ extubation. Received ativan 2 mg IV x 1 during noc for anxiety after propofol gtt d/c'd after MRI.\n\nCV: ST, no VEA. Radial pulses, RLE pulses 2+; LLE DP +Doppler signal. 4+ anasarca. Pboots x 1 limb; lovenox in am pending team approval in am.\n\nPulm: Self-extubated 0545, no distress. Immediate husky vocalization, strong cough productive thick yellow secretions. Face tent 100%, racemic epi neb w/ productive cough and clearer airway. BS CTA throughout, diminished bibasilar. Right pleural CT draining scant s/s; no fluctuation, no leak, no crepitus.\n\nGI: abd soft, hypo BS. OGT out w/ ETT; dark bilious bile sumped overnoc, 300cc. +flatus, no stool. NPO; sip of ice water after extubation, stable cough and gag.\n\nGU: F/C urine clear amber; OP 30-80cc/hr. LOS +19 liters; 24 hrs +2 L\nLR @ 75cc/hr. Lytes aggressively repleted.\n\nSkin: abrasions head, neck, torso red, oozing serous. RLE/LLE puncture wounds from ex-fixes open, draining s/s. Left hip dressing D/I. Right CT dressing D/I. Splint LLE intact; splint ULE intact. Dressing RUE w/ serous drainage medial aspect.\n\nEndo: RISS, adequate coverage.\n\nID: Tmax 101.3 po; WBC WNL. Cont on cefapime.\n\nHeme: Hct 21.3, down from 25.\n\nPsychosocial: father called this am, told of extubation and pt's stable status. He will be in this am.\n\nP: d/c fentanyl gtt; prn analgesic. Clear CS now that pt is awake w/ intact mentation. Follow fever curve, ? cx T>101.5. ? transfuse for Hct 21 before next OR. Wean FiO2 as able, start nebs, encourage aggressive bronchial hygeine w/ IS, CDB q 1-2 hrs. Start po w/ clear liquids, advance as tol to protein shakes if able. ? lasix for volume overload. Closely monito vascular status of all limbs. Plan OR tomorrow to fix left arm and hip.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-24 00:00:00.000", "description": "Report", "row_id": 1622334, "text": "respiratory care\npt on the vent back from the OR no changes. see respiratory care page of carevue for more inforamtion.\n" }, { "category": "Nursing/other", "chartdate": "2199-09-24 00:00:00.000", "description": "Report", "row_id": 1622335, "text": "Nursing Progress Note\nSee Careview for specific data.\n\nSignificant Events: Pt tolerated breathing on own in the AM-maintained O2 sat 95-100% with face tent at 70% FiO2. Attending Trauma team assessed cervical spine and D/C'd collar. 2 Units PRBCs ordered & started pre-op for HCT 21. Pt sent to OR for humerus & radial head repair @ 1015. VAC dsg in place to LUE post-op; HCT up to 22.9. Patient returned to ICU intubated, anesthesia not reversed. Received paralytic at end of case so remains sedated(propofol drip) with narcotic support until fully reversed.\n\nNeuro: Pt alert, oriented to self,knows there was a plane crash; unaware that he is in hospital,has questions about what happened. Recognizes family members, appropriate/calm behavior. Able to move all four extremities pre-op, unable to assess mobility post-op d/t sedation. Ortho team reports possible radial nerve damage, so assessment for left thumb movement needed once patient is awake. Head lac on right ear/right cheek, but no brain injuries.\nPropofol infusion ongoing at present.\n\nPain: Morphine 2mg increments for c/o intermittant pain in back/hip. Given pain medication with morphine post-op for vital signs indicating pain(elevated heart rate & blood pressure).\n\nCV: bounding pedal pulses in AM, palpable pulses post-op (doppler needed for left wrist). ABP/CVP WNL, NSR without ectopy. on Lovenox & pneumo boot (right leg only) for DVT prophylaxis. Propofol for sedation post-op to keep pt calm, tolerated well. 20 mEq KCL repleted, calcium gluconate 2gm repleted post-op.\n\nResp: Intubated on full ventilator support. Clear upper lobe lung sounds, diminished in bases, some coarse sounds d/t congestion. Right lung a bit more diminished than the left. Pt has strong/productive cough-able to move clear/thin secretions in AM, post-op required suction to help move light yellow/thick secretions. O2 sats 95-100%. ABG post-op revealed hypercarbia: tidal volume increased. Right CT placed to water seal pre-op: no fluctuation/leak in AM, positive fluctuation/no leak post-op, scant s/s drainage; DSD d & i. Post-op CXR: no pntx reported.\n\nSkin: Multiple abrasions/lacerations on body per careview. Leg wounds covered with DSDs-required change d/t leaking serous/serosanguinous fluid. T max 101.6 pre-op (still 24 hours post-op from last surgery). Skin warm/moist pre-op: skin cool post-op but perfusing adequately. No pressure sores upon assessment at position change/bed cleaning. Multipodus boot on right leg for pressure sore prophylaxis. Brisk cap refill.\nVAC dsg to LUE @ 125mm suction. VAC required due to inability to close incision due to edema; will assess for closure possibly on thursday.\n\nGI: Diet NPO. Positive BS/no BM, abdomen soft, not distended.\n No gastric access at this time.\n pepcid therapy continues.\n\nGU: Foley catheter draining adequate UO > 50mL/hr: clear, yellow urine pre-op. pt's urine was cloudy and more concentrated, but had adequate UO intra-op. IVF @ 125cc/hour.\n\nID: Cefazolin therapy c\n" }, { "category": "Nursing/other", "chartdate": "2199-09-24 00:00:00.000", "description": "Report", "row_id": 1622336, "text": "Nursing Progress Note\n(Continued)\nontinues. WBC wnl post-op.\n\nSocial: Family visited throughout the day, expressed concerns with pt's emotional reaction to this trauma, desire to speak with social work to plan how to deal with discussing details of event with him, long-lasting effects. Very supportive network of family/friends, wife/brother/mother express desire to keep visitors to a minimum tomorrow to deal with telling pt details.\n\nPlan: Attempt wean to extubate tonight as ordered per HO. Change dressings as needed to prevent skin breakdown. Continue to support pt and family emotionally. Assess mobility and sensation in LUE specifically. Plan for OR on thursday to repair left hip fx and ?left ankle.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-25 00:00:00.000", "description": "Report", "row_id": 1622337, "text": "NPN, 1900-0700\nneuro: since extubation 0615 this am, pt is x , amnestic for all previous events. Calm and cooperative; follows commands as able w/ limb limitation. Strong and gag. PERRLA. Significant pain LUE, treated w/ morphine w/ fair effect.\n\nCV: ST to 120's, no VEA. SBP 100-130's. CVP 8-11. RUE, RLE pulses 3+, digits cool, CRT<3. LLE + Doppler DP, cool toes, CRT<3. LUE cool hand, + Doppler CRT>3. Pboot x 1 limb. Lovenox to start today.\n\nPulm: Extubated 0615 this am to face tent w/o any problems. productive thick light yellow mucous. BS essentially CTAb, dim right base. CT to H2O seal draining scant serous fluid, no leak or crepitus.\n\nGI: abd softly distende; hypoactive BS. Tol sips ice H2O since extubation. +flatus, no stool.\n\nGU: F/C urine initially sediment laden amber, now clear.OP marginal 40-80cc/hr. LR @ 125cc/hr. +~18 liters LOS. Lytes repleted aggressively.\n\nSkin: surface degloving injury right axilla, inner right arm, draining copious serous fluid. Multiple incision and stab wounds bilateral legs draining copious s/s fluid. Abrasions, lacs face and head draining scant serous, some remain beefy. VAC LUE draining scant s/s.\n\nEndo: RISS, adequate coverage.\n\nID: Tmax 101po. WBC WNL. Cont on cefepime.\n\nHeme: post op Hct 20.3, transfused w/ 2 units PRBC; 24 post transfusion.\n\nPsychosocial: wife, brother and mother in last eve w/ concerns about pt's coping after he is extubated. Pt does not know of death of other plane passengers. Family is supportive and appropriate.\n\nP: transition to PCA dilaudid. Monitor and replete lytes and hct carefully, transfuse to maintain hct >22. Aggressive bronchial hygeine, wean FiO2 as able. Progress DAT. Wound care to maintain dry skin as able. HOB<45. Keep exts elevated. Contact SS this am; family is expecting call from nursing re meeting time today w/ SS. Plan OR Thursday for hip, ? ankle.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-25 00:00:00.000", "description": "Report", "row_id": 1622338, "text": "***PLEASE SEE CAREVUE FOR EXACT DATA***\n\nEVENTS: R CT discontinued\n CXR done showed L side atelectasis, no appearance of pneumothorax.\n\nROS:\n\nNEURO: A+Ox3. Responds to verbal stim. Follows all commands. eyes open spontaneously. Able to move fingers/toes on all extremities. pain consistantly in Larm, occ. to left hip. PRN Morphine 1-10mg for pain control. Pain controled with Morphine. Activity order for HOB up to 45degs, brace needed when OOB. Tech in to fit brace today, however spoke with Mr who asked him to come back at end of week for proper fitting.\n\nCV: HR 97-106. NSR-ST. -ectopy. ABP 110-140s/50s-60s, sharp waveform, RR A-line, WNL. CVP 3-8, TLC RSC, WNL, sharp waveform. +PP, doppler necessary for DP of LLE. All extrems warm/pink. cap refill <3secs. HCT stable. Multipodus boot (RLE), compression sleeve (RLE) and SC Lovenox for prophylaxis.\n\nRESP: NC 2L, weaned off face tent. tolerating well. O2sat 96-100%. RR 14-28, increased with repositioning. Diamox ordered to tx alkalosis. strong , expectorating thck/yel secretions. LS clear bilaterally with diminished bases. C&DB, incentive spirometry (1000cc) taught to and used by pt with +results. R post CT discontinued, DSD, -drnge, -crepitus.\n\nGI: Pt advanced to Regular diet. Tolerating jello and ice cream. NPO after midnight d/t OR tomorrow. +BS. -BM. Abd soft, nontender. H2Blkr for propylaxis.\n\nGU: Foley draining adequate amts of ambr/yel urine. 10mg Lasix ordered X2. lytes repleted. KVO LR 5cc/hr.\n\nENDO: SS. Minimal coverage required.\n\nHEME: Hct 24.1. stable since this AM. no transfusion necessary.\n\nID: Tmax 101.7. IV Cephazolin q8hrs for tx/prophylaxis. No Tylenol at this time per Dr .\n\nSKIN: Oral ulcerations on side of mouth. Oral care performed. Face abrasion, R ear & nose lacs open to air, -drg, Bacitracin applied. RU arm ?degloving, s/s drng, Adaptic with DSD. RU leg (old pin sites, or site), moderate s/s drg, softsorb sponge dsg. L arm, splint, DSD, s/s drg, VAC @125. leg moderate s/s (old pin sites), softsorb sponge dsg. LLwr leg/ankle splint, DSD, ace wrap, -drng. Small abrasion extending across upper back, no dressing. All open pin sites only to have DSD's no drainage bags per ortho.\n\nSOCIAL: Family in to visit. Social work in contact with family RE: informing pt about accident/death of friends. Pts wife states: \" doesn't want to talk about it.\" According to pts wife, she believes he knows about accident and death of his best friend. Social work and wife will follow up with patient once surgeries are completed.\n\nPOC: develop POC w/ OR Re: in AM. pt first case for Dr. , but no time established yet. Pain control. cont to monitor hemodynamics. cont to monitor Hct. cont to replete lytes. cont to develop POC with social work Re: informing pt about accident/deaths and RE: best way and time for family to inform pt.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2199-09-26 00:00:00.000", "description": "Report", "row_id": 1622339, "text": "neuro: Lethargic but oriented x3. MAE to command. Medicated q3h with 5mg mso4. for c/o pain. Good effect. However, has difficulty getting comfortable.\n\nCv/Resp. VSS o2 3lnp good o2 sat lungs clear. Encouraged to and deep breath. HR stable. NSR. CVP now -2 - 0.\n\ngi/gu NPO for OR today. foley with brisk UOP. No stools overnight.\n\ninteg. Multiple skin abrasions noted facial, torso, etc.\npin site dsgs on thighs changed for large amt serous drainage.\n\nPlan: Plan OR today for left acetabular repair and ? left ankle repair. Pt. has 2 units prbc in blood bank.\n\nLytes repleted on sliding scale\n" }, { "category": "ECG", "chartdate": "2199-09-27 00:00:00.000", "description": "Report", "row_id": 220392, "text": "Sinus rhythm\nEarly precordial QRS transition - is nonspecific\nNonspecific ST-T abnormalities\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Echo", "chartdate": "2137-09-23 00:00:00.000", "description": "Report", "row_id": 94052, "text": "PATIENT/TEST INFORMATION:\nIndication: CABG\nStatus: Inpatient\nDate/Time: at 16:10\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Focal calcifications in aortic\narch. Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. No atrial septal defect is seen by 2D or color\nDoppler.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are focal calcifications in the aortic arch. There are complex (>4mm)\natheroma in the descending thoracic aorta.\nThe aortic valve leaflets are moderately thickened. There is caclification\nofnon coronary cusp. There is mild aortic valve stenosis (valve area 1.7 cm2).\nThe mitral valve leaflets are mildly thickened. The posterior leaflet has\ncalcium on top. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\nDr. was notified in person of the results before surgical incision and\nespecially the 1.7cm2.\nPOST-BYPASS:\nPreserved biventricular systolic function. LVEF 55%.\nIntact throacic aorta.\nNo new valvular findings.\n\n\n" }, { "category": "Echo", "chartdate": "2137-09-17 00:00:00.000", "description": "Report", "row_id": 94053, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Myocardial infarction.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 145/76\nHR (bpm): 51\nStatus: Inpatient\nDate/Time: at 09:03\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and 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: basal\ninferolateral - hypo; mid inferolateral - hypo;\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: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the basal inferolateral wall. The remaining\nsegments contract normally (LVEF = 50-55 %). The estimated cardiac index is\nnormal (>=2.5L/min/m2). 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 are moderately thickened. There is mild\naortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild to moderate (+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size with mild regional systolic\ndysfunction c/w CAD. Mild aortic valve stenosis. Mild-moderate mitral\nregurgitation. Pulmonary artery hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2137-09-23 00:00:00.000", "description": "Report", "row_id": 250030, "text": "Junctional bradycardia and slowing of the rate as compared with previous\ntracing of . Followup and clinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2137-09-19 00:00:00.000", "description": "Report", "row_id": 250031, "text": "Ectopic atrial bradycardia. No diagnostic change compared to tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2137-09-18 00:00:00.000", "description": "Report", "row_id": 250032, "text": "Ectopic atrial rhythm. Compared to the previous tracing of no\ndiagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2137-09-16 00:00:00.000", "description": "Report", "row_id": 250033, "text": "Ectopic atrial bradycardia. No previous tracing available for comparison.\n\n" } ]

[ { "category": "General", "chartdate": "2173-11-29 00:00:00.000", "description": "Generic Note", "row_id": 609814, "text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Continuing to have very heavy\n vagnal bleeding.\n 98.9 79 116/75\n Alert\n Chest\n few basilar crackles\n CV\n w/o incr P2\n Extrem 1+ edema\n Hct 28 stable\n Very difficult challenge. Continuing with heavy bleeding but she has\n substantial clot burden. Awaiting Gyn recs but seems we may need to\n wait for Lupron to have effect to see decrease in bleeding. Will need\n long term anticoag\n likely 3 mos of coumadin if her bleeding can be\n managed w/o OCPs which is very desirable. Will continue to monitor\n hct. Access is adequate. Holding on tx but will need iron\n supplementation long term\n Time spent 35 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2173-11-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 609817, "text": "Chief Complaint:\n 24 Hour Events:\n - GYN consult feels that patient should start on Lupron as soon as\n possible, though effect may not be fully seen until 2 to 3 weeks from\n now. Also may consider progesterone, though hold off while HCT stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Other medications:\n Acetaminophen 3. Docusate Sodium 4. Ferrous Gluconate 5. Heparin 6.\n Leuprolide Acetate 7. Naproxen\n 8. OxycoDONE (Immediate Release) 9. Potassium Chloride 10. Senna 11.\n Sodium Chloride 0.9% Flush\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: pt reports continued pleuritic CP on the left side,\n with dyspnea on exertion. Has not been out of bed yet but is eating.\n Reports using 2 pads Q2H and soaking through the sheets. No\n lightheadedness or dizziness.\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: 37.8\nC (100\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 103) bpm\n BP: 131/87(96) {86/58(64) - 142/106(114)} mmHg\n RR: 22 (14 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 544 mL\n 461 mL\n PO:\n 400 mL\n 350 mL\n TF:\n IVF:\n 144 mL\n 111 mL\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -156 mL\n 161 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Gen: NAD\n Neck: no JVD\n Cv: RRR nl s1/s2 no mrg\n Pulm: CTA b/l\n Abd: +BS, soft NTND\n Ext: no edema, NT\n Labs / Radiology\n 251 K/uL\n 9.0 g/dL\n 102 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 136 mEq/L\n 28.1 %\n 5.8 K/uL\n [image002.jpg]\n 06:30 PM\n 12:01 AM\n 02:56 AM\n WBC\n 5.8\n Hct\n 30.8\n 27.7\n 28.1\n Plt\n 251\n Cr\n 0.7\n Glucose\n 102\n Other labs: PT / PTT / INR:13.8/86.6/1.2, Differential-Neuts:47.2 %,\n Lymph:43.3 %, Mono:6.7 %, Eos:2.8 %, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:4.0 mg/dL\n Imaging: FINDINGS: There are multiple filling defects in the bilateral\n pulmonary\n arteries supplying the right upper lobe, anterior segment (2, 23) and\n right\n lower lobe (2, 31-40). There is a nodular subpleural opacity within the\n periphery of the right lower lobe (2, 40) which may represent a small\n pulmonary infarct. Filling defects within the left upper lobe segmental\n arteries (2, 19), lingula (2, 24), and left lower lobe (2, 36)\n segmental\n arteries are also identified. There is no axillary, hilar, or\n mediastinal\n lymphadenopathy. There is no pericardial effusion. There is a small\n left pleural effusion. There is no evidence of bowing of the\n interventricular\n septum to suggest right heart failure at this time.\n Limited views of the upper abdomen are unremarkable.\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions\n identified.\n IMPRESSION: Extensive bilateral pulmonary emboli as described above.\n Possible right lower lobe pulmonary infarct.\n Microbiology: none\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. PEs: Patient noting 3 days of severe pleuritic chest pain. No\n association with hemoptysis. CTA shows extensive bilateral PE without\n evidence of Right Heart Strain. EKG shows TWI in lead III, otherwise\n without signs of right heart strain. Heart rate and blood pressure have\n been stable.\n - Discontinued OCPs\n - Continue heparin drip for systemic anticoagulation and initiate\n warfarin when stability more assured\n - LENIs to help determine if large lower extremity clot burden, which\n may require IVC filter if too much uterine bleeding with full\n anticoagulation\n - TTE to assess for any right heart strain in setting of large\n bilateral pulmonary embolism\n - will have to determine best outpatient anticoagulation strategy and\n when this should start as an inpatient. Would favor keeping on heparin\n gtt alone as long as possible given ability to reverse rapidly\n #. Uterine bleeding:\n -Patient noting increased bleeding in the 4 to 5 days leading up to\n presentation to the hospital. Denies lightheadedness, syncope.\n - Patient received Lupron .\n - f/u OB/Gyn recsto assist in management of uterine bleeding while on\n full anticoagulation: suggested if hematocrit dropping significantly\n and heavy bleeding\n persists, once therapeutically anticoagulated, can consider a course\n medroxyprogesterone 10mg daily to help stabilize the endometrium\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation\n - Maintain active type and screen\n - Two large bore IVs\n #. Anemia: Currently her HCT is stable.\n - Ferrous gluconate 325 mg \n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: start PO H2B \n VAP:\n Comments:\n Communication: Comments: With patient and patient's mother, \n , Phone: \n Code status: Full code\n Disposition: call out to gyn\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 609828, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt. Changing peripad every\n 90-120minutes. Hct has been stable. Heparin gtt at 1800units and ptt in\n therapeutic range. Followed closely by GYN. She got 1 dose of Lupron\n last evening.\n Plan for LENIs today. If clots present would consider placing IVC\n filter.\n" }, { "category": "Physician ", "chartdate": "2173-11-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 609786, "text": "Chief Complaint:\n 24 Hour Events:\n - GYN consult feels that patient should start on Lupron as soon as\n possible, though effect may not be fully seen until 2 to 3 weeks from\n now. Also may consider progesterone, though hold off while HCT stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Other medications:\n Acetaminophen 3. Docusate Sodium 4. Ferrous Gluconate 5. Heparin 6.\n Leuprolide Acetate 7. Naproxen\n 8. OxycoDONE (Immediate Release) 9. Potassium Chloride 10. Senna 11.\n Sodium Chloride 0.9% Flush\n Changes to medical 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: 37.8\nC (100\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 103) bpm\n BP: 131/87(96) {86/58(64) - 142/106(114)} mmHg\n RR: 22 (14 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 544 mL\n 461 mL\n PO:\n 400 mL\n 350 mL\n TF:\n IVF:\n 144 mL\n 111 mL\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -156 mL\n 161 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 251 K/uL\n 9.0 g/dL\n 102 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 136 mEq/L\n 28.1 %\n 5.8 K/uL\n [image002.jpg]\n 06:30 PM\n 12:01 AM\n 02:56 AM\n WBC\n 5.8\n Hct\n 30.8\n 27.7\n 28.1\n Plt\n 251\n Cr\n 0.7\n Glucose\n 102\n Other labs: PT / PTT / INR:13.8/86.6/1.2, Differential-Neuts:47.2 %,\n Lymph:43.3 %, Mono:6.7 %, Eos:2.8 %, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:4.0 mg/dL\n Imaging: FINDINGS: There are multiple filling defects in the bilateral\n pulmonary\n arteries supplying the right upper lobe, anterior segment (2, 23) and\n right\n lower lobe (2, 31-40). There is a nodular subpleural opacity within the\n periphery of the right lower lobe (2, 40) which may represent a small\n pulmonary infarct. Filling defects within the left upper lobe segmental\n arteries (2, 19), lingula (2, 24), and left lower lobe (2, 36)\n segmental\n arteries are also identified. There is no axillary, hilar, or\n mediastinal\n lymphadenopathy. There is no pericardial effusion. There is a small\n left pleural effusion. There is no evidence of bowing of the\n interventricular\n septum to suggest right heart failure at this time.\n Limited views of the upper abdomen are unremarkable.\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions\n identified.\n IMPRESSION: Extensive bilateral pulmonary emboli as described above.\n Possible right lower lobe pulmonary infarct.\n Microbiology: none\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. Pleuritic chest pain: Patient noting 3 days of severe pleuritic\n chest pain. No association with hemoptysis. CTA shows extensive\n bilateral PE without evidence of Right Heart Strain. EKG shows TWI in\n lead III, otherwise without signs of right heart strain. Heart rate and\n blood pressure have been stable.\n - Discontinued OCPs\n - Continue heparin drip for systemic anticoagulation and initiate\n warfarin when stability more assured\n - LENIs to help determine if large lower extremity clot burden, which\n may require IVC filter if too much uterine bleeding with full\n anticoagulation\n - TTE to assess for any right heart strain in setting of large\n bilateral pulmonary embolism\n #. Uterine bleeding:\n -Patient noting increased bleeding in the 4 to 5 days leading up to\n presentation to the hospital. Denies lightheadedness, syncope.\n - Patient received Lupron .\n - f/u OB/Gyn recsto assist in management of uterine bleeding while on\n full anticoagulation: suggested if hematocrit dropping significantly\n and heavy bleeding\n persists, once therapeutically anticoagulated, can consider a course\n medroxyprogesterone 10mg daily to help stabilize the endometrium\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation\n - Maintain active type and screen\n - Two large bore IVs\n #. Anemia: Currently her HCT is stable.\n - Ferrous gluconate 325 mg \n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: With patient and patient's mother, \n , Phone: \n Code status: Full code\n Disposition:ICU care pending further monitoring\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609886, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. Heparin gtt\n at 1800units and ptt in therapeutic range. Followed closely by GYN.\n She got 1 dose of Lupron last evening. LENIs today., read pnd. If clots\n present would consider placing IVC filter.\n At 1500 she passed lg amt blood vaginally. Hemodynamically stable. Hct\n 2hrs earlier was stable. Repeat hct and ptt sent. Team to consult\n w/GYN. #18 PIV placed. Pt has 3 IVs.\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609785, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/Ox3, very pleasant. Mildly febrile Tmax 99.6, oral. Spo2 95%R/A.\n Pt gets slightly short of breath while getting OOB to commode. Keeps O2\n on and off.\n Continues to have bleeding PV with clots.\n On heparin gtt. HCT 28.1, from 30.8 yesterday. VSS. Urine output\n adequate..\n Action:\n Moitored vital signs closely. Leuprolide acetate 3.75mg IM given\n x1dose. Heparin gtt at 1800units/hr. No changes made this shift. PTT\n remained within therapeutic limits. Bleeding precautions maintained.\n Response:\n Ongoing\n Plan:\n Continue to monitor vitals, follow up with labs. For TTE and bilateral\n lower extremities ultrasound I today.\n" }, { "category": "Physician ", "chartdate": "2173-11-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 609950, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:43 AM\n ULTRASOUND - At 01:45 PM\n LEs\n - 1pm Hct stable, had episode of significant bleeding at 3:30pm, sent\n Hct and coags. 9pm Hct 25.6 from 28.4, gave 1 unit blood as still\n actively bleeding. Had another episode of heavy bleeding in the middle\n of night. Ordered repeat Hct at 11am after seeing am labs which were\n drawn about 1 hour after blood finished.\n - Gyn: consider myomectomy vs uterine artery embolization but not yet,\n transfuse to Hct 25. Consider preop placement of IVF filter if surgery\n necessary. Afternoon update was that UAE would be favored over\n myomectomy. Leupron should work within a week. IR knows about her\n (contact , or person on-call).\n - TTE: LVEF >55%, borderline pulm hypertension, otherwise relatively\n normal\n - LENIs: No evidence of DVT on either side\n This AM:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.7\n HR: 100 (79 - 111) bpm\n BP: 129/80(94) {108/55(67) - 133/105(113)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,603 mL\n 741 mL\n PO:\n 1,160 mL\n 270 mL\n TF:\n IVF:\n 443 mL\n 121 mL\n Blood products:\n 350 mL\n Total out:\n 550 mL\n 0 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,053 mL\n 741 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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 234 K/uL\n 8.8 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 138 mEq/L\n 27.1 %\n 5.3 K/uL\n [image002.jpg]\n 06:30 PM\n 12:01 AM\n 02:56 AM\n 01:06 PM\n 03:17 PM\n 08:53 PM\n 04:56 AM\n WBC\n 5.8\n 5.7\n 5.3\n Hct\n 30.8\n 27.7\n 28.1\n 28.1\n 28.4\n 25.6\n 27.1\n Plt\n \n Cr\n 0.7\n 0.7\n Glucose\n 102\n 104\n Other labs: PT / PTT / INR:13.9/97.9/1.2, Differential-Neuts:47.2 %,\n Lymph:43.3 %, Mono:6.7 %, Eos:2.8 %, Ca++:8.4 mg/dL, Mg++:2.3 mg/dL,\n PO4:4.2 mg/dL\n TEE : The left atrium is elongated. No atrial septal defect is\n seen by 2D or color Doppler. Left ventricular wall thickness, cavity\n size and regional/global systolic function are normal (LVEF >55%).\n There is no ventricular septal defect. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is borderline pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n LENIs : No evidence of deep vein thrombosis in either lower\n extremity.\n Microbiology: None\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PULMONARY EMBOLISM (PE), ACUTE\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n 22 Gauge - 07:00 PM\n 18 Gauge - 04:57 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments: Naproxen, tylenol and oxycodone for pain control, bowel\n regimen with senna and colace\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now, possible callout later this PM\n" }, { "category": "Physician ", "chartdate": "2173-11-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 609951, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:43 AM\n ULTRASOUND - At 01:45 PM\n LEs\n - 1pm Hct stable, had episode of significant bleeding at 3:30pm, sent\n Hct and coags. 9pm Hct 25.6 from 28.4, gave 1 unit blood as still\n actively bleeding. Had another episode of heavy bleeding in the middle\n of night. Ordered repeat Hct at 11am after seeing am labs which were\n drawn about 1 hour after blood finished.\n - Gyn: consider myomectomy vs uterine artery embolization but not yet,\n transfuse to Hct 25. Consider preop placement of IVF filter if surgery\n necessary. Afternoon update was that UAE would be favored over\n myomectomy. Leupron should work within a week. IR knows about her\n (contact , or person on-call).\n - TTE: LVEF >55%, borderline pulm hypertension, otherwise relatively\n normal\n - LENIs: No evidence of DVT on either side\n This AM:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.7\n HR: 100 (79 - 111) bpm\n BP: 129/80(94) {108/55(67) - 133/105(113)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,603 mL\n 741 mL\n PO:\n 1,160 mL\n 270 mL\n TF:\n IVF:\n 443 mL\n 121 mL\n Blood products:\n 350 mL\n Total out:\n 550 mL\n 0 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,053 mL\n 741 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Gen: NAD\n Neck: no JVD\n Cv: RRR nl s1/s2 no mrg\n Pulm: CTA b/l\n Abd: +BS, soft NTND\n Ext: no edema, NT\n Labs / Radiology\n 234 K/uL\n 8.8 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 138 mEq/L\n 27.1 %\n 5.3 K/uL\n [image002.jpg]\n 06:30 PM\n 12:01 AM\n 02:56 AM\n 01:06 PM\n 03:17 PM\n 08:53 PM\n 04:56 AM\n WBC\n 5.8\n 5.7\n 5.3\n Hct\n 30.8\n 27.7\n 28.1\n 28.1\n 28.4\n 25.6\n 27.1\n Plt\n \n Cr\n 0.7\n 0.7\n Glucose\n 102\n 104\n Other labs: PT / PTT / INR:13.9/97.9/1.2, Differential-Neuts:47.2 %,\n Lymph:43.3 %, Mono:6.7 %, Eos:2.8 %, Ca++:8.4 mg/dL, Mg++:2.3 mg/dL,\n PO4:4.2 mg/dL\n TEE : The left atrium is elongated. No atrial septal defect is\n seen by 2D or color Doppler. Left ventricular wall thickness, cavity\n size and regional/global systolic function are normal (LVEF >55%).\n There is no ventricular septal defect. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is borderline pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n LENIs : No evidence of deep vein thrombosis in either lower\n extremity.\n Microbiology: None\n Assessment and Plan\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. PEs: Patient noting 3 days of severe pleuritic chest pain. No\n association with hemoptysis. CTA shows extensive bilateral PE without\n evidence of Right Heart Strain. EKG shows TWI in lead III, otherwise\n without signs of right heart strain. Heart rate and blood pressure have\n been stable. LENIs negative and TTE with no signs of right heart\n strain.\n - Discontinued OCPs\n - Continue heparin drip for systemic anticoagulation and initiate\n warfarin when stability more assured\n - will have to determine best outpatient anticoagulation strategy and\n when this should start as an inpatient. Would favor keeping on heparin\n gtt alone as long as possible given ability to reverse rapidly and\n possibility of procedures this admission\n #. Uterine bleeding: Patient noting increased bleeding in the 4 to 5\n days leading up to presentation to the hospital. Denies\n lightheadedness, syncope.\n - Patient received Lupron .\n - f/u OB/Gyn recs to assist in management of uterine bleeding while on\n full anticoagulation: suggested if hematocrit dropping significantly\n and heavy bleeding persists, once therapeutically anticoagulated, can\n consider a course medroxyprogesterone 10mg daily to help stabilize the\n endometrium\n -F/u Ob/Gyn decision re myomect vs uterine artery embolization and\n timing\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation -> next Hct due 11 am because AM labs drawn\n right after transfusion\n - Maintain active type and screen\n - Two large bore Ivs\n #. Anemia: Currently her HCT is stable.\n - Ferrous gluconate 325 mg \n stopped\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n 22 Gauge - 07:00 PM\n 18 Gauge - 04:57 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments: Naproxen, tylenol and oxycodone for pain control, bowel\n regimen with senna and colace\n Communication: Comments: With patient and patient's mother, \n , Phone: \n Code status: Full code\n Disposition: ICU for now, possible callout later this PM\n" }, { "category": "Nursing", "chartdate": "2173-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609954, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem - Description In Comments\n Assessment:\n Anemia caused by uterine fibroid bleeding. Pt had an episode of heavy\n bleeding (like a water faucet turned on low) during the last shift and\n another episode this shift. Pt had a drop in HCT from 28.4 yesterday\n afternoon at 1500 to 25.6 at 2100 last evening.\n Action:\n Pt has been on high dose of OCP for bleeding. Is receiving a unit of\n prbc.\n Response:\n Hct 27.1\n Plan:\n Follow hct and provide blood products as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Bilat PE on CTA in the ew.\n Action:\n Pt is on heparin gtt currently at 1800 units/hr.\n Response:\n Ptt 96.2.\n Plan:\n Target is 60-100.\n" }, { "category": "Nursing", "chartdate": "2173-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610056, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem\n blood loss due to fibroid bleeding\n Assessment:\n Cont. with vaginal bleeding this shift. S/P transfusion of 1 unit of\n PRBC overnight.\n Action:\n Hct check Q 6-8 hr.\n Response:\n Hct 27.8 at 11 am and 28.3 at 1700. Saturated 3 large pads this shift.\n Pt. reports some cloths.\n Plan:\n Follow hct and provide blood products as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Bilat PE on CTA. Pt. c/o occ L side pleuritic chest pain.\n Action:\n Pt is on heparin gtt with PTT checks q 6 hrs. Medicated with Naproxen\n 500mg x1 this shift for pain.\n Response:\n Ptt 100 at 1100 and\n Plan:\n Target is 60-100. Cont. Heparin gtt and transition to coumadin.\n" }, { "category": "General", "chartdate": "2173-11-30 00:00:00.000", "description": "Generic Note", "row_id": 609985, "text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Comfortable.\n 99.4 97 124/84\n Alert\n Chest few mid insp crackles\n CV w/o accentuated P2\n Abd soft\n PTT 97.9\n Hct 27 after 1 U PRBC\n Hemodyn stable for now. PTT is in range but she is continuing to bleed\n heavily. Gyn prefers to avoid a procedure if at all possible so we are\n going to try to support with current plan unless bleeding becomes\n unsupportable. Continuing hct check q6h.\n Time spent 35 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609776, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/Ox3, very pleasant. Mildly febrile Tmax 99.6, oral. Spo2 95%R/A.\n Pt gets slightly short of breath while getting OOB to commode. Keeps O2\n on and off.\n Continues to have bleeding PV with clots.\n On heparin gtt. HCT 28.1, from 30.1 yesterday.\n Action:\n Moitored vital signs closely. Leuprolide acetate 3.75mg IM given\n x1dose. Heparin gtt at 1800units/hr. No changes made this shift.\n Bleeding precautions maintained.\n Response:\n Ongoing\n Plan:\n Continue to monitor vitals, follow up with labs. For TTE and LENI\n today.\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609777, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/Ox3, very pleasant. Mildly febrile Tmax 99.6, oral. Spo2 95%R/A.\n Pt gets slightly short of breath while getting OOB to commode. Keeps O2\n on and off.\n Continues to have bleeding PV with clots.\n On heparin gtt. HCT 28.1, from 30.8 yesterday. VSS. Urine output\n adequate..\n Action:\n Moitored vital signs closely. Leuprolide acetate 3.75mg IM given\n x1dose. Heparin gtt at 1800units/hr. No changes made this shift.\n Bleeding precautions maintained.\n Response:\n Ongoing\n Plan:\n Continue to monitor vitals, follow up with labs. For TTE and LENI\n today.\n" }, { "category": "Nursing", "chartdate": "2173-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610045, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem\n blood loss due to fibroid bleeding\n Assessment:\n Cont. with vaginal bleeding this shift. S/P transfusion of 1 unit of\n PRBC overnight.\n Action:\n Hct check Q 6-8 hr.\n Response:\n Hct 27.8 at 11 am and at 1700. Saturated 3 large pads this shift. Pt.\n reports some cloths.\n Plan:\n Follow hct and provide blood products as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Bilat PE on CTA in the ew.\n Action:\n Pt is on heparin gtt currently at 1800 units/hr.\n Response:\n Ptt 96.2.\n Plan:\n Target is 60-100.\n" }, { "category": "Nursing", "chartdate": "2173-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610047, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem\n blood loss due to fibroid bleeding\n Assessment:\n Cont. with vaginal bleeding this shift. S/P transfusion of 1 unit of\n PRBC overnight.\n Action:\n Hct check Q 6-8 hr.\n Response:\n Hct 27.8 at 11 am and at 1700. Saturated 3 large pads this shift. Pt.\n reports some cloths.\n Plan:\n Follow hct and provide blood products as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Bilat PE on CTA. Pt. c/o occ L side pleuritic chest pain.\n Action:\n Pt is on heparin gtt with PTT checks q 6 hrs. Medicated with Naproxen\n 500mg x1 this shift for pain.\n Response:\n Ptt 100 at 1100 and\n Plan:\n Target is 60-100. Cont. Heparin gtt and transition to coumadin.\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609868, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. Heparin gtt\n at 1800units and ptt in therapeutic range. Followed closely by GYN.\n She got 1 dose of Lupron last evening. LENIs today., read pnd. If clots\n present would consider placing IVC filter.\n At 1500 she passed lg amt blood vaginally. Hemodynamically stable. Hct\n 2hrs earlier was stable. Repeat hct and ptt sent. Team to consult\n w/GYN. #18 PIV placed. Pt has 3 IVs.\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610099, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem\n bleeding fibroids\n Assessment:\n Pt dx with fibroids which are bleeding. Pt had 2 episodes of standing\n and passing lg amts of blood with several med sized clots.\n Action:\n Monitored bleeding and change of pads. Mionitor hct q6hrs.\n Response:\n Hct is trending down. At 1700 yesterday hct28.3. 2100 27.4 and this am\n 26.5.\n Plan:\n Cont to monitor hct and pads\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt dx with bil pe by CTA on adm\n Action:\n On heparin gtt. heparin was decreased by 200 units hr this am for high\n ptt.\n Response:\n Ptt had been within the target but this am was 102.6.\n Plan:\n Pt will remain on heparin and transition to coumadin when ordered.\n Pt was scheduled to have surgery on the fibroids in . pt is 29 and\n has no children and would like to start a family soon.\n" }, { "category": "Physician ", "chartdate": "2173-11-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 609995, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:43 AM\n ULTRASOUND - At 01:45 PM\n LEs\n - 1pm Hct stable, had episode of significant bleeding at 3:30pm, sent\n Hct and coags. 9pm Hct 25.6 from 28.4, gave 1 unit blood as still\n actively bleeding. Had another episode of heavy bleeding in the middle\n of night. Ordered repeat Hct at 11am after seeing am labs which were\n drawn about 1 hour after blood finished.\n - Gyn: consider myomectomy vs uterine artery embolization but not yet,\n transfuse to Hct 25. Consider preop placement of IVF filter if surgery\n necessary. Afternoon update was that UAE would be favored over\n myomectomy. Leupron should work within a week. IR knows about her\n (contact , or person on-call).\n - TTE: LVEF >55%, borderline pulm hypertension, otherwise relatively\n normal\n - LENIs: No evidence of DVT on either side\n This AM: Continues to c/o left sided pleuritic chest pain, which has\n been stable. Continues to have heavy vaginal bleeding,\nlike\n urinating.\n Otherwise denies pain, f/c, nausea, vomiting. Tolerating\n PO diet.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.1\nC (98.7\n HR: 100 (79 - 111) bpm\n BP: 129/80(94) {108/55(67) - 133/105(113)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,603 mL\n 741 mL\n PO:\n 1,160 mL\n 270 mL\n TF:\n IVF:\n 443 mL\n 121 mL\n Blood products:\n 350 mL\n Total out:\n 550 mL\n 0 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,053 mL\n 741 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Gen: NAD\n Neck: no JVD\n Cv: RRR nl s1/s2 no mrg\n Pulm: CTA b/l\n Abd: +BS, soft NTND\n Ext: no edema, NT\n Labs / Radiology\n 234 K/uL\n 8.8 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 138 mEq/L\n 27.1 %\n 5.3 K/uL\n [image002.jpg]\n 06:30 PM\n 12:01 AM\n 02:56 AM\n 01:06 PM\n 03:17 PM\n 08:53 PM\n 04:56 AM\n WBC\n 5.8\n 5.7\n 5.3\n Hct\n 30.8\n 27.7\n 28.1\n 28.1\n 28.4\n 25.6\n 27.1\n Plt\n \n Cr\n 0.7\n 0.7\n Glucose\n 102\n 104\n Other labs: PT / PTT / INR:13.9/97.9/1.2, Differential-Neuts:47.2 %,\n Lymph:43.3 %, Mono:6.7 %, Eos:2.8 %, Ca++:8.4 mg/dL, Mg++:2.3 mg/dL,\n PO4:4.2 mg/dL\n TEE : The left atrium is elongated. No atrial septal defect is\n seen by 2D or color Doppler. Left ventricular wall thickness, cavity\n size and regional/global systolic function are normal (LVEF >55%).\n There is no ventricular septal defect. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve appears structurally normal with\n trivial mitral regurgitation. There is no mitral valve prolapse. There\n is borderline pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n LENIs : No evidence of deep vein thrombosis in either lower\n extremity.\n Microbiology: None\n Assessment and Plan\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. PEs: Patient noting 3 days of severe pleuritic chest pain. No\n association with hemoptysis. CTA shows extensive bilateral PE without\n evidence of Right Heart Strain. EKG shows TWI in lead III, otherwise\n without signs of right heart strain. Heart rate and blood pressure have\n been stable. LENIs negative and TTE with no signs of right heart\n strain.\n - Discontinued OCPs\n - Continue heparin drip for systemic anticoagulation and initiate\n warfarin when stability more assured\n - will have to determine best outpatient anticoagulation strategy and\n when this should start as an inpatient. Would favor keeping on heparin\n gtt alone as long as possible given ability to reverse rapidly and\n possibility of procedures this admission\n #. Uterine bleeding: Patient noting increased bleeding in the 4 to 5\n days leading up to presentation to the hospital. Denies\n lightheadedness, syncope.\n - Patient received Lupron .\n - f/u OB/Gyn recs to assist in management of uterine bleeding while on\n full anticoagulation: suggested if hematocrit dropping significantly\n and heavy bleeding persists, once therapeutically anticoagulated, can\n consider a course medroxyprogesterone 10mg daily to help stabilize the\n endometrium\n - Per Ob/Gyn would like to avoid procedure such as myomectomy or UAE;\n will not pursue unless patient transfusion resistant and unable to\n maintain Hct > 25.\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation -> next Hct due 11 am because AM labs drawn\n right after transfusion\n - Maintain active type and screen\n - Two large bore Ivs\n #. Anemia: Currently her HCT is stable.\n - Ferrous gluconate 325 mg \n -f/u iron studies\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n 22 Gauge - 07:00 PM\n 18 Gauge - 04:57 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments: Naproxen, tylenol and oxycodone for pain control, bowel\n regimen with senna and colace\n Communication: Comments: With patient and patient's mother, \n , Phone: \n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2173-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610067, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem\n blood loss due to fibroid bleeding\n Assessment:\n Cont. with vaginal bleeding this shift. S/P transfusion of 1 unit of\n PRBC overnight.\n Action:\n Hct check Q 6-8 hr.\n Response:\n Hct 27.8 at 11 am and 28.3 at 1700. Saturated 3 large pads this shift.\n Pt. reports some cloths.\n Plan:\n Follow hct and provide blood products as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Bilat PE on CTA. Pt. c/o occ L side pleuritic chest pain.\n Action:\n Pt is on heparin gtt with PTT checks q 6 hrs. Medicated with Naproxen\n 500mg x1 this shift for pain.\n Response:\n Ptt 100 at 1100 and 89.1 at 1700, both within target range. Heparin\n gtt cont. at 1800 unit/hr.\n Plan:\n Target is 60-100. Cont. Heparin gtt and transition to coumadin. Next\n PTT at 2300.\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609863, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. Heparin gtt\n at 1800units and ptt in therapeutic range. Followed closely by GYN.\n She got 1 dose of Lupron last evening. LENIs today., read pnd. If clots\n present would consider placing IVC filter.\n At 1500 she passed lg amt blood vaginally. Hemodynamically stable. Hct\n 2hrs earlier was stable. Repeat hct and ptt sent. Team to consult\n w/GYN.\n" }, { "category": "Nursing", "chartdate": "2173-11-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609749, "text": "29 yo female with H/O uterine fibroids, menometrorrhagia and anemia\n presented to ED with L chest/flank/hip pain and dyspnea. Ct scan showed\n bilateral PEs. Started on IV heparin and transferred to ICU for further\n mgmt.\n A&O x3 on arrival. DOE. Pleasant and cooperative. On 2L N/C which was\n weaned to RA with O2sats 98%.\n Stool in ED OB-. UCG negative. Has vaginal bleeding. Hct 29.6. Says\n her pain is mild-moderate but does not need pain med at this time.\n Heparin gtt at 1800u/hr. Plan for ptt/Hct at 1900.\n Accompanied by her mother who is her HCP.\n house diet. No stool. Using commode without problem.\n for TTE and LENIs tomorrow. Cont heparin gtt. Titrate to\n therapeutic level as per protocol. Bleeding precautions.\n" }, { "category": "Physician ", "chartdate": "2173-11-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 609751, "text": "Chief Complaint: Chest pain\n HPI:\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week. She notes that she felt some left chest cramping last week;\n however, the pain did not become severe until . Pain\n initially radiated to back and now is going down to her elft buttocks.\n This is in background of ~2 months of dyspnea on exertion which has\n noticably worsened in last two weeks. Also patient is reporting that\n she had sudden onset BLE edema that she first noticed after a plane\n trip to St. (4 hour leg to was longest time on\n plane). She denies any LE edema at this time. Also denies cough,\n hemoptysis, fevers, chills, sick contacts.\n Regarding her uterine fibroid bleeding, patient is seen in OB/Gyn by\n Dr. . She notes that her last menstral period (and start of her\n abnormal uterine bleeding) was . Patient took a high dose OCP\n taper starting for large uterine fibroids that were causing\n significant uterine bleeding. At time of admission she was taking one\n pill daily, though she had been instructed to start another high dose\n OCP taper due to increased vaginal bleeding in the last 4 to 5 days.\n She did not take the high dose OCPs due to not feeling well in the last\n few days. She had planned for an open myommectomy on due to\n persistent bleeding. As a bridge to surgery, patient was going to\n receive information about a Lupron injection this week. She explicitly\n denies any history of pregnancy, abortions, or miscarriages.\n Upon presentation to the ED vitals were T 98.8, HR 96, BP 138/83, RR\n 16, O2Sats 100% RA. Presented with chest pain. Was found to have\n elevated d-dimer to ~ and subsequently found to have extensive\n bilateral PE on CTA chest. Was started on a heparin drip. EKG was\n without wigns of right heart strain. Troponin was negative at <0.01.\n Was originally destined for the floor, though the floor attending was\n concerned about full anticoagulation in the setting of recent uterine\n bleeding. Needs to be typed, crossed, and consented for blood products\n in the event of uterine bleeding while anticoagulated. Vitals prior to\n transfer to the ICU were T 98.4, HR 92, BP 119, RR 28, 100%/4L NC.\n REVIEW OF SYSTEMS:\n (+)ve: pleuritic chest pain, dyspnea on exertion, menorrhagia,\n occasional abdominal cramping\n (-)ve: fever, chills, night sweats, loss of appetite, fatigue,\n palpitations, rhinorrhea, nasal congestion, cough, sputum production,\n hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting,\n diarrhea, constipation, hematochezia, melena, dysuria, urinary\n frequency, urinary urgency, focal numbness, focal weakness, myalgias,\n arthralgias\n Allergies:\n No Known Drug Allergies\n MEDICATIONS:\n 1) Desogestrel-ethinyl .15mg-.03 mg tablet daily\n 2) Iron 325 mg \n Past medical history:\n Family history:\n Social History:\n 1) Uterine fibroids\n 2) Anemia, iron-deficiency\n 3) Bacterial vaginosis\n 4) Gonorrhea\n 5) Trichomonas\n 6) Cosmetic surgery on left thigh (redundant skin) as a child\n MGM, MGF, PGF: Diabetes\n PGF: Died from MI\n No history of blood clots, sudden death, autoimmune disorders\n Currently works as an art consultant. Past work as a law librarian at a\n law firm downtown.\n Tobacco: Rare\n EtOH: Occasional, less use since she has struggled with uterine\n bleeding\n Illicits: Denies\n Physical Examination\n VS: T 100, HR 85, BP 126/91, RR 30, O2Sat 97% RA\n GEN: NAD, healthy-appearing female\n HEENT: PERRL, EOMI, oral mucosa moist\n NECK: Supple, JVP approximately 6 cm\n PULM: CTAB\n CARD: RR, nl S1, nl S2, no M/R/G\n ABD: BS+, somewhat firm midline, otherwise soft, non-tender,\n non-distended, no hepatosplenomegaly\n EXT: no C/C/E\n SKIN: no rashes\n NEURO: Oriented x 3, CN II-XII intact, grossly normal extremity motor\n exam, gait not asessed\n PSYCH: Mood and affect appropriate\n Labs / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 10:00AM\n 6.8\n 4.18*\n 9.6*#\n 29.6*\n 71*\n 23.1*#\n 32.5\n 23.8*\n 252\n BASIC COAGULATION (PT, PTT, PLT, INR)\n PT\n PTT\n Plt Smr\n Plt Ct\n INR(PT)\n [2] 10:00AM\n 12.6\n 24.2\n 1.1\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [3] 10:00AM\n 91\n 10\n 0.8\n 139\n 4.0\n 106\n 22\n 15\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n [4] 10:00AM\n 59\n CPK ISOENZYMES\n CK-MB\n cTropnT\n [5] 10:00AM\n <0.01[1]\n HEMATOLOGIC\n D-Dimer\n [6] 10:00AM\n *\n OTHER URINE CHEMISTRY\n UCG\n [7] 09:50AM\n NEGATIVE[1]\n DIPSTICK URINALYSIS\n Blood\n Nitrite\n Protein\n Glucose\n Ketone\n Bilirub\n Urobiln\n pH\n Leuks\n [8] 09:50AM\n LG\n NEG\n 100\n NEG\n NEG\n SM\n 0.2\n 6.0\n NEG\n MICROSCOPIC URINE EXAMINATION\n RBC\n WBC\n Bacteri\n Yeast\n Epi\n TransE\n RenalEp\n [9] 09:50AM\n >50\n 0-2\n MOD\n NONE\n \n CTA CHEST :\n !! WET READ !!\n Bilateral extensive pulmonary emboli, likely RLL infarct.\n Transabdominal and transvaginal ultrasounds :\n A markedly enlarged fibroid uterus is again demonstrated, currently\n measuring 16.5 x 14.4 x 9.4 cm which is overall increased in size since\n in which greatest sagittal dimension measured 13.4 cm. The\n large dominant fibroid within the posterior myometrium is also larger\n than , currently measuring 10.5 x 10.3 x 8.2 cm, previously\n measuring 8.9 cm in greatest dimension. The endometrium is better seen\n transabdominally than transvaginally due to fibroid, but measures 3 mm\n and is displaced anteriorly by the dominant posterior fibroid. No free\n pelvic fluid is identified. The ovaries are normal in appearance with a\n 2.3 cm dominant hemorrhagic cyst within the right ovary.\n Assessment and Plan\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. Pleuritic chest pain:\n Patient noting 3 days of severe pleuritic chest pain. No association\n with hemoptysis. CTA shows extensive bilateral PE. No evidence of right\n heart strain on CT imaging. EKG shows TWI in lead III, otherwise\n without signs of right heart strain. Heart rate and blood pressure have\n been stable.\n - Discontinue OCPs\n - Start heparin drip for systemic anticoagulation and initiate warfarin\n when stability more assured\n - LENIs to help determine if large lower extremity clot burden, which\n may require IVC filter if too much uterine bleeding with full\n anticoagulation\n - TTE to assess for any right heart strain in setting of large\n bilateral pulmonary embolism\n - Follow-up final CTA read\n #. Uterine bleeding:\n Patient noting increased bleeding in the 4 to 5 days leading up to\n presentation to the hospital. Denies lightheadedness, syncope.\n - Consult OB/Gyn to assist in management of uterine bleeding while on\n full anticoagulation\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation\n - Maintain active type and screen\n - Consent for blood products\n - Two large bore IVs\n #. Anemia:\n Currently her HCT is at 29.6, which is up from most recent prior of\n 23.7.\n - Ferrous gluconate 325 mg \n ICU Care\n Nutrition: Regular diet\n Lines:\n 20 Gauge - 04:34 PM\n Prophylaxis:\n - DVT ppx with heparin drip systemic anticoagulation\n - Bowel regimen docusate, senna\n - Pain management with acetaminophen initially and will escalate as\n needed\n Communication: With patient and patient's mother, ,\n Phone: \n Code status: Full code\n Disposition: ICU for monitoring of bleeding while initiating systemic\n anticoagulation\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_4%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_5%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_7%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_8%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_10%22);\n 7. JavaScript:parent.POPUP(self,%22_WEBTAG=_19%22);\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_13%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_14%22);\n" }, { "category": "Nursing", "chartdate": "2173-11-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609759, "text": "29 yo female with H/O uterine fibroids, menometrorrhagia and anemia\n presented to ED with L chest/flank/hip pain and dyspnea. Ct scan showed\n bilateral PEs. Started on IV heparin and transferred to ICU for further\n mgmt.\n A&O x3 on arrival. DOE. Pleasant and cooperative. On 2L N/C which was\n weaned to RA with O2sats 98%.\n Stool in ED OB-. UCG negative. Has vaginal bleeding. Hct 29.6. Says\n her pain is mild-moderate but does not need pain med at this time.\n Heparin gtt at 1800u/hr. Plan for ptt/Hct at 1900.\n Accompanied by her mother who is her HCP.\n house diet. No stool. Using commode without problem.\n for TTE and LENIs tomorrow. Cont heparin gtt. Titrate to\n therapeutic level as per protocol. Bleeding precautions.\n" }, { "category": "Physician ", "chartdate": "2173-11-28 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 609738, "text": "TITLE:\n Chief Complaint: Chest pain\n I saw and examined the patient, and was physically present with Dr.\n for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 29 y/o with b/l extensive PE.\n Recent hx notable for dyspnea attributed to anemia, worse in past few\n weeks; chest pain x ~1 week worse on Friday, persistent pain - to ED.\n B/L LE edema after recent plane flight to St. , self -resolved,\n without pain.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n At home: iron, multiple OCPs\n Past medical history:\n Family history:\n Social History:\n Fibroids and anemia d/t refractory uterine bleeding; most recently with\n persistent bleeding since on 2 OCPs. Scheduled for ?lupron\n prior to myomectomy in .\n Diabetes\n no coagulopathy / lung disease\n Occupation: prior - law librarian, active in arts community; currently\n unemployed\n Drugs: None\n Tobacco: Rare intermittent 'social' in past, none current\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Epistaxis\n Cardiovascular: Chest pain, Edema\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Signs or concerns for abuse : No\n Flowsheet Data as of 04:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 85 (85 - 85) bpm\n BP: 126/91(98) {126/91(98) - 126/91(98)} mmHg\n RR: 30 (30 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), , no RV heave\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present),\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Bronchial: , No(t) Wheezes : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 252\n 29 <- 23 in \n 0.8\n 22\n 7\n [image002.jpg]\n Fluid analysis / Other labs: Ddimer 18,000\n Imaging: CTA - extensive b/l thrombus in multiple segments. RLL wedge\n shaped opacity c/w infarct. No septal displacement.\n ECG: sinus; nl axis intervals, TWI III\n Assessment and Plan\n 29 y/o with extensive b/l PE with uterine bleeding.\n For PE, radiographically extensive but submassive by normal HR, BP,\n negative troponin, lack of RV strain by EKG.\n Risk factors include high dose OCPs; also weight, ?plane flight;\n symptoms make it difficult to determine clear duration of clot but at\n least several days to a week at minimum.\n Treatment heparin gtt though may need IVC filter if hemorrhage becomes\n more active. Hct today actually higher than in .\n For uterine bleeding, d/c OCPs and consult gyn. ?Role of lupron, IR,\n timing of surgery. In meantime clot to BB, 2 IVs, follow Hcts and\n hemodynamics.\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2173-11-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 609838, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. Heparin gtt\n at 1800units and ptt in therapeutic range. Followed closely by GYN.\n She got 1 dose of Lupron last evening.\n Plan for LENIs today. If clots present would consider placing IVC\n filter.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1600\n" }, { "category": "Nursing", "chartdate": "2173-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 609906, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem - Description In Comments\n Assessment:\n Anemia caused by uterine fibroid bleeding. Pt had an episode of heavy\n bleeding (like a water faucet turned on low) during the last shift and\n another episode this shift. Pt had a drop in HCT from 28.4 yesterday\n afternoon at 1500 to 25.6 at 2100 last evening.\n Action:\n Pt has been on high dose of OCP for bleeding. Is receiving a unit of\n prbc.\n Response:\n Plan:\n Follow hct and provide blood products as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Bilat PE on CTA in the ew.\n Action:\n Pt is on heparin gtt currently at 1800 units/hr.\n Response:\n Ptt 96.2.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 610089, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Echo", "chartdate": "2173-11-29 00:00:00.000", "description": "Report", "row_id": 76517, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for Right heart strain.\nHeight: (in) 66\nWeight (lb): 225\nBSA (m2): 2.10 m2\nBP (mm Hg): 116/75\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 09:29\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. The IVC was not visualized. The RA pressure\ncould not be estimated.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Mild [1+] TR.\nBorderline 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 elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nThere is borderline pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n" }, { "category": "Physician ", "chartdate": "2173-12-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 610131, "text": "Chief Complaint:\n 24 Hour Events:\n Hct 27.1 -> 27.8 -> 28.3\n -per gyn, cont to transfuse to Hct > 25. UAE is distant 2nd line tx.\n -Fe 82, ferritin 36\n -IR will see patient if/when she decompensates\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,600 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Acetaminophen 3. Docusate Sodium 4. Ferrous Gluconate 5. Heparin 6.\n Magnesium Sulfate 7. Milk of Magnesia\n 8. Naproxen 9. OxycoDONE (Immediate Release) 10. Potassium Chloride 11.\n Ranitidine 12. Senna 13. Sodium Chloride 0.9% Flush\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 83 (83 - 103) bpm\n BP: 121/80(90) {101/51(64) - 143/88(100)} mmHg\n RR: 17 (0 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,064 mL\n 124 mL\n PO:\n 270 mL\n TF:\n IVF:\n 444 mL\n 124 mL\n Blood products:\n 350 mL\n Total out:\n 650 mL\n 200 mL\n Urine:\n 650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 414 mL\n -76 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\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 253 K/uL\n 8.4 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 26.5 %\n 5.5 K/uL\n [image002.jpg]\n 12:01 AM\n 02:56 AM\n 01:06 PM\n 03:17 PM\n 08:53 PM\n 04:56 AM\n 10:42 AM\n 04:50 PM\n 10:45 PM\n 02:59 AM\n WBC\n 5.8\n 5.7\n 5.3\n 5.5\n Hct\n 27.7\n 28.1\n 28.1\n 28.4\n 25.6\n 27.1\n 27.8\n 28.3\n 27.4\n 26.5\n Plt\n 53\n Cr\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 104\n 94\n Other labs: PT / PTT / INR:13.8/102.6/1.2, Ca++:8.2 mg/dL, Mg++:1.9\n mg/dL, PO4:3.7 mg/dL\n Imaging: none\n Microbiology: none\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PULMONARY EMBOLISM (PE), ACUTE\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. PEs: Patient noting 3 days of severe pleuritic chest pain. No\n association with hemoptysis. CTA shows extensive bilateral PE without\n evidence of Right Heart Strain. EKG shows TWI in lead III, otherwise\n without signs of right heart strain. Heart rate and blood pressure have\n been stable. LENIs negative and TTE with no signs of right heart\n strain.\n - Discontinued OCPs\n - Continue heparin drip for systemic anticoagulation and initiate\n warfarin when stability more assured\n - will have to determine best outpatient anticoagulation strategy and\n when this should start as an inpatient. Would favor keeping on heparin\n gtt alone as long as possible given ability to reverse rapidly and\n possibility of procedures this admission\n #. Uterine bleeding: Patient noting increased bleeding in the 4 to 5\n days leading up to presentation to the hospital. Denies\n lightheadedness, syncope.\n - Patient received Lupron .\n - f/u OB/Gyn recs to assist in management of uterine bleeding while on\n full anticoagulation: suggested if hematocrit dropping significantly\n and heavy bleeding persists, once therapeutically anticoagulated, can\n consider a course medroxyprogesterone 10mg daily to help stabilize the\n endometrium\n - Per Ob/Gyn would like to avoid procedure such as myomectomy or UAE;\n will not pursue unless patient transfusion resistant and unable to\n maintain Hct > 25.\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation\n - Maintain active type and screen\n - Two large bore Ivs\n #. Iron Deficiency Anemia: Currently her HCT is stable.\n - Ferrous gluconate 325 mg \n ICU Care\n Nutrition: Regular diet\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: H2 blocker\n Comments: Naproxen, tylenol and oxycodone for pain control, bowel\n regimen with senna and colace\n Communication: Comments: With patient and patient's mother, \n , Phone: \n Code status: Full code\n Disposition: ICU for now, ?c/o to Gyn\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n 18 Gauge - 04:57 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": "2173-12-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610152, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. 1uPRBCs\n , no other transfusions. Heparin gtt at 1600units and ptt in\n therapeutic range. Followed closely by GYN. She got 1 dose of Lupron\n .\n LENIs negative.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1600\n" }, { "category": "General", "chartdate": "2173-12-01 00:00:00.000", "description": "Generic Note", "row_id": 610163, "text": "Chief Complaint: VTE\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. Mild pleuritic chest pain persists\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,600 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, 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: Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, 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, No(t) Dialysis, vaginal\n bleeding\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Pain: Minimal\n Flowsheet Data as of 09:58 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: 37.1\nC (98.7\n HR: 84 (82 - 103) bpm\n BP: 132/92(103) {101/51(64) - 143/92(103)} mmHg\n RR: 26 (0 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,064 mL\n 369 mL\n PO:\n 270 mL\n 200 mL\n TF:\n IVF:\n 444 mL\n 169 mL\n Blood products:\n 350 mL\n Total out:\n 650 mL\n 200 mL\n Urine:\n 650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 414 mL\n 169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\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, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic), 2/6 sem\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) Dullness : ), (Breath Sounds: No(t)\n Clear : , Crackles : few basilar, No(t) Bronchial: , No(t) Wheezes : ,\n No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: 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: Normal\n Labs / Radiology\n 8.4 g/dL\n 253 K/uL\n 94 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 26.5 %\n 5.5 K/uL\n [image002.jpg]\n 12:01 AM\n 02:56 AM\n 01:06 PM\n 03:17 PM\n 08:53 PM\n 04:56 AM\n 10:42 AM\n 04:50 PM\n 10:45 PM\n 02:59 AM\n WBC\n 5.8\n 5.7\n 5.3\n 5.5\n Hct\n 27.7\n 28.1\n 28.1\n 28.4\n 25.6\n 27.1\n 27.8\n 28.3\n 27.4\n 26.5\n Plt\n 53\n Cr\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 104\n 94\n Other labs: PT / PTT / INR:13.8/102.6/1.2, Differential-Neuts:47.2 %,\n Lymph:43.3 %, Mono:6.7 %, Eos:2.8 %, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.7 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PULMONARY EMBOLISM (PE), ACUTE\n Bleeding continues with very slow decline in her hct. Will discuss\n transfusion with Gyn. Still hoping Lupron will begin to work soon. In\n meantime we are maintaining her on heparin. Will still need conversion\n to coumadin once vaginal bleeding is controlled. uterine cramping\n remains a problem - will try to d/c NSAIDs due to anti-platelet effect\n ICU Care\n Nutrition:\n Comments: full\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n 18 Gauge - 04:57 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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": "2173-12-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 610178, "text": "Chief Complaint:\n 24 Hour Events:\n Hct 27.1 -> 27.8 -> 28.3\n -per gyn, cont to transfuse to Hct > 25. UAE is distant 2nd line tx.\n -Fe 82, ferritin 36\n -IR will see patient if/when she decompensates\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,600 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Acetaminophen 3. Docusate Sodium 4. Ferrous Gluconate 5. Heparin 6.\n Magnesium Sulfate 7. Milk of Magnesia\n 8. Naproxen 9. OxycoDONE (Immediate Release) 10. Potassium Chloride 11.\n Ranitidine 12. Senna 13. Sodium Chloride 0.9% Flush\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: CP improving, improves with Naproxen, dyspnea only\n with activity. Has been Oob to commode only. Using 1 large pad Q2H.\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 83 (83 - 103) bpm\n BP: 121/80(90) {101/51(64) - 143/88(100)} mmHg\n RR: 17 (0 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,064 mL\n 124 mL\n PO:\n 270 mL\n TF:\n IVF:\n 444 mL\n 124 mL\n Blood products:\n 350 mL\n Total out:\n 650 mL\n 200 mL\n Urine:\n 650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 414 mL\n -76 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///20/\n Physical Examination\n Gen: NAD\n CV: Rrr nl s1s2 no mrg\n Pulm: cta b/l\n Abd: unchanged distention and firmness, +BS, NT\n Ext: no edema, warm\n Labs / Radiology\n 253 K/uL\n 8.4 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 26.5 %\n 5.5 K/uL\n [image002.jpg]\n 12:01 AM\n 02:56 AM\n 01:06 PM\n 03:17 PM\n 08:53 PM\n 04:56 AM\n 10:42 AM\n 04:50 PM\n 10:45 PM\n 02:59 AM\n WBC\n 5.8\n 5.7\n 5.3\n 5.5\n Hct\n 27.7\n 28.1\n 28.1\n 28.4\n 25.6\n 27.1\n 27.8\n 28.3\n 27.4\n 26.5\n Plt\n 53\n Cr\n 0.7\n 0.7\n 0.6\n Glucose\n 102\n 104\n 94\n Other labs: PT / PTT / INR:13.8/102.6/1.2, Ca++:8.2 mg/dL, Mg++:1.9\n mg/dL, PO4:3.7 mg/dL\n Imaging: none\n Microbiology: none\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PULMONARY EMBOLISM (PE), ACUTE\n 29 yo female with history of anemia secondary to uterine fibroid\n bleeding, presents with pleuritic chest pain for approximately one\n week.\n #. PEs: Patient noting 3 days of severe pleuritic chest pain. No\n association with hemoptysis. CTA shows extensive bilateral PE without\n evidence of Right Heart Strain. EKG shows TWI in lead III, otherwise\n without signs of right heart strain. Heart rate and blood pressure have\n been stable. LENIs negative and TTE with no signs of right heart\n strain.\n - Discontinued OCPs\n - Continue heparin drip for systemic anticoagulation and initiate\n warfarin when stability more assured\n - will have to determine best outpatient anticoagulation strategy and\n when this should start as an inpatient. Would favor keeping on heparin\n gtt alone as long as possible given ability to reverse rapidly and\n possibility of procedures this admission\n - advised patient that we would like to switch from naproxen because of\n bleeding risk.\n #. Uterine bleeding: Patient noting increased bleeding in the 4 to 5\n days leading up to presentation to the hospital. Denies\n lightheadedness, syncope.\n - Patient received Lupron .\n -check Hct at 10am with PTT\n - f/u OB/Gyn recs to assist in management of uterine bleeding while on\n full anticoagulation: suggested if hematocrit dropping significantly\n and heavy bleeding persists, once therapeutically anticoagulated, can\n consider a course medroxyprogesterone 10mg daily to help stabilize the\n endometrium\n - Per Ob/Gyn would like to avoid procedure such as myomectomy or UAE;\n will not pursue unless patient transfusion resistant and unable to\n maintain Hct > 25.\n - Telemetry and Q8H HCT monitoring to assure no brisk bleed in setting\n of full anticoagulation\n - Maintain active type and screen\n - Two large bore Ivs\n #. Iron Deficiency Anemia: Currently her HCT is stable.\n - Ferrous gluconate 325 mg \n ICU Care\n Nutrition: Regular diet\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: H2 blocker\n Comments: Naproxen, tylenol and oxycodone for pain control, bowel\n regimen with senna and colace\n Communication: Comments: With patient and patient's mother, \n , Phone: \n Code status: Full code\n Disposition: ?c/o to gyn today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:34 PM\n 18 Gauge - 04:57 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610186, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. 1uPRBCs\n , no other transfusions. Heparin gtt at 1600units and ptt in\n therapeutic range. Followed closely by GYN. She got 1 dose of Lupron\n .\n LENIs negative.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610187, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. 1uPRBCs\n , no other transfusions. Heparin gtt at 1600units and ptt in\n therapeutic range. Will need second therapeutic Ptt at 1600. Followed\n closely by GYN. She got 1 dose of Lupron .\n LENIs negative.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610188, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. 1uPRBCs\n , no other transfusions. Heparin gtt at 1600units and ptt in\n therapeutic range. Will need second therapeutic Ptt at 1600. Followed\n closely by GYN. She got 1 dose of Lupron .\n LENIs negative.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:93\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 99 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,174 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:59 AM\n Potassium:\n 3.7 mEq/L\n 02:59 AM\n Chloride:\n 107 mEq/L\n 02:59 AM\n CO2:\n 20 mEq/L\n 02:59 AM\n BUN:\n 8 mg/dL\n 02:59 AM\n Creatinine:\n 0.6 mg/dL\n 02:59 AM\n Glucose:\n 94 mg/dL\n 02:59 AM\n Hematocrit:\n 27.2 %\n 10:00 AM\n Valuables / Signature\n Patient valuables: LAP TOP CELL PHONE\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 EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610190, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. 1uPRBCs\n , no other transfusions. Heparin gtt at 1600units and ptt in\n therapeutic range. Followed closely by GYN. She got 1 dose of Lupron\n .\n LENIs negative.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:75\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\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 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,174 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:59 AM\n Potassium:\n 3.7 mEq/L\n 02:59 AM\n Chloride:\n 107 mEq/L\n 02:59 AM\n CO2:\n 20 mEq/L\n 02:59 AM\n BUN:\n 8 mg/dL\n 02:59 AM\n Creatinine:\n 0.6 mg/dL\n 02:59 AM\n Glucose:\n 94 mg/dL\n 02:59 AM\n Hematocrit:\n 27.2 %\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2173-12-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 610197, "text": "Pleasant 29 yo female with H/O uterine fibroids, menometrorrhagia and\n anemia presented to ED with L chest/flank/hip pain and dyspnea. She had\n been on high dose OCP taper. Also smokes occaissionally when out with\n friends. Ct scan showed bilateral PEs. Started on IV heparin and\n transferred to ICU for further mgmt.\n She is A&O x3.\n Alternates RA w/2L N/C. Maintaining good O2sats on both. Some DOE but\n able to change peripad w/minimal assist and dyspnea resolves with rest.\n Intermittently c/o L chest pain down to her L hip especially with\n coughing.. Usually tolerable. On prn Tylenol and naproxene.\n Vaginal bleeding has increased on heparin gtt w/intermittent clots. .\n Changing peripad every 90-120minutes. Hct has been stable. 1uPRBCs\n , no other transfusions. Heparin gtt at 1600units and ptt in\n therapeutic range. Will need second therapeutic Ptt at 1600. Followed\n closely by GYN. She got 1 dose of Lupron .\n LENIs negative.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:96\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 899 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 105 mEq/L\n 02:56 AM\n CO2:\n 22 mEq/L\n 02:56 AM\n BUN:\n 9 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 102 mg/dL\n 02:56 AM\n Hematocrit:\n 28.1 %\n 01:06 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:93\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 99 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,174 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:59 AM\n Potassium:\n 3.7 mEq/L\n 02:59 AM\n Chloride:\n 107 mEq/L\n 02:59 AM\n CO2:\n 20 mEq/L\n 02:59 AM\n BUN:\n 8 mg/dL\n 02:59 AM\n Creatinine:\n 0.6 mg/dL\n 02:59 AM\n Glucose:\n 94 mg/dL\n 02:59 AM\n Hematocrit:\n 27.2 %\n 10:00 AM\n Valuables / Signature\n Patient valuables: LAP TOP CELL PHONE\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 EAST\n Transferred to: 12R\n Date & time of Transfer: 1300\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 102.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: uterine fibroids, menometrorrhagia, h/o gonorrhea\n and trichomonas\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:75\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 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 99% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 24h total in:\n 1,174 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:59 AM\n Potassium:\n 3.7 mEq/L\n 02:59 AM\n Chloride:\n 107 mEq/L\n 02:59 AM\n CO2:\n 20 mEq/L\n 02:59 AM\n BUN:\n 8 mg/dL\n 02:59 AM\n Creatinine:\n 0.6 mg/dL\n 02:59 AM\n Glucose:\n 94 mg/dL\n 02:59 AM\n Hematocrit:\n 27.2 %\n 10:00 AM\n Valuables / Signature\n Patient valuables: lap top cell phone\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: 12R\n Date & time of Transfer: 1400\n" }, { "category": "ECG", "chartdate": "2173-12-02 00:00:00.000", "description": "Report", "row_id": 194685, "text": "Sinus rhythm. Normal tracing for age. Since the previous tracing of \nST-T waves have improved.\n\n" }, { "category": "ECG", "chartdate": "2173-11-28 00:00:00.000", "description": "Report", "row_id": 194686, "text": "Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available\nfor comparison.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-29 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1112174, "text": " 1:35 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: BILAT LEG SWELLING,\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with extensive PEs, history of LE swelling one month ago.\n REASON FOR THIS EXAMINATION:\n Any evidence of LE DVTs?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Pulmonary embolus, history of lower extremity one month\n ago.\n\n TECHNIQUE: -scale, color and duplex Doppler imaging of bilateral lower\n extremities was performed from the common femoral veins through the proximal\n calves. There are no prior studies for comparison.\n\n FINDINGS: There is normal spontaneous phasic flow, compressibility and\n augmentation, without evidence of deep vein thrombosis.\n\n IMPRESSION:\n No evidence of deep vein thrombosis in either lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-12-11 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1113762, "text": " 11:01 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o abscess\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with fever and likely infarcted lung on CXR (recent b/l PE)\n REASON FOR THIS EXAMINATION:\n r/o abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl SAT 12:32 PM\n - no evidence of pulmonary abscess\n - LLL pleural based opacity - atelectasis vs infarct\n - markedly decreased PE, with a small amount of residual RLL PE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 29-year-old woman with fever and probable infarcted lung on chest x-\n ray. Recent bilateral PE.\n\n COMPARISON: Chest CTA and chest radiograph .\n\n TECHNIQUE: MDCT axial images were acquired through the lungs following\n administration of 100 mL of Optiray IV contrast. Multiplanar reformatted\n images were generated.\n\n CT CHEST WITH IV CONTRAST: Medial left basilar pleural-based opacity\n consistent with atelectasis has decreased from . Otherwisse,\n dependent Laterally, left basilar atelectasis has increased slightly, but\n remains mild. There is no pleural effusion or pericardial effusion. There is\n no evidence of pulmonary abscess or consolidation. The airways are patent\n bilaterally to subsegmental level. Filling defects in right lower lobe\n segmental bronchi (2:46) are consistent with pulmonary emboli. The thrombus\n burden has decreased in comparison to the prior study. No left pulmonary\n emboli are identified. There is no mediastinal, hilar or axillary\n lymphadenopathy. There are no concerning osseous lesions.\n\n IMPRESSION:\n 1. No evidence of pulmonary abscess or pneumonia.\n 2. Markedly decreased thrombus burden in the pulmonary arteries, with a small\n amount of residual right lower lobe segmental pulmonary embolus.\n\n\n\n\n\n\n (Over)\n\n 11:01 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o abscess\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-12-10 00:00:00.000", "description": "MRV PELVIS W&W/O CONTRAST", "row_id": 1113698, "text": " 2:31 PM\n MRV PELVIS W&W/O CONTRAST Clip # \n Reason: R/o septic pelvic thrombophlebitis\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n Contrast: MULTIHANCE Amt: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with b/l PE and fibroid uterus with periodic fevers to\n 101-102.\n REASON FOR THIS EXAMINATION:\n R/o septic pelvic thrombophlebitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl SAT 2:04 PM\n Prelim read by :\n Suboptimal study due to patient difficulty tolerating examination. The\n external iliac veins, internal iliac veins and common femoral veins are patent\n bilaterally, with no evidence of thrombus. No inflammatory changes are seen\n adjacent to these veins. The superior portions of both common iliac veins and\n the distal IVC are effaced by the large degenerative uterine fibroid. However,\n the IVC is patent superior to the level of the fibroid. spoke\n to about these findings at .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Female with bilateral PE and fibroid uterus with periodic fevers, to\n assess for septic pelvic thrombophlebitis.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic 3D imaging, obtained prior to, during, and\n after the uneventful intravenous administration of 38 mL of MultiHance.\n\n Multiplanar 2D and 3D reformations and subtraction images were generated on an\n independent workstation.\n\n Correlation is made with prior pelvic ultrasound of and lower\n extremity Doppler ultrasound of .\n\n FINDINGS:\n\n There is a 15 x 11 x 14 cm fibroid within the uterus (image 19, series 10 and\n image 34, series 17). This fibroid does not demonstrate enhancement on the\n dynamic series, consistent with degenerated/necrosed fibroid. There are\n several smaller, up to 15 mm intramural fibroids (image 14, 18 and 24, series\n 10). The ovaries are unremarkable. There is no pelvic lymphadenopathy.\n There is no free fluid in the pelvis.\n\n The gonadal veins are patent bilaterally. The IVC and the proximal common\n iliac veins are compressed by the mass effect from the large uterine fibroid\n at the level of the sacral promontory. The distal iliac veins just above the\n bifurcation and the internal and external iliac veins are prominent, most\n likely due to stasis caused by compression from the enlarged uterus. However,\n there is no evidence of a thrombus in the pelvic veins, IVC or the femoral\n veins.\n (Over)\n\n 2:31 PM\n MRV PELVIS W&W/O CONTRAST Clip # \n Reason: R/o septic pelvic thrombophlebitis\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n Contrast: MULTIHANCE Amt: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Multiplanar 2D and 3D reformations and subtraction images provided multiple\n perspectives of the dynamic series.\n\n IMPRESSION:\n 1. Very large nonenhancing uterine fibroid is most consistent with a\n degenerated/necrosed fibroid.\n 2. Mass effect from the fibroid causing compression of the distal IVC and the\n proximal common iliac veins at the level of the sacral promontory with no\n evidence of a DVT. Patent bilateral gonadal veins.\n The findings were discussed with Dr. by Dr. at 10 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2173-12-07 00:00:00.000", "description": "PELVIS, NON-OBSTETRIC", "row_id": 1113247, "text": " 8:36 AM\n PELVIS, NON-OBSTETRIC; PELVIS U.S., TRANSVAGINAL Clip # \n Reason: evaluate for evidence of fibrroid degeneration and possible\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with recurring fever in setting of known large uterine\n fibroid s/p lupron\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of fibrroid degeneration and possible pyometria.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CPMe TUE 12:42 PM\n Large uterine fibroids, consistent with prior ultrasound examination.\n Endometrium difficult to visualize, but no obvious thickening. Solid\n structure in right adnexa shows no significant change in size since prior\n ultrasound scan and may represent a prominent right ovary or an exophytic\n fibroid.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for evidence of fibroid degeneration, possible pyometra.\n\n TECHNIQUE: Transabdominal and transvaginal imaging was performed.\n\n FINDINGS: A large intramural uterine fibroid is identified, measuring\n approximately 18.0 cm craniocaudal dimension x 12.9 cm x 14.2 cm. This\n fibroid has slightly increased in size in comparison to prior ultrasound\n when it measured 16.5 cm x 14.4 cm x 9.4 cm. The fibroid is\n heterogeneous in echogenicity, with no significant change in appearance since\n prior study. The fibroid causes distortion of the uterine architecture,\n making visualization of the endometrium difficult. However, no obvious\n endometrial thickening is identified. A 4.5 cm x 2.1 cm x 2.0 cm solid\n structure in the right adnexa has not changed significantly in size, and may\n represent a prominent right ovary or an exophytic fibroid. The left ovary\n appears unremarkable. A loop of fluid-containing small bowel is identified\n adjacent to the left adnexa.\n\n IMPRESSION:\n 1. Large uterine fibroid is present as on prior ultrasound scan. The fibroid\n causes distortion of the uterine architecture, but no obvious endometrial\n thickening is identified.\n\n 2. A solid structure in the region of right adnexa has not changed\n significantly in size, and may represent a prominent right ovary or an\n exophytic fibroid.\n\n" }, { "category": "Radiology", "chartdate": "2173-12-07 00:00:00.000", "description": "PELVIS, NON-OBSTETRIC", "row_id": 1113248, "text": ", GYN 12R 8:36 AM\n PELVIS, NON-OBSTETRIC; PELVIS U.S., TRANSVAGINAL Clip # \n Reason: evaluate for evidence of fibrroid degeneration and possible\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with recurring fever in setting of known large uterine\n fibroid s/p lupron\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of fibrroid degeneration and possible pyometria.\n ______________________________________________________________________________\n PFI REPORT\n Large uterine fibroids, consistent with prior ultrasound examination.\n Endometrium difficult to visualize, but no obvious thickening. Solid\n structure in right adnexa shows no significant change in size since prior\n ultrasound scan and may represent a prominent right ovary or an exophytic\n fibroid.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-28 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1112055, "text": " 12:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please eval for PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with pleuritic chest pain while on high dose estrogen\n REASON FOR THIS EXAMINATION:\n Please eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SUN 12:27 PM\n b/l extensive pulmonary emboli, likely rll infarct.\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST WITH CONTRAST\n\n COMPARISON: None.\n\n HISTORY: Pleuritic chest pain, on high-dose estrogen.\n\n TECHNIQUE: MDCT axially-acquired images of the chest were obtained. IV\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: There are multiple filling defects in the bilateral pulmonary\n arteries supplying the right upper lobe, anterior segment (2, 23) and right\n lower lobe (2, 31-40). There is a nodular subpleural opacity within the\n periphery of the right lower lobe (2, 40) which may represent a small\n pulmonary infarct. Filling defects within the left upper lobe segmental\n arteries (2, 19), lingula (2, 24), and left lower lobe (2, 36) segmental\n arteries are also identified. There is no axillary, hilar, or mediastinal\n lymphadenopathy. There is no pericardial effusion. There is a small left\n pleural effusion. There is no evidence of bowing of the interventricular\n septum to suggest right heart failure at this time.\n\n Limited views of the upper abdomen are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n\n IMPRESSION: Extensive bilateral pulmonary emboli as described above.\n Possible right lower lobe pulmonary infarct.\n\n Findings were discussed with Dr. at 12:30 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2173-12-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1113201, "text": " 9:26 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for PNA or other pulm etiology\n Admitting Diagnosis: BILATERAL PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with bilateral PE and now with T 101.9\n REASON FOR THIS EXAMINATION:\n Please evaluate for PNA or other pulm etiology\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Bilateral pulmonary embolism and high fever.\n\n COMPARISON: Chest CT from .\n\n Heart size is normal. Mediastinal position, contour and width are\n unremarkable. The lungs are clear. There is no pleural effusion or\n pneumothorax.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2142-10-16 00:00:00.000", "description": "EARLY OB US <14WEEKS", "row_id": 933869, "text": " 11:26 AM\n EARLY OB US <14WEEKS; TV OB US Clip # \n Reason: please assess for fetal viability.\n Admitting Diagnosis: HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with hypoglycemia\n REASON FOR THIS EXAMINATION:\n please assess for fetal viability.\n ______________________________________________________________________________\n WET READ: KCLd TUE 12:16 PM\n embryonic pole measuring 7weeks 5days, consistent with size by dates of 7\n weeks 4 days\n\n heartrate of 140 bpm seen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old woman with early pregnancy, hypoglycemia. Please\n evaluate fetal viability.\n\n COMPARISON: None.\n\n FINDINGS:\n\n LMP .\n\n Transabdominal and transvaginal ultrasound examinations were performed, the\n latter for further evaluation of the intrauterine contents. Intrauterine\n gestational sac is seen with a single living embryo, with a crown-rump length\n of 1.36 cm, corresponding to a gestational age of 7 weeks 5 days. This\n corresponds satisfactorily with menstrual dates of 7 weeks 4 days. Heart rate\n of 140 beats per minute is identified. The uterus and ovaries appear\n unremarkable.\n\n IMPRESSION: Single live intrauterine pregnancy with size equals dates. Heart\n rate of 140 beats per minute identified.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-10-17 00:00:00.000", "description": "Report", "row_id": 1456725, "text": "Nursing Assessment Note 0100-0700\nPt is 29 yo woman who is 7 1/2 weeks pregnant, U/S in EW confirmed fetal viability, pt was at home when she woke up feeling lightheaded and sweaty, pt took blood sugar and found it to be 22, pt called ambulance and came to EW, pt was observed overnight and was found to have sugars ranging from 23-338, pt continued to have liabile blood sugars and it was finally decided to admit pt to MICU for close monitoring of blood sugars and possible Insulin drip if needed.\n\nNEURO: Pt A&O x3, pleasant and cooperative, pt moves all extremities well and ambulates independently with steady gait\n\nCV: Pt's vss, afebrile, pt denies pain at this time, but does state she has occasional tooth pain, pt also states that she is scheduled to have dental work done to problem, pt has #20 in right A/C, which is patent and intact, skin is wnl for race, warm, and dry, pp + & =, without edema, Pt in nsr without ectopy\n\nRESP: Pt's lung sounds are clear throughout, pt denies cough or sob at this time, pt sats 99-100% on R/A\n\nGI: Pt tol po intake well without N/V, bowel sounds are positive with soft abd\n\nGU: Pt voids clear yellow urine qs\n\nPLAN:\n-Monitor blood sugars q1 hour, treat as needed\n\n" }, { "category": "Nursing/other", "chartdate": "2142-10-17 00:00:00.000", "description": "Report", "row_id": 1456726, "text": "nursing progress note\nendo: initially this am pt was on an insulin drip at 4u/hr--fs was 119, so drip decreased to 3u/hr. within an hour pt's fingerstick was 13--given juice and crackers, only bumped to 41 so pt rec'd amp of d50 with improvement of sugar. next fingerstick so elevated that the insulin drip was restarted.(see carevue for hourly sugars). recommendations were to give 6u nph, which was given at 10:45a, keep the drip infusing until pt begins to eat lunch then cover with humalog insulin per fingerstick and then within 30mins or so, shut off the drip, which was done. cover with humalog at designated times and 10u nph at breakfast and bed time.\n\ncardiac: 95-111/53-65 with a pulse of 86-92 sr, no ectopy noted. iv of d5 1/2ns was dc'd several hours ago.\n\nresp: lung sounds are clear. resp rate of 18-22 with sats of 98-100%.\n\nid: temps of 97.3 ax, 99 po, 98.9 po.\n\ngi: abdomin soft/distended, + bowel sounds. appetite is great. pt has stooled, a large amt of golden loose brown stool, after every meal. stool sent for c-diff and o+p. stool is very foul smelling.\n\ngu: gets up to use the bedside commode. no difficulties urinating. bun 12 and creat .5.\n" } ]

[ { "category": "Radiology", "chartdate": "2115-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865420, "text": " 2:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: placement...s/p intubation\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fever\n\n REASON FOR THIS EXAMINATION:\n placement...s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, status post endotracheal tube placement.\n\n COMPARISON: Portable chest exam at 12:57.\n\n SEMIUPRIGHT AP CHEST: The endotracheal tube tip is located at the thoracic\n inlet, 8 cm from the carina. There is an NG tube within the esophagus\n terminating beneath the left hemidiaphragm, beyond the radiograph. The right\n central venous catheter is unchanged in position. There is no pneumothorax.\n There is interval worsening of congestive failure. Possible infiltrate\n developing in the left base.\n\n IMPRESSION: Tubes and lines positioned as described. Congestive failure with\n possible infiltrate developing at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-25 00:00:00.000", "description": "L FOOT (AP & LAT) SOFT TISSUE LEFT", "row_id": 865558, "text": " 8:10 AM\n FOOT (AP & LAT) SOFT TISSUE LEFT Clip # \n Reason: r/o periosteal reaction (osteomyelitis)\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with LLE heel ulcer\n REASON FOR THIS EXAMINATION:\n r/o periosteal reaction (osteomyelitis)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Left heel ulcer. Assess for osteomyelitis.\n\n AP & LATERAL RADIOGRAPHS THE LEFT FOOT: Comparison is made to .\n Study is limited due to patient positioning ability. No true lateral\n radiograph was able to be obtained. A focal lucency is seen within the region\n of the calcaneal fat pad, which likely represents the patient's known ulcer.\n The ulcer tract does not appear to extend to bone radiographically. No\n definite periosteal reaction is seen within the bone. There is no osseous\n destruction. Appearance of the neuropathic fragmentation and sclerosis in the\n mid foot is unchanged. Again seen is diffuse vascular calcification.\n\n IMPRESSION: Ulcer seen along the plantar fat pad. No definite evidence of\n osteomyelitis.\n\n" }, { "category": "Radiology", "chartdate": "2115-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865411, "text": " 12:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fever\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n WET READ: KKXa SAT 2:20 PM\n Evidence of fluid overload.\n Left basilar consolidation.\n WET READ VERSION #1 KKXa SAT 1:37 PM\n Evidence of fluid overload.\n Possible consolidation at the left base, but the opacity may be due to\n technique or overlying soft tissue and PA and lateral will be helpful once pt\n condition permits.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, evaluate for infiltrate.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: This exam was performed at the bedside. There is a right-\n sided central venous catheter seen terminating in the right atrium. There is\n mild cardiomegaly, unchanged. The pulmonary vascular markings are again\n prominent, consistent with fluid overload. There is increased opacity within\n the left lower lung. It is not clear if this is related to technique,\n overlying soft tissue, or an underlying infiltrate. There is no definite\n pleural effusion. There is no pneumothorax. The osseous structures are\n unchanged.\n\n IMPRESSION:\n 1) Fluid overload vs. congestive failure.\n 2) Possible developing left infiltrate.\n\n" }, { "category": "Radiology", "chartdate": "2115-03-23 00:00:00.000", "description": "LP UNILAT LOWER EXT VEINS LEFT PORT", "row_id": 865460, "text": " 11:48 PM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: LLE CELLULITIS\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with ESRD, DM, DKA, LLE cellulitis and LLE > RLE in diameter.\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of end-stage renal disease and diabetes with left lower\n extremity cellulitis. Evaluate for DVT.\n\n COMPARISON: None.\n\n UNILATERAL LOWER EXTREMITY ULTRASOUND: scale and color Doppler\n son was performed of the left common femoral, superficial femoral, and\n popliteal veins. Normal waveforms, flow, compressibility, and augmentation\n are demonstrated. No intraluminal thrombus is identified.\n\n IMPRESSION: No DVT identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 865410, "text": " 12:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: CONFUSION, ? BLEED, MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with confusion\n REASON FOR THIS EXAMINATION:\n assess for bleed, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe SAT 5:49 PM\n no acute intracranial pathology including mass, hemmorhage, or infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with change in mental status.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine noncontrast head CT.\n\n FINDINGS: There is no intracranial mass lesions, hydrocephalus, shift of\n normally midline structures or acute minor or major vascular territorial\n infarction seen. There are no intra-axial or extra-axial fluid collections,\n including hemorrhage. The density values of the brain parenchyma are within\n normal limits and -white matter differentiation is preserved throughout.\n The surrounding osseous and soft tissue structures are unremarkable. The\n visualized paranasal sinuses are clear.\n\n IMPRESSION: No acute intracranial pathology, including hemorrhage, mass or\n infarction.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865511, "text": " 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT position\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47m intubated, assess ETT position\n\n REASON FOR THIS EXAMINATION:\n assess ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation.\n\n The ETT terminates 6 cm above the carina. The failure pattern persists but is\n somewhat improved since the last chest x-ray of . The right IJ catheter\n terminates in the right atrium. There are no focal infiltrates. An NGT below\n the lower edge of the image show well below the GE junction. There is no\n pneumothorax.\n\n IMPRESSION: The ETT is more optimally positioned currently than on ,\n and there has been some improvement in the failure/fluid overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-25 00:00:00.000", "description": "LP WRIST(3 + VIEWS) LEFT PORT", "row_id": 865587, "text": " 10:46 AM\n WRIST(3 + VIEWS) LEFT PORT Clip # \n Reason: please remove splint prior to films. vs. nonunion\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with L wrist and hand swelling after falling on ice yesterday.\n Decreased ROM and pain with flexion of wrist.\n REASON FOR THIS EXAMINATION:\n please remove splint prior to films. vs. nonunion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Decreased range of motion and pain with flexion of wrist.\n History of prior fracture of the radius.\n\n AP, LATERAL AND OBLIQUE VIEWS OF THE LEFT WRIST: Images from the , study are not available. Reference is made to the report.\n\n No definite fracture plane is visualized through the distal radius. There is\n cortical irregularity over the distal surface of the dorsal radius, which\n could represent a small fracture. Carpal alignment is within normal limits.\n There is diffuse demineralization, and extensive vascular calcification.\n\n IMPRESSION:\n 1. Questionable cortical irregularity along the dorsal surface of distal left\n radius. No acute fracture plane visible. Recommend correlation with physical\n exam findings of pain localized over the dorsum of the distal radius.\n\n 2. Extensive vascular calcifications.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865779, "text": " 6:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check NGT placement\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47m s/p NGT placement\n REASON FOR THIS EXAMINATION:\n check NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check NG tube placement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: The tip of the endotracheal tube is poorly visualized. A\n nasogastric tube is in place with tip terminating in the gastric fundus. Right\n internal jugular venous access catheter with tip in the deep right atrium.\n Stable cardiomegaly. Stable congestive heart failure in comparison with the\n previous examination. No pneumothorax. The osseous structures appear\n unchanged.\n\n IMPRESSION:\n 1) Nasogastric tube with tip terminating in the gastric fundus.\n 2) Endotracheal tube tip is not visualized. Recommend repeat portable chest\n x-ray to evaluate endotracheal tube tip position if clinically indicated.\n 3) Cardiomegaly and stable congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 865819, "text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT placement\n Admitting Diagnosis: HYPERKALEMIA;DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47m s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess NG tube position.\n\n Portable semi-upright frontal radiograph. COMPARISON: . The NG tube\n is clearly seen below the diaphragm with its tip in the stomach. There has\n been a slight increase in aeration at the left lung base. There is stable\n cardiomegaly. No definite CHF is seen on this study. An area of increased\n opacification is seen at the left lung apex which extends outside of the lung\n margin, and is likely artifactual in nature.\n\n IMPRESSION: Slight improvement in aeration at the left lung base. No\n definite CHF. NG tube within the stomach.\n\n" }, { "category": "ECG", "chartdate": "2115-03-23 00:00:00.000", "description": "Report", "row_id": 196198, "text": "Technically difficult study\nProbable sinus rhythm with no major change from \nSuggest repeat tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2115-03-27 00:00:00.000", "description": "Report", "row_id": 1377849, "text": "NPN 1500-1900;\n\nNEURO; AOOX3 MAE TO COMMAND OOB TO CHAIR SLIGHTLY UNSTEADY ON FEET. STILL SLIGHLY CONFUSED AND SAYS BIZAARE THINGS AT TIMES.BUT IS EASILY ORIENTATED.\n\nRESP; LUNGS COARSE POS UNPRODUCTIVE COUGH SATS 98-99 ON RA.RR30\n\nCVS; TMAX 98 PO NSR 58-60.LABETOLOL HELD AS HR UNDER 60.BP 120/70 SEE CAREVUE FOR DETAILS.\n\nGU; VOIDING SMALL AMOUNTS WITH STOOL\n\nGI; BELLY SOFT POS BS EATING MOD AMOUNT OF DIET. FREQUENT LIQUID STOOL SENT PT SAYS THAT BRAND \"CAUSES HIM TO GO.\"\n\nENDO; BS 495 AT 1700 GIVEN GLARGINE 20 UNITS AND HUMALOG 10 UNITS S/C\n\nSKIN PICKING AT SORES, OPENING SMALL SORE ON ULNAR SIDE ON PALM ANTIBIOTIC CREAM APPLIED COVERED WITH DSD PR INSTUCTED NOT TO PICK AT SKIN AS HE COULD CAUSE INFECTION AND REMINDED THAT DIABETICS IN GENERAL ARE SLOW TO HEAL.\n\nSOC; NO FAMILY CONTACT SO FAR.\n\nA/ PLAN ATTEMPTING TO TRANSITION TO S/C INSULIN COVER MONITORING SUGARS FREQUENTLY.\nREORIENTATE PT AND ENCOURAGE AMBULATION AS TOLERATED.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-03-28 00:00:00.000", "description": "Report", "row_id": 1377850, "text": "NPN 1900-0700\nPt A&Ox 3, forgetful, uses call-bell frequently, no c/o pain, able to use BSC with as his gait is unsteady, continues with jerking mvmts. of lower extremities. Lungs CTA, O2 sats 99% on RA, no c/o SOB. HR 60-61 SR, SBP 150's, did not recive x 2 doses labetolol d/t HR 60. FBS 64-300's, continue to titrate insulin gtt, needs lantus order for today. X2 liquid bm's. Tolerating solid diabetic diet. Voids without difficulty in adequate amts. Drsg to foot. Dc'd aline.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-28 00:00:00.000", "description": "Report", "row_id": 1377851, "text": "MICU NPN 11AM-9PM:\nPt stable and called out to the floor after being off insulin drip since :30AM. Tolerated dialysis today which took off 2.8 liters. Sat in chair most of the evening. Labs are stable and pt no longer has anion gap so pt has been called out to the floor and is awaiting bed assignment.\n\nNeuro: Pt awake and alert, oriented times three. MAE. transfer to chair. gait steady but pt says he needs cane so PT consult put in for tomorrow as pt may go home.\n\nCV: Vital signs are stable.\n\nResp: Pt is on RA with good sat. Lungs are clear.\n\nGI: Tolerating renal/diabetic diet well. Stools are still loose so colace held.\n\nGU/Renal: Dialysis tolerated well.\n\nID: Afebrile given vanco with dialysis and continues to get ceftriaxone.\n\nIV Access: Two peripheral IV's in place working well.\n\nPlan: Transfer to the floor when bed becomes available.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-24 00:00:00.000", "description": "Report", "row_id": 1377837, "text": "PT. IS PRESENTLY SEDATED ON BOTH FENTANYL AND VERSEED. THESE ARE PRESENTLY BEING WEANED FOR PLANNED EXTUBATION. REFER TO CAREVUE FOR PRESENT RATES. PT. EXHIBITED A LOW GRADE TEMP WITH T MAX 99.1. PT. HAS REMAINED IN A NSR 60-70'S WITH NO NOTED ECTOPY. B/P HAS BEEN STABLE WITH MAP'S >60. LABETOLOL DOSES FROM 0000 AND 0600 HELD DUE TO SBP <100. PEDAL PULSES ARE WEAK BUT PALPABLE AND TRACE EDEMA NOTED. PT'S LEFT HEEL HAS 3CMX3CM AREA ON OUTER ASPECT OF FOOT, WHILE 1/4CM DIAMETER ROUND HOLE NOTED TO HEEL REGION. HEEL SITE WAS CULTURED TO SPECIMEN SENT. BOTH AREAS EXHIBITED PURULENT DRAINAGE, AND WERE CLEANSED WITH N/S AND STERILE DRESSING APPLIED. PT. HAD POTASSIUM 20MEQ REPLETED LAST HS DUE TO DROPPING LEVELS FROM INSULIN GTT. AM LABS PENDING. RESP. PT. REMAINS CLEAR THROUGHOUT, WITH SPUTUM CULTURE UNOBTAINABLE. RESP RATE HAS REMAINED CONTROLLED AND REGULAR, WHILE ON VENTILATOR. AM ABG PENDING, O2 SATS >98% PT. REMAINS NPO WITH PLANS TO EXTUBATE. ABD. IS BENIGN WITH BOWEL SOUNDS EASILY AUDIBLE AND PT. HAVING TWO LARGE SEMI FORMED STOOLS, GUAICED NEGATIVE. PT'S BLOOD SUGARS HAVE BEEN MUCH MORE CONTROLLED WITH INSULIN GTT OFF FOR SEVERAL HOURS AND THAN AGAIN RESTARTED FOR SPIKE UPWARDS FROM 93-290. REFER TO CAREVUE FOR PRESENT RATE. PT. HAS REMAINED ANURIC, PT. REMAINS ON HEMODIALYSIS. PT'S LINES REMAIN SECURED AND FUNCTIONING WELL. CENTRAL LINE NOT ATTEMPTED AFTER REASSESSMENT. PT. REMAINS A FULL CODE AT THIS TIME. SPOKE WITH SISTER LAST EVENING. FAMILY WAS UNAWARE THAT PT. HAD BEEN INTUBATED BUT UNDERSTANDS HIS PRESENT CONDITION WELL.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-24 00:00:00.000", "description": "Report", "row_id": 1377838, "text": "Respiratory Therapy\nPt remains orally intubated on full mechanical support. PSV attempted this shift, but pt becomes extremely agitated. ETT advanced 3cm per CXR, now 24cm @ lip, ETT remains secure/patent & in good position. BLBS essentially clear, no secretions being suctioned. SpO2 remained 90s. PIP/Pplat = 21/18. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; continue to assess readiness to wean\n" }, { "category": "Nursing/other", "chartdate": "2115-03-24 00:00:00.000", "description": "Report", "row_id": 1377839, "text": "0700-1900 NPN:\n\nEVENTS- WEANED DOWN SEDATION, VERSED @ 0.5MG/HR AND FENTANYL @ 12.5MCG/HR FOR MOST OF SHIFT W/ GOOD EFFECTS. SMALL BOLUSES GIVEN FOR INTERMITTENT EPISODES OF AGITAION. PT HAS EPISODES OF BOLTING UP IN BED, THRASHING HEAD AND HANDS W/ EYES WIDE OPEN AND JERKING MOVEMENTS NOTED. PT SETTLES DOWN AFTER APPROX 2-3 MINS, DOES NOT FOLLOW COMMANDS OR APPEAR ORIENTED DURING THESE EPISODES. ATTEMPTED PSV THIS AM, PT DID NOT TOLERATE. FIO2 WEANED FROM 50% TO 40%. ABGS= 7.37/39/117. PT RECEIVED HEMODIALYSIS TODAY W/O COMPLICATION, APPROX 2 LITERS REMOVED.\nCONTINUES TO BE ?PSEUDOHYPONATREMIC, NA LEVEL=120-123 THIS AM.\n\nNEURO- AS STATED ABOVE, SEE CAREVUE FLOWHSEET FOR FURTHER INFORMATION AND OBJECTIVE DATA. BILAT WRIST RESTRAINTS ON FOR SAFETY.\n\nRESP/CV- CONTINUES ON AC 600/16/40%/PEEP=5. REPEAT ABG W/ AM LABS PER TEAM. LS= CLEAR/DIM. NO ET/ORAL SECRETIONS, UNABLE TO COLLECT SPUTUM SPEC. NSR AT 60-80'S, W/ NO ECTOPY NOTED. REPLETED W/ MAG SULFATE AND CA GLUC THIS SHIFT. RIGHT RADIAL ALINE INTACT. RIGHT ANTECUB PIV X2 #18G INTACT. LABETALOL GIVEN AS ORDERED THIS SHIFT FOR HTN, SEE .\n\nGI/GU- ABD SOFT. PRESENT BS, NO BM. COLACE GIVEN VIA OGT AS ORDERED . NPO STATUS MAINTAINED. OGT CLAMPED FOR MEDS. PT ANURIC, HEMODIALYSIS DONE TODAY. STILL NEED URINE CX IF VOIDS.\n\nENDO- CURRENT INSULIN GTT AT 2U/HR. FS=50-211 THIS SHIFT. TREATED W/ 1 AMP D50 X 1 FOR FS=50. CONTINUOUS IVF W/ DEXTROSE CONTRAINDICATED R/T CRF, LIMIT FLUID INTAKE PER TEAM. SEE CAREVUE FLOWSHEET FOR DATA.\n\nSOCIAL- FULL CODE. FAMILY CALLED X2 THIS SHIFT FOR UPDATE, NO VISITORS. PT NEED SOCIAL SERVICES CONSULT FOR HOME VNA R/T DRSG AND / MEDICATIONS.\n\nPLAN- RECHECK LYTES 2 HRS AFTER DIALYSIS PER TEAM- DUE AT 2100. MAINTAIN COMFORT LEVEL W/ VERSED AND FENTANYL, WEAN AS TOLERATED. CONTINUE TO ASSESS FOR POSSIBLE EXTUBATION. MONITOR FS Q 1HR, ADJUST INSULIN GTT PROTOCOL, AND ADMIN IV DEXTROSE 50% PER TEAM FOR HYPOGLYCEMIA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-03-26 00:00:00.000", "description": "Report", "row_id": 1377844, "text": "neuro: pt oriented to place and year, but otherwise extremely disoriented. pt restless throughout shift with severe agitation in afternoon. bilat soft hand restraints applied self removal of 02, iv's and attempting to get oob. pt reoriented with poor effect. dr aware and up to eval. pt cont with myoclonic movements of extremites. eeg done at bedside this afternoon with results pending. neuro consult in place, however does not feel this to be seizure activity.\ncv: monitor shows nsr with no ectopy noted. r radial aline with good waveform analysis, +csm noted and correlates with nibp.\nresp: ls with coarse bs's bibasilar. desats into high 80's with o2 removal.\ngi: abd soft and nontender. +bs noted. inc loose brown stool x2 heme-. pt with difficulty taking po meds and swallowing liquids. awaiting ngt placement by dr . nutrition recommendations in chart and to start on tf's once placement obtained with + cxr confirmation.\ngu: hnv this shift. pt had hd at bedside this am with 3.5 kg removed.\nskin: podiatry service did w-d dsg at bedside this am...this rn did not visualize dsg change. ortho up to d/c cast on L arm. +csm noted.\ni-d: temp max 102 po. bld cx sent from dialysis line. tylenol given. pt had +MRSA in l foot wound and LLL pna by cxr. remains on ceftriaxome and azithromycin.\nendo: pt is brittle diabetic. bs's labile this shift. insulin gtt off in afternoon for bs of 66. repeat check 44...dr notified and and amp dextrose given as ordered. cont with glucose checks. consult in place.\naccess: piv's x2 found out in bed this am...resited with #18 G l ac and #22 r hand. r radial aline.\npsy-soc: sister in law called x1 and updated on status and plan of care. remains full code on micu service.\n\n" }, { "category": "Nursing/other", "chartdate": "2115-03-26 00:00:00.000", "description": "Report", "row_id": 1377845, "text": "dr placed ngt at bedside...need cxr confirmation and plan to start nepro tf's this evening. held 1800 po meds impaired mental status and difficulty wtih swallowing po meds...will need to be given once confirmation obtained. bs's on the rise and insulin gtt resumed...plan to start on fixed and s/s this evening once bs's better controlled. brother called x1 this afternoon and updated on status and plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-23 00:00:00.000", "description": "Report", "row_id": 1377834, "text": "Respiratory Therapy\nPt admitted from ER where he was intubated for airway protection. PMH includes IDDM, renal insufficiency. Presented to ER w/ dangerously high blood sugars, and one pupil appearing larger than the other w/ pt becoming increasingly agitated. Pt intubated w/ #7.5ETT secured 21@lip w/out incident. Placement confirmed by CXR. Traveled to and from CT for scan of head w/out incident. BLBS essentially clear. No secretions. PIP/Pplat = 20/15. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2115-03-23 00:00:00.000", "description": "Report", "row_id": 1377835, "text": "1530-1900 NPN:\n\nADMIT FROM ER AT 1530 W/ DX OF HYPERGLYCEMIA AND DKA. GLUCOSE TRENDING DOWN 1072/832/542- INSULIN GTT INFUSING @ 8U/HR. PMH= IDDM, CRF, HD 3X/WEEK, ANEMIA, HTN, CHF, PERIPHERAL NEUROPATHY, MI, HYPERKALEMIA, GERD, HYPERLIPIDEMIA. INTUBATED IN ER, RECEIVED PT ON AC VENT SETTINGS 600/16/100%/PEEP=5. PA02=330, WEANED FIO2 TO 50%. RECENT ABG= 7.37/39/131. LACTATE TRENDING UP 1.8 TO 2.1. NA LEVEL IMPROVING 111 TO 123. BLD CX DONE AND TX W/ VANCO, CEFTRIAXONE, NA BICARB IN ER. HEAD CT DONE PRIOR TO ADMIT TO MICU. ALINE PLACED IN MICU. MEDS GIVEN VIA OGT. VERSED AND FENTANYL STARTED FOR SEDATION. BILAT WRIST RESTRAINTS ON FOR SAFETY. AWAIT CENTRAL ACCESS PLACEMENT BY TEAM.\n\n RECEIVED PT VERY AGITATED FROM ER/HEAD CT. MULTIPLE BOLUSES GIVEN. PT CALM AT THIS TIME, VERSED AT 4MG/HR AND FENTANYL AT 75MCG/HR. MAE. UNABLE TO ASSESS MENTAL STATUS.\n\nRESP- CURRENT VENT SETTINGS AC 600/16/50%/5. O2 SAT= 98-99%. LS= CRACKLES AT BASES. MINIMAL SECRETIONS. NEED SPUTUM CX. PER TEAM CXR FROM ER SHOWED INFILTRATE.\n\nCV- NSR AT 60-70'S, W/ NO ECTOPY NOTED. PMH OF HTN, ER REPORTED NBP ELEVATED TO 230/110. GOOD EFFECTS NOTED FROM SEDATION ON B/P, ALSO NORVASC GIVEN AS ORDERED. PER TEAM LABETALOL DOSE HELD. SEE .\nTEMP MAX= 100.8 RECTALLY. TREATED W/ TYLENOL PR IN ER. BILAT PEDAL EDEMA NOTED, WEAK PEDAL PULSES. ABP=128-156/70-80.\n\nGI/GU- ABD SOFT, PRESENT BS. NO BM. OGT INTACT AND CLAMPED, CONFIRMED PLACEMENT BY AUSCULTATION. HEMODIALYSIS PT /THURS/SAT. PT VOIDS APPROX QOD PER ER REPORT. NEED URINE CX. PT IS DUE FOR DIALYSIS TODAY, MISSED TREATMENT THIS AM.\n\nSKIN- IMPAIRED. LEFT WRIST IN CAST R/T HX OF FRACTURE IN . POSSIBLE CELLULITS OF LOWER EXT. TEAM TO FOLLOW UP.\n\nSOCIAL- FULL CODE. NO FAMILY/FRIENDS WITH PT ON ADMISSION TO MICU. SEE ADMIT DOCUMENTATION FOR CONTACT PERSON INFO.\n\nPLAN- CENTRAL LINE PLACEMENT BY TEAM. FS Q 1HR OR GLUCOSE LEVEL R/T CRITICAL HIGH, CONTINUE INSULIN GTT AND TITRATE FOR FS 90-120. MAINTAIN COMFORT W/ VERSED AND FENTANYL. REPEAT ABG PER TEAM AS NEEDED. FOLLOW UP HEAD CT SCAN RESULTS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-03-24 00:00:00.000", "description": "Report", "row_id": 1377836, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. Vesicular BS, no ett secretions with SX. Plan: wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2115-03-25 00:00:00.000", "description": "Report", "row_id": 1377840, "text": "PT. IS PRESENTLY A/A/O AND DENIES ANY PAIN OF DISCOMFORT AT THIS TIME. PT. HAS BEEN SUCCESSFULLY EXTUBATED AS OF 0230. HE DID EXHIBIT A SLIGHT TEMP WITH TMAX 101.2, BUT NOW IS AFEBRILE AT 98.8 ORALLY. PT. RECEIVED TYLENOL X'S 1, LAST GIVEN LAST EVENING. NO NEURO DEFICITS NOTED AT THIS TIME, PUPILS ARE EQUALLY REACTIVE. PT. HAS REMAINED NSR IN THE 60-70'S WITH NO ECTOPY, B/P HAS BEEN STABLE WITH MAP'S >60. LABETOLOL HELD LAST EVENING DUE TO SBP <100. PEDAL PULSES ARE WEAK DIFFICULT TO PALPATE BUT NOTED BILAT. NO REPLETION REQUIRED DURING THIS SHIFT. PT. HAS BEEN EXTUBATED AND HAS BEEN CLEAR IN ALL LOBES PRIOR AND POST EXTUBATION. ABG'S DRAWN PRE AND POST WITH CO2 SLIGHTLY ELEVATED WITH TEAM IS AWARE. O2 SATS REMAIN >97% RESP RATE CONTROLLED. PT. REMAINS NPO WITH BOWEL SOUNDS EASILY AUDIBLE AND FREQUENT LIQUID STOOLS NOTED WITH MUSHROOM CATHETER APPLIED AND FUNCTIONING WELL. STOOL IS GUAIC NEG. BLOOD SUGARS HAVE BEEN AS LOW AS 45 AND HIGH AS 129. INSULIN GTT IS PRESENTLY OFF, WITH NEW SLIDING SCALE AND DAILY INSULIN ORDERED. PT. RECEIVED HEMODIALYSIS YESTERDAY AND REMOVED 2LITERS. PT. REMAINS ANURIC, THROUGHOUT THIS SHIFT. THERE IS STILL A NEED FOR A URINE CULTURE. ALL PT'S LINES REMAIN SECURELY IN PLACE AND FUNCTIONING WELL. PT. HAS DRESSING TO LEFT HEEL WHICH REMAINS D&I AT THIS TIME. PT. REMAINS A FULL CODE, WITH PLANS TO RE EVALUATE NEED FOR H.D. TODAY. AWAITING VARIOUS CULTURES TO RESULT. CONTINUE MONITORING OF BLOOD SUGARS.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-25 00:00:00.000", "description": "Report", "row_id": 1377841, "text": "0700-1900 NPN:\n\n RECEIVED PT LETHARGIC, NO MORE AWAKE AND ALERT. BECOMING MORE RESTLESS THIS PM. ASSISTED OOB TO CHAIR. PMH OF RESTLESS LEG SYNDROME. PT HAS MYOCLONIC UPPER BODY JERKING/TWITCHING. TEAM FULLY AWARE. NOTED THIS FINDING IN ER PREVIOUS TO HEAD CT SCAN ON . PT'S FAMILY REPORTS OCCAS LOWER AND UPPER BODY JERKING. LYTES WNL THIS AM, 1700 LABS PENDING. ALERT/ORIENTED, ABLE TO ANSWER QUESTIONS APPROPRIATELY. FOLLOWING COMMANDS AT TIMES, SLOW TO COMPREHEND.\n\nRESP- EXTUBATED AM ON NIGHT SHIFT APPROX MN. CXR SHOWING LLL PNA. IV CEFTAZ/IV VANCO/PO AZITHROMYCIN GIVEN AS ORDERED. ORIGINALLY PT INTUBATED IN ER FOR AIRWAY PROTECTION, PRESENTED W/ GLUCOSE ABOVE 1000. RECEIVED PT ON 3L N/C, AM ABG= 7.35/35/113. CURRENTLY PT ON RA, PM ABG= 7.33/33/100. O2 SAT 95-96%. LS= CLEAR/DIM. PT DENIES SOB.\n\nCV- NSR AT 70-80'S, NO ECTOPY NOTED. SEE CAREVUE FLOWSHEET FOR VITAL SIGNS AND OBJECTIVE DATA. MAP ABOVE 65 AND BELOW 95. PMH OF HTN, LABETALOL ORDERED . TEMP MAX=103.1 RECTALLY. BLD CX DRAWN X2, URINE CX SENT, UNABLE TO OBTAIN SPUTUM CX R/T NO SECRETIONS. PT PRESENTED TO ER W/ TEMP 100.8, BLD CX LAST DRAWN ON ADMISSION.\n\nGI/GU- ABD SOFT. PRESENT BS, RECEIVED PT W/ MUSHROOM CATH. LIQUID DIARRHEA OVER NIGHT, COLACE HELD THIS AM. BM X 1 TODAY, SMALL LOOSE BROWN STOOL AROUND MUSHROOM CATH. PT VOIDS PER FAMILY, PT VOIDED APPROX 360CC THIS SHIFT, FIRST TIME SINCE ADMIT. HEMODIALYSIS PT- ROUTINE /THURS/SAT. PT MISSED HD ON SAT PRIOR TO ADMIT, DIALYSIS PERFORMED SUNDAY - REMOVED APPROX 2 LITERS.\n\nENDO- INSULIN GTT STOPPED ON NIGHT SHIFT AND TEAM SWITCHED TO S/S COVERAGE W/ FS Q 1HR AND GLAGARINE AT HS (NOT GIVEN LAST HS). FS=65-409 THIS SHIFT. MEDICATED W/ 1 AMP D50 AT 1400 FOR FS=65, PT REBOUNDED TO 383 AT 1700 AND REQUIRED 8 UNITS REGULAR INSULIN PER S/S. TEAM CALLED R/T FS=409 AT 1800, PLAN TO RESUME INSULIN GTT AFTER PM ROUNDS R/T CONTINUED FLUCTUATING FS.\n\nACCESS- RIGHT ANTECUB #18G PIV X 2, RIGHT RADIAL ALINE INTACT, AND DIALYSIS TUNNELED CATH TO RIGHT CHEST.\n\nSKIN- LEFT WRIST FRACTURE IN , OLD BRACE/CAST ON W/ ACE WRAP. LEFT WRIST XRAY DONE TODAY TO EVAL NEED FOR ANOTHER BRACE/CAST. ORTHO TEAM ON CASE. LEFT FOOT ULCER NON-HEALING X 1YEAR, POSITIVE MRSA. CONTACT PRECAUTIONS MAINTAINED. PT HAD SERVICE AT HOME 1X/WEEK TO ASSESS. LEFT FOOT W/ TELFA AND DSD INTACT AT THIS TIME.\n\nSOCIAL- REMIANS FULL CODE. NO VISITORS TODAY. SISTER IN LAW IS CONTACT PERSON AND CALLS EVERY SHIFT FOR UPDATE.\n\nPLAN- REPLETE 1700 LYTES AS NEEDED PER TEAM. HEMODIALYSIS SCHEDULED FOR TOMORROW. ASSESS NEURO STATUS FOR CHANGES AND REPORT TO TEAM. MONITOR FS Q 1HR AND FOLLOW S/S COVERGE VS RESUMING INSULIN GTT.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-26 00:00:00.000", "description": "Report", "row_id": 1377842, "text": "pmicu nursing progress 7p-7a\nreview of systems\nCV-vs have been stable.receiving antihypertensives as ordered.a-line is becoming positional.\n\nRESP-on room air sats were dipping to 88%, so was placed on 2L nasal cannula.lungs sound clear, coarse at bases.\n\nID-afebrile.wbc pnd.L heel + for MRSA\n\nF/E-voided small amt yellow urine.no ivf infusing.no peripheral edema noted, pt c/o mild thirst.am labs pnd. usually dialysed on tuesdays\n\nGI-abd is soft with positive bowel sounds. has been incontinent of small amts soft brown stool.taking only small sips ginger ale.\n\nNEURO-has been a+ o x , alert and cooperative.has been involuntarily thrashing arms and legs around, apologizing for this behavior.no sleeping meds given.resting in naps.\n\nENDO-was restarted on insulin drip at 2u/hr and fingerstick sugars have been 120-100 for several hours.\n\nSKIN-L heel with dry dressing intact +MRSA\n\nIV ACCESS-has an a-line R wrist, peripheral heplock\n\nSocial-sister in law phoned for an update\n\na-stable,uneventful night\n\nP-will follow fingersticks closely on insulin drip.reorient , provide safe environment.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-26 00:00:00.000", "description": "Report", "row_id": 1377843, "text": "pmicu nursing progress addendum\npt incontinent again of stool.seems unaware.also, fingerstick at 6:45 was 146 and so was replaced on insulin drip at 2 u/hr.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-27 00:00:00.000", "description": "Report", "row_id": 1377848, "text": "LISW SPOKE WITH PT AT LENGTH THIS AFTERNOON PLEASE SEE NOTE IN CHART.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-27 00:00:00.000", "description": "Report", "row_id": 1377846, "text": "PT. REMAINS AWAKE ALERT AND DISORIENTED X1. PT. HAS BECOME MORE SHARP AS THIS SHIFT HAS GONE ON. PT. HAS REMAINED TO EXHIBIT JERKING MOVEMENT IN BOTH UPPER AND LOWER EXT'S/ NEURO IN TO ASSESS PT. YESTERDAY WITH EVALUATION NEG FOR ANY NEURO DEFICITS. THEY FEEL JERKING MOVEMENT IS SECONDARY TO SEPSIS PROCESS. PT. HAS REMAINED AFEBRILE DURING SHIFT. PT. HAS BEEN NSR 60'S WITH NO NOTED ECTOPY. PT'S B/P HAS ALSO BEEN STABLE WITH MAP'S >60 ALINE IN RIGHT RADIAL IS VERY POSITIONAL. NO REPLETION REQUIRED DURING THIS SHIFT. PT'S LUNGS REMAIN CLEAR AND O2 SATS >95% PT. IS NPO AT THIS TIME. WITH BOWEL SOUNDS EASILY AUDIBLE AND, BLOOD SUGARS MORE STABLE. PT. REMAINS ON INSULIN GTT AT PRESENT WITH GTT RANGIN BETWEEN 2-2.5 UNITS/HR. PRESENTLY B.S. IS 89, WITH AM LABS PENDING. PT. HAS HAD MULTIPLE EPISODES OF LOOSE STOOLS. MUSHROOM CATHETER PLACED WITH DESIRED EFFECTS REACHED. NGT IS IN PLACE WITH PT. ACCIDENTALLY PULLING IT OUT. THIS TUBE REPLACED BY NURSE, WITH XRAY PENDING. PT. IS TYPICALLY ANURIC, WITH HIM VOIDING ONLY ONCE A WEEK. PT. DID VOID 110CC OF CLEAR AMBER URINE. PT. RECEIVES HEMODIALYSIS THREE TIMES A WEEK. PT'S LINES ALL REMAIN INTACT AND SECURED. ALINE IS POSITIONAL AT THIS TIME. PT. HAS A DRY STERILE DRESSING TO LEFT FOOT. THIS IS COVERING A 1/4CM ROUND OPEN AREA, AND A 2X3CM SQUARE AREA ON THE OUTER ASPECT OF HIS LEFT FOOT. THIS DRESSING REMAINS D&I AT THIS TIME. PT. REMAINS A FULL CODE AND WILL BE CLOSELY MONITORED FOR POSSIBLE WORSENING SEPSIS.\n" }, { "category": "Nursing/other", "chartdate": "2115-03-27 00:00:00.000", "description": "Report", "row_id": 1377847, "text": "Neuro:Pt. appeares more awake, A&Ox3. Cooperative, following commands. +MAE, occasional extremities jerking noted, on Neuronting at home due to extremities twiching, dose is greater than ordered here, will notify team. Denies pain or discomfort. ,intact cough/gag. Neurology evaluated this AM.\nResp: On RA Sats 95-100%. LS clear. Denies SOB. No cough noted.\nCV: HR 60s-70s, NSR, no ectopy. BP 110s-150s/60s-80s. Remains on Labetalol, Norvasc PO. Palpable pedal pulses. Trace pedal edema noted.\nGI/GU: Pt. started on clears, advanced to diabetic diet. NGT d/c'ed. Abd. soft, nondistended, nontender, +BS, passed small loose brown stools x2. Tolerating meds PO. Remains anuric, last void yesterday.\nHepato/renal: On HD three times/week, last HD yesterday.\nCr 4.6 this AM, K 4.0, Alk Phos 248.\nEndo: Insulin gtt off since 0500. Pt. received AM fixed dose of NPH 8 U, BS checked , covered scale.\nID: Afebrile. Remains on Ceftaz IV.\nSkin: Lt. foot old debridement site with sm. yellow drng, and sm round open area washed with NS, dsd c/d/i.\nSOcial: Sister in law called, updated on status and plan of care, provided with social worker contact information to discuss discharge planning.\nPt. is s/p DKA, sepsis due to lt. foot MRSA infection. Extubated on Sunday. Plan: continue monitor neuro status, blood sugars, possibly call out to floor if stable.\n" } ]

[ { "category": "Physician ", "chartdate": "2153-02-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447125, "text": "Chief Complaint:\n 24 Hour Events:\n -EGD w/ 4 grade 2 varices - all banded, some old blood in stomach\n -Cont octreotide gtt/hold nadolol for today/call GI if rebleed\n -Start abx 1 gm ctx daily\n ENDOSCOPY - At 02:00 PM\n gastric varices banded\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:27 PM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:20 PM\n Fentanyl - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.4\n HR: 59 (56 - 91) bpm\n BP: 121/58(74) {95/43(56) - 151/88(92)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,907 mL\n 594 mL\n PO:\n TF:\n IVF:\n 668 mL\n 594 mL\n Blood products:\n 539 mL\n Total out:\n 1,125 mL\n 0 mL\n Urine:\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 782 mL\n 594 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Scalp lac, staples in place\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 88 K/uL\n 10.5 g/dL\n 154 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 102 mEq/L\n 137 mEq/L\n 30.5 %\n 4.7 K/uL\n [image002.jpg]\n 05:51 PM\n 12:52 AM\n 05:05 AM\n WBC\n 4.7\n Hct\n 31.0\n 30.1\n 30.5\n Plt\n 88\n Cr\n 0.6\n Glucose\n 154\n Other labs: PT / PTT / INR:15.9/28.2/1.4, Differential-Neuts:75.3 %,\n Lymph:17.7 %, Mono:6.2 %, Eos:0.5 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n GASTRIC VARICES / PORTAL HYPERTENSIVE GASTROPATHY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-02-02 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 446997, "text": "Chief Complaint: hematemesis\n HPI:\n This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n .\n At this time, she denies any melena, BRBPR, diarrhea, abdominal pain or\n other symptoms, see below. She has not felt lightheaded since being at\n the OSH. She has no current complaints.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Asacol 800mg \n Ativan 0.5mg QHS\n Citracal + D TID\n Fioricet PRN\n Flaxseed oil 3 capsules TID\n Glucosamine 3 tabs daily\n Nadolol 20mg daily\n Omeprazole 40mg daily\n Prednisone 5mg daily\n Singulair 10mg daily\n Trazodone m QHS\n Vagifem 25mcg 2x week vaginally\n Valtrex 2000mg prn herpes outbreak\n Vitamin C 250mg daily\n Past medical history:\n Family history:\n Social History:\n 1. Autoimmune hepatitis\n 2. Cirrhosis\n - 2 cords of grade II and 3 cords of grade I varices ()\n 3. Hypertensive gastropathy\n 4. Connective tissue disorder\n 5. Fibrocystic disease\n 6. Asthma\n 7. Recurrent pericarditis\n 8. Arthritis\n NC\n Occupation: Retired management consultant\n Drugs: Denies\n Tobacco: Denies\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: Anemia\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 02:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 66 (63 - 68) bpm\n BP: 118/65(77) {118/61(77) - 131/65(78)} mmHg\n RR: 16 (16 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 272 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n 261 mL\n Total out:\n 0 mL\n 325 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -53 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Scalp lac, staples in place\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 107\n 94\n 0.6\n 35\n 30\n 106\n 4.1\n 141\n 26.9\n 6.1\n [image002.jpg]\n Other labs: PT / PTT / INR:15.9/27.8/1.4, Differential-Neuts:80,\n Lymph:14, Mono:5.3, Eos:0.2\n Fluid analysis / Other labs: UA negative\n Imaging: CT scan OSH: read pending here\n EGD :\n 2 cords of grade II and 3 cords of grade I varices were seen in the\n lower third of the esophagus. The varices were not bleeding. Erythema,\n congestion and mosaic appearance of the mucosa were noted in the whole\n stomach. These findings are compatible with portal hypertensive\n gastropathy. A probabale small non bleeding varix were seen in the\n cardia.\n Microbiology: None\n ECG: Sinus, rate of 63, normal axis and intervals, TWI in V1 and TWF in\n V2, no ischemic changes. No priors for comparison\n Assessment and Plan\n This is a 69 yo F with history of autoimmune hepatitis, cirrhosis and\n known varices who is admitted with hematemesis.\n .\n # Hematemesis: Patient has known grade I and II varices, last EGD on\n . Patient reports compliance with her meds. No recent\n illnesses. Patient reported the urge to vomit prior to syncope and\n falling. Last Hct in was 34.7, and baseline appears to be 36-38\n - Will give 2 units prbcs now, tx to goal of 30\n - Active T&C, 2 additional units\n - Serial Hct Q4-6H for now\n - IV PPI \n - Octreotide gtt\n - Plan for EGD in ICU today\n - Appreciate GI recs, will continue to follow with them\n - NPO for now\n - Maintain access with 2 large bore PIV\n - Hold Nadolol pending EGD\n .\n # AIH/cirrhosis:\n - Continue prednisone, nadolol as above, will add back with holding\n parameters after scope\n - LFTs at baseline, will add on albumin and tbili\n .\n # Syncope: Appears to have been in the setting of nausea/vomiting and\n acute blood loss anemia. Patient had a negative CT of her head at the\n OSH, though no report on file. She was accompanied by images, however.\n - Blood and fluid resuscitation as above\n - CT images to radiology for review\n - Check orthostatics post resuscitation\n .\n # Asthma: Continue spiriva\n .\n # Insomnia: Continue trazodone, ativan prn\n .\n # FEN: NPO pending EGD, replete lytes prn,\n .\n # Prophylaxis: Pneumoboots, IV PPI \n .\n # Access: peripherals, large bore\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above by Dr. , including the assessment and plan.\n I would emphasize and add the following points: 69F AIH c/b ESLD, and\n varicies, admitted with UGIB. EGD confirms 4 grade 2 varicies, banded.\n Currently HD stable but at risk for rebleed.\n Exam notable for Tm 97.8 BP 110/70 HR 80 RR 18 with sat 96 on 2L. Frail\n woman, NAD. CTA B. RRR s1s2. Soft +BS. Labs notable for WBC 6K, HCT 27,\n K+ 4.1, Cr 0.6.\n Agree with plan to manage variceal UGIB and blood loss anemia with\n serial HCT (q6 for now), octreotide, PPI IV, and antibiotics. Will hold\n nadolol and check f/u coags. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n" }, { "category": "Nursing", "chartdate": "2153-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446991, "text": "This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Pt admitted from ED, awake, alert, oriented x3, no c/o nausea or\n vomiting, no stool , hemodynamically stable.\n Action:\n Endoscopy performed at bedside, pt given total of 100 mcg fentanyl and\n 4mg versed, transfused with 2 units PC= repeat hct to be checked\n after second unit infused, octretide gtt insfusing\n Response:\n 4 cords of grade ll varices seen and 4 bands successfully placed,\n tolerated procedure well\n Plan:\n Continue octretide gtt, check hct q6hrs, monitor hemodynamics\n" }, { "category": "Nursing", "chartdate": "2153-02-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447160, "text": "Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-02-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447161, "text": "This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446989, "text": "Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446990, "text": "This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Pt admitted from ED, awake, alert, oriented x3, no c/o nausea or\n vomiting, no stool , hemodynamically stable.\n Action:\n Endoscopy performed at bedside, pt given total of 100 mcg fentanyl and\n 4mg versed, transfused with 2 units PC= repeat hct to be checked\n after second unit infused, octretide gtt insfusing\n Response:\n 4 cords of grade ll varices seen and 4 bands successfully placed\n Plan:\n" }, { "category": "Physician ", "chartdate": "2153-02-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447124, "text": "Chief Complaint:\n 24 Hour Events:\n -EGD w/ 4 grade 2 varices - all banded, some old blood in stomach\n -Cont octreotide gtt/hold nadolol for today/call GI if rebleed\n -Start abx 1 gm ctx daily\n ENDOSCOPY - At 02:00 PM\n gastric varices banded\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:27 PM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:20 PM\n Fentanyl - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.4\n HR: 59 (56 - 91) bpm\n BP: 121/58(74) {95/43(56) - 151/88(92)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,907 mL\n 594 mL\n PO:\n TF:\n IVF:\n 668 mL\n 594 mL\n Blood products:\n 539 mL\n Total out:\n 1,125 mL\n 0 mL\n Urine:\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 782 mL\n 594 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 88 K/uL\n 10.5 g/dL\n 154 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 102 mEq/L\n 137 mEq/L\n 30.5 %\n 4.7 K/uL\n [image002.jpg]\n 05:51 PM\n 12:52 AM\n 05:05 AM\n WBC\n 4.7\n Hct\n 31.0\n 30.1\n 30.5\n Plt\n 88\n Cr\n 0.6\n Glucose\n 154\n Other labs: PT / PTT / INR:15.9/28.2/1.4, Differential-Neuts:75.3 %,\n Lymph:17.7 %, Mono:6.2 %, Eos:0.5 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n GASTRIC VARICES / PORTAL HYPERTENSIVE GASTROPATHY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-02-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447126, "text": "Chief Complaint:\n 24 Hour Events:\n -EGD w/ 4 grade 2 varices - all banded, some old blood in stomach\n -Cont octreotide gtt/hold nadolol for today/call GI if rebleed\n -Start abx 1 gm ctx daily\n ENDOSCOPY - At 02:00 PM\n gastric varices banded\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:27 PM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:20 PM\n Fentanyl - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.4\n HR: 59 (56 - 91) bpm\n BP: 121/58(74) {95/43(56) - 151/88(92)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,907 mL\n 594 mL\n PO:\n TF:\n IVF:\n 668 mL\n 594 mL\n Blood products:\n 539 mL\n Total out:\n 1,125 mL\n 0 mL\n Urine:\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 782 mL\n 594 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Scalp lac, staples in place\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 88 K/uL\n 10.5 g/dL\n 154 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 102 mEq/L\n 137 mEq/L\n 30.5 %\n 4.7 K/uL\n [image002.jpg]\n 05:51 PM\n 12:52 AM\n 05:05 AM\n WBC\n 4.7\n Hct\n 31.0\n 30.1\n 30.5\n Plt\n 88\n Cr\n 0.6\n Glucose\n 154\n Other labs: PT / PTT / INR:15.9/28.2/1.4, Differential-Neuts:75.3 %,\n Lymph:17.7 %, Mono:6.2 %, Eos:0.5 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n This is a 69 yo F with history of autoimmune hepatitis, cirrhosis and\n known varices who is admitted with hematemesis.\n .\n # Hematemesis: Patient has known grade I and II varices, last EGD on\n . Patient reports compliance with her meds. No recent\n illnesses. Patient reported the urge to vomit prior to syncope and\n falling. Last Hct in was 34.7, and baseline appears to be 36-38\n - Will give 2 units prbcs now, tx to goal of 30\n - Active T&C, 2 additional units\n - Serial Hct Q4-6H for now\n - IV PPI \n - Octreotide gtt\n - Plan for EGD in ICU today\n - Appreciate GI recs, will continue to follow with them\n - NPO for now\n - Maintain access with 2 large bore PIV\n - Hold Nadolol pending EGD\n .\n # AIH/cirrhosis:\n - Continue prednisone, nadolol as above, will add back with holding\n parameters after scope\n - LFTs at baseline, will add on albumin and tbili\n .\n # Syncope: Appears to have been in the setting of nausea/vomiting and\n acute blood loss anemia. Patient had a negative CT of her head at the\n OSH, though no report on file. She was accompanied by images, however.\n - Blood and fluid resuscitation as above\n - CT images to radiology for review\n - Check orthostatics post resuscitation\n .\n # Asthma: Continue spiriva\n .\n # Insomnia: Continue trazodone, ativan prn\n .\n # FEN: NPO pending EGD, replete lytes prn,\n .\n # Prophylaxis: Pneumoboots, IV PPI \n .\n # Access: peripherals, large bore\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-02-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 446977, "text": "Chief Complaint: hematemesis\n HPI:\n This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n .\n At this time, she denies any melena, BRBPR, diarrhea, abdominal pain or\n other symptoms, see below. She has not felt lightheaded since being at\n the OSH. She has no current complaints.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Asacol 800mg \n Ativan 0.5mg QHS\n Citracal + D TID\n Fioricet PRN\n Flaxseed oil 3 capsules TID\n Glucosamine 3 tabs daily\n Nadolol 20mg daily\n Omeprazole 40mg daily\n Prednisone 5mg daily\n Singulair 10mg daily\n Trazodone m QHS\n Vagifem 25mcg 2x week vaginally\n Valtrex 2000mg prn herpes outbreak\n Vitamin C 250mg daily\n Past medical history:\n Family history:\n Social History:\n 1. Autoimmune hepatitis\n 2. Cirrhosis\n - 2 cords of grade II and 3 cords of grade I varices ()\n 3. Hypertensive gastropathy\n 4. Connective tissue disorder\n 5. Fibrocystic disease\n 6. Asthma\n 7. Recurrent pericarditis\n 8. Arthritis\n NC\n Occupation: Retired management consultant\n Drugs: Denies\n Tobacco: Denies\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: Anemia\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 02:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 66 (63 - 68) bpm\n BP: 118/65(77) {118/61(77) - 131/65(78)} mmHg\n RR: 16 (16 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 272 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n 261 mL\n Total out:\n 0 mL\n 325 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -53 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Scalp lac, staples in place\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 107\n 94\n 0.6\n 35\n 30\n 106\n 4.1\n 141\n 26.9\n 6.1\n [image002.jpg]\n Other labs: PT / PTT / INR:15.9/27.8/1.4, Differential-Neuts:80,\n Lymph:14, Mono:5.3, Eos:0.2\n Fluid analysis / Other labs: UA negative\n Imaging: CT scan OSH: read pending here\n EGD :\n 2 cords of grade II and 3 cords of grade I varices were seen in the\n lower third of the esophagus. The varices were not bleeding. Erythema,\n congestion and mosaic appearance of the mucosa were noted in the whole\n stomach. These findings are compatible with portal hypertensive\n gastropathy. A probabale small non bleeding varix were seen in the\n cardia.\n Microbiology: None\n ECG: Sinus, rate of 63, normal axis and intervals, TWI in V1 and TWF in\n V2, no ischemic changes. No priors for comparison\n Assessment and Plan\n This is a 69 yo F with history of autoimmune hepatitis, cirrhosis and\n known varices who is admitted with hematemesis.\n .\n # Hematemesis: Patient has known grade I and II varices, last EGD on\n . Patient reports compliance with her meds. No recent\n illnesses. Patient reported the urge to vomit prior to syncope and\n falling. Last Hct in was 34.7, and baseline appears to be 36-38\n - Will give 2 units prbcs now, tx to goal of 30\n - Active T&C, 2 additional units\n - Serial Hct Q4-6H for now\n - IV PPI \n - Octreotide gtt\n - Plan for EGD in ICU today\n - Appreciate GI recs, will continue to follow with them\n - NPO for now\n - Maintain access with 2 large bore PIV\n - Hold Nadolol pending EGD\n .\n # AIH/cirrhosis:\n - Continue prednisone, nadolol as above, will add back with holding\n parameters after scope\n - Add on LFTs\n .\n # Syncope: Appears to have been in the setting of nausea/vomiting and\n acute blood loss anemia. Patient had a negative CT of her head at the\n OSH, though no report on file. She was accompanied by images, however.\n - Blood and fluid resuscitation as above\n - CT images to radiology for review\n - Check orthostatics post resuscitation\n .\n # Asthma: Continue spiriva\n .\n # Insomnia: Continue trazodone, ativan prn\n .\n # FEN: NPO pending EGD, replete lytes prn,\n .\n # Prophylaxis: Pneumoboots, IV PPI \n .\n # Access: peripherals, large bore\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-02-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 446978, "text": "Chief Complaint: hematemesis\n HPI:\n This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n .\n At this time, she denies any melena, BRBPR, diarrhea, abdominal pain or\n other symptoms, see below. She has not felt lightheaded since being at\n the OSH. She has no current complaints.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Asacol 800mg \n Ativan 0.5mg QHS\n Citracal + D TID\n Fioricet PRN\n Flaxseed oil 3 capsules TID\n Glucosamine 3 tabs daily\n Nadolol 20mg daily\n Omeprazole 40mg daily\n Prednisone 5mg daily\n Singulair 10mg daily\n Trazodone m QHS\n Vagifem 25mcg 2x week vaginally\n Valtrex 2000mg prn herpes outbreak\n Vitamin C 250mg daily\n Past medical history:\n Family history:\n Social History:\n 1. Autoimmune hepatitis\n 2. Cirrhosis\n - 2 cords of grade II and 3 cords of grade I varices ()\n 3. Hypertensive gastropathy\n 4. Connective tissue disorder\n 5. Fibrocystic disease\n 6. Asthma\n 7. Recurrent pericarditis\n 8. Arthritis\n NC\n Occupation: Retired management consultant\n Drugs: Denies\n Tobacco: Denies\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: Anemia\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 02:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 66 (63 - 68) bpm\n BP: 118/65(77) {118/61(77) - 131/65(78)} mmHg\n RR: 16 (16 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 272 mL\n PO:\n TF:\n IVF:\n 11 mL\n Blood products:\n 261 mL\n Total out:\n 0 mL\n 325 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -53 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Scalp lac, staples in place\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 107\n 94\n 0.6\n 35\n 30\n 106\n 4.1\n 141\n 26.9\n 6.1\n [image002.jpg]\n Other labs: PT / PTT / INR:15.9/27.8/1.4, Differential-Neuts:80,\n Lymph:14, Mono:5.3, Eos:0.2\n Fluid analysis / Other labs: UA negative\n Imaging: CT scan OSH: read pending here\n EGD :\n 2 cords of grade II and 3 cords of grade I varices were seen in the\n lower third of the esophagus. The varices were not bleeding. Erythema,\n congestion and mosaic appearance of the mucosa were noted in the whole\n stomach. These findings are compatible with portal hypertensive\n gastropathy. A probabale small non bleeding varix were seen in the\n cardia.\n Microbiology: None\n ECG: Sinus, rate of 63, normal axis and intervals, TWI in V1 and TWF in\n V2, no ischemic changes. No priors for comparison\n Assessment and Plan\n This is a 69 yo F with history of autoimmune hepatitis, cirrhosis and\n known varices who is admitted with hematemesis.\n .\n # Hematemesis: Patient has known grade I and II varices, last EGD on\n . Patient reports compliance with her meds. No recent\n illnesses. Patient reported the urge to vomit prior to syncope and\n falling. Last Hct in was 34.7, and baseline appears to be 36-38\n - Will give 2 units prbcs now, tx to goal of 30\n - Active T&C, 2 additional units\n - Serial Hct Q4-6H for now\n - IV PPI \n - Octreotide gtt\n - Plan for EGD in ICU today\n - Appreciate GI recs, will continue to follow with them\n - NPO for now\n - Maintain access with 2 large bore PIV\n - Hold Nadolol pending EGD\n .\n # AIH/cirrhosis:\n - Continue prednisone, nadolol as above, will add back with holding\n parameters after scope\n - LFTs at baseline, will add on albumin and tbili\n .\n # Syncope: Appears to have been in the setting of nausea/vomiting and\n acute blood loss anemia. Patient had a negative CT of her head at the\n OSH, though no report on file. She was accompanied by images, however.\n - Blood and fluid resuscitation as above\n - CT images to radiology for review\n - Check orthostatics post resuscitation\n .\n # Asthma: Continue spiriva\n .\n # Insomnia: Continue trazodone, ativan prn\n .\n # FEN: NPO pending EGD, replete lytes prn,\n .\n # Prophylaxis: Pneumoboots, IV PPI \n .\n # Access: peripherals, large bore\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-02-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 447154, "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 69 yo women with autoimmune cirrhosis, admitted with UGIB secondary to\n varices, had them banded last night. Has been stable since.\n 24 Hour Events:\n ENDOSCOPY - At 02:00 PM\n gastric varices banded\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:27 PM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:20 PM\n Fentanyl - 02:20 PM\n Other medications:\n protonix\n prednisone\n ceftriaxone\n sucralfate\n ativan\n trazadone\n cephacol\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 Gastrointestinal: Abdominal pain, No(t) Emesis, No(t) Diarrhea\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Flowsheet Data as of 11:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.4\n HR: 64 (56 - 91) bpm\n BP: 126/60(77) {95/43(56) - 151/88(92)} mmHg\n RR: 15 (11 - 18) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,907 mL\n 694 mL\n PO:\n TF:\n IVF:\n 668 mL\n 694 mL\n Blood products:\n 539 mL\n Total out:\n 1,125 mL\n 250 mL\n Urine:\n 1,125 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 782 mL\n 444 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Tender: mild epigastric\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 10.5 g/dL\n 88 K/uL\n 154 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 102 mEq/L\n 137 mEq/L\n 30.5 %\n 4.7 K/uL\n [image002.jpg]\n 05:51 PM\n 12:52 AM\n 05:05 AM\n WBC\n 4.7\n Hct\n 31.0\n 30.1\n 30.5\n Plt\n 88\n Cr\n 0.6\n Glucose\n 154\n Other labs: PT / PTT / INR:15.9/28.2/1.4, Differential-Neuts:75.3 %,\n Lymph:17.7 %, Mono:6.2 %, Eos:0.5 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n GASTRIC VARICES / PORTAL HYPERTENSIVE GASTROPATHY: No further\n bleeding, as Hct has been stable.\n Cirrhosis: continue SBP prophylaxis\n Can start PO diet.\n asthma\n insomnia\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2153-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447084, "text": "Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Octreotide gtt cont\n IVF @ 75cc/hr\n + with c/o throat pain scope\n Action:\n Repeat crit\n Response:\n Crit stable at 30\n Throat pain slightly relieved with cephacol\n Slept well overnoc after given HS trazadone and ativan\n Plan:\n Monitor hemodynamics.\n Cont with frequent crit checks\n Cont with current plan of care\n TNF to floor this am\n" }, { "category": "Nursing", "chartdate": "2153-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 447010, "text": "This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitte to the ICU from an OSH\n with hematemesis.\n .\n She reports feeling well until yesterday afternoon when she began to\n feel nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomiting a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n SHe also had a head lac that was cleaned and dressed. She rec'd 2L of\n NS as well as 4 mg Zofran for nausea. A CT head was negative per\n report, though there is currently no documentation in her transfer\n paperwork. She was transferred to the ED here for further management.\n .\n In the ED, T 98.2, BP 121/49, HR 62, 97% on room air. She was given\n protonix 40 mg IV x1 and octreotide 100 mg IV x1. She was\n hemodynamically stable throughout her ED stay. Her Hct here was down\n to 26.9 after IVF. She was transferred to the ICU for further\n management.\n Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Pt admitted from ED, awake, alert, oriented x3, no c/o nausea or\n vomiting, no stool , hemodynamically stable.\n Action:\n Endoscopy performed at bedside, pt given total of 100 mcg fentanyl and\n 4mg versed, transfused with 2 units PC= repeat hct to be checked\n after second unit infused, octretide gtt insfusing\n Response:\n 4 cords of grade ll varices seen and 4 bands successfully placed,\n tolerated procedure well\n Plan:\n Continue octretide gtt, check hct q6hrs, monitor hemodynamics\n" }, { "category": "Nursing", "chartdate": "2153-02-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447179, "text": "This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitted to the ICU from an\n OSH with hematemesis.\n .\n She reports feeling well until afternoon when she began to feel\n nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomited a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n She also had a head lac that was cleaned and dressed w/4 staples in\n place. She rec'd 2L of NS as well as 4 mg Zofran for nausea. A CT head\n was negative per report, though there is currently no documentation in\n her transfer paperwork. She was transferred to the ED here for further\n management. . She was given protonix 40 mg IV x1 and octreotide 100 mg\n IV x1. She was hemodynamically stable throughout her ED stay. Her Hct\n here was down to 26.9 after IVF. She was transferred to the ICU for\n further management.\n ENDOSCOPY - At 02:00 PM\ngastric varices banded.\n Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Alert and oriented x3, c/o feeling weak and discomfort in her throat\n and when she swallows. Hemodynamically stable. No further vomiting or\n bleeding.\n Action:\n OOB to chair and commode. Continues on Octreotide drip IV. Protonix and\n Carafate given. Advanced diet.\n Response:\n Stable, tolerating po intake.\n Plan:\n Transfer out to the floor. Continue Octreotide.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n UPPER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 50 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: GI Bleed\n CV-PMH:\n Additional history: hx gastric varices, portal HTN, autoimmune\n hepatitis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:74\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 72 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 1,111 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:05 AM\n Potassium:\n 4.0 mEq/L\n 05:05 AM\n Chloride:\n 102 mEq/L\n 05:05 AM\n CO2:\n 30 mEq/L\n 05:05 AM\n BUN:\n 23 mg/dL\n 05:05 AM\n Creatinine:\n 0.6 mg/dL\n 05:05 AM\n Glucose:\n 154 mg/dL\n 05:05 AM\n Hematocrit:\n 30.5 %\n 05:05 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: @1630\n" }, { "category": "Physician ", "chartdate": "2153-02-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 447166, "text": "Chief Complaint:\n 24 Hour Events:\n -EGD w/ 4 grade 2 varices - all banded, some old blood in stomach\n -Cont octreotide gtt/hold nadolol for today/call GI if rebleed\n -Start abx 1 gm ctx daily per GI\n This \n Pt complaining of difficulty breathing due to\noveractive sinuses,\n apparently a chronic problem that she is due to get work up for as\n outpatient.\n Also has vague epig pain and LLQ, which she attributes to not having\n had BM yet.\n ENDOSCOPY - At 02:00 PM\n gastric varices banded\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:27 PM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 02:20 PM\n Fentanyl - 02:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.4\n HR: 59 (56 - 91) bpm\n BP: 121/58(74) {95/43(56) - 151/88(92)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,907 mL\n 594 mL\n PO:\n TF:\n IVF:\n 668 mL\n 594 mL\n Blood products:\n 539 mL\n Total out:\n 1,125 mL\n 0 mL\n Urine:\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 782 mL\n 594 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Scalp lac, staples in place\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, mildly tender in epig and LLQ. No guarding or\n rebound.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Not assessed, No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 88 K/uL\n 10.5 g/dL\n 154 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 102 mEq/L\n 137 mEq/L\n 30.5 %\n 4.7 K/uL\n [image002.jpg]\n 05:51 PM\n 12:52 AM\n 05:05 AM\n WBC\n 4.7\n Hct\n 31.0\n 30.1\n 30.5\n Plt\n 88\n Cr\n 0.6\n Glucose\n 154\n Other labs: PT / PTT / INR:15.9/28.2/1.4, Differential-Neuts:75.3 %,\n Lymph:17.7 %, Mono:6.2 %, Eos:0.5 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n This is a 69 yo F with history of autoimmune hepatitis, cirrhosis and\n known varices who is admitted with hematemesis.\n .\n # Hematemesis: EGD done yesterday and varices banded. Hct has been\n stable since then.\n - continue monitoring Hct\n - Continue Octreotide gtt, IV PPI , and maintain large bore IVs\n - Active T&C\n - Advance diet as tolerated\n .\n # AIH/cirrhosis:\n - Continue prednisone, nadolol on hold\n - LFTs at baseline.\n .\n # Syncope: Appears to have been in the setting of nausea/vomiting and\n acute blood loss anemia. Patient had a negative CT of her head at the\n OSH, though no report on file. Denies any further syncopal symptoms.\n - OSH CT images to radiology for review\n - check orthostatics\n .\n # Asthma: Continue spiriva\n .\n # Insomnia: Continue trazodone, ativan prn\n .\n # FEN: replete lytes PRN and advance diet as tolerated\n .\n # Prophylaxis: Pneumoboots, IV PPI \n .\n # Access: peripherals, large bore\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: call out to floor today\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2153-02-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 447165, "text": "This is a 69 yo F w/ past medical history of autoimmune hepatitis,\n cirrhosis, known grade II varices who is admitted to the ICU from an\n OSH with hematemesis.\n .\n She reports feeling well until afternoon when she began to feel\n nauseated and unwell. She became increasingly nauseated over the\n course of the night and at around 4 am, she felt the need to vomit. As\n she was running to the bathroom, she bumped into the door, hit her head\n and fell. She subsequently vomited a large amount of coffee grounds\n with bright red blood. No further emesis. She called EMS and was sent\n to .\n .\n There, she was found to have a Hct of 29.4. Transiently, her BP\n decreased to 82/62 but returned to baseline with minimal intervention.\n She also had a head lac that was cleaned and dressed w/4 staples in\n place. She rec'd 2L of NS as well as 4 mg Zofran for nausea. A CT head\n was negative per report, though there is currently no documentation in\n her transfer paperwork. She was transferred to the ED here for further\n management. . She was given protonix 40 mg IV x1 and octreotide 100 mg\n IV x1. She was hemodynamically stable throughout her ED stay. Her Hct\n here was down to 26.9 after IVF. She was transferred to the ICU for\n further management.\n ENDOSCOPY - At 02:00 PM\ngastric varices banded.\n Gastric Varices / Portal Hypertensive Gastropathy\n Assessment:\n Alert and oriented x3, c/o feeling weak and discomfort in her throat\n and when she swallows. Hemodynamically stable. No further vomiting or\n bleeding.\n Action:\n OOB to chair and commode. Continues on Octreotide drip IV. Protonix and\n Carafate given. Advanced diet.\n Response:\n Stable, tolerating po intake.\n Plan:\n Transfer out to the floor. Continue Octreotide.\n" }, { "category": "ECG", "chartdate": "2153-02-02 00:00:00.000", "description": "Report", "row_id": 246029, "text": "Sinus rhythm. Non-specific lateral ST-T wave changes. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2102-09-17 00:00:00.000", "description": "Report", "row_id": 1338850, "text": "ADMISSION NOTE\nD: PT ADMITTED INTUBATED AND UNRESPONSIVE AWOKE 1 HR AFTER ADMISSION\nRESTLESS BUT FOLLOWING COMMANDS. EXTUBATED WITH O2 SAT 90% NP 3L ADDED. LUNGS CLEAR UPPER BUT DIMINISHED LOWER LOBES L>R WITH BIBASILAR RALES NOTED. C/O HIS CHEST HURTING AT TIMES WANTING TO COUGH WAS LETHARGIC BUT EASILY AROUSABLE, CONFUSED TO PLACE WITH SPEECH GARBLED AND DIFFICULT TO UNDERSTAND. CURRENTLY IS ORIENTED X 3 AND WANTING TO GO HOME. HE DOES NOT APPEAR TO UNDERSTAND THE SEVERITY OF WHAT HAPPENED TO HIM LAST NIGHT. PT STATES HE HAS FELT LIKE THIS BEFORE AND BEEN OK. HIS EYES ARE VERY IRRITATED AND C/O BURNING WHEN HE OPENS THEM. LOW GRADE TEMP 100 REMAINS TACHYCARDIC 110-130'S WITH MOVEMENT. BP 137-105/50'S\nA: MONITORING SERIAL CK'S TO REPEAT EKG TONIGHT AND IN AM. CARDIOLOGY CONSULTED AND TO HAVE A CARDIAC ECHO TOMORROW TO R/O PERICARDITIS LASIX 20 MG IV GIVEN\nR: VOIDED 550CC AFTER LASIX SEDATION HAS WORN OFF AND IS AWAKE AND ORIENTED.\nPLAN: CARDIAC ECHO TOMORROW TO MONITOR RESP STATUS S/P DIUERSIS FROM LASIX\n" }, { "category": "Nursing/other", "chartdate": "2102-09-18 00:00:00.000", "description": "Report", "row_id": 1338851, "text": "NURSING, TX OUT OF ICU.\n25 Y/O W. MALE. PT TO FROM OSH ON . PT WAS FOUND AFTER PT OUT AT PARTY, TOX SCREEN POSITIVE FOR COCAINE., ALSO REPORTED USING GHB. EMS CALLED, PT INTUBATED FOR RESPIRATORY FAILURE.\nALL: NKDA\nPMHX: NONE.\n\nNEURO: PT 3. MAE'S. OOB TO CHAIR. PT DENIES PAIN.\nCV: EKG DONE. CARDIAC ECHO ORDERED. SINUS TACH. BP STABLE. AFEBRILE. TROPONIN NEG FOR MI. PERIPH IV HEPLOCK.\nPULM: ON 2L NC, NOW ON RA WITH GOOD SAO2. USING IS.\nGI: TOL SOFT DIET THIS AM. GOOD PO INTAKE.\nGU: VOIDING, GOOD UO.\nS/S: PT ANXIOUS, WANTING TO GO HOME, NOT COMPREHENDING REASON FOR REMAINING IN HOSP. MD & RN DISCUSSED AT EXTENT WITH PT AND FAMILY RE: SEVERITY OF CONDITION UPON AND NEED FOR W/U AND EVAL. TX TO FLOOR.\n\n" }, { "category": "Echo", "chartdate": "2102-09-18 00:00:00.000", "description": "Report", "row_id": 94881, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 195\nBSA (m2): 2.05 m2\nBP (mm Hg): 133/61\nStatus: Inpatient\nDate/Time: at 11:18\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal. Regional left ventricular wall motion is normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\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.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal. Regional left ventricular wall motion is normal.\n2. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2102-09-18 00:00:00.000", "description": "Report", "row_id": 273306, "text": "Normal sinus rhythm, rate 95\nModest nonspecific inferior T wave abnormalities\nSince last ECG, no significant change\nBorderline ECG\n\n" }, { "category": "ECG", "chartdate": "2102-09-18 00:00:00.000", "description": "Report", "row_id": 273307, "text": "Sinus tachycardia. Right atrial enlargement. Left ventricular hypertrophy.\nST-T wave flattening in lead V6, though there is variation in precordial lead\nplacement. Compared to the previous tracing of , no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2102-09-17 00:00:00.000", "description": "Report", "row_id": 273308, "text": "Sinus rhythm with tachycardia. Axis to the right. Deep S waves in lead V3. Tall\npeaked symmetric T waves in leads V3-V4. ST segment depressions with T wave\ninversions in leads III and aVF. INT: Abnormal ECG. Sinus tachycardia. Right\naxis deviation. T wave abnormalities suggestive of hyperkalemia. Inferior\nST-T wave abnormalities are non-specific - they could represent ischemia.\n\n" }, { "category": "ECG", "chartdate": "2102-09-17 00:00:00.000", "description": "Report", "row_id": 273309, "text": "Sinus tachycardia, rate 112\nModest Nonspecific inferior T wave abnormalities\nBorderline ECG\n\n" }, { "category": "Radiology", "chartdate": "2102-09-17 00:00:00.000", "description": "CT EMERGENCY HEAD W/O CONTRAST", "row_id": 741619, "text": " 8:35 AM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: intub and unresponsive, , r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with\n REASON FOR THIS EXAMINATION:\n intub and unresponsive\n\n r/o bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated, unresponsive, r/o intracranial hemorrhage.\n\n No comparison studies available.\n\n TECHNIQUE: CT head without IV contrast.\n\n CT HEAD WITH NO CONTRAST: There is no evidence of acute intracranial\n hemorrhage or infact. The CSF spaces appear unremarkable. There is no abnormal\n intra or extra axial collection. There is no mass, mass effect, or shift of\n midline structures. The grey and white differentiation appears within normal\n limits.\n\n Bone windows reveal no evidence of acute fracture. Small air fluid levels are\n noted in both maxillary sinuses and sphenoid sinuses. There is also mucosal\n thickening of the ethmoid sinuses. The left frontal sinus is hypoplastic.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. Sinus disease as\n described above.\n\n" }, { "category": "Radiology", "chartdate": "2102-09-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741620, "text": " 8:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intub, tube placement, r/o infil\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with\n REASON FOR THIS EXAMINATION:\n intub\n tube placement\n r/o infil\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 25 year old man unresponsive and intubated.\n\n Portable AP chest: Endotracheal tube tip is approximately 4.5 cm above the\n carina. A nasogastric tube is within the stomach. The heart size is normal.\n There is no infiltrate or effusion. There is indistinctness of the vasculature\n centrally as well as perihilar haziness suggesting pulmonary edema. Correlate\n clinically.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 867604, "text": " 1:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pneumonia, CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with fever, productive cough, hypoxia and h/o CHF\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cough and hypoxia.\n\n COMPARISON: .\n\n Compared to the prior study, there has been development of a new opacity in\n the right cardiophrenic angle worrisome for an infiltrate. The base of the\n left lung was not well seen on the prior study and this most likely represents\n chronic scarring. However, there is a new opacity in the left lower lobe.\n The heart is enlarged.\n\n IMPRESSION: Likely chronic scarring at the left lung base. However, there is\n a new opacity in the right cardiophrenic angle as well as in the left lower\n lobe suggestive of pneumonia. Clinical correlation is advised. A repeat film\n when the patient's symptoms resolve is recommended. There is no radiographic\n evidence of CHF.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-06-28 00:00:00.000", "description": "Report", "row_id": 1370199, "text": "CCU Nursing Progress Note\nS-\"I feel so weak I can't sit up anymore\".\nO-Neuro alert and oriented x3, cooperative without any complaints. General malaise with c/o weakness and fatigues easily with ADL and OOB chair. Periods of restlessness because he can't get comfortable with couging.\nCV-+Orthostatic hypotensive this am with SBP 66-72/ asymptomatic, received 250cc NS bolus over 15 minutes with good effect. Remains off dopamine gtt x 16hrs. Carvedilol d/c'd. HR 80-100's NSR.\nResp-LS coarse with basilar atelectasis, freq productive coughing spells thick rusty sputum. Started guaifensin with codeine 10cc with good effect. Physical therapy to follow for CPT.\nID-Afebrile but with bandemia 10, +strep pneumo RLL and LLL on cefriaxone and Azithromax Day# . Blood cultures x2 to be sent.\nGU-foley draining 30-40cc/hr.\nGI-appetite poor with 2 loose stools and using commode.\nActivity-OOB chair for 2 hours to help with coughing spell but became easily fatigued and wanted to get back to bed.\n wife visited, concerned that pt will go out to the floor and not get the care he needs. She feels he gets so weak from coughing and then SOB. Apparently she had a bad experience when the pt had his heart attack that he got moved around so much and then left him to fend for himself. They have a total of 8 people living in their house with children and grand children, which can be alittle stressful at times. Plan to have social services see pt in am.\nA/P-Bibasilar strep pneumonia on abx.\nContinue to monitor LS and O2 sats prn nebs.\nEncourage cough and deep breathing. Cough meds prn.\nSocial service consult in am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-06-29 00:00:00.000", "description": "Report", "row_id": 1370200, "text": "CCU NSG PROGRESS NOTE 7P-7A/ PNA; R/O CHF\n\nS- \" I HAVE TO GO TO THE BATHROOM...CAN I WALK OVER THERE?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\nCV- HR- 70-90'S ST, SR, NO VEA.\nAM LYTES/CBC PENDING.\nHEMODYNAMICS REMAIN STABLE OFF PRESSOR- NO FURTHER IVF BOLUS.\nBP- 110/- 138/ VIA DYNAMAP.\nNO ISSUES CURRENTLY\n\nRESP- COUGHING UP YELLOW/BLOOD TINGED SPUTUM- SOME COUGHING FITS- RECEIVING COUGH SYRUP WITH SOME SUPRESSION.\nCOARSE BREATH SOUNDS- O2 SATS ABOVE 95%- ON /OFF NP 2-3 L.\nWALKING ACROSS TO BATHROOM WITHOUT DESATURATION OR SIGNIFICANT SOB.\nREMAINS ON CEFTRIAXONE AND AZITHROMYCIN.\n\nID- SEE ABOVE- (+) BILATERAL INFILTRATES/STREP PNA- AFEBRILE THIS SHIFT. ANTIBX X ORDERED.\n\nGU- 70-80CC/HOUR- VIA FOLEY CATHETER-\nYELLOW/AMBER CLEAR URINE.\n\nGI- TAKING FOOD/LIX WITHOUT ISSUE\nREMAINS ON QID FINGER STICKS/CHECKS.\nNO INSULIN THIS SHIFT.\nUP X TO TO IN-ROOM BATHROOM- SUCCESS 2ND TIME UP- LARGE SOFT G (-) STOOL. PROTONIX QD.\n\n PT UNABLE TO GET TO SLEEP - NEEDING TO GO TO BATHROOM AND NOT COMFORTABLE..BY 1AM - PT WITH SUCCESS IN BATHROOM BUT INSOMNIA- SO GIVEN AMBIEN 10 MG.\nUP SITTING AT TIMES WITH COUGHING JAGS- GIVEN MORE COUGH MEDICINE.\nFELL ASLEEP BY 3AM. CURRENTLY ASLEEP.\n\nA/ PT WITH CURRENTLY AFEBRILE\n\nCONTINUE ANTIBX AS ORDERED.\nWATCH FOR FEVER- TYLENOL, COUGH SYRUP AS ORDERED.\nCONTINUE TO INCREASE PT , INCENTIVE SPIROMETER- ? TRANSFER TO FLOOR TODAY IF CONTINUES TO BE HEMODYNAMICALLY STABLE.\nKEEP PT AWARE OF PLAN OF CARE, SUPPORT FOR PT AND FAMILY.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-06-27 00:00:00.000", "description": "Report", "row_id": 1370197, "text": "CCU NPN 1300-1900\nS: \"Call me or ...\" \"My breathing feels fine.\"\nO: see carevue and admit note for complete assessment data\nHPI: 69yo man saw his PCP after 2 weeks of cough and \"loss of equilibrium\" and 1 day of N/V/D. Noted pale and tachycardic w/ t wave inversions on ECG; admitted to Hosp ED-> hypotensive after diuresis w/ lasix (tx'd w/ fluid and dopamine). Tmax in ed per report 101, BCs growing GPC in chains 2/2 bottles, started abx. CXR questionable for pulm edema/CHF v. infiltrate-> decision made to tx as CHF exacerbation d/t low SpO2 (requiring venti onoc) and rales 1/2 up bases. Tx'd to for further management. Arrived via ambulance @ 1300 in apparent resp distress but denying dyspnea; BP 90s-100s/ on 9mcgs/kg of dopa (pt. normal SBP 80).\nROS:\nNEURO/HEENT: A&Ox3, eye opening spontaneously. Follows commands, MAE w/ equal grasp. PERRLA, 3mm and brisk. Moving in bed independently, dangling @ bedside. No c/o pain or SOB. Skin pale, mucous membranes dry, dentures intact, glasses @ bedside.\n\nCV: Dopa weaned slowly to 6.4mcg w/ SBP mid 80s (goal >80). Gave 250cc NS bolus x2 followed by NS @ 150cc/hr x 500cc for apparent hypovolemia (no JVD, peripheral edema). EF 30%. HR ST 100s-110s w/ no ectopy noted on tele. No c/o CP/palpitations. Extremities cool w/ no edema; DP +2 PT by dop; +cap refill, CSM. Pneumo boots on.\n\nRESP: no c/o SOB. SpO2 on RA 90-93%, on 3L NC 96%. LS coarse/rhonchorus throughout R>L w/ coarse rales 1/2 up bases bilat. Minimally productive (thick tan/pink tinged), congested cough->gave guiafenasen. Using IS w/ encouragement.\n\nGI/GU: abdomen obese (larger than normal per wife-since yesterday; KUB @ negative for ileus/obstruction), soft and nontender. +BS/ LBM explosive diarrhea prior to admit to Jorday. Tolerating /heart healthy diet and PO meds. Foley draining CY/amber urine; +300 since admit. Cr 1.5\n\nENDO: type 2 diabetic, took metformin and avandia this am. Metformin held @ this time d/t ^ Cr. RISS as needed, BG @ 1800 141.\n\nID: low grade temp, tmax 99.3. Cont zithromax and ceftriaxone.\n\nACCESS: 2 20 G PIVs inserted @ , wnl.\n\nSOC: wife in to visit, updated on by RN and MD.\n\nA: 69yo w/ RLL infiltrate, questionable CHF exacerbation (clinically not volume overloaded), Tolerating slow wean of dopamine w/ SBP 80s after 250cc NS bolus x2. Currently afebrile, maintaining SpO2 on 3L NC.\nP: cont to wean dopamine as tolerated (SBP >80), monitor resp sts w/ fluid administration. Cont to encourage IS and coughing, cont w/ expectorants. If unable to wean dopamine to off by plan for PA line placement. Cont to montior temp and WBC, tylenol and abx.\n" }, { "category": "Nursing/other", "chartdate": "2164-06-28 00:00:00.000", "description": "Report", "row_id": 1370198, "text": "Nursing Note 7p-7a\nS:\"I can't get comfortable\".\nO: See careview for objective data.\nCV- Tele ST rare PVCs, HR 100-110. NBPs 86-116/44-70, received an additional 250cc NS for hypovolemia/hypotension and by 0200 was able to wean pt off Dopamine gtt. No c/o cp, held 8pm carvedilol per parameters.\nResp- LS rhonchi in upper lobes, crackles in bases. Conts on 4L nc sats 94-98%, productive coughing thick blood tinged yellow sputum using IS, spec was sent.\nNeuro- A+Ox3, PEARL/MAE and is cooperative. Restless/uncomfortable in a hosp bed, given prn ambien/apap with good effect.\nEndo- Fsbs below ss coverage.\nID- Tmax 99.8 po, wbc 13.3 conts on zithomax ceftiaxone for RLL pneumonia (gram+ rods)\nGI/ Pt obese, abd soft distended +bs +flatus no stool, drinking liquids. Foley patent voiding qs clu. BUN 33 Cre 1.1\nSkin- No issues.\nA/P: 69yo male with RRL pneumonia, tx for ? CHF exacerbation with diuretics. C/b hypotension/hypovolemia requiring CCU admission for pressors and iv fluids. Cont to monitor BPs off dopa, strict I+Os, watch for temp spikes. Cont abx tx, support pt and family.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2154-04-15 00:00:00.000", "description": "Report", "row_id": 1573584, "text": "Nursing Progress Note\n7 pm - 7 am\nVF Arrest/Slow Neuro recovery\nOpens eyes to name ....Moaning and groaning throughout the night ..Unable to answer questions asked ..I.E ..( Are you having Pain ? ...What is your name ? ) At one point during the night..patient found with legs over the siderail ..pulling off mask ..attempting to d/c foley catheter. QTC .49 ...Fentanyl 25 mcgs given times 2 ..siderails up and bed alarm on.... Does not squeeze hands to command ..but moving all extremities in the bed ..slight withdrawal to nailbed stimuli.\nCV\nHeart rate 70-110's..Lopressor ^^ to 10 mg iv q4 ...captopril to be increased to 12.5 mg tid ...SBP by NBP 120-160's/70's..\nResp\nrr 18-24..shallow ..rare cough ..but swallows sxns ..Lungs diminished and coarse at the bases ..\nGI\nNPO\nGU\nUrine output 60-80 cc q2 ...\nA Remains extubated following VF arrest ..slow neuro recovery\nP Olanzapine qhs..\nMonitor neuro exam\n" }, { "category": "Nursing/other", "chartdate": "2154-04-15 00:00:00.000", "description": "Report", "row_id": 1573585, "text": "Nursing Progress Note\n\nS: \"I'm in the hospital.\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. Lopressor dose changed to 25mg TID. Captopril dose ^'d to 25mg TID. Given ASA and Plavix via feeding tube once placed and confirmed by CXR.\n\nResp: Lungs coarse in bases. Coughing with raising. O2 sats >96% on 3l np.\n\nNeuro: Pt somulent this am. Arousing to his name but not following commands. Later in the shift pt more responsive to family members. Speaking in short sentences nodding appropriately. OOB to chair with slide board x's 3hrs. To be seen by PT in am. All sedation is to be held.\n\nGU/GI: Feeding tube placed by house staff this pm d/t pt lethargy and concern for aspiration. CXR done. TF restarted on Probalance at 20hr for goal rate of 60/hr. Abd is soft with bowel sounds present. No BM today. foley draining dark amber urine.\n\nID: Antibiotics changed to vancomycin and zosyn. + sputum & urine cultures.\n\nSocial: wife and sons in this pm along with several brothers and sisters.\n\nA&P: Stable post extubation. Attempt to hold sedation. Advance tube feeding as tolerated. Cont with POC.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-14 00:00:00.000", "description": "Report", "row_id": 1573582, "text": "Nursing Progress Note\n7 pm - 7 am\nVF Arrest/Anoxic Brain Injury\nPls see careview flowsheet for all obj/numerical data\nCV\nHR 60-90's.. Sinus ..( QTC .49 ) SBP 100-170's/60-80's..Tolerating Captopril/Lopressor..Right radial aline tracing lost ..multiple attmepts to change over wire/re-site unsuccessful.\nResp\nTolerating CPAP/PS ( ) ..RR 14-22 ..Spon Tidal Volumes 500-700' ..Lungs diminished at the bases ..Suctioned q3 fore small amounts of thick tan sxns ..ABG on per flowsheet ...\nGI\nTolerating OGT clamped ..No stool ..\nGU\nUrine output per flowsheet ..Urine foul smelling..\nID\nTemp spike 101.8..Bld Cxs/Urine Cxs sent ..Sputum spec with 3+ GNR\nGiven one gm of tylenol\nNeuro\nOpens eyes to name called .. Does not track.. ( + ) Threat..Does not follow commands ..Bringing arms up toward pillow.. .Requires wrist restraints ..Moving head side to side ..sitting up in bed ...Haldol given times 2 ..Fentanyl 50 mcgs with ETT re-taping ..aline insertion attempts...\nA Tolerating PS Trail in setting of anoxic injury\np Anticipate Extubation\nABX for temp spike\n\n" }, { "category": "Nursing/other", "chartdate": "2154-04-14 00:00:00.000", "description": "Report", "row_id": 1573583, "text": "CCU NPN 7A-7P\nCV: HR 60-100 NSR, no ectopy, BP 120-140/60-70, gave captopril sl, lopressor changed to IV since extubation.\n\nResp: did well on PS5/peep 5 all night with good abg, RSBI 20, pt extubated at 0900, weak cough, RR 20-25, sats 94-99% on 2l NC. LS scattered rhonchi. Increased to 4L NC for ABG post extubation of 73/37/7.44\n\nNeuro: this AM, was nodding head and following simple commands, remained lethargic, arouses to name. After extubation, remains lethargic, family not sure that he recognizes them, moaning at times, coughing and swallowing secretions, opens eyes to name and has responded verbally \"yes\" to some questions but still very sleepy. Seems confused and surprised with each time he is told he has had a heart attack. Had MRI, received 2mg haldol and 1 mg ativan IV in order for test to be done. sice returning from MRI has been more sedate, less easily aroused. ABG without hypercarbia.\n\nGI: unable to take po's. speach and swallow study ordered, will have to wait until pt more alert. (+)BS, no stool. NG asp rior to removal of OGT were brown and heme(+). HCT 32.\n\nGU: vigorous responce to lasix 40mg given at 1630. Being treated for UTI with po cipro(given in AM prior to OGT being dc'd, will need IV AB.\n\nID: T to 100.4 po, cipro for uti, ceftriaxone for gr(-)rods in sputum. WBC 10\n\nSkin: intact. Cont freq turning.\n\nEndo: has not required SS reg ins.\n\nSoc: wife and 3 sons in, encouraged by pts ability to follow commands.\n\na/P: pt doing well so far extubated, may need NT suctioning, follow sats, RR, lung exam, some improvement in neurological state, cont to follow, await MRI report. IV AB for infections(UTI, ?pna). cont inform and support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 1573576, "text": "CCU NPN:please see flowsheet for objective data\n\nCardiac: HR 84-88 IABP mean 86-100 good augmentation and systolic unloading. BP 120-150/60-70's with warming started captopril and lopressor. HR now in 70's.lst CK over \n\nHypothermia protocol: reached rectal temp of 97 at 9:30,vecuronium off. weaning of fent and versed started. fent now at 25mcg/hr and versed 0.5mg/hr.\n\nNeuro: no change in neuro signs. does not open eyes,no movement of any extremity.\n\nResp: last ABG 7.28/47/95 rate increased from 14 to 19.\n\nGU: uo 15-50/hr +1200.\n\nSocial:wife and three sons in to visit,one son is staying overnight in waiting room.\n\nA/P: 61 you man s/p vfib arrest now intubated with IABP,moderate hypothermia applied via artic sun. currently no improvement yet noted in neurologic status.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-13 00:00:00.000", "description": "Report", "row_id": 1573577, "text": "Resp Care Note:\n\nPt cont intub with OETT on mech vent and IABP as per Carevue. Lung sounds ess clear after suct sm th off white sput. ABGs stable after vent adjusted. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-13 00:00:00.000", "description": "Report", "row_id": 1573578, "text": "Nursing Progress Note\n11 pm - 7 am\nVF Arrest/Anoxic injury\nS Orally Intubated\nVecuronium/Fentanyl/Versed off at ~~ 1800 ( ) Opening eyes to Name at 0200.. Episode of biting ETT @ 0500 Unable to ventilate ..Bite block inserted. Slight withdrawal to Nailbed Pressure ...Does not track/focus. Pupils are equal and reactive. Impaired cough. Absent GAG\nCV\nHR 70-90's .SR/ST ..one 3 beat run VT ..K 4.2 ..Calcium repleted. MG 2.1. CK's rising. Remains on IAB. 1:1 mode. Assisted Systole 110-120's.. Augmented diastole 110-120's. BAEDP 60-70. MAPS 90-100's. Systolic Unloading . Good Waveform. Tolerating Captopril\nResp\nAC Mode. Rate of 19. TV 500. Fi02 40% 5 PEEP. Lungs diminished. Suctioned q2-3 hours for moderate amounts thick tan secretions. Rare Overbreathing. Sputum Spec sent.\nGI\nOGT to constant suction. Output bilious ..OB pos. Abd soft ..bowel sounds present. No Stool\nGU\nUrine output 40-80 cc q2 ..concentrated in appearance.\nRight Groin with transparent dsg on...Small amount controlled oozing. Feet Cool..Pulses 3+/2+. HCT stable.\nSon .. stayed overnight, and will call mother in am\nVF Arrest ..Cooling Protocal Complete\nP Hold Sedation if possible. Assess Neuro Recovery\n" }, { "category": "Nursing/other", "chartdate": "2154-04-13 00:00:00.000", "description": "Report", "row_id": 1573579, "text": "CCU NPN 7A-7P\nCV: IABP dc'd at 1130, R groin without bleeding or hematoma, DP/PT pulses palp. HR 70-130 SR/ST, no ectopy. (tachy to 120-130's with agitation). K+, mag and Calcium repleated. BP 95-120/50-60, up to 140-160/ with agitation. Given captopril and lopressor when NG asp reduced and had started reglan. Echo done EF 45%(IVF's increased for rhabdo), CK's down sl to , MB 107\n\nResp: vented, no changes in settings, remains on AC 40%/500x19, 5 peep. LS clear despite suctioning q 2-3 hrs for mid amts of thick tan sputum. Sat 99-100%. PT has strong cough and gag.\n\nNeuro: seen by Dr. from neurology today. PT with (+) dolls eyes, (brain stem intact, but not awake enough to use vision), withdraws to nailbed pressure in all limbs except L arm, Pt opens eyes to speech, does not focus or follow commands, turns away from nocious stimuli. Is becoming very agitated with stimulation, and occ awakes on his own ie: with coughing, becomes very agitated, pulling at restraints, lifting head off bed, coughing, moving about bed. Started haldol , and may use fent/versed prn to prevent self-extubation(use sparingly). Haldol prn, following QTC. Once nocious stimulation over pt does return to sleeping state. Trying verbal reassurances which seem to have some effect.\n\nGI: NG asp decreasing through day, gave po meds and clamped OGT, 2 hours after residual 50cc. Reglan started. Aspirates are brown and trace (+), Bowel sounds present, no stool. NPO.\n\nGU: UO remains marginal, IVF's increased to 250cc/hr. BUN/Cr 18/0.9\n\nID: afebrile, cont to have thick tan sputum.\n\nEndo: BS 140-150's, cov with 2 u reg at 12n.\n\nSkin: intact. Becomes very diaphoretic with episodes agitation. Cont freq turning.\n\nSoc: wife and 2 sons in, they have been updated by RN/MD, Dr (neuro) spoke with them stating that with the responces he is having now he has a ~50% chance of meaningful neurological recovery, that the next several days will be difficult as pt will be delerious, agitated, and that hopefully this will improve over time. Family now understanding that this may be a long including rehab.\n\nA/P: 61 yr old s/p VF arrest in field with bystander CPR, LAD stented, s/p coolingx18hrs, remains intubated, now off IABP, hemodynamically stable. Closely follow neuro status/recovery, sedatives as needed for pt safety though will need to move from narcs/benzos to agents like haldol, zyprexa. Dr. will be back on Tues to follow-up, available by pager for assistance with agitation management.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-13 00:00:00.000", "description": "Report", "row_id": 1573580, "text": "Resp Care: pt remains intubated via #7 ETT advanced to 27cm at lip, MD . Pt having periods of SEVERE agitation/diaphoresis requiring sedation to advance and retape ETT. Team Present. Pt vomitted in AM. Sx'd vomitus from ETT per nsg report. BS bilat rhonchi. Sx'd for lg amts thick tan/yellow/ rusty sputum. RSBI was UTO in AM. Most recent ABG WNL. No vent changes made this shift. Plan: cont vent support. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-14 00:00:00.000", "description": "Report", "row_id": 1573581, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct mod th tan sput. ABGs stable on PSV. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 1573571, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear. ABGs stable after vent adjusted. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 1573572, "text": "CCU NPN 1900-0700 ADMIT\nO: 60yo male with (+) Family hx, (+) ETT per family, s/p witnessed arrest .\nPMH: ? high chol. on lipitor at home. (+) tob. quit 15yrs ago. , per son, pt. has had episodes of SOB/CP in past. had stress test which was positive. social drink.\n\nHPI: doing yard work with friend when pt. had friend went for ASA in house, came back and witnessed pt. falling to ground. called 911 and did CPR with instructions from 911. EMS arrived 5-10min. pulseless: intubated. asystole-epi/atropine->vfib->shock x10. started lido/amio.\nEW: ASA, plavix, started integrillin. cath lab occluded LAD- stent x2. IABP placed. integrillin d/c'd d/t bloody nose.\ntransferred to for cooling MI.\n\nCCU: Arrived approx. 1830 from OSH. IABP/intubated.\ncooling with Artic Sun initiated at with target temp 34c. propofol was started and titrated up to 90mcq/k/min per protocol to prevent shivering/resisting rx. HR initially 100- down to 85 after cooling started. MAP 85->56 within 1hr of cooling.\nvecuronium was started as adjuct with sedation per protocol with IVB and gtt at .05mcq/k/hr.\nMAPS contin. to stay low 60-63 while on propofol. given 500cc NSbolus x2 with minimal effect.\ndecision made to change to fent/versed at 0100. MAPS coming up to 90-120. HR 46-55SB with episodes of AIVR 4-10bts. K+ 5.1 , Mg+ 2.0.\nHO aware. AM lytes pnd at 0500.\n\nIABP 1:1, good augemtation and unloading. MAPS contin. to be high despite increase in sedation. given captopril 6.25 at 0500- results pnd.\n\nartic sun: achieved target temp approx. 2230- goal to stay at target for 18hrs.\n\nintegrillin started without bolus at 1mcq/k/min (renal) for total 18hrs.\nCPK 3348/124. HCT 42.7\n\nResp: CXR showing good position of ETT. retaped at 21lip. scant to no secretions initially. 0500, suctioned for small amt. thin tan secretions. suctioning bloody secretions from mouth although cannot visualize any lesions/cuts\nLS clear to diminished.\nABG 7.38/28/207 on 600x20-> changed to 600x17/5peep/.40. ABG 7.35/31/173.\n\nGU: foley draining concentrated 20cc/hr, then increasing to 50-80cc/hr with higher MAPS. Creatinine 1.2 on admit.\nGI: NGT advanced ~ 4cm MD CXR report. repeat CXR to be done this AM- pnd at 0530. . small amt. of clear liq. aspirated.\n\nNeuro: paralyzed/sedated. fent. currently at 150mcq/k/min and versed at 4mg/hr. also using boluses as needed when shivering detected on cooling maching. good effect. no movement. no cough/gag. pupils 2mm and brisk.\nskin: intact. right fem. IABP site D/I.\npulses Doppler bilat. ABI's .7-.8. extrem. cool/pale. unable to get periph. O2 sats.\n\nsocial: 2 sons visited and updated by MD . wife staying home with 3rd son. will come in today. lives in . works for .\n\nA/P: s/p arrest/MI. stable hemodynamics on IABP and cooling Artic Sun for neuro protection.\n- contin. cooling for total 18hrs per protocol. cont. integrillin x18hr total. titrate fent/versed to achie\n" }, { "category": "Nursing/other", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 1573573, "text": "CCU NPN 1900-0700 ADMIT\n(Continued)\nve adaquate sedation/no shivering.\n- follow u/o, GI aspirates. CXR pnd for NGT check.\n- contin. to cycle CK's, lytes, coags.\n- family support/updating .\ncontin. IABP support.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 1573574, "text": "Nursing Progress Note\n\nS: Pt remains intubated and sedated.\n\nO: Please see flow sheet for objective data. Tele remains in sinus brady 40's -50's with occ PVC and short runs of IVR. Hemodynamically stable. IABP remains on 1: 1 with minimal augmentation. R groin is C&D distal pulses are dopplerable. Integrilin dc'd at 1pm IV Heparin started this am at 1200u/hr without a bolus. ASA and Plavix given this am. BB and ace held while pt is being cooled. Ck 8630 222 MB's. K Mg and Ca repleted.\n\nResp: Pt remains intubated A/C 40% 500 14 5. Lungs are CTA. Suctioned for scant amt of bld tinged sputum. Please see flow sheet for abgs.\n\nNeuro: Pt paralyzed and sedated as per protocol for cooling x's 18hrs post VF arrest. No shivering noted. At 430 pm pt started to be warmed back to 37c over 6.5 hrs. Vecuronium is at .05mcgs/kg/min Fentanyl at 100mcgs/hr and Versed at 3mg/hr. Pt not responsive to TOF. Baseline not able to be obtained.\n\nGU/GI: Pt is NPO. Bleeding noted from mouth and R nares. OGT draining coffee ground material quiac pos. Abd is soft with hypoactive bowel sounds. Foley draining amber colored urine with sediment. Creat .9 this am. Pt received 500NS bolus prior to beginning of rewarming.\n\nEndo: RISS no need for coverage.\n\nSocial: Wife and sons in off and on throughout the day. Updated by MD .\n\nA&P: 62 yo man s/p VF arrest and PCI to LAD now undergoing cooling post arresst. Cont with rewarming as per protocol. Cont to assess hemodynamics. Monitor lytes closely. dc vecuronium once temp >97. Lightened sedation as tolerated. ? dc IABP in am. ? head CT in am.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 1573575, "text": "REspiratory Care\nPt remains on A/c vent weaned to 500 X 14 5 peep 40% , Pt will be warmed over 6 hour period. last abg 730/39/121/20/-.\n" }, { "category": "Echo", "chartdate": "2154-04-13 00:00:00.000", "description": "Report", "row_id": 81668, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p VT/VF arrest and 10 shock. 100% occl LAD.\nWeight (lb): 176\nBP (mm Hg): 122/61\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 14:33\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 thicknesses and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; anterior apex - hypo; septal apex - hypo; apex - hypo;\nremaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the distal half of the septum, distal anterior\nwall, and apex. The remaining left ventricular segments contract normally. No\napical aneurysm or thrombus is seen. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are structurally normal. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD\nlesion). 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": "2154-04-15 00:00:00.000", "description": "Report", "row_id": 200314, "text": "Sinus rhythm. Delayed anterior precordial R wave progression with deep T wave\ninversions in the anterior precordial leads. Compared to the previous tracing\nof QRS duration has now normalized with marked repolarization\nabnormalities in the anterior precordial leads suggestive of an ischemic\nprocess, possibly acute.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2154-04-15 00:00:00.000", "description": "Report", "row_id": 200315, "text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2154-04-14 00:00:00.000", "description": "Report", "row_id": 200316, "text": "Sinus rhythm.\nLeft bundle branch block\nSince previous tracing of , anterolateral T wave abnormalities less\nprominent\n\n" }, { "category": "ECG", "chartdate": "2154-04-13 00:00:00.000", "description": "Report", "row_id": 200317, "text": "Sinus tachycardia, rate 75. Since the previous tracing of the heart\nrate is faster. The QRS complexes are widened to an incomplete left\nbundle-branch block pattern. Deep T wave inversions are now limited to the\nlateral precordium.\n\n\n" }, { "category": "ECG", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 200318, "text": "Sinus bradycardia, rate 47. Since the previous tracing the heart rate has\nslowed somewhat. The Q-T interval is further prolonged. Deep T wave inversions\nare now seen in leads I, aVL and V4-V5 as well.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2154-04-12 00:00:00.000", "description": "Report", "row_id": 200319, "text": "Sinus rhythm, rate 54. The Q-T interval is prolonged. Borderline first degree\nheart block. Deep T wave inversions awre seen over the anterior and\nmid-precordium. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2154-04-16 00:00:00.000", "description": "Report", "row_id": 200312, "text": "Sinus rhythm. Compared to the previous tracing of QRS complex has\nnarrowed, again with repolarization abnormalities in the anterior precordial\nleads suggestive of an acute ischemic process.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2154-04-16 00:00:00.000", "description": "Report", "row_id": 200313, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof left bundle-branch block has returned.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2154-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911617, "text": " 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement and re-eval consolidation vs. effusions\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ETT tube s/p MI with stent to 100% occluded LAD and VT\n arrest requiring shocks.\n REASON FOR THIS EXAMINATION:\n ETT placement and re-eval consolidation vs. effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post shock treatment for VT arrest.\n\n COMPARISON: .\n\n FINDINGS: Pulmonary edema has resolved. The tip of the aortic pump lies 7 cm\n below the top of the aortic arch. There are no pleural effusions. The\n cardiac and mediastinal silhouettes are within normal limits. NG tube has\n been advanced into the stomach, and an ET tube is unchanged in position.\n\n IMPRESSION: 1) Improved pulmonary edema.\n 2) Low lying intra-aortic balloon pump. Dr. and I discussed these\n findings over the telephone on .\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-12 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 911609, "text": " 4:58 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: please evaluate placement of NG tube\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p MI/vfib arrest, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate placement of NG tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISON: Evaluation of the lungs and osseous structures limited secondary\n to exposure. Again seen is NG tube tip just above the gastroesophageal\n junction with side port within the mid-to-lower mediastinum. Endotracheal\n tube tip in similar position. Overall, mediastinal contours are grossly\n unchanged. However, recommend dedicated chest film if there is concern within\n the thorax. No free air. Distended stomach.\n\n IMPRESSION: Nasogastric tube tip located just above the gastroesophageal\n junction. Recommend advancing. No evidence of free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911754, "text": " 7:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated man, please eval ETT placement and for any other l\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ETT tube s/p MI with stent to 100% occluded LAD and VT\n arrest requiring shocks.\n REASON FOR THIS EXAMINATION:\n Intubated man, please eval ETT placement and for any other lung pathology\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:50 A.M. \n\n HISTORY: ET tube placement. Status post MI with stent.\n\n IMPRESSION: AP chest compared to and 12:\n\n Tip of the endotracheal tube is between 2 and 3 cm above the upper margin of\n the clavicles and approximately 10 cm from the carina, 5 cm above optimal\n placement.\n\n Tip of the intra-aortic balloon pump projects just superior to the level of\n the left main bronchus, between 4 and 5 cm from the apex of the aortic knob.\n Nasogastric tube is looped in the stomach.\n\n Overall heart size is mildly enlarged with probable left ventricular\n dilatation, not changed appreciably over 48 hours. Mild pulmonary edema has\n recurred with slightly lower lung volumes, so that changes in positive\n pressure ventilation support may be responsible. There is no pleural\n effusion.\n\n Dr. paged to report these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911970, "text": " 1:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p vfib arrest LAD occlusion, s/p extubation with\n fevers now s/p NGT placement\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF AT 13:50\n\n COMPARISON: , 7:28 a.m.\n\n INDICATION: Nasogastric tube placement.\n\n A nasogastric tube is in place, terminating in the region of the\n gastroduodenal junction. Cardiac and mediastinal contours are stable. There\n is improving aeration at both bases with residual patchy and linear\n atelectasis remaining. A small left effusion is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911916, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for CHF vs. PNA in this pt with increasingly\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p vfib arrest LAD occlusion, s/p extubation with\n fevers\n REASON FOR THIS EXAMINATION:\n Please evaluate for CHF vs. PNA in this pt with increasingly coarse BS.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:28 A.M., \n\n HISTORY: V-fib arrest. CHF or pneumonia. Increasingly coarse breath sound.\n\n IMPRESSION: AP chest compared to and 14:\n\n The increasing opacification at both lung bases can be explained by\n atelectasis and dependent edema, though pneumonia cannot be excluded, since\n there is persistent engorgement of mediastinal veins and upper lobe pulmonary\n vessels. Small left pleural effusion is present. No pneumothorax.\n\n Mild tubulated narrowing of the subglottic and upper trachea has been evident\n since extubation on and could be due to that or previous intubation as\n well as enlargement of the thyroid gland.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911879, "text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p vfib arrest LAD occlusion, s/p extubation with\n fevers\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 15:48\n\n INDICATION:\n\n Fevers after extubation.\n\n COMPARISON: .\n\n FINDINGS: Lines and tubes have been removed. There is no PTX. There is some\n increased retrocardiac density compared to prior and differentiating\n atelectasis from pneumonia is not possible. No other significant interval\n changes are noted; the current study is obtained with a shallower level of\n inspiration. Pulmonary vascular markings are somewhat prominent but no\n different than prior.\n\n IMPRESSION:\n\n Increased density in the retrocardiac region - atelectasis versus pneumonia.\n No other significant interval changes.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-14 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 911877, "text": " 2:13 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: wish to assess amount of anoxic injury\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cardiac arrest, neurologic function depressed.\n REASON FOR THIS EXAMINATION:\n wish to assess amount of anoxic injury\n ______________________________________________________________________________\n FINAL REPORT\n MRI SCAN OF THE BRAIN AND MR ANGIOGRAPHY\n\n HISTORY: Cardiac arrest and depressed neurologic function.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained.\n\n COMPARISON STUDIES: None.\n\n FINDINGS: There is a solitary punctate area of elevated signal on diffusion-\n weighted scanning in the left periatrial white matter. As this finding is\n also noted on the conventional images, it may merely represent T2 shine\n through. Within the limitations of the ADC map, this area is not hypointense.\n Thus, taken together, the findings do not appear to be typical for acute brain\n ischemia. The conventional images also show scattered tiny foci of elevated\n T2 signal within the white matter of both cerebral hemispheres, mostly in a\n subcortical location. While nonspecific in etiology, given patient age,\n chronic microvascular infarction would appear to be the most likely diagnosis.\n There is no major vascular territorial infarct noted. There is no\n hydrocephalus or shift of normally midline structures. There is near total\n loss of aeration of all of the paranasal sinuses. Has patient been intubated?\n Much less loss of aeration is seen, possibly for similar reasons, within the\n mastoid sinuses.\n\n CONCLUSION: No major vascular territorial infarct seen. Other findings as\n noted above.\n\n MR ANGIOGRAPHY OF THE CIRCLE OF AND ITS TRIBUTARIES\n\n TECHNIQUE: Three-dimensional time-of-flight imaging with multiplanar\n reconstructions.\n\n FINDINGS: This study is of limited quality due to extensive contamination by\n T1 hyperintense fat. Allowing for this limitation, no definite vascular\n pathology is seen.\n\n\n\n (Over)\n\n 2:13 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: wish to assess amount of anoxic injury\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2154-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911574, "text": " 6:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval placement\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ETT tube\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube, evaluate placement.\n\n COMPARISON: None.\n\n PORTABLE AP SUPINE CHEST RADIOGRAPH: An endotracheal tube is seen with tip\n terminating approximately 5.3 cm above the carina. A nasogastric tube tip is\n seen at the gastroesophageal junction and should be advanced for more optimal\n placement. Note is made of intra-aortic ballon pump. There is pulmonary edema.\n No pneumothorax or pleural effusion is seen on this supine image. Heart is\n not enlarged. Air in seen within the stomach lumen, likely related to recent\n intubation.\n\n IMPRESSION:\n 1. Endotracheal tube in appropriate position. Nasogastric tube tip is at the\n gastroesophageal junction and should be advanced for more optimal placement.\n 2. Interstitial pulmonary edema.\n\n Findings discussed with Dr. at 7:35pm .\n\n" } ]

[ { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590004, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguionous fluid\n /hr.\n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis with PA line dc\nd. R radial arterial line dc\n Response:\n Tolerating lopressor.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Physician ", "chartdate": "2137-08-24 00:00:00.000", "description": "ICU Note - CVI", "row_id": 590006, "text": "CVICU\n HPI:\n 65M POD 1-CABGx2(LIMA->LAD, SVG->PDA)\n Chief complaint:\n PMHx:\n HTN, dyslipidemia, TIA, glucose intolerance,varicaose veins,ED, R\n shoulder pain, Bell's Palsy, s/p R veing stripping, s/p L groin lipoma\n Current medications:\n Acetaminophen , Aspirin EC ,Calcium Gluconate ,CefazoLIN, Clopidogrel\n ,Dextrose 50% ,Docusate Sodium, Furosemide ,Insulin , Ketorolac ,\n Lescol , Magnesium Sulfate ,Metoprolol Tartrate ,Metoclopramide ,Milk\n of Magnesia , Morphine Sulfate, Nitroglycerin ,Oxycodone-Acetaminophen\n , Phenylephrine ,Pneumococcal Vac Polyvalent , Potassium Chloride ,\n Ranitidine , Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 12:15 PM\n from or\n CORDIS/INTRODUCER - START 12:15 PM\n PA CATHETER - START 12:15 PM\n ARTERIAL LINE - START 12:15 PM\n OR RECEIVED - At 12:15 PM\n INVASIVE VENTILATION - START 12:15 PM\n NASAL SWAB - At 12:30 PM\n EKG - At 12:52 PM\n EXTUBATION - At 05:15 PM\n INVASIVE VENTILATION - STOP 05:15 PM\n Post operative day:\n POD#1 - 2 v cabg lima to lad and svg to pda\n Allergies:\n Zestril (Oral) (Lisinopril)\n Wheezing;\n Statins-Hmg-Coa Reductase Inhibitors\n muscle aches wi\n Last dose of Antibiotics:\n Cefazolin - 05:15 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:33 PM\n Morphine Sulfate - 12:23 AM\n Other medications:\n Flowsheet Data as of 11:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.9\nC (98.4\n HR: 83 (52 - 89) bpm\n BP: 121/67(80) {119/64(79) - 133/68(83)} mmHg\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 4 (1 - 10) mmHg\n PAP: (23 mmHg) / (9 mmHg)\n CO/CI (Thermodilution): (8.52 L/min) / (4.2 L/min/m2)\n SVR: 601 dynes*sec/cm5\n SV: 108 mL\n SVI: 53 mL/m2\n Total In:\n 5,867 mL\n 399 mL\n PO:\n 180 mL\n Tube feeding:\n IV Fluid:\n 5,367 mL\n 219 mL\n Blood products:\n 500 mL\n Total out:\n 2,572 mL\n 975 mL\n Urine:\n 1,485 mL\n 875 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,295 mL\n -576 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 97%\n ABG: 7.36/35/186/24/-4\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 : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 209 K/uL\n 10.9 g/dL\n 80 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 11 mg/dL\n 108 mEq/L\n 138 mEq/L\n 32.6 %\n 9.6 K/uL\n [image002.jpg]\n 11:07 AM\n 11:25 AM\n 11:32 AM\n 12:44 PM\n 12:45 PM\n 03:44 PM\n 04:53 PM\n 06:18 PM\n 01:16 AM\n WBC\n 4.8\n 7.5\n 9.6\n Hct\n 30\n 29.2\n 32\n 30.0\n 31.1\n 32.6\n Plt\n 174\n 191\n 209\n Creatinine\n 0.6\n 0.6\n TCO2\n 26\n 24\n 25\n 18\n 21\n Glucose\n 143\n 114\n 102\n 116\n 80\n Other labs: PT / PTT / INR:13.8/40.5/1.2, Fibrinogen:267 mg/dL, Lactic\n Acid:3.1 mmol/L\n Imaging: CXR: clear, lines in good position\n Microbiology: Neg\n Assessment and Plan\n H/O ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ),\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: Pt. doing very well post op. Chest tubes d/c'd\n without incident. Start Lopressor and Lasix. Transfer to F6. Will\n have pt.'s wife bring in Lescol as pt. has muscle pain with other\n statins.\n Neurologic:\n Cardiovascular: Aspirin, , Statins, Pt.'s wife to bring in\n Lescol.\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Neg\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires, Chest tubes d/c'd without incident.\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 20 Gauge - 05:14 AM\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": "2137-08-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589948, "text": "Coronary artery bypass graft (CABGx2, lima->lad & svg->pda)\n Assessment:\n To cvicu Intubated & sedated on Propofol. Apaced. Low dose neo for\n bp support. Ci 1.8. ct w/mod amt drainage during transport. Lungs\n clear. Abg\ns good. Abd soft. Absent bs. Og w/scant amt clear\n drainage, +placement by xray per pa. Adequate uop. +pp bilat.\n Action:\n Medicated w/morphine prn. Labile bp treated w/neo, fluid, ntg. Peep\n increased to 10upon arrival per dr . Ci treated w/ivf.\n Reversals given vent weaned. Bs 176, insulin gtt started per protocol.\n Response:\n Good effect from morphine. Currently on ntg 0.5mcg/kg/min. lopressor\n iv given x1. ci>2.0. hct stable. Extubated to oft, sat\ns>95%.\n A&ox3. mae.\n Plan:\n Pain management. Cont to monitor hemodynamics, resp status, i&o,\n labs. Insulin gtt per protocol. ?deline & transfer to floor in am.\n" }, { "category": "Respiratory ", "chartdate": "2137-08-23 00:00:00.000", "description": "Generic Note", "row_id": 589942, "text": "TITLE: Resp. Care Note\n Pt received from OR S/P CABG, intubated and vented on settings as per\n Resp. flowsheet. Pt stable post-op and weaned per fask track protocol.\n Extubated to 50% face tent.\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590020, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguionous fluid\n /hr.\n BS 119 at 1130\n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis with PA line dc\nd. R radial arterial line dc\n Chest tubes dc\nd by PA.\n OOB to chair with 1 assist, no change in vital signs.\n 2 units regular insulin sc at 1145.\n Response:\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when gotten up to chair. Skin W&D, no change\n in VS.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590010, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguionous fluid\n /hr.\n BS 119 at 1130\n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis with PA line dc\nd. R radial arterial line dc\n Chest tubes dc\nd by PA.\n OOB to chair with 1 assist.\n 2 units regular insulin sc at 1145.\n Response:\n Tolerating lopressor.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 589955, "text": "Coronary artery bypass graft (CABG) NEURO PT A/O RELAXED TALKATIVE IN\n GOOD SPIRITS C/O CHEST PAIN AT SITE OF MSO4 USED RESULTS MD\n CALLED AND UP DATED TORADOL ORDERED AND USED SLEPT WELL THRU SHIFT MAE\n NO ISSUES AT THIS TIME\n HEART\n S1S2 DISTANT NSR PR .16 QRS .08 QT WNL FOR AGE AND GENDER PA LOW VALUES\n WITH NORMAL CI AND SVR SYS BP STABLE NOW ON PO LOPRESSOR NTG WEAN TO\n OFF MD ORDER TO KEEP SYS BP LESS THAN 136 PULSES DOPPLER FEET WARM CT\n SCANT DRAINAGE NO LEAK OR CREP\n RESP\n CLEAR DIM AT BASELINE WEAN TO NP SAO2 TOL CPT WELL\n GI POS\n B/S THRU OUT PO WELL SOFT NON TENDOR\n PLAN\n SUPPORTIVE WEAN INSULIN DRIP TO OFF DE LINE PROGRESSIVE\n CARE PT AMBULATE FAMILY SUPPORT\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590043, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguionous fluid\n /hr.\n BS 119 at 1130\n Rating pain \n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis with PA line dc\nd. R radial arterial line dc\n Chest tubes dc\nd by PA.\n OOB to chair with 1 assist, no change in vital signs.\n 2 units regular insulin sc at 1145.\n Percocet 2 po at 0900 and 1630.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 84 kg\n Daily weight:\n Allergies/Reactions:\n Zestril (Oral) (Lisinopril)\n Wheezing;\n Statins-Hmg-Coa Reductase Inhibitors\n muscle aches wi\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: dyslipidemia, TIA , glucose intolerance,\n varicose veins, erectile dysfunction, right shoulder pain, bell's\n palsy.\n surgical: vein stripping right gsv, left groin lipoma s/p surgery &\n radiation \n Surgery / Procedure and date: s/p cabg x2. lima->lad, svg->pda.\n intubation using glidoscope w/o difficulty (h/o difficult intubation).\n cpb 50\" xc 41\". no prob off pump. ivf 2800cc, kefzol x2 ld at 1200,\n 500cs, uop 730. to cvicu intubated on propofol & neo. apaced. ct\n w/mod amt drain from or->cvicu, peep increased to 10.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:66\n Temperature:\n 97\n Arterial BP:\n S:129\n D:51\n Respiratory rate:\n Heart Rate:\n 77 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 50% %\n 24h total in:\n 1,099 mL\n 24h total out:\n 1,565 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 58 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular sensitivity setting:\n 2 mV\n Temporary ventricular stimulation threshold :\n 7 mA\n Temporary ventricular stimulation setting :\n 14 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 22\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:16 AM\n Potassium:\n 4.3 mEq/L\n 01:16 AM\n Chloride:\n 108 mEq/L\n 01:16 AM\n CO2:\n 24 mEq/L\n 01:16 AM\n BUN:\n 11 mg/dL\n 01:16 AM\n Creatinine:\n 0.6 mg/dL\n 01:16 AM\n Glucose:\n 80 mg/dL\n 01:16 AM\n Hematocrit:\n 32.6 %\n 01:16 AM\n Finger Stick Glucose:\n 119\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Response:\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when gotten up to chair. Skin W&D, no change\n in VS. ambulated ~ 30 fet.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590044, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguinous fluid\n /hr.\n BS 119 at 1130\n Rating pain \n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis with PA line dc\nd. R radial arterial line dc\n Chest tubes dc\nd by PA.\n OOB to chair with 1 assist, no change in vital signs.\n 2 units regular insulin sc at 1145.\n Percocet 2 po at 0900 and 1630.\n Response:\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when gotten up to chair. Skin W&D, no change\n in VS. ambulated ~ 30 fet.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when gotten up to chair. Skin W&D, no change\n in VS. ambulated ~ 30 fet.\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 84 kg\n Daily weight:\n Allergies/Reactions:\n Zestril (Oral) (Lisinopril)\n Wheezing;\n Statins-Hmg-Coa Reductase Inhibitors\n muscle aches wi\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: dyslipidemia, TIA , glucose intolerance,\n varicose veins, erectile dysfunction, right shoulder pain, bell's\n palsy.\n surgical: vein stripping right gsv, left groin lipoma s/p surgery &\n radiation \n Surgery / Procedure and date: s/p cabg x2. lima->lad, svg->pda.\n intubation using glidoscope w/o difficulty (h/o difficult intubation).\n cpb 50\" xc 41\". no prob off pump. ivf 2800cc, kefzol x2 ld at 1200,\n 500cs, uop 730. to cvicu intubated on propofol & neo. apaced. ct\n w/mod amt drain from or->cvicu, peep increased to 10.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:66\n Temperature:\n 97\n Arterial BP:\n S:129\n D:51\n Respiratory rate:\n Heart Rate:\n 77 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 50% %\n 24h total in:\n 1,099 mL\n 24h total out:\n 1,565 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 58 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular sensitivity setting:\n 2 mV\n Temporary ventricular stimulation threshold :\n 7 mA\n Temporary ventricular stimulation setting :\n 14 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 22\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:16 AM\n Potassium:\n 4.3 mEq/L\n 01:16 AM\n Chloride:\n 108 mEq/L\n 01:16 AM\n CO2:\n 24 mEq/L\n 01:16 AM\n BUN:\n 11 mg/dL\n 01:16 AM\n Creatinine:\n 0.6 mg/dL\n 01:16 AM\n Glucose:\n 80 mg/dL\n 01:16 AM\n Hematocrit:\n 32.6 %\n 01:16 AM\n Finger Stick Glucose:\n 119\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Response:\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when gotten up to chair. Skin W&D, no change\n in VS. ambulated ~ 30 fet.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590046, "text": "Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 84 kg\n Daily weight:\n Allergies/Reactions:\n Zestril (Oral) (Lisinopril)\n Wheezing;\n Statins-Hmg-Coa Reductase Inhibitors\n muscle aches wi\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: dyslipidemia, TIA , glucose intolerance,\n varicose veins, erectile dysfunction, right shoulder pain, bell's\n palsy.\n surgical: vein stripping right gsv, left groin lipoma s/p surgery &\n radiation \n Surgery / Procedure and date: s/p cabg x2. lima->lad, svg->pda.\n intubation using glidoscope w/o difficulty (h/o difficult intubation).\n cpb 50\" xc 41\". no prob off pump. ivf 2800cc, kefzol x2 ld at 1200,\n 500cs, uop 730. to cvicu intubated on propofol & neo. apaced. ct\n w/mod amt drain from or->cvicu, peep increased to 10.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:66\n Temperature:\n 97\n Arterial BP:\n S:129\n D:51\n Respiratory rate:\n Heart Rate:\n 77 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 50% %\n 24h total in:\n 1,099 mL\n 24h total out:\n 1,565 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 58 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular sensitivity setting:\n 2 mV\n Temporary ventricular stimulation threshold :\n 7 mA\n Temporary ventricular stimulation setting :\n 14 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 22\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:16 AM\n Potassium:\n 4.3 mEq/L\n 01:16 AM\n Chloride:\n 108 mEq/L\n 01:16 AM\n CO2:\n 24 mEq/L\n 01:16 AM\n BUN:\n 11 mg/dL\n 01:16 AM\n Creatinine:\n 0.6 mg/dL\n 01:16 AM\n Glucose:\n 80 mg/dL\n 01:16 AM\n Hematocrit:\n 32.6 %\n 01:16 AM\n Finger Stick Glucose:\n 119\n 12:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CVICU 795\n Transferred to:\n Date & time of Transfer: \n Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguinous fluid\n /hr.\n BS 119 at 1130\n Rating pain \n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis and PA line dc\nd. R radial arterial line dc\n Chest tubes dc\nd by PA.\n OOB to chair with 1 assist, no change in vital signs. Ambulated ~ 30\n feet.\n 2 units regular insulin sc at 1145.\n Percocet 2 po at 0900 and 1630.\n Response:\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when up to chair. Skin W&D, no change in VS.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Nursing", "chartdate": "2137-08-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 590047, "text": "Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 84 kg\n Daily weight:\n Allergies/Reactions:\n Zestril (Oral) (Lisinopril)\n Wheezing;\n Statins-Hmg-Coa Reductase Inhibitors\n muscle aches wi\n Precautions:\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: dyslipidemia, TIA , glucose intolerance,\n varicose veins, erectile dysfunction, right shoulder pain, bell's\n palsy.\n surgical: vein stripping right gsv, left groin lipoma s/p surgery &\n radiation \n Surgery / Procedure and date: s/p cabg x2. lima->lad, svg->pda.\n intubation using glidoscope w/o difficulty (h/o difficult intubation).\n cpb 50\" xc 41\". no prob off pump. ivf 2800cc, kefzol x2 ld at 1200,\n 500cs, uop 730. to cvicu intubated on propofol & neo. apaced. ct\n w/mod amt drain from or->cvicu, peep increased to 10.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:66\n Temperature:\n 97\n Arterial BP:\n S:129\n D:51\n Respiratory rate:\n Heart Rate:\n 77 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 50% %\n 24h total in:\n 1,099 mL\n 24h total out:\n 1,565 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 58 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular sensitivity setting:\n 2 mV\n Temporary ventricular stimulation threshold :\n 7 mA\n Temporary ventricular stimulation setting :\n 14 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 22\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:16 AM\n Potassium:\n 4.3 mEq/L\n 01:16 AM\n Chloride:\n 108 mEq/L\n 01:16 AM\n CO2:\n 24 mEq/L\n 01:16 AM\n BUN:\n 11 mg/dL\n 01:16 AM\n Creatinine:\n 0.6 mg/dL\n 01:16 AM\n Glucose:\n 80 mg/dL\n 01:16 AM\n Hematocrit:\n 32.6 %\n 01:16 AM\n Finger Stick Glucose:\n 119\n 12:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CVICU 795\n Transferred to:\n Date & time of Transfer: \n Coronary artery bypass graft (CABG)\n Assessment:\n A&O x 3, MAE, pleasant and cooperative.\n Afebrile, NSR 70-80\ns, no ectopy. SBP 120-130\ns. pedal pulses palpated\n x 4. Epicardial A & V wires both working appropriately, see metavision\n for settings.\n Lungs crackles bases, using IS to 750cc, strong productive cough,\n swallows secretions. Chest tubes draining 0-20cc serosanguinous fluid\n /hr.\n BS 119 at 1130\n Rating pain \n Action:\n Metoprolol 12.5mg po at 0800.\n A back-up rate 52.\n RIJ cordis and PA line dc\nd. R radial arterial line dc\n Chest tubes dc\nd by PA.\n OOB to chair with 1 assist, no change in vital signs. Ambulated ~ 30\n feet.\n 2 units regular insulin sc at 1145.\n Percocet 2 po at 0900 and 1630.\n Response:\n Hemodynamically stable.\n Tolerating lopressor.\nI feel a little dizzy\n when up to chair. Skin W&D, no change in VS.\n Plan:\n OOB to chair. Transferred to 6 to continue cardiopulmonary rehab.\n Case management, PT to follow for discharge needs.\n" }, { "category": "Echo", "chartdate": "2137-08-23 00:00:00.000", "description": "Report", "row_id": 60156, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraop CABG\nStatus: Inpatient\nDate/Time: at 10:28\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic 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. Focal calcifications in ascending aorta. Normal aortic arch\ndiameter. Complex (>4mm) atheroma in the aortic arch. Mildly dilated\ndescending aorta. Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: 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:\nPre Bypass: The left atrium and right atrium are normal in cavity size. No\natrial septal defect is seen by 2D or color Doppler. There is mild symmetric\nleft ventricular hypertrophy. The left ventricular cavity size is normal.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. There are complex (>4mm) atheroma in the aortic\narch. The descending thoracic aorta is mildly dilated. There are complex\n(>4mm) atheroma in the descending thoracic aorta. There are three aortic valve\nleaflets. There is no aortic valve stenosis. Trace aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nPost Bypass: Preserved biventricular function, LVEF >55%. MR remains mild.\nAortic contours intact. Remaining exam is unchanged. All findings discussed\nwith surgeons at the time of the exam.\n\n\n" }, { "category": "ECG", "chartdate": "2137-08-23 00:00:00.000", "description": "Report", "row_id": 108478, "text": "Baseline artifact. Probable sinus rhythm. Low amplitude P waves. Low voltage\nthroughout. Intraventricular conduction delay. Leftward axis. RSR' pattern in\nlead V1. Atypical right bundle-branch block type. Since the previous tracing\nof the axis is more leftward. The intraventricular conduction delay is\nmore prominent. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2137-08-25 00:00:00.000", "description": "Report", "row_id": 108429, "text": "Atrial fibrillation with rapid ventricular response. Non-specific\nintraventricular conduction delay. Non-specific ST-T wave changes.\nCompared to tracing #1 RSR' pattern is now absent in leads V1-V2.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2137-08-25 00:00:00.000", "description": "Report", "row_id": 108430, "text": "Atrial fibrillation with rapid ventricular response. RSR' pattern in\nleads V1-V2 - consider incomplete right bundle-branch block. Non-specific\nST-T wave changes. Compared to the previous tracing of rapid atrial\nfibrillation and ST-T wave changes are new.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2137-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1093505, "text": " 12:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Patient with removal of chest tube. Evaluate for pneumothorax.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There has been interval removal of the left basilar chest tube. No\n pneumothorax is identified. There is a left retrocardiac opacity and a small\n left-sided pleural effusion. There are no signs for overt pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-08-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1093351, "text": " 12:54 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact #- will be in CVICU appro\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p cabg x2\n REASON FOR THIS EXAMINATION:\n postop film-contact #- will be in CVICU approx. 12PM - please\n call first\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest port line placement.\n\n REASON FOR EXAM: 65-year-old man following CABG.\n\n FINDINGS: In comparison to the preoperative chest radiograph, there is a new\n Swan-Ganz catheter in satisfactory position. The ET tube is satisfactory with\n its tip at the thoracic inlet and 5.2 cm above the carina. There is a left-\n sided chest drain. No pneumothorax. Normal postoperative appearances in the\n mediastinum including widening of the superior mediastinum and\n pneumomediastinum are noted. The lungs are fully expanded and clear.\n\n IMPRESSION: Normal appearances post-CABG with pneumomediastinum and widening\n of the superior mediastinum. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2137-08-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1093822, "text": " 4:19 PM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man S/P CABG\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, please evaluate interval change.\n\n Comparison is made to the prior study of .\n\n Finidngs: The small right apical pneumothorax is unchnaged. Small to moderate\n left pleural effusion is increasing. The elevated left hemidiaphragm is\n unchanged. The heart size is normal, aorta is tortuous.\n\n Findings were discussed with (N.P) at the time of dictation.\n\n IMPRESSION:\n 1. Unchanged small right apical pneumothorax.\n 2. Increasing left pleural effusion.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2118-07-28 00:00:00.000", "description": "Report", "row_id": 1600424, "text": "POST OP NOTE\n\n\n PT ARRIVED FROM OR @ 2145, SEDATED AND HTN. FULLY VENTED. PROPOFOL GTT INFUSING @ 75 MCG/KG/MIN AND NTG GTT STARTED FOR HTN. PT , 1L LR GIVEN. TMAX 101.5, TYLENOL GIVEN. U/O MARGINAL. JP X 3 DRAINING SANGEOUS DRAINAGE. SEE CAREVIEW FOR VS. LYTES REPLACED AS NEEDED. HUSBAND UPDATED AND WENT HOME.\n PLAN-KEEP SEDATED AND INTUBATED THROUGHOUT NIGHT, DIFFICULT INTUBATION (GRADE 3), PER ANESTHESIA.\n" }, { "category": "Nursing/other", "chartdate": "2118-07-28 00:00:00.000", "description": "Report", "row_id": 1600425, "text": "SHIFT SUMMARY\n\n NEURO-PT SEDATED WITH PROPOFOL GTT, AND INTERMITTENT DOSES OF MSO4 IV. AWAKES WITH VERBAL STIMULI, APPEARS TO BE AOO X3, ABLE TO INDICATE NEEDS BY MOUTHING WORDS. MAE'S WELL. INDICATING SHE IS HAVING A LOT OF DISCOMFORT IN RT ABD. REGION WHEN AWAKE.\n\n RESP-FULLY VENT ABG'S AND SATS WNL. SEE CAREVIEW FOR DETAILS. CLEAR ORAL SECRETIONS ONLY. NO ETT SXN REQUIRED. PT IS A GRADE 3 DIFFICULT INTUBATION PER ANESTHESIA.\n\n CV-RHYTHM ST 100-110'S, BP INITALLY HTN, NTG GTT USED FOR CONTROL. BP HYPOTENSIVE THIS AM, IVF GIVEN. TMAX 101.7, TYLENOL GIVEN X2. RESIDENT MADE AWARE, ST AND HYPO 2' TEMP? NO FURTHER MEDS GIVEN.\n\n GI/GU-NGT PLACE UPON ARRIVIAL, DRAINING MOD AMT OF BILIOUS DRAINAGE. U/O MARGINAL ALL SHIFT, RESIDENT AWARE.\n\n INEG-PT HAS INCISION AND RT ABD INCISION CDI. BREAST BINDER IN PLACE. 3 JP'S FROM FLAP SITES TO BULB SXN. SEE CAREVIEW FOR AMT. MYSTATIN POWDER ORDERED FOR SKIN FOLDS, AREAS ARE ESCORATED. RT VEIN GRAFT SITE HAVING SMALL OPEN AREA, WITH MINIMAL YELLOWISH DRAINING, RESIDENT WAS AWARE AND LOOKED AT SITE.\n\n PLAN- WEAN TO EXTUBATE. CONTINUE ANTIBX'S. PAIN MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2118-07-28 00:00:00.000", "description": "Report", "row_id": 1600426, "text": "Resp Care: Pt continues sedated intubated and on ventilatory support with simv 700x12 fio2 .5 +5 peep and psv 5 with acceptable abg, will wean to extubate when awake.\n" }, { "category": "Nursing/other", "chartdate": "2118-07-28 00:00:00.000", "description": "Report", "row_id": 1600427, "text": "PATIENT WEANED FROM SIMV TO PSV THEN EXTUBATED POST ABG7.41-42-89-28.PATIENT IS NOW ON 50% OPEN FACE MASK, ALERT, COOP, HR 126, PB 130/64, SAT 96%. BEING TRANSFUSED WITH SECOND UNIT OF , CONTINUE TO MONITOR PATIENT CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2118-07-28 00:00:00.000", "description": "Report", "row_id": 1600428, "text": "CSRU UPDATE NOTE\nReview of Systems:\n\nNeuro: A/A/O X 3, MAE, FC's, pain controlled with Morphine SQ initially, no that pt is extubated pain controlled with Percocet with fair effect, will follow closely pt may need PCA.\n\nCV: Tele St 130's, no ectopy, BP stable, started on lopressor for rate control. Distal pulses palp, skin pink, warm and dry.\n\nResp: extubated to 50% FT, 02sats 95-96%, no c/o SOB, Ls with end-expiratory wheezes, pt started on lasix IV, post- extubation ABG with adequate ventilation and p02 72. RR 20/min even and unlabored, dry cough.\n\nGI: Pt taking in clears, no nausea no vomitting, abd soft, nt, nd.\n\nGU: Foley patent for clear, yellow urine, adequate UO.\n\nHeme: Pt transfused with 2units PRBC for HCT 26.0, repeat 38.\n\nSkin: incision with DSD, CDI, JP's-SS draining sanguinous drainage.\n\nA. Stable\nP. Replete lytes, pulmonary toilet, monitor response to lopressor, encourage po's\n" }, { "category": "Nursing/other", "chartdate": "2118-07-28 00:00:00.000", "description": "Report", "row_id": 1600429, "text": "C/O MILD NAUSEA & INCOMPLETE PAIN RELIEF AFTER PERCOCET. MSO4 GIVEN W REGLAN.WILL RE-EVAL. EFFECT LATER.INCISION W TRANSPARENT DSG INTACT,JP'S ->SS W SCANT SERO-SANG. DNG. HYPOACTIVE BS,TOL. SIPS H20 W PILLS. BS CLEAR,DECREASED IN BASES W DRY COUGH. WEANING SPO2 AS TOLERATED KEEPING SPO2 > 94%.DIURESIS FROM EARLIER LASIX CONTINUES.PERSISTENT TACHYCARDIA CONTINUES AFTER EARLIER PRBC'S. LOPRESSOR 5 MG IV GIVEN W TRANSIENT EFFECT. PO LOPRESSOR RESUMED.\n" }, { "category": "Nursing/other", "chartdate": "2118-07-29 00:00:00.000", "description": "Report", "row_id": 1600430, "text": "NEURO: PT AWAKE ALERT ORIENTED.\nRESP: O2 SAT 95% ON 3L NP. PT COUGHING AND DEEP BREATHING WHEN MEDICATED.\nC/V: REMAINS TACHYCARDIC WITH HEART RATE OF 100-115 SINUS NO ECTOPY HO AWARE. PRESSURE STABLE.\nGI: TOLERATING LIQUIDS NO COMPLAINTS OF NAUSEA.\nGU: PASSING QS URINE. WEIGHT REMAINS UP APPROXIMATELY 9KGS FROM PREOP.\nSKIN: PT C/O ITCHY SKIN AROUND LEFT SIDE NEAR MAMMORY SUPPORT. SKIN PINK WITH SOME DARK RED PATCHES. POWDER APPLIED PER PT FELT BETTER. INCISION DSG INTACT. RIGHT LEG INCISON APPROXIMATED BUT PINK AND MOIST LOOKING IN SOME AREAS. CLEAN DSD APPLIED. PT MEDICATED WITH 2 PERCOCETTS X2 WITH GOOD RELIEF. SLEEPING MOST OF NIGHT.\nPLAN TO TRANSFER TO FLOOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2118-07-29 00:00:00.000", "description": "Report", "row_id": 1600431, "text": "CRSU TRANSFER NOTE\nREVIEW OF SYSTEMS\n\nNEURO: A/A/O X 3, MAE, FC'S PAIN CONTROLLED WITH TORADOL AND PERCOCET WITH EXCELLENT EFFECT.\n\nCV: TELE IN SR 90'S, NO ECTOPY, ON LOPRESSOR, BP STABLE. DISTAL PULSES PALP, SKIN WARM PINK AND DRY, CONT TO COMPLAIN OF R FOOT TINGLING. POST~OP CONDITION OCCURRING WITH PROLONGED BEDREST OR SITTING FOR LONG PERIODS.\n\nRESP: ON 4L NP, SATS:95~97%, LS CLEAR THRUOUT, RR:16~20, DRY COUGH, OOB TO CHAIR @ 10 AM, TOL WELL.\n\nGI: TOL PO FLUIDS AND JELLO WELL, PASSING GAS, ABD SOFT, BS +.\n\nGU: FOLEY PATENT, VOIDING CLEAR YELLOW URINE,U/O EXCELLENT.\n\nHEME: HCT 31.\n\nID: VANCO LEVEL 27.4, ON VANCO AND CEFTAZ WBC:21\n\nSKIN: INTACT, INCISIONS D&I, ALL CHANGED THIS AM BY DR.\n\nA: STABLE FOR TRANSFER\n\nP: CONT TO ENCOURAGE PO'S, PULMONARY TOILET, AMB TODAY.\n" }, { "category": "ECG", "chartdate": "2118-07-25 00:00:00.000", "description": "Report", "row_id": 147196, "text": "Normal sinus rhythm, rate 64\nConsider left atrial enlargement\nHigh QRS voltage\nAnterolateral T wave abnormalities\nPossible ischemia\nProbable left ventricular hypertrophy\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2118-07-24 00:00:00.000", "description": "Report", "row_id": 147197, "text": "Normal sinus rhythm, rate 62\nConsider left atrial enlargement\nHigh QRS voltage\nNonspecific anterolateral T abnormalities\nCannot R/O Anteroseptal myocardial infarct\nProbable Left ventricular hypertrophy\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2118-07-12 00:00:00.000", "description": "Report", "row_id": 147198, "text": "Sinus tachycardia, rate 115\nConsider left atrial enlargement\nHigh QRS voltage\nNonspecific Lateral T wave abnormalities\nST segment elevation in Anterior leads\nConsider R/O acute injury\nAbnormal ECG\n\n" }, { "category": "Radiology", "chartdate": "2118-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740268, "text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pleural effusion and r/o sternal dehiscence.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p cabg with sternal wound infection and shortness of breath\n REASON FOR THIS EXAMINATION:\n eval pleural effusion and r/o sternal dehiscence.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58 year old woman status post CABG with sternal wound infection and\n shortness of breath.\n\n Comparison to prior exam from .\n\n PORTABLE CHEST: There is complete opacification of the left mid and lower\n lung zones secondary to pleural effusion and likely atelectasis. There is an\n accessory minor fissure on the left. The right lung appears clear. Pulmonary\n vasculature is normal. Heart size is difficult to evaluate secondary to\n complete opacification of the left mid and lower lung zones.\n\n IMPRESSION: Opacification of the left mid and lower lung zones secondary to\n pleural effusion with adjacent atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2118-07-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740357, "text": " 9:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p sternal debridement and flap, evaluate ett\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p cabg with sternal wound infection and shortness of breath\n REASON FOR THIS EXAMINATION:\n s/p sternal debridement and flap\n evaluate ett\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG. Sternal wound infection. SOB.\n\n COMPARISON: .\n\n PORTABLE SUPINE CHEST @ 22:03: There is an ETT at the level of the clavicles.\n There is a right IJ central venous catheter with tip in the SVC. No\n pneumothorax. There is an overlying pacer pad obscuring the right apex. There\n is a small left pleural effusion with associated atelectasis at the left base.\n There is probably some atelectasis in the right mid lung zone as well. There\n is no evidence of vascular congestion or focal consolidations, however, the\n possibility of consolidation at the left base cannot be excluded.\n\n IMPRESSION: Supporting lines and tubes in satisfactory position. Small left\n pleural effusion with associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2118-08-01 00:00:00.000", "description": "CVL/PICC", "row_id": 740560, "text": " 2:06 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: MRSA\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: MRSA infection.\n\n RADIOLOGISTS: Drs. and Radiologist Dr. \n performed the procedure.\n\n TECHNIQUE: Patient's left arm was prepped and draped in sterile fashion after\n informed written consent was obtained. An ultrasound was utilized as no\n suitable superficial vein was identified visually. Subsequently, a 21-gauge\n micropuncture needle was inserted into the left basilic vein, followed by\n placement of a wire. A 4.5-French peel-away sheath was advanced over the\n wire, followed by insertion of a longer wire. A single-lumen PICC catheter\n was advanced with tip positioned within the lower superior vena cava.\n\n Post-procedure chest radiograph demonstrates appropriate placement of PICC\n with tip in the lower superior vena cava. No pneumothorax is seen.\n\n CONTRAST/MEDICATIONS: None.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Status post successful placement of single-lumen left PICC.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-07-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 740115, "text": " 9:19 AM\n CHEST (PA & LAT) Clip # \n Reason: Status post CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cad, S/P CABG\n REASON FOR THIS EXAMINATION:\n Status post CABG\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, TWO VIEWS, .\n\n HISTORY: CABG.\n\n The heart is enlarged. There is considerable opacification in the lower half\n of the left hemithorax, likely on the basis of a large pleural effusion. The\n lung parenchyma is however, obscured at the left base an underlying area of\n consolidaton or collapse cannot be excluded. Post-CABG changes are noted and\n there are numerous skin staples and metallic sutures in the sternum. The\n right lung is clear. There are numerous clips in the right axilla.\n\n IMPRESSION: S/P CABG changes with considerable opacification at the left base.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2119-01-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1217650, "text": " 2:10 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p bentall\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Status post Bentall, assess for effusion.\n\n Comparison is made with prior study of .\n\n Cardiomegaly and widened mediastinum have improved. There is no pneumothorax,\n pulmonary edema or pneumonia. Bilateral pleural effusions are small. Sternal\n wires are aligned. Aside from minimal atelectasis is in the left lower lobe\n in the retrocardiac area, the lungs are clear. Patient is status post AVR.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-12-28 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1216958, "text": " 8:37 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: eval aortic dissection\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with chest pain and differential pulses in UE (R 2+, L 1+) with\n differentail pressures\n REASON FOR THIS EXAMINATION:\n eval aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa WED 9:12 PM\n type A aortic dissection beginning at the aortic root. dissection flap extends\n to left common carotid and left subclavian arteries. dissection extends\n through the arch and thoracic aorta to abdominal aorta where the inferior\n extent is not well visualized due to contrast mixing. the flap extends at\n least to the level of the SMA. kidneys perfuse symmetrically.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain and differential pulses in the upper extremities.\n\n TECHNIQUE: Multidetector helical CT scan of the chest was obtained before and\n after the administration of 100 cc IV Optiray contrast. Delayed imaging of\n the abdomen and pelvis was also obtained. Coronal, sagittal and oblique\n reformations of the chest were prepared. Coronal and sagittal reformations of\n the abdomen and pelvis were also prepared.\n\n COMPARISON: None available.\n\n FINDINGS: There is a type A aortic dissection originating at the level of the\n aortic root, extending throughout the aortic arch, descending aorta, and into\n the abdomen. The left main coronary artery is supplied by the true lumen.\n The supply of the right main coronary artery is not well visualized due to\n motion artifact. The brachiocephalic artery is supplied by the true lumen.\n Dissection flap extends into the left common carotid and left subclavian\n arteries. The thoracic aorta is aneurysmal measuring up to 5.2 x 5.1 cm at\n the level of the bifurcation of the main pulmonary artery. The descending\n aorta measures up to 3.5 x 3.3 cm (3:37) at the same level.\n\n The inferior extent of the dissection is not well evaluated due to mixing of\n contrast; however definitively, the dissection extends to at least the level\n of the SMA and likely reaches to the iliac arteries. The dissection flap\n appears to involve the ostia of the celiac artery and SMA. The right renal\n artery appears supplied by the true lumen and the left renal artery by the\n false lumen. The kidneys enhance symmetrically. The supply of the is not\n well evaluated.\n\n The lungs appear grossly clear without focal consolidation. No filling defect\n to suggest pulmonary embolism is seen. No evidence of endobronchial lesion.\n No lymphadenopathy is identified. There is no pericardial effusion.\n (Over)\n\n 8:37 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: eval aortic dissection\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The liver contains two sub-cm hypodensities in the left lobe, too small to\n characterize (6:17). The patient is status post cholecystectomy. No focal\n abnormality is identified in the spleen. The pancreas and adrenal glands\n appear unremarkable. The kidneys contain hypodensities compatible with simple\n cysts bilaterally. The kidneys enhance symmetrically. Loops of small and\n large bowel are normal in size and caliber. There is diverticulosis without\n evidence of diverticulitis.\n\n The bladder, distal ureters and prostate gland appear within normal limits.\n\n No free air, free fluid or lymphadenopathy is seen.\n\n Several benign-appearing sclerotic foci are noted within the ribs. No\n concerning osseous lesion is seen.\n\n IMPRESSION: Type A aortic dissection extending from the aortic root\n throughout the thoracic aorta and into the abdomen. The inferior extent is\n not well evaluated due to mixing of contrast; however, the dissection extends\n to at least the SMA and likely the iliac arteries. If further delineation is\n required, this may be performed with repeat CTA or MRA.\n\n The true lumen supplies the great vessels with dissection flap extending to\n the left common carotid and subclavian arteries. Dissection flap appears to\n involve the ostia of the celiac and SMA.\n\n" }, { "category": "Radiology", "chartdate": "2118-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1217127, "text": " 1:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for ptx\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p aortic dissection repair, CTs and PWs d/c'd\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post aortic dissection, repair, evaluation for\n pneumothorax.\n\n COMPARISON: , 4:53 a.m.\n\n FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter and\n the right-sided chest tube as well as the mediastinal drain has been removed.\n A right venous introduction sheath remains in place. There is no indication\n for the presence of a pneumothorax. Unchanged mild cardiomegaly with signs of\n mild fluid overload. Bilateral basal areas of atelectasis. No pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-12-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1216991, "text": " 6:01 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Fast Track Early Extubation Cardiac surgery\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with Bentall\n REASON FOR THIS EXAMINATION:\n Fast Track Early Extubation Cardiac surgery\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH DATED .\n\n No previous chest radiographs for comparison.\n\n FINDINGS: Tip of endotracheal tube terminates 5.6 cm above the carina,\n Swan-Ganz catheter terminates in right pulmonary artery, nasogastric tube\n terminates below the diaphragm, and midline drains and low lying right chest\n tube are in place. Cardiomediastinal contours are slightly widened,\n consistent with recent post-operative status of the patient. Small amount of\n pneumopericardium is present. Patchy bibasilar atelectasis is demonstrated as\n well as a small left pleural effusion, but no visible pneumothorax is evident\n on this semi-upright projection.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1217215, "text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p Bentall\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:35 A.M., \n\n HISTORY: 55-year-old man. Rule out pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n The interval increase in caliber of the mediastinum between the earliest and\n the latest examination of has stabilized. Whether this represents\n hemorrhage or mediastinal venous distention is indeterminate. The lungs look\n clear aside from mild left lower lobe atelectasis and there is no pneumothorax\n or pleural effusion. Right internal jugular introducer ends above the\n thoracic inlet. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1217070, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p repair of aortic disection r/o PTX\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p repair of aortic disection r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Repair of aortic dissection, to assess for pneumothorax.\n\n FINDINGS: In comparison with the study of , the endotracheal tube and\n nasogastric tube have been removed. No evidence of pneumothorax. Swan-Ganz\n catheter and right chest tube remain in place.\n\n Lower lung volumes with minimal atelectatic changes. The degree of\n pneumopericardium has decreased.\n\n\n" }, { "category": "Echo", "chartdate": "2118-12-29 00:00:00.000", "description": "Report", "row_id": 96068, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for repair of ascending aortic dissection\nStatus: Inpatient\nDate/Time: at 01:00\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated ascending aorta Mildly dilated descending aorta.\nAscending aortic intimal flap/dissection.. Aortic arch intimal\nflap/dissection. Descending aorta intimal flap/aortic dissection.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Mechanical aortic valve\nprosthesis (AVR). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. 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 under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPRE-CPB:\nThe left atrium is mildly dilated. No thrombus is seen in the left atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler.\n\nThere is mild symmetric left ventricular hypertrophy. 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.\n\nThe ascending aorta is moderately dilated. The descending thoracic aorta is\nmildly dilated. A mobile density is seen in the ascending aorta consistent\nwith an intimal flap/aortic dissection. A mobile density is seen in the aortic\narch consistent with an intimal flap/aortic dissection. The dissection flap\nextends through the arch to descending aorta. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion. There is no aortic\nvalve stenosis. Trace central aortic regurgitation is seen.\n\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n\nThere is no pericardial effusion.\n\nPOST-CPB:\nThere is a bileaflet mechanical valve in the aortic position. The valve is\nwell-seated with normal leaflet motion. There are the normal washing jets.\nThere are no apparent paravalvular leaks. The peak gradient across the aortic\nvalve is 24mmHg, the mean gradient is 10mmHg with a cardiac output of 9L/min.\nThere is echogenic material in the root and ascending aorta, consistent with\ntube graft.\n\nThe LV systolic function is preserved, estimated EF>55%. The RV systolic\nfunction remains normal.\n\nThe dissection flap seen in the distal arch and descending aorta appear\ngrossly unchanged from pre-op.\n\n\nDr. was notified in person of the results at time of study.\n\n\n" }, { "category": "ECG", "chartdate": "2118-12-29 00:00:00.000", "description": "Report", "row_id": 261518, "text": "Sinus rhythm. Borderline left ventricular hypertrophy. Intraventricular\nconduction delay with T wave inversions in leads II and aVF. Compared to\nthe previous tracing QRS duration has increased and T wave changes in\nleads III and aVF are new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2118-12-28 00:00:00.000", "description": "Report", "row_id": 261519, "text": "Sinus rhythm. Left ventricular hypertrophy. Compared to the previous tracing\nthe rate is increased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2118-12-28 00:00:00.000", "description": "Report", "row_id": 261520, "text": "Sinus bradycardia. Left ventricular hypertrophy. Compared to the previous\ntracing of the rate is slower.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2200-02-15 00:00:00.000", "description": "Intensivist Note", "row_id": 439494, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI, family\n contact attempted not achieved\n Chief complaint:\n subarachnoid and subdural bleed\n PMHx:\n unknown\n Current medications:\n Acetaminophen 3. Atenolol 4. Bisacodyl 5. Cholestyramine\n 6. Docusate Sodium 7. Ferrous Sulfate 8. Hydrochlorothiazide 9. Insulin\n 10. Influenza Virus Vaccine\n 11. LeVETiracetam 12. Lisinopril 13. Lorazepam 14. Meclizine 15.\n Mirtazapine 16. Omeprazole 17. Oxycodone SR (OxyconTIN)\n 18. Pneumococcal Vac Polyvalent 19. Senna 20. Vesicare 21. traZODONE\n 24 Hour Events:\n MULTI LUMEN - START 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n head\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 106 (106 - 122) bpm\n BP: 113/57(71) {88/49(57) - 170/85(108)} mmHg\n RR: 23 (11 - 27) insp/min\n SPO2: 100%\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 405 mL\n Urine:\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -405 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 265 K/uL\n 8.8 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 19 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.4 %\n 5.7 K/uL\n [image002.jpg]\n 02:55 AM\n WBC\n 5.7\n Hct\n 26.4\n Plt\n 265\n Creatinine\n 0.7\n Glucose\n 111\n Other labs: PT / PTT / INR:16.5/27.7/1.5\n Assessment and Plan\n .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH),\n .H/O CANCER (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan:\n Neurologic: Subdural /subarachnoid bleed, MRI to investigate other\n possible masses, keppra, ativan\n Cardiovascular: maintain BP < 180 a line if needed prn nicardipine or\n nitro, femorql triple lumen acces, Atenolol, Hydrochlorothiazide\n Lisinopril\n Pulmonary: stable on NC\n Gastrointestinal / Abdomen: NPO, PPI\n Nutrition: NPO, NS 20 KCl at 70ml/hr\n Renal: Foley follow UOP\n Hematology: Follow am CBC, coags\n Endocrine: RISS\n Infectious Disease: no abx\n Lines / Tubes / Drains: femoral triple lumen, foley, piv need to D/C\n groin line ? PICC\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 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: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2200-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439422, "text": ".H/O subdural hemorrhage (SDH)\n Assessment:\n 85 yr old man with SAH and SDH over left parietal lobe. No known\n trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.\n Action:\n MRI, ativan total 1mg IVP given for MRI as pt not still.\n Response:\n SBP dropped to 89 but increased to 100 when pt stimulated.\n Plan:\n Freq NVS\n Keep SBP< 140\n .H/O cancer (Malignant Neoplasm), Prostate\n Assessment:\n Per history from and per ABD xray. Pt is uncomfortable when\n he is turned or touched abd tender, pain evident (nonverbal cues)\n Action:\n Pain med held after MRI due to hypotension related to ativan.\n Response:\n Pt resting quietly\n Plan:\n Continue to assess pt for pain and treat accordingly with orsered pain\n med.\n" }, { "category": "Physician ", "chartdate": "2200-02-15 00:00:00.000", "description": "Intensivist Note", "row_id": 439459, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI, family\n contact attempted not achieved\n Chief complaint:\n subarachnoid and subdural bleed\n PMHx:\n unknown\n Current medications:\n Acetaminophen 3. Atenolol 4. Bisacodyl 5. Cholestyramine\n 6. Docusate Sodium 7. Ferrous Sulfate 8. Hydrochlorothiazide 9. Insulin\n 10. Influenza Virus Vaccine\n 11. LeVETiracetam 12. Lisinopril 13. Lorazepam 14. Meclizine 15.\n Mirtazapine 16. Omeprazole 17. Oxycodone SR (OxyconTIN)\n 18. Pneumococcal Vac Polyvalent 19. Senna 20. Vesicare 21. traZODONE\n 24 Hour Events:\n MULTI LUMEN - START 12:00 AM\n MAGNETIC RESONANCE IMAGING - At 02:00 AM\n head\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 106 (106 - 122) bpm\n BP: 113/57(71) {88/49(57) - 170/85(108)} mmHg\n RR: 23 (11 - 27) insp/min\n SPO2: 100%\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 405 mL\n Urine:\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -405 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 265 K/uL\n 8.8 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 19 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.4 %\n 5.7 K/uL\n [image002.jpg]\n 02:55 AM\n WBC\n 5.7\n Hct\n 26.4\n Plt\n 265\n Creatinine\n 0.7\n Glucose\n 111\n Other labs: PT / PTT / INR:16.5/27.7/1.5\n Assessment and Plan\n .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH),\n .H/O CANCER (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan:\n Neurologic: Subdural /subarachnoid bleed, MRI to investigate other\n possible masses, keppra, ativan\n Cardiovascular: maintain BP < 180 a line if needed prn nicardipine or\n nitro, femorql triple lumen acces, Atenolol, Hydrochlorothiazide\n Lisinopril\n Pulmonary: stable on NC\n Gastrointestinal / Abdomen: NPO, PPI\n Nutrition: NPO, NS 20 KCl at 70ml/hr\n Renal: Foley follow UOP\n Hematology: Follow am CBC, coags\n Endocrine: RISS\n Infectious Disease: no abx\n Lines / Tubes / Drains: femoral triple lumen, foley, piv\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 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: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2200-02-16 00:00:00.000", "description": "Intensivist Note", "row_id": 439694, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI, family\n contact attempted not achieved\n Chief complaint:\n AMS\n PMHx:\n unknown\n Current medications:\n 1. 1000 mL NS 2. Acetaminophen 3. Atenolol 4. Bisacodyl 5.\n Cholestyramine 6. Docusate Sodium 7. Ferrous Sulfate\n 8. Hydrochlorothiazide 9. 10. Insulin 11. Influenza Virus Vaccine 12.\n LeVETiracetam 13. Lisinopril\n 14. Lorazepam 15. Lorazepam 16. Lorazepam 17. Meclizine 18. Metoprolol\n Tartrate 19. Mirtazapine\n 20. Omeprazole 21. Oxycodone SR (OxyconTIN) 22. Pneumococcal Vac\n Polyvalent 23. Senna 24. traZODONE\n 24 Hour Events:\n MRI with and without contrast done to assess if any evidence of brain\n masses.\n Called out to the floor but no beds available\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 12:39 AM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 101 (99 - 116) bpm\n BP: 116/59(72) {72/46(52) - 143/74(95)} mmHg\n RR: 23 (18 - 34) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 520 mL\n 298 mL\n PO:\n Tube feeding:\n IV Fluid:\n 520 mL\n 298 mL\n Blood products:\n Total out:\n 1,725 mL\n 360 mL\n Urine:\n 1,725 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,205 mL\n -62 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress. Intermittently agitated.\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: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 256 K/uL\n 8.7 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 19 mg/dL\n 102 mEq/L\n 134 mEq/L\n 25.8 %\n 5.0 K/uL\n [image002.jpg]\n 02:55 AM\n 03:00 AM\n WBC\n 5.7\n 5.0\n Hct\n 26.4\n 25.8\n Plt\n 265\n 256\n Creatinine\n 0.7\n Glucose\n 111\n Other labs: PT / PTT / INR:16.5/27.7/1.5\n Assessment and Plan\n TACHYCARDIA, OTHER, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID\n HEMORRHAGE (SAH), .H/O CANCER (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan: 85yM with small SAH, SDH\n Neurologic: Subdural /subarachnoid bleed, F/U MRI\n Cardiovascular: maintain BP < 180, prn nicardipine or nitro, D/C\n femoral TLC, Atenolol, HCTZ, Lisinopril\n Pulmonary: stable on NC\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley follow UOP. NS @ 75/hr\n Hematology: Hct stable at 25 from 26\n Endocrine: RISS\n Infectious Disease: no antibiotics, no issues\n Lines / Tubes / Drains: PIV,D/C femoral TLC, aline\n Wounds:\n Imaging: F/U MRI read today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n 22 Gauge - 08:05 AM\n 20 Gauge - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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:\n" }, { "category": "Nursing", "chartdate": "2200-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439764, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt more alert today. At times a/ox3, majority of time oriented x2.\n Moves all extremities, left side stronger than right. Rarm showing\n more strength than yesterday. Pt inconsistently following commands.\n Pupils unequal\n surgical. Pt denies pain or sob. Pt frequently\n agitated. Yelling out, combative.\n Action:\n Pt frequently reoriented. Q2hr neuro checks continued per neurosurg\n orders. Ativan and haldol prn\n Response:\n Mental status unchanged.\n Plan:\n Cont close neuro assessment. Monitor for s/s of bleeding. Transfer to\n neuro-stepdown when bed available.\n Tachycardia, Other\n Assessment:\n Cont to be tachycardic\nespecially w/ periods of agitation.\n Action:\n Lopressor given md\ns orders.\n Response:\n Hr 90\ns to low 100\n Plan:\n Cont close cardiac assessment. Beta blockers as ordered. Plan for\n speech and swallow to enable pt to restart po meds.\n" }, { "category": "Nursing", "chartdate": "2200-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439779, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt more alert today. At times a/ox3, majority of time oriented x2.\n Moves all extremities, left side stronger than right. Rarm showing\n more strength than yesterday. Pt inconsistently following commands.\n Pupils unequal\n surgical. Pt denies pain or sob. Pt frequently\n agitated. Yelling out, combative.\n Action:\n Pt frequently reoriented. Q2hr neuro checks continued per neurosurg\n orders. Ativan and haldol prn\n Response:\n Mental status unchanged.\n Plan:\n Cont close neuro assessment. Monitor for s/s of bleeding. Transfer to\n neuro-stepdown when bed available.\n Tachycardia, Other\n Assessment:\n Cont to be tachycardic\nespecially w/ periods of agitation.\n Action:\n Lopressor given md\ns orders.\n Response:\n Hr 90\ns to low 100\n Plan:\n Cont close cardiac assessment. Beta blockers as ordered. Plan for\n speech and swallow to enable pt to restart po meds.\n" }, { "category": "Nursing", "chartdate": "2200-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439543, "text": ".H/O subarachnoid hemorrhage (SAH)/SDH\n Assessment:\n Pt arouseable to voice and stimuli. Confused, uncooperative\n does not\n answer questioning or follow commands. Moves all extremities on bed,\n localizes pain. Left side much stronger than right, see flowsheets for\n specifics. Pupils unequal\n both surgical in nature. VSS.\n Action:\n Pt kept npo md\ns orders. Sbp closely monitored. MRI done.\n Response:\n Pt remains confused. VSS. Neuro assessment unchanged.\n Plan:\n Cont close neuro assessment. Monitor for s/s of bleeding. Maintain pt\n safety. Transfer to stepdown when bed available.\n" }, { "category": "Nursing", "chartdate": "2200-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439762, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt more alert today. At times a/ox3, majority of time oriented x2.\n Moves all extremities, left side stronger than right. Rarm showing\n more strength than yesterday. Pt inconsistently following commands.\n Pupils unequal\n surgical. Pt denies pain or sob. Pt frequently\n agitated. Yelling out, combative.\n Action:\n Pt frequently reoriented. Pt medicated w/ ativan and haldol md\n orders.\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 439940, "text": "85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI,\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 439980, "text": ",\n 85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.\n Imaging;\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440033, "text": ",\n 85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.MRi and\n head ct consisent with hemangioma\n .H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt waxes and wanes between difficultto rouse to alert and comative\n consistently calling out Pt very HOH, generally oriented X 1-2knows\n name and year) when pt cooperative with neuro exam. Pt noted to have\n continued right sided weakness but does inconsistently squeeze hands\n with lt hand and wriggles toes on both. Speech is somewhat slurredand\n difficult to understand ? worsened by pt\ns poor dentitian. Pupils are\n surgical and unequal at baseline. During periods of agitation pt will\n yell out, resist care and has been combative at times\n pt seems to be in pain ? from metastasis from prostate ca cries out in\n pain when touched\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n changed from wrist restraints to mitt on rt hand occasionally hits when\n startled.\n Response:\n Pt had good response after ativan for agitation\n pt seems more comfortable.\n Plan:\n Continue to follow neuro exams q2. Plan to have speech and swallow eval\n so pt can possibly restart PO medication.\n Pt neice called for results of mri referred to md. ?\n whether neice aware of transfer to sdu.\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440035, "text": "85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.MRi and\n head ct consisent with hemangioma\n .H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt waxes and wanes between difficultto rouse to alert and comative\n consistently calling out Pt very HOH, generally oriented X 1-2knows\n name and year) when pt cooperative with neuro exam. Pt noted to have\n continued right sided weakness but does inconsistently squeeze hands\n with lt hand and wriggles toes on both. Speech is somewhat slurredand\n difficult to understand ? worsened by pt\ns poor dentitian. Pupils are\n surgical and unequal at baseline. During periods of agitation pt will\n yell out, resist care and has been combative at times\n pt seems to be in pain ? from metastasis from prostate ca cries out in\n pain when touched\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n changed from wrist restraints to mitt on rt hand occasionally hits when\n startled.\n Response:\n Pt had good response after ativan for agitation and Dilaudid for pain\n pt seems more comfortable.\n Plan:\n Continue to follow neuro exams q2. Plan to have speech and swallow eval\n so pt can possibly restart PO medication.\n Pt neice called for results of mri referred to md. ?\n whether neice aware of transfer to sdu.\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440030, "text": ",\n 85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440034, "text": ",\n 85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.MRi and\n head ct consisent with hemangioma\n .H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt waxes and wanes between difficultto rouse to alert and comative\n consistently calling out Pt very HOH, generally oriented X 1-2knows\n name and year) when pt cooperative with neuro exam. Pt noted to have\n continued right sided weakness but does inconsistently squeeze hands\n with lt hand and wriggles toes on both. Speech is somewhat slurredand\n difficult to understand ? worsened by pt\ns poor dentitian. Pupils are\n surgical and unequal at baseline. During periods of agitation pt will\n yell out, resist care and has been combative at times\n pt seems to be in pain ? from metastasis from prostate ca cries out in\n pain when touched\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n changed from wrist restraints to mitt on rt hand occasionally hits when\n startled.\n Response:\n Pt had good response after ativan for agitation and Dilaudid for pain\n pt seems more comfortable.\n Plan:\n Continue to follow neuro exams q2. Plan to have speech and swallow eval\n so pt can possibly restart PO medication.\n Pt neice called for results of mri referred to md. ?\n whether neice aware of transfer to sdu.\n" }, { "category": "Physician ", "chartdate": "2200-02-18 00:00:00.000", "description": "Intensivist Note", "row_id": 440165, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to \n Chief complaint:\n altered mental status\n PMHx:\n colon CA with mets to bones\n Current medications:\n 1. 1000 mL D5 1/2NS 2. Acetaminophen 3. Bisacodyl 4. Cholestyramine 5.\n Cyanocobalamin 6. Docusate Sodium\n 7. HYDROmorphone (Dilaudid) 8. HYDROmorphone (Dilaudid) 9. Haloperidol\n 10. HydrALAzine 11. 12. Insulin\n 13. LeVETiracetam 14. Metoprolol Tartrate 15. Metoprolol Tartrate 16.\n Metoprolol Tartrate 17. Mirtazapine\n 18. Omeprazole 19. Senna\n 24 Hour Events:\n CALLED OUT\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:39 AM\n Metoprolol - 05:16 AM\n Haloperidol (Haldol) - 05:23 AM\n Hydromorphone (Dilaudid) - 06:15 AM\n Other medications:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.1\nC (98.8\n HR: 115 (92 - 121) bpm\n BP: 155/74(94) {107/52(66) - 175/100(118)} mmHg\n RR: 35 (14 - 37) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 62.2 kg (admission): 63.1 kg\n Total In:\n 1,959 mL\n 647 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,959 mL\n 647 mL\n Blood products:\n Total out:\n 1,092 mL\n 444 mL\n Urine:\n 1,092 mL\n 444 mL\n NG:\n Stool:\n Drains:\n Balance:\n 867 mL\n 203 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 102 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 106 mEq/L\n 135 mEq/L\n 25.4 %\n 4.2 K/uL\n [image002.jpg]\n 02:55 AM\n 03:00 AM\n 02:00 AM\n 02:09 AM\n WBC\n 5.7\n 5.0\n 4.8\n 4.2\n Hct\n 26.4\n 25.8\n 28.2\n 25.4\n Plt\n 265\n 256\n 276\n 297\n Creatinine\n 0.7\n 0.6\n 0.6\n 0.6\n Glucose\n 111\n 85\n 107\n 102\n Other labs: PT / PTT / INR:16.5/27.7/1.5, CK / CK-MB / Troponin\n T:225//, ALT / AST:, Alk-Phos / T bili:1498/0.5, Albumin:2.7 g/dL,\n Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, CHRONIC PAIN, TACHYCARDIA, OTHER, .H/O SUBDURAL\n HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH), .H/O CANCER\n (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan: 85yM with small SAH, SDH, altered mental status\n Neurologic: Subdural/subarachnoid bleed, underlying meningioma on MRI,\n altered mental status, likely related to multiple sedative medications,\n however will continue pain medication for bone mets, haldol prn\n agitation, B-12 injections, keppra\n Cardiovascular: Beta-blocker, Lopressor, hydralazine for HTN\n Pulmonary:\n Gastrointestinal / Abdomen: Place NGT, NPO, PPI, consider placing\n doboff and starting tube feeds, converting meds to PO\n Nutrition: consider starting TF\n Renal: Foley\n Hematology: anemia, stable\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley Place Dobhoff\n Wounds:\n Imaging: follow neuro surgery recs re further imaging\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 22 Gauge - 11:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status: Full\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2200-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440169, "text": "HPI: 85 male sent to ER with mental status changes from the\n nursing home. There is no report of a fall or any other trauma. . He\n had a head CT which\n revealed a SDH and small SAH. Neurosurgery was consulted for\n evaluation.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2200-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440170, "text": "HPI: 85 male sent to ER with mental status changes from the\n nursing home. There is no report of a fall or any other trauma. . He\n had a head CT which\n revealed a SDH and small SAH. Neurosurgery was consulted for\n evaluation.\n" }, { "category": "Nursing", "chartdate": "2200-02-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440172, "text": "HPI: 85 male sent to ER with mental status changes from the\n nursing home. There is no report of a fall or any other trauma. . He\n had a head CT which\n revealed a SDH and small SAH. Neurosurgery was consulted for\n evaluation.\n Chronic Pain\n Assessment:\n Pt on oxycoden sr at home. For metastatic prostate cancer. Pt unable\n to swallow at this time. Pt needs -Hoff for PO access.\n Action:\n Pt on Dilaudid .125,mg iv q3 prn for pain. Dilaudid given for pain.\n As to yelling out and very restless in the bed.\n Response:\n Pt seems more comfortable after dilauded and not yelling and seems to\n have fallen asleep. Hr down from 120\ns to 104. sinus tach. Requiring 2L\n NC during sleep for O2 sat dropping around 91%. SBP lowered from\n hypertensive ~160s to ~105-110.\n Plan:\n Monitor effectiveness of dilaudid. If feeding tube is placed ? start\n back on meds from prior to hospitalization\n Hypertension, benign\n Assessment:\n Pt hypertensive to greater than 160.\n Action:\n Pt treated with lopressor 5mg RTC. PRN hydralazine 10mg iv available.\n Response:\n Good response to lopressor and hydralazine.\n Plan:\n Treat bp greater than 160. if feeding tube placed. ? begin usual\n antihypertensive meds.\n Tachycardia, Other\n Assessment:\n Hr up to with no ectopy.\n Action:\n Dilaudid given with no response. Lopressor given with good response.\n Response:\n Hr down to 104 st with no ectopy\n Plan:\n Lopressor q6 as ordered.\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Neuro is unchanged. Pt agitated at times refusing to follow commands\n and swinging left arm at staff. Pt refusing to follow commands,.\n Normal strength to left arm able to lift and hold left leg. Moves right\n arm on bed and right leg on bed. Left pupil is surgical lens and\n nonreactive to light. Right pupil is 2 and reacts briskly.\n Action:\n Continue with neuro checks. Haldol ordered and given overnoc with\n minimal to no effect reported.\n Response:\n No change in neuro exam.\n Plan:\n Monitor agitation, PRN Dilaudid for pain.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Height:\n Admission weight:\n 63.1 kg\n Daily weight:\n 62.2 kg\n Allergies/Reactions:\n Precautions:\n PMH: Anemia\n CV-PMH: Hypertension\n Additional history: Vertigo\n Failure to thrive\n GERD\n HOH\n metastatic prostate CA\n Progressive colon Ca with METS\n metastitic prostate CA\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:59\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 31 insp/min\n Heart Rate:\n 114 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 91% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,085 mL\n 24h total out:\n 524 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:09 AM\n Potassium:\n 3.9 mEq/L\n 02:09 AM\n Chloride:\n 106 mEq/L\n 02:09 AM\n CO2:\n 19 mEq/L\n 02:09 AM\n BUN:\n 18 mg/dL\n 02:09 AM\n Creatinine:\n 0.6 mg/dL\n 02:09 AM\n Glucose:\n 102 mg/dL\n 02:09 AM\n Hematocrit:\n 25.4 %\n 02:09 AM\n Finger Stick Glucose:\n 116\n 10:00 PM\n Valuables / Signature\n Patient valuables: GLASSES, HEARING AID.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 1119\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2200-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440092, "text": "Chronic Pain\n Assessment:\n Pt on oxycoden sr at home. For metastatic prostate cancer. Pt unable\n to swallow at this time. Pt needs feeding tube or speech and swallow\n eval or possibley both.\n Action:\n Pt on Dilaudid .125,mg iv q3 prn for pain. Dilaudid given for pain.\n As to yelling out and very restless in the bed.\n Response:\n Pt seems more comfortable after dilauded and not yelling and seems to\n have fallen asleep. Hr down from 120\ns to 104. sinus tach.\n Plan:\n Monitor effectiveness of dilaudid. If feeding tube is placed ? start\n back on meds from prior to hospitalization\n Hypertension, benign\n Assessment:\n Pt hypertensive to greater than 160. bp still up after Dilaudid. Hr up\n to the .\n Action:\n Pt treated with lopressor 5mg iv x2 and hydralazine 10mg iv. Usually\n good response to hydrazine and lopressor\n Response:\n Good response to lopressor and hydralazine.\n Plan:\n Treat bp greater than 160. if feeding tube placed. ? begin usual\n antihypertensive meds.\n Tachycardia, Other\n Assessment:\n Hr up to with no ectopy. Sbp great than 160.\n Action:\n Dilaudid given with no response. Lopressor given with good response.\n Response:\n Hr down to 104 st with no ectopy\n Plan:\n Lopressor q6 as ordered.\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Neuro is unchanged. Pt agitated at times refusing to follow commands\n and swinging left arm at staff. Pt refusing to follow commands,.\n Normal strength to left arm able to lift and hold left leg. Moves right\n arm on bed and right leg on bed. Left pupil is surgical lens and\n nonreactive to light. Right pupil is 2 and reacts briskly.\n Action:\n Continue with neuro checks. Haldol ordered for agitation. ? transfer to\n sdu today. Meds dc\nd by dr. per medicine to help with\n confusion.\n Response:\n No change in neuro exam.\n Plan:\n Haldol for agitation.\n" }, { "category": "Physician ", "chartdate": "2200-02-17 00:00:00.000", "description": "Intensivist Note", "row_id": 439905, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI, family\n contact attempted not achieved\n Chief complaint:\n 85yM with small SAH, SDH\n PMHx:\n unknown\n Current medications:\n 1. 1000 mL NS 2. Acetaminophen 3. Atenolol 4. Bisacodyl 5.\n Cholestyramine 6. Docusate Sodium 7. Ferrous Sulfate\n 8. HYDROmorphone (Dilaudid) 9. Haloperidol 10. HydrALAzine 11.\n Hydrochlorothiazide 12. 13. Insulin\n 14. Influenza Virus Vaccine 15. LeVETiracetam 16. Lisinopril 17.\n Lorazepam 18. Lorazepam 19. Lorazepam\n 20. Meclizine 21. Metoprolol Tartrate 22. Mirtazapine 23. Omeprazole\n 24. Oxycodone SR (OxyconTIN)\n 25. Pneumococcal Vac Polyvalent 26. Senna 27. traZODONE\n 24 Hour Events:\n MULTI LUMEN - STOP 10:33 AM\n CALLED OUT\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 01:07 AM\n Lorazepam (Ativan) - 02:14 AM\n Hydromorphone (Dilaudid) - 02:14 AM\n Metoprolol - 06:12 AM\n Other medications:\n Flowsheet Data as of 09:19 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: 36.8\nC (98.2\n HR: 108 (89 - 134) bpm\n BP: 153/79(97) {103/52(65) - 178/96(117)} mmHg\n RR: 23 (16 - 32) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 62.2 kg (admission): 63.1 kg\n Total In:\n 1,911 mL\n 689 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,911 mL\n 689 mL\n Blood products:\n Total out:\n 1,116 mL\n 427 mL\n Urine:\n 1,116 mL\n 427 mL\n NG:\n Stool:\n Drains:\n Balance:\n 795 mL\n 262 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///20/\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: 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 276 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 105 mEq/L\n 136 mEq/L\n 28.2 %\n 4.8 K/uL\n [image002.jpg]\n 02:55 AM\n 03:00 AM\n 02:00 AM\n WBC\n 5.7\n 5.0\n 4.8\n Hct\n 26.4\n 25.8\n 28.2\n Plt\n 265\n 256\n 276\n Creatinine\n 0.7\n 0.6\n 0.6\n Glucose\n 111\n 85\n 107\n Other labs: PT / PTT / INR:16.5/27.7/1.5, CK / CK-MB / Troponin\n T:225//, ALT / AST:, Alk-Phos / T bili:1498/0.5, Albumin:2.7 g/dL,\n Ca:8.3 mg/dL, Mg:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID\n HEMORRHAGE (SAH), .H/O CANCER (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan: 85 year old male treated for UTI at outside\n hospital, MS changes when returned to , back to OSH where head CT\n showed small subarachnoid and subdural bleed, transfered to full\n body x ray for MRI, family contact attempted not achieved\n Neurologic: Subdural /subarachnoid bleed, F/U MRI, ativan prn agitation\n Cardiovascular: CV:maintain BP < 180, prn nicardipine or nitro, femoral\n TLC, Atenolol, HCTZ, Lisinopril\n Pulmonary: Resp:stable on NC\n Gastrointestinal / Abdomen: GI:NPO, PPI\n Nutrition: NPO, GI:NPO, PPI\n Renal: Foley, Renal: Foley follow UOP, NS @ 75/hr\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: no abx\n Lines / Tubes / Drains: TLD:femoral triple lumen, foley, piv\n Wounds: None\n Imaging: ?MRI\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 08:05 AM\n 20 Gauge - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439882, "text": ".H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt more alert and appropriate during first half of shift. Pt began to\n get increasingly agitated and restless at around 0200. Pt very HOH,\n generally oriented X 1 when pt cooperative with neuro exam. Pt noted to\n have continued right sided weakness but does MAE. Speech is somewhat\n garbled and difficult to understand ? worsened by pt\ns poor dentitian.\n Pupils are surgical and unequal at baseline. During periods of\n agitation pt will yell out, resist care and has been combative at\n times\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n Response:\n Pt had good response after ativan for agitation\n Plan:\n Continue to follow neuro exams. Plan to have speech and swallow eval so\n pt can possibly restart PO medication. Pt can transfer to neuro SDU\n when bed becomes available\n" }, { "category": "Physician ", "chartdate": "2200-02-17 00:00:00.000", "description": "Intensivist Note", "row_id": 439917, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI, family\n contact attempted not achieved\n Chief complaint:\n 85yM with small SAH, SDH\n PMHx:\n unknown\n Current medications:\n 1. 1000 mL NS 2. Acetaminophen 3. Atenolol 4. Bisacodyl 5.\n Cholestyramine 6. Docusate Sodium 7. Ferrous Sulfate\n 8. HYDROmorphone (Dilaudid) 9. Haloperidol 10. HydrALAzine 11.\n Hydrochlorothiazide 12. 13. Insulin\n 14. Influenza Virus Vaccine 15. LeVETiracetam 16. Lisinopril 17.\n Lorazepam 18. Lorazepam 19. Lorazepam\n 20. Meclizine 21. Metoprolol Tartrate 22. Mirtazapine 23. Omeprazole\n 24. Oxycodone SR (OxyconTIN)\n 25. Pneumococcal Vac Polyvalent 26. Senna 27. traZODONE\n 24 Hour Events:\n MULTI LUMEN - STOP 10:33 AM\n CALLED OUT\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 01:07 AM\n Lorazepam (Ativan) - 02:14 AM\n Hydromorphone (Dilaudid) - 02:14 AM\n Metoprolol - 06:12 AM\n Other medications:\n Flowsheet Data as of 09:19 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: 36.8\nC (98.2\n HR: 108 (89 - 134) bpm\n BP: 153/79(97) {103/52(65) - 178/96(117)} mmHg\n RR: 23 (16 - 32) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 62.2 kg (admission): 63.1 kg\n Total In:\n 1,911 mL\n 689 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,911 mL\n 689 mL\n Blood products:\n Total out:\n 1,116 mL\n 427 mL\n Urine:\n 1,116 mL\n 427 mL\n NG:\n Stool:\n Drains:\n Balance:\n 795 mL\n 262 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///20/\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: 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 276 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 105 mEq/L\n 136 mEq/L\n 28.2 %\n 4.8 K/uL\n [image002.jpg]\n 02:55 AM\n 03:00 AM\n 02:00 AM\n WBC\n 5.7\n 5.0\n 4.8\n Hct\n 26.4\n 25.8\n 28.2\n Plt\n 265\n 256\n 276\n Creatinine\n 0.7\n 0.6\n 0.6\n Glucose\n 111\n 85\n 107\n Other labs: PT / PTT / INR:16.5/27.7/1.5, CK / CK-MB / Troponin\n T:225//, ALT / AST:, Alk-Phos / T bili:1498/0.5, Albumin:2.7 g/dL,\n Ca:8.3 mg/dL, Mg:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID\n HEMORRHAGE (SAH), .H/O CANCER (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan: 85 year old male treated for UTI at outside\n hospital, MS changes when returned to , back to OSH where head CT\n showed small subarachnoid and subdural bleed, transfered to full\n body x ray for MRI, family contact attempted not achieved\n Neurologic: Subdural /subarachnoid bleed, F/U MRI, ativan prn agitation\n Cardiovascular: CV:maintain BP < 180, prn nicardipine or nitro, femoral\n TLC, Atenolol, HCTZ, Lisinopril\n Pulmonary: Resp:stable on NC\n Gastrointestinal / Abdomen: GI:NPO, PPI\n Nutrition: NPO, GI:NPO, PPI\n Renal: Foley, Renal: Foley follow UOP, NS @ 75/hr\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: no abx\n Lines / Tubes / Drains: TLD:femoral triple lumen, foley, piv\n Wounds: None\n Imaging: ?MRI\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 08:05 AM\n 20 Gauge - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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 Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2200-02-18 00:00:00.000", "description": "Intensivist Note", "row_id": 440135, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to \n Chief complaint:\n altered mental status\n PMHx:\n colon CA with mets to bones\n Current medications:\n 1. 1000 mL D5 1/2NS 2. Acetaminophen 3. Bisacodyl 4. Cholestyramine 5.\n Cyanocobalamin 6. Docusate Sodium\n 7. HYDROmorphone (Dilaudid) 8. HYDROmorphone (Dilaudid) 9. Haloperidol\n 10. HydrALAzine 11. 12. Insulin\n 13. LeVETiracetam 14. Metoprolol Tartrate 15. Metoprolol Tartrate 16.\n Metoprolol Tartrate 17. Mirtazapine\n 18. Omeprazole 19. Senna\n 24 Hour Events:\n CALLED OUT\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 04:39 AM\n Metoprolol - 05:16 AM\n Haloperidol (Haldol) - 05:23 AM\n Hydromorphone (Dilaudid) - 06:15 AM\n Other medications:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.1\nC (98.8\n HR: 115 (92 - 121) bpm\n BP: 155/74(94) {107/52(66) - 175/100(118)} mmHg\n RR: 35 (14 - 37) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 62.2 kg (admission): 63.1 kg\n Total In:\n 1,959 mL\n 647 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,959 mL\n 647 mL\n Blood products:\n Total out:\n 1,092 mL\n 444 mL\n Urine:\n 1,092 mL\n 444 mL\n NG:\n Stool:\n Drains:\n Balance:\n 867 mL\n 203 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Labs / Radiology\n 297 K/uL\n 8.4 g/dL\n 102 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 106 mEq/L\n 135 mEq/L\n 25.4 %\n 4.2 K/uL\n [image002.jpg]\n 02:55 AM\n 03:00 AM\n 02:00 AM\n 02:09 AM\n WBC\n 5.7\n 5.0\n 4.8\n 4.2\n Hct\n 26.4\n 25.8\n 28.2\n 25.4\n Plt\n 265\n 256\n 276\n 297\n Creatinine\n 0.7\n 0.6\n 0.6\n 0.6\n Glucose\n 111\n 85\n 107\n 102\n Other labs: PT / PTT / INR:16.5/27.7/1.5, CK / CK-MB / Troponin\n T:225//, ALT / AST:, Alk-Phos / T bili:1498/0.5, Albumin:2.7 g/dL,\n Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, CHRONIC PAIN, TACHYCARDIA, OTHER, .H/O SUBDURAL\n HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH), .H/O CANCER\n (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan: 85yM with small SAH, SDH, altered mental status\n Neurologic: Subdural/subarachnoid bleed, underlying meningioma on MRI,\n altered mental status, likely related to multiple sedative medications,\n however will continue pain medication for bone mets, haldol prn\n agitation, B-12 injections, keppra\n Cardiovascular: Beta-blocker, Lopressor, hydralazine for HTN\n Pulmonary:\n Gastrointestinal / Abdomen: Place NGT, NPO, PPI, consider placing\n doboff and starting tube feeds, converting meds to PO\n Nutrition: consider starting TF\n Renal: Foley\n Hematology: anemia, stable\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: follow neuro surgery recs re further imaging\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 22 Gauge - 11:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440039, "text": "85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.MRi and\n head ct consisent with hemangioma\n .H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt waxes and wanes between difficultto rouse to alert and comative\n consistently calling out Pt very HOH, generally oriented X 1-2knows\n name and year) when pt cooperative with neuro exam. Pt noted to have\n continued right sided weakness but does inconsistently squeeze hands\n with lt hand and wriggles toes on both. Speech is somewhat slurredand\n difficult to understand ? worsened by pt\ns poor dentitian. Pupils are\n surgical and unequal at baseline. During periods of agitation pt will\n yell out, resist care and has been combative at times\n pt seems to be in pain ? from metastasis from prostate ca cries out in\n pain when touched\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n changed from wrist restraints to mitt on rt hand occasionally hits when\n startled.\n Response:\n Pt had good response after ativan for agitation and Dilaudid for pain\n pt seems more comfortable.\n Plan:\n Continue to follow neuro exams q2. Plan to have speech and swallow eval\n so pt can possibly restart PO medication.\n Pt neice called for results of mri referred to md. ?\n whether neice aware of transfer to sdu.\n Addendum: seen by medicine and pt medication changed per\n recommendations. Ativan dc\nd. hadol prn started and dilaudid frequency\n increased to Q4 prn. Pt agitated and hr up to 120\ns with pt yelling\n out. Dilaudid .125mg iv given with pt appearing less agitated and more\n comfortable. Hr remains in the 120\ns and pt given a one time extra\n dose of 5mg of lopressor hr down to 109 st\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440040, "text": "85 yr old man with SAH and SDH over left parietal lobe. Previously\n treated at osh for uti found to have ms changes when returned to No\n known trauma. No intraparenchymal hemorrhage per Head CT. Pt loud and\n agitated on arrival to SICU at 2300. Pt MAE but has a definite Rt sided\n weakness. Pupils difficult to assess ? surgical pupils. Pt OX1 (name)\n only, Pt is very HOH even with a hearing aide in the left ear.MRi and\n head ct consisent with hemangioma\n .H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt waxes and wanes between difficultto rouse to alert and comative\n consistently calling out Pt very HOH, generally oriented X 1-2knows\n name and year) when pt cooperative with neuro exam. Pt noted to have\n continued right sided weakness but does inconsistently squeeze hands\n with lt hand and wriggles toes on both. Speech is somewhat slurredand\n difficult to understand ? worsened by pt\ns poor dentitian. Pupils are\n surgical and unequal at baseline. During periods of agitation pt will\n yell out, resist care and has been combative at times\n pt seems to be in pain ? from metastasis from prostate ca cries out in\n pain when touched\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n changed from wrist restraints to mitt on rt hand occasionally hits when\n startled.\n Response:\n Pt had good response after ativan for agitation and Dilaudid for pain\n pt seems more comfortable.\n Plan:\n Continue to follow neuro exams q2. Plan to have speech and swallow eval\n so pt can possibly restart PO medication.\n Pt neice called for results of mri referred to md. ?\n whether neice aware of transfer to sdu.\n Addendum: seen by medicine and pt medication changed per\n recommendations. Ativan dc\nd. hadol prn started and dilaudid frequency\n increased to Q4 prn. Pt agitated and hr up to 120\ns with pt yelling\n out. Dilaudid .125mg iv given with pt appearing less agitated and more\n comfortable. Hr remains in the 120\ns and pt given a one time extra\n dose of 5mg of lopressor hr down to 109 st\n ------ Protected Section ------\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Height:\n Admission weight:\n 63.1 kg\n Daily weight:\n 62.2 kg\n Allergies/Reactions:\n Precautions:\n PMH: Anemia\n CV-PMH: Hypertension\n Additional history: Vertigo\n Failure to thrive\n GERD\n HOH\n metastatic prostate CA\n Progressive colon Ca with METS\n metastitic prostate CA\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:175\n D:100\n Temperature:\n 97.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 120 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,782 mL\n 24h total out:\n 982 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 02:00 AM\n Potassium:\n 4.1 mEq/L\n 02:00 AM\n Chloride:\n 105 mEq/L\n 02:00 AM\n CO2:\n 20 mEq/L\n 02:00 AM\n BUN:\n 19 mg/dL\n 02:00 AM\n Creatinine:\n 0.6 mg/dL\n 02:00 AM\n Glucose:\n 107 mg/dL\n 02:00 AM\n Hematocrit:\n 28.2 %\n 02:00 AM\n Finger Stick Glucose:\n 104\n 10:00 AM\n Valuables / Signature\n Patient valuables: eye glasses, hearing aid on pt .\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu to 1120\n Date & time of Transfer:\n ------ Protected Section Addendum Entered By: , RN\n on: 21:01 ------\n" }, { "category": "Nursing", "chartdate": "2200-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439542, "text": ".H/O subarachnoid hemorrhage (SAH)/SDH\n Assessment:\n Pt arouseable to voice and stimuli. Confused, uncooperative\n does not\n answer questioning or follow commands. Moves all extremities on bed,\n localizes pain. Left side much stronger than right, see flowsheets for\n specifics. Pupils unequal\n both surgical in nature. VSS.\n Action:\n Pt kept npo md\ns orders. Sbp closely monitored. MRI done.\n Response:\n Pt remains confused. VSS. Neuro assessment unchanged.\n Plan:\n Cont close neuro assessment. Monitor for s/s of bleeding. Maintain pt\n safety. Transfer to stepdown when bed available.\n" }, { "category": "Nursing", "chartdate": "2200-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439596, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt arouses to verbal stimuli. Pt is uncooperative with neuro exam but\n reponds to name when called. Pt is restless in bed and gets easily\n agitated (ie yelling out, resisting care) when doing any kind of care\n with patient. Pt verbalizing but thoughts are confused, not following\n any commands but is noted to move all extremities with some right sided\n weakness.\n Action:\n Q 2 hour neuro exams, pt frequently reoriented throughout shift\n Response:\n No change\n Plan:\n Continue Q 2 hour neuro exams, transfer to step down unit when bed\n available\n" }, { "category": "Nursing", "chartdate": "2200-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439597, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt arouses to verbal stimuli. Pt is uncooperative with neuro exam but\n reponds to name when called. Pt is restless in bed and gets easily\n agitated (ie yelling out, resisting care) when doing any kind of care\n with patient. Pt verbalizing but thoughts are confused, not following\n any commands but is noted to move all extremities with some right sided\n weakness.\n Action:\n Q 2 hour neuro exams, pt frequently reoriented throughout shift\n Response:\n No change\n Plan:\n Continue Q 2 hour neuro exams, transfer to step down unit when bed\n available\n Tachycardia, Other\n Assessment:\n Pt HR running 110-130s if agitated. SBP 120-140\n Action:\n Dr. notified that pt unable to take PO meds d/t pt\ns mental\n status. Lopressor 5mg ordered IV Q 6 hours while pt is unable to take\n lisinopril and atenolol\n Response:\n Pt\ns HR down to 92 and BP into 80s after getting only 2.5mg of 5mg dose\n Plan:\n Monitor HR, lopressor IV per parameters until pt can tolerate PO intake\n" }, { "category": "Physician ", "chartdate": "2200-02-16 00:00:00.000", "description": "Intensivist Note", "row_id": 439601, "text": "SICU\n HPI:\n 85 year old male treated for UTI at outside hospital, MS changes when\n returned to , back to OSH where head CT showed small subarachnoid and\n subdural bleed, transfered to full body x ray for MRI, family\n contact attempted not achieved\n Chief complaint:\n AMS\n PMHx:\n unknown\n Current medications:\n 1. 1000 mL NS 2. Acetaminophen 3. Atenolol 4. Bisacodyl 5.\n Cholestyramine 6. Docusate Sodium 7. Ferrous Sulfate\n 8. Hydrochlorothiazide 9. 10. Insulin 11. Influenza Virus Vaccine 12.\n LeVETiracetam 13. Lisinopril\n 14. Lorazepam 15. Lorazepam 16. Lorazepam 17. Meclizine 18. Metoprolol\n Tartrate 19. Mirtazapine\n 20. Omeprazole 21. Oxycodone SR (OxyconTIN) 22. Pneumococcal Vac\n Polyvalent 23. Senna 24. traZODONE\n 24 Hour Events:\n MRI with and without contrast done to assess if any evidence of brain\n masses.\n Called out to the floor but no beds available\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 12:39 AM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 101 (99 - 116) bpm\n BP: 116/59(72) {72/46(52) - 143/74(95)} mmHg\n RR: 23 (18 - 34) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 520 mL\n 298 mL\n PO:\n Tube feeding:\n IV Fluid:\n 520 mL\n 298 mL\n Blood products:\n Total out:\n 1,725 mL\n 360 mL\n Urine:\n 1,725 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,205 mL\n -62 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ////\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: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 256 K/uL\n 8.7 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 19 mg/dL\n 102 mEq/L\n 134 mEq/L\n 25.8 %\n 5.0 K/uL\n [image002.jpg]\n 02:55 AM\n 03:00 AM\n WBC\n 5.7\n 5.0\n Hct\n 26.4\n 25.8\n Plt\n 265\n 256\n Creatinine\n 0.7\n Glucose\n 111\n Other labs: PT / PTT / INR:16.5/27.7/1.5\n Assessment and Plan\n TACHYCARDIA, OTHER, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID\n HEMORRHAGE (SAH), .H/O CANCER (MALIGNANT NEOPLASM), PROSTATE\n Assessment and Plan: 85yM with small SAH, SDH\n Neurologic: Subdural /subarachnoid bleed, F/U MRI\n Cardiovascular: maintain BP < 180, prn nicardipine or nitro, femoral\n TLC, Atenolol, HCTZ, Lisinopril\n Pulmonary: stable on NC\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley follow UOP. NS @ 75/hr\n Hematology: Hct stable at 25 from 26\n Endocrine: RISS\n Infectious Disease: no antibiotics, no issues\n Lines / Tubes / Drains: PIV, femoral TLC, aline\n Wounds:\n Imaging: F/U MRI read today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n 22 Gauge - 08:05 AM\n 20 Gauge - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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:\n" }, { "category": "Nursing", "chartdate": "2200-02-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439809, "text": ".H/O subdural hemorrhage (SDH)/(SAH)\n Assessment:\n Pt more alert and appropriate during first half of shift. Pt began to\n get increasingly agitated and restless at around 0200. Pt very HOH,\n generally oriented X 1 when pt cooperative with neuro exam. Pt noted to\n have continued right sided weakness but does MAE. Speech is somewhat\n garbled and difficult to understand ? worsened by pt\ns poor dentitian.\n Pupils are surgical and unequal at baseline. During periods of\n agitation pt will yell out, resist care and has been combative at\n times\n Action:\n Pt given ativan for periods of agitation. New order for IV dilaudid for\n pain management as pt has been taking pain med PO at baseline\n Response:\n Pt had good response after ativan for agitation\n Plan:\n Continue to follow neuro exams. Pt can transfer to neuro SDU when bed\n becomes available\n" }, { "category": "Nursing", "chartdate": "2200-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439648, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt arouses to verbal stimuli. Pt is uncooperative with neuro exam but\n reponds to name when called. Pt is restless in bed and gets easily\n agitated (ie yelling out, resisting care) when doing any kind of care\n with patient. Pt verbalizing but thoughts are confused, not following\n any commands but is noted to move all extremities with some right sided\n weakness.\n Action:\n Q 2 hour neuro exams, pt frequently reoriented throughout shift\n Response:\n No change\n Plan:\n Continue Q 2 hour neuro exams, transfer to step down unit when bed\n available\n Tachycardia, Other\n Assessment:\n Pt HR running 110-130s if agitated. SBP 120-140\n Action:\n Dr. notified that pt unable to take PO meds d/t pt\ns mental\n status. Lopressor 5mg ordered IV Q 6 hours while pt is unable to take\n lisinopril and atenolol\n Response:\n Pt\ns HR down to 92 and BP into 80s after getting only 2.5mg of 5mg dose\n Plan:\n Monitor HR, lopressor IV per parameters until pt can tolerate PO intake\n Addendum: Placed pt\ns hearing aide and glasses and pt now following\n commands inconsistently. Pt very HOH but more cooperative with exams\n after hearing aide adjusted. ? need for speech/swallow eval prior to\n giving Pos.\n" }, { "category": "Radiology", "chartdate": "2200-02-15 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1060020, "text": " 1:40 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for underlying pathology\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with apparent subdural hemorrhage, with partial subarachnoid\n REASON FOR THIS EXAMINATION:\n eval for underlying pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa SAT 10:25 PM\n Limited examination secondary to motion artifact. Blood products are\n demonstrated in the left parietal convexity, likely consistent with a\n combination of subarachnoid hemorrhage and small subdural hematoma of\n indeterminate etiology and chronicity. There is no evidence of mass effect or\n midline shifting. Areas of restricted diffusion are visualized in the\n hematoma, likely consistent with T2 shine-through effect. Effacement of the\n sulci are demonstrated in the left parietal region, the possibility of an\n underlying mass lesion cannot be completely excluded, followup with gadolinium\n contrast material is recommended.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MRI of the head without contrast.\n\n CLINICAL INDICATION: 85-year-old man with apparent subdural hemorrhage with\n partial subarachnoid hemorrhage, please evaluate for underlying pathology.\n\n COMPARISON: Prior CT of the head dated .\n\n TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility,\n and diffusion-weighted sequences were obtained.\n\n FINDINGS: This is a limited examination secondary to motion artifacts. Ill-\n defined hemorrhagic changes are visualized in the left parietal convexity\n likely consistent with a combination of subarachnoid hemorrhage and possible\n subdural hematoma over the left parietal lobe. Mild restricted diffusion is\n identified in the core of the hematoma, possibly related with magnetic\n susceptibility changes. An underlying mass lesion cannot be completely\n excluded in this area, given the fact that there is evidence of narrowing of\n the sulci and mass effect in the left ventricle, correlation with MRI with\n contrast is strongly recommended to rule out underlying conditions such as\n mass or vascular abnormalities. In the sagittal view, there are areas of\n hyperintensity in the cerebellum, likely consistent with pulsation artifacts.\n Prominence of the sulci and ventricles is demonstrated, possibly age related\n and involutional in nature. Few scattered areas of hyperintensity signal are\n noted in the periventricular white matter, likely indicating chronic\n microvascular ischemic disease. The orbits demonstrate a scleral band on the\n left eye globe, the paranasal sinuses with mild mucosal thickening in the\n sphenoidal sinus. Normal flow void signal is identified in the major vascular\n structures.\n\n IMPRESSION: Ill-defined subarachnoid and subdural hematoma in the left\n (Over)\n\n 1:40 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for underlying pathology\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n parietal convexity, the possibility of an underlying mass lesion or vascular\n abnormality cannot be completely ruled out, this is a limited examination\n secondary to motion artifacts, correlation with MRI with gadolinium contrast\n is recommended. Effacement of the sulci and mass effect is demonstrated in\n the left parietal convexity with mild anterior displacement of the left\n lateral ventricle. Areas of hyperintensity signal are noted in the\n periventricular white matter, likely consistent with chronic microvascular\n ischemic changes.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1059995, "text": " 7:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with apparent intraparenchymal bleed on left with right sided\n negelect\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WWM 8:34 PM\n Subarachnloid hemorrhage and small subdural hematoma over high left parietal\n convexity. No intraparenchymal hemorrhage.\n WET READ VERSION #1 WWM 8:26 PM\n Subarachnloid hemorrhage over high left parietal convexity. No definite\n intraparenchymal hemorrhage. Will confirm with recons.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST AT 20:03 HOURS.\n\n HISTORY: Apparent intraparenchymal hemorrhage on left with right-sided\n neglect.\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n brain and reconstructed at stacked 5-mm increments. Coronal and sagittal\n reformatted images were generated.\n\n COMPARISON: None.\n\n FINDINGS: The extracalvarial soft tissues are unremarkable. The calvarium\n and skull base are intact with no underlying fracture. There is a general\n diffuse ill-defined sclerosis involving the clivus and portions of the skull\n base. No discrete mass lesion is identified. There is suggestion of\n underlying coarsening of the trabeculations. There is mucosal thickening of\n bilateral sphenoid sinuses. No air-fluid levels noted. The mastoid air cells\n are hypoaerated. There is a scleral band around the left globe.\n\n Intracranially, the ventricles are mildly prominent but midline. There is\n subarachnoid hemorrhage over the high left parietal convexity extending to the\n vertex. A small adjacent subdural hematoma 11 mm in width is identified best\n on sagittal reformations, series 104b, image 23. There is a mild sulcal\n effacement in the area of hemorrhage, but otherwise, no significant mass\n effect results. There is a confluent low attenuation and predominantly a\n periventricular distribution likely related to chronic microvascular ischemic\n change. There is no CT evidence of acute cortical stroke.\n\n IMPRESSION: Subarachnoid hemorrhage and small subdural hematoma over left\n parietal lobe near the vertex of indeterminate etiology. History of trauma\n has not been provided. Depite history given, no intraparenchymal hemorrhage\n seen.\n (Over)\n\n 7:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2200-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060001, "text": " 9:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evalaute for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with fever and ? hypotension\n REASON FOR THIS EXAMINATION:\n Evalaute for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 21:13 HOURS\n\n HISTORY: Fever and question of hypotension.\n\n COMPARISON: None.\n\n FINDINGS: Lung volumes are diminished with bibasilar atelectasis, more\n notable on the right. No definite focal consolidation or superimposed edema\n is noted. There is a markedly tortuous aorta. The cardiac silhouette size is\n difficult to assess but is likely at least borderline enlarged. No definite\n effusion or pneumothorax is noted. There is diffuse sclerosis of the included\n skeleton highly suggestive of widespread metastatic disease of the prostate\n given age and gender of patient.\n\n IMPRESSION: No definite acute pulmonary process. Although history not\n provided, there is high suspicion for metastatic prostate cancer.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-14 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2-3 VIEWS", "row_id": 1060006, "text": " 10:05 PM\n C-SPINE NON-TRAUMA VIEWS; ABDOMEN (SUPINE ONLY) Clip # \n Reason: MR SCREEN. NO CXR. NO HEAD..ALLEXAMS DONE PRIOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with head bleed\n REASON FOR THIS EXAMINATION:\n screen for metal/pacer\n ______________________________________________________________________________\n FINAL REPORT\n C-SPINE TWO VIEWS, LUMBAR SPINE TWO VIEWS, AT 22:07 HOURS\n\n HISTORY: Screen for metal in pacemaker pre-MRI.\n\n COMPARISON: Chest x-ray and head CT acquired earlier.\n\n FINDINGS: There is marked increased density of the skeletal structures\n throughout the body which, given patient demographics, is highly consistent\n with metastatic prostate cancer. There is an indwelling dental filling.\n Otherwise, no metallic foreign bodies are noted in the field of view. Please\n note the chest and skull were excluded, but have been imaged earlier today.\n There is an indwelling right femoral central venous catheter. A non-\n obstructive bowel gas pattern is present. Degenerative changes are noted in\n the lower cervical spine.\n\n IMPRESSION: Aside from a metal filling, no metal is noted throughout the body\n imaged. Sclerotic bones are highly suggestive of diffuse prostate metastases.\n Hyperparathyroidism could conceivably result in this imaging appearance.\n Correlate clinically.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1060296, "text": " 10:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with altered mental status, left parietal SAH and SDH\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT MON 4:19 PM\n No short-interval change in the overall appearance, with the lobulated,\n predominantly hyperdense process, in the extra-axial space at the left\n parietal vertex, given its stability and MR characteristics more likely an en\n plaque meningioma, partially calcified, accounting for the MR \ncs. Moreover, the findings on both this exam, as well as the\n recent enhanced MR study raise the serious possibility of at least partial\n invasion of the immediately subjacent superior sagittal sinus, without\n definite thrombosis, and possible venous obstruction-related edema in\n subjacent white matter.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST, \n\n HISTORY: 85-year-old man with left parietal SAH and SDH and altered mental\n status; evaluate for interval change.\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 initial NECT of and the\n interval unenhanced and enhanced MR examinations of . Over the three-\n day interval, there has been little change in the overall appearance of the\n heterogeneous but predominantly hyperattenuating lobulated process centered in\n the extra-axial space of the left parietovertex. This appears to \"mold\" to\n the contour of the subjacent convexity, where there is focal low-attenuation\n in the immediate subcortical white matter, corresponding to the FLAIR-signal\n abnormality in this region, which may represent edema secondary to venous\n congestion, gliosis, or both. The overall appearance is most suggestive of a\n partially calcified en plaque meningioma, though there is no specific evidence\n of \"reactive change\" in the suprajacent inner table of the skull. There has\n been no other short-interval change.\n\n IMPRESSION: No short-interval change in the overall appearance, with the\n lobulated, predominantly hyperdense, process, in the extra-axial space at the\n left parietovertex, given its stability and MR characteristics more likely an\n en plaque meningioma, partially calcified, accounting for the MR \ns.\n\n Moreover, the findings on both this exam and the recent enhanced MR study\n raise the serious possibility of at least partial invasion of the immediately\n subjacent superior sagittal sinus, without definite thrombosis, and possible\n (Over)\n\n 10:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n venous obstruction-related edema in local white matter. If this will affect\n therapeutic decision, dedicated MR venography might be considered.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1060297, "text": ", C. NSURG SICU-B 10:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with altered mental status, left parietal SAH and SDH\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No short-interval change in the overall appearance, with the lobulated,\n predominantly hyperdense process, in the extra-axial space at the left\n parietal vertex, given its stability and MR characteristics more likely an en\n plaque meningioma, partially calcified, accounting for the MR \ns. Moreover, the findings on both this exam, as well as the\n recent enhanced MR study raise the serious possibility of at least partial\n invasion of the immediately subjacent superior sagittal sinus, without\n definite thrombosis, and possible venous obstruction-related edema in\n subjacent white matter.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-15 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1060105, "text": " 4:11 PM\n MR HEAD W/ CONTRAST Clip # \n Reason: subarachnoid/subdural bleed\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with CT shoing subarachnoid and subdural bleed on outside film\n REASON FOR THIS EXAMINATION:\n subarachnoid/subdural bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SUN 6:22 PM\n\n Study significantly limited due to motiona rtifacts.\n Enahncement noted in the region of the left pariet-occipital hemorrhage-\n underlying vascular or space occupying lesion cannot be excluded given the\n presence of hemorrhage which limits accurate assessment. Repeat evaluation\n including MRA after resolution of hemorrhage; CT as clinically indicated.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old male patient, CT showing subarachnoid and subdural\n bleed on outside film, for further evaluation.\n\n COMPARISON: Non-contrast MR of the head done on .\n\n TECHNIQUE: Post-contrast MR sequences were obtained.\n\n FINDINGS;\n The study is significantly limited due to patient motion artifacts. There is\n enhancement noted in the area of known hemorrhage in the left parieto-\n occipital region, compared to the pre-contrast sequences done on the prior\n study. However, the etiology of enhancement is not clear as there is\n significant amount of hemorrhage in this location, as seen on the prior CT and\n MR studies. Mildly dilated ventricles are visualized, not adequately assessed.\n\n IMPRESSION:\n\n 1. Study significantly limited due to motion artifacts. Enhancement noted in\n the left parieto-occipital region, partly extending along the dura, the\n etiology of which is uncertain, as this is in the region of the known\n hemorrhage. Repeat evaluation, after resolution of the hemorrhage can be\n considered, to evaluate for any underlying vascular or space-occupying lesion.\n Close followup with CT scan can also be considered as clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-15 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1060021, "text": ", C. NSURG SICU-B 1:40 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for underlying pathology\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with apparent subdural hemorrhage, with partial subarachnoid\n REASON FOR THIS EXAMINATION:\n eval for underlying pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Limited examination secondary to motion artifact. Blood products are\n demonstrated in the left parietal convexity, likely consistent with a\n combination of subarachnoid hemorrhage and small subdural hematoma of\n indeterminate etiology and chronicity. There is no evidence of mass effect or\n midline shifting. Areas of restricted diffusion are visualized in the\n hematoma, likely consistent with T2 shine-through effect. Effacement of the\n sulci are demonstrated in the left parietal region, the possibility of an\n underlying mass lesion cannot be completely excluded, followup with gadolinium\n contrast material is recommended.\n\n" } ]

[ { "category": "Echo", "chartdate": "2192-09-24 00:00:00.000", "description": "Report", "row_id": 61075, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 111/61\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV free wall\nhypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic 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. Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. The right ventricular cavity is markedly dilated with\nmoderate global free wall hypokinesis. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is minimal mitral regurgitation. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis\nand moderate pulmonary artery hypertension c/w primary pulmonary process\n(pulmonary embolism, COPD, etc.). Preserved global and regional left\nventricular systolic function.\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": "2192-09-23 00:00:00.000", "description": "Report", "row_id": 115184, "text": "Sinus rhythm. Prolonged Q-T interval. Inferior and anteroseptal ST-T wave\nchanges are non-specific. Compared to the previous tracing of no\nsignificant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2192-09-23 00:00:00.000", "description": "Report", "row_id": 115185, "text": "Sinus rhythm. Prolonged Q-T interval. Inferior and anteroseptal ST-T changes\nare non-specific. Compared to the previous tracing of no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-09-23 00:00:00.000", "description": "Report", "row_id": 115186, "text": "Sinus rhythm. Extensive ST-T wave changes may be due to myocardial ischemia.\nCompared to the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2192-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 932921, "text": " 10:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with AIDS and new fever\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AIDS. Fever.\n\n AP BEDSIDE CHEST. The heart is probably enlarged with straightening of the\n left heart border and probable prominence of the pulmonary artery. No\n vascular congestion, consolidations, effusions, or PTX (on this semi-erect\n exam). Since exam two days ago (), the right subclavian line has\n been removed with otherwise no change.\n\n IMPRESSION: No pneumonia or other acute process.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-09-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 932594, "text": " 3:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with RSC line\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with right subclavian venous line.\n\n PORTABLE AP CHEST RADIOGRAPH: The right subclavian venous line is terminating\n in mid SVC. There is no evidence of pneumothorax. Cardiac and mediastinal\n contours are within normal limits, and there is no consolidation or effusion.\n\n IMPRESSION: Subclavian venous line as described above. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-09-23 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 932606, "text": " 6:03 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please assess for abscess ,bowel pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with hypotension and diarrhea, h/o vascular neuropathy and hiv,\n unable to rely on exam\n REASON FOR THIS EXAMINATION:\n please assess for abscess ,bowel pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd SUN 7:02 PM\n no evidence of abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension and diarrhea, history of vascular neuropathy and\n HIV, evaluate for abscess.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained\n without IV contrast secondary to elevated creatinine.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST. Dependent changes are seen at the lung\n bases. Allowing for limitations of a non-contrast study, the liver,\n gallbladder, pancreas, spleen, and kidneys appear unremarkable. Again seen is\n a rounded hypodensity in the right adrenal likely representing adrenal\n adenoma, not significantly changed in appearance from prior study. Visualized\n portions of bowel appear unremarkable. There is no evidence of free air or\n free fluid within the abdomen. Scattered lymph nodes are seen throughout the\n mesentery and retroperitoneum, however, none appear to meet CT criteria for\n pathological enlargement.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid appear\n unremarkable. Air is seen within the bladder, likely secondary to Foley\n catheterization. No evidence of free air or free fluid within the pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n IMPRESSION: No evidence of intraabdominal abscess.\n\n" }, { "category": "Radiology", "chartdate": "2192-09-24 00:00:00.000", "description": "LUNG SCAN", "row_id": 932767, "text": "LUNG SCAN Clip # \n Reason: 52YR OLD MAN WITH H/O CAD P/W CP, HYPOTENSION, TROP 0.11, TTE C/W PE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 5.1 mCi Tc-m MAA ();\n 40.0 mCi Tc-99m DTPA Aerosol ();\n INTERPRETATION:\n Ventilation images obtained with Tc-99m aerosol in 8 views demonstrate bilateral\n posterobasal segmental defects.\n\n Perfusion images in the same 8 views show bilateral posterobasilar segmental\n defects.\n\n Chest x-ray from shows no focal areas of consolidation.\n\n The above findings are consistent with a low probabibility scan for pulmonary\n embolism\n\n IMPRESSION:\n Matched segmental defects of the posterobasilar segments consistent with a low\n probability scan for pulmonary embolism.\n\n\n , M.D.\n , M.D. Approved: WED 2:57 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": "2192-09-26 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 933004, "text": " 10:53 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: Signs of pulmonary embolus?\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with chest pain and new R heart strain on echo.\n REASON FOR THIS EXAMINATION:\n Signs of pulmonary embolus?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE CHEST WITH AND WITHOUT CONTRAST\n\n INDICATION: This is a 52-year-old gentleman with a history of chest pain and\n new right-sided heart strain on recent echo. Rule out pulmonary embolism.\n\n COMPARISONS: Comparison is made to a prior CT torso study dated .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired from the thoracic\n inlet to the upper abdomen. Approximately 100 cc of Optiray contrast was\n injected intravenously and axial images of the chest were acquired. Coronal,\n sagittal, and oblique reformatted images were then obtained.\n\n CTA OF THE CHEST WITH AND WITHOUT IV CONTRAST: Examination of the pulmonary\n vasculature shows no evidence of filling defects consistent with pulmonary\n embolism. The pulmonary artery is noted to be prominent and measures\n approximately 3.7 cm in diameter which is considered large. The upper limit\n of normal is approximately 3.0 cm. The right ventricle is noted to be\n enlarged compared to the left ventricle and measures approximately 5.4 cm in\n diameter at the level of the tricuspid valve. This is compared to 4.5 cm in\n diameter for the left ventricle, measured at the mitral valve. There appears\n to be thickening of the interatrial septum. Analysis of the attenuation\n characteristics of this area would be consistent with fat. This area measures\n approximately 15 mm and its overall appearance and length are likely\n consistent with lipomatous hypertrophy of the interatrial septum. There are\n at least two coronary stents noted in the right coronary artery and left\n anterior descending artery, respectively. There are small bilateral pleural\n effusions. There is small pericardial effusion. Examination of the lung\n parenchyma with the lung windows is limited secondary to patient motion. There\n are no focal nodules or opacities identified.\n\n Limited views of the upper abdomen are unremarkable. There are no suspicious\n lytic or blastic lesions identified.\n\n IMPRESSION:\n 1. This is a limited study secondary to patient breathing and bolus timing.\n There is no evidence of pulmonary embolism.\n 2. Prominent pulmonary artery measuring 3.7 cm in diameter. Large right\n ventricle and right atrium. These findings are consistent with underlying\n pulmonary hypertension. No specific findings on CT to explain pulmonary\n hypertension.\n (Over)\n\n 10:53 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: Signs of pulmonary embolus?\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Incidental note made of lipomatous hypertrophy of the atrial septum.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-09-24 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 932747, "text": " 7:03 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PES, EVAL FOR DVTS\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with h/o CAD p/w CP, trop 0.11, TTE c/w PE.\n REASON FOR THIS EXAMINATION:\n eval for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Possible PE. Query lower extremity source.\n\n RIGHT LOWER EXTREMITY DOPPLER/DUPLEX ULTRASOUND: Normal compressibility,\n color flow, Doppler waveforms again seen in the deep venous system from the\n common femoral vein to the popliteal.\n\n LEFT LOWER EXTREMITY DOPPLER/DUPLEX ULTRASOUND: Normal compressibility, color\n flow, and Doppler waveforms are seen in the deep venous system from the common\n femoral vein to the popliteal.\n\n IMPRESSION: No evidence of DVT in either lower extremity.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2192-09-24 00:00:00.000", "description": "Report", "row_id": 1477242, "text": "7a-7p MICU Nursing Progress Note\nEvents: Heparin gtt d/c'ed this am secondary to HCT drop and guaiac + stool on rectal exam. Repeat HCT was sent this am and = 28.1 (up from 26.1 last pm). SQ Heparin started. IV ABX d/c'ed (pt. never received a dose) secondary to no source of infection. HCT repeated @ noon = 26.1 (down again). 1 unit PRBC ordered to infuse over 4 hr. Blood ^ @ 1400. Due for repeat cbc/lytes ~ 21:00 tonight (3 hrs post-txn). C/O to floor.\n\nReview of Systems:\n\nNeuro: Pt. alert, oriented x 3. Sleeping most of day, but awakens easily. MAE. Able to turn self in bed. Spastic lower extremities (secondary to myelopathy per pt). Pt. pleasant and cooperative. C/O constant RUE pain....takes morphine @ home prn.\n\nCV: Heart rate 70's-80's, NSR on monitor, no ectopy noted. NIBP low 100's-120 / 50's-70's. CVP 5-13. No c/o chest pain today. Heparin gtt d/c'ed. SQ heparin started. Only sign of active bleeding is @ right subclavian CVL insertion site...oozing blood since insertion on . Initial Troponin in ED was 0.11; however, trending down. 3rd trop from this am = 0.03; ? NSTEMI vs. ARF-related. Cards recs: continue asa, plavix, b-blocker, check echo. Bedside echo done today; results pending. AM HCT = 26.1; 1 unit PRBC infusing; needs repeat labs ~ 2100.\n\nResp: LS clear, diminished @ bases. RR 15-20, O2 sat 99-100% on 2L O2 via NC. Denies SOB/DOE. Resp even, nonlabored.\n\nGI/GU: Abdomen soft, nt/nd. + bs. No bm today, though needs stool sent for multiple tests when available. Guaiac + on rectal exam this am MD. liquids without difficulty; diet advanced to regular for dinner. + N, - V. Antiemetics prn. Daily PPI. Foley draining clear/yellow urine, ~ 30-180 cc/hr (2 liters + since midnight). BUN/Cr trending down, this am = 30/2.8 (from 41/5.7 in ED). ARF likely secondary to hypovolemia, although could be NSTEMI related.\n\nID: HAART meds on hold today secondary to ARF. Pt. afebrile. WBC this am = 3.3 ABX d/c'ed secondary to no source of infection. All cx pending.\n\nAccess: #18G PIV in LAC and RFA....both flushed/patent. Right Triple Lumen Subclavian continues to ooze blood; to be d/c'ed tonight.\n\nSocial: Wife in to visit today; spoke w/ intern and RN, updated on POC. Pt. is DNR/I.\n\nPlan: Continue asa/plavix/b-blocker; monitor fluid balance closely; repeat labs @ 2100 (3 hrs post-txn); c/o to floor; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2192-09-25 00:00:00.000", "description": "Report", "row_id": 1477243, "text": "Nursing Progress Note 1900-0700\nEVENTS: Pt was c/o yesterday eve, then called back in after ECHO showed RV strain and pulm htn. Sent to VQ scan (unable to CTA d/ elevated crt). results pending. No resp distress. LENI's also done at bedside, negative for thrombus. Per MICU team request, restart on heparin gtt. Hct did not bump w/ previous shifts RBC's. Given additional 1 units PRBC's overnoc w/ >2 pt hct elevation. No evidence of GIB, but + odor of GIB when passing flatus. platelets trending down- ?HIT?, MICU team aware. Overall hemodynamically stable.\n\nROS/PE:\n\nCV: NSR HR 70-80's, no ectoy. NIBP 80-110's systolic. down into 80's when asleep, quickyly elevates when awoken. neg edema. hct 28.9. as mentioned, no evidence of bleeding.\n\nRESP: LS clear. no resp distress. rare NP. maintained on 2L NC w/ spo2 100%. 97-98% on RA.\n\nNEURO: A&O x3, MAE on the bed. LE's very spastic, will suddenly jerk upward. R >L. c/o intermittent LE and R arm pain, given 1mg morphine w/ good effect. Appears comfortable. Slept on and off most of evening. decreased sensation to LE's. Baseline: uses WC and has weakness from chest down.\n\nGI/GU: Tolerating clear liquids, denies nausea. No stool this shift. passing flatus. and soft /NT/ND. Foley patent w/ clear yellow urine out.\n\nSKIN: sacrum a bit erythemic, cream applied. warts to feet bilat and anal region. SKin otherwise intact.\n\nACCESS: Piv x2, R SC TLC in place, all patent.\n\nSOCIAL: wife phoned, updated.\n\nPLAN: serial hct;s, monitor for s/s of GIB. This RN discussed dc'ing heparin gtt given pt's low hct's and dropping platelets. MICU team prefering to keep gtt on until completely r/o PE by VQ scan (still pending). ?mobilize OOB to chair today. Pt is DNR/DNI.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2192-09-24 00:00:00.000", "description": "Report", "row_id": 1477241, "text": "Nursing Note (2100-0700)\n\nPt is a 52yr old adm with prob dehydration. Has had longstanding diarrhea for 2mo as well as waxing/ of appetite and recent N/V for past 2-3 days. Complaints of dizziness and lack of urine for 2 days. Complaints of CP as well and thus being r/o for MI. Pmhx: MI with 2 vessed disease, 3 stents placed approx 6 mo ago; vacuolar myelopathy, HIV, neuropathy, spastic bladder, muscle spasticity of leg, appy, gastritis.\n\nReview of systems:\nNeuro: A&Ox3; answering questions appropriately; complaining of general fatigue. Slept fairly well thru night. Denied pain med offered.\n\nCV: HR 70's, no ectopy, SR. Stable hypotension in 90's/40-60's. R SC TLCL with bleeding at site since insertion; hemostat dsg applied with some cont ooze. #18 to left AC. Heparin gtt therapeutic with first PTT draw at 1000u/hr. Next PTT due at 9am. CPK's/MB trending down; peak trop 0.11. Decreased Hct to 26.1 (33.8) after ~6L IVF. Dr. aware of borderline lytes. Blood and fungal cx drawn. stim done\n\nResp: LS clear; diminished to right. Maitained on 2L nc; no SOb/dyspnea\n\nGi/GU: Tol clear lix; denies n/v but states no appetite. team to f/u on pt's reflux med. Abd soft; stainining on bedsheets of foul stool however insignificant for sample. Very good u/o with hydration. U/A sent; US of kidneys pnd.\n\nSocial: No calls/visits from wife. son in school. Pt is a DNr/DNI--states this has been discussed with wife in past.\n\nPlan: IVF bolus with CVP <8. Await labs. Heparin gtt per sl scale. IV meropenum. Stool sample for multiple samples needed. Wean o2. Clear lix, ? ADAT; obtain nutrition consult for hi protein frappes/supplements.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2192-09-25 00:00:00.000", "description": "Report", "row_id": 1477244, "text": "7A-3P\nSEE TRANSFER NOTE\n" }, { "category": "Nursing/other", "chartdate": "2192-09-25 00:00:00.000", "description": "Report", "row_id": 1477245, "text": "Nursing evening note (1500-1900):\n\nEvents..Post transfusion HCT @ 1600 = 33.6. Pt to be started on agatroban this evening (baseline PTT sent..results pnd'ing)...Pt is HIT +. Temp Increased this eve to 100.8 from 98.9 this afternoon. Pan cx'd. D/C'd right SC TLC..pt now w/ 2 PIVs. Pt c/o pain ..given 2mg IV morphine w/ adequate effect.\n\nNeuro: Pt alert and oriented x 3. Following commands. Pt moving BUE. BLE w/ vacuolar myelopathy - quick/sudden involuntary jerky mvts. Pt stated he is w/c bound @ home, but is fully Independent w/ ADLs and transfers.\n\nResp: LS clear throughout. O2 sats >95% on RA.\n\nCV: VSS. NSR. HCT 33.6 @ 1600- next due @ 2200 (Q 6H). K 4.5.\n\nGI: BS present. Rectal flatus, but no BM. Abd. soft, ND, NT. Pt c/o nausea, but quickly subsided..denied anti-nausea med.\n\nGU: foley patent..voiding clear/yellow urine. U/O adequate. UA/UC collected.\n\nsocial: pt's wife visited.\n\nCode status: DNR/DNI\n\nPlan: Monitor cardiopulmonary status, f/u on labs and cultures, cont. w/ HCT Q6 hrs (next due @ 2200) monitor temp curve, start on agatroban gtt- PTT due 2 hrs after starting gtt, pain mgmt, Pt to remain in ICU d/t agatroban gtt.\n" }, { "category": "Nursing/other", "chartdate": "2192-09-25 00:00:00.000", "description": "Report", "row_id": 1477246, "text": "NPN 1900-2330:\n\nPTT therapeutic on Argatroban gtt; Hct stable at 33; no evidence of bleeding. Still with low-grade temp. Transferred to 3 in stable condition.\n" } ]

[ { "category": "Radiology", "chartdate": "2201-01-23 00:00:00.000", "description": "CHANGE PERC TUBE OR CATH W/CONTRAST", "row_id": 1228410, "text": " 9:50 AM\n PERC NEPHROSTO Clip # \n Reason: Please drain and sample fluid\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OMNIPAQUE Amt: 20\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with possible pyelonephritis\n REASON FOR THIS EXAMINATION:\n Please drain and sample fluid\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Right percutaneous nephrostomy catheter placement: .\n\n CLINICAL INDICATION: 62 year-old man with suspected pyelonephritis and\n urosepsis. There is evidence of moderate right-sided hydronephrosis and\n proximal hydroureter on a CT scan of the abdomen which is new in comparison\n with previous cross-sectional imaging studies.\n\n PHYSICIANS: MD (fellow) and MD (attending\n physician).\n\n SEDATION: Fentanyl drip per ICU protocol, endotracheal intubation.\n\n ANESTHESIA: Local, 1% lidocaine subcutaneously.\n\n TECHNIQUE/FINDINGS:\n\n Informed consent for the procedure was obtained from the healthcare\n proxy after risks, benefits, and potential complications had been discussed.\n The patient was positioned on the angiography table in prone position, skin of\n the right flank was prepped and draped in a sterile fashion, and the\n procedural site was marked. Timeout protocol was carried out prior to the\n procedure according to the hospital policy.\n\n Using the sector transducer, a hydronephrotic right kidney was visualized.\n Under realtime ultrasound visualization, a 21-gauge Cook needle was advanced\n into a posterior interpolar calyx without difficulty. Viscous purulent\n exudate was aspirated and samples were saved for laboratory analysis and\n microbiological studies. Over a 0.018 inch guidewire, the 21-gauge Cook\n needle was then exchanged for an AccuStick system followed by placement of\n 0.035 inch Bentson guidewire into the right renal pelvis. Cannulation of the\n right ureter was facilitated by exchanging the wire for a 0.035 inch\n angled Glidewire. Antegrade pyelogram was performed demonstrating complete\n obstruction of the right ureter at the level of the L4 vertebral body\n terminating abruptly adjacent to the right common iliac artery stent in the\n vicinity of the surgical clips associated with explantation of the failed\n pancreatic transplant. After appropriate dilatation of the needle tract, a 10\n French locking loop nephrostomy catheter was advanced into the right renal\n (Over)\n\n 9:50 AM\n PERC NEPHROSTO Clip # \n Reason: Please drain and sample fluid\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OMNIPAQUE Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pelvis.\n\n The nephrostomy catheter was secured to the skin using a 0 silk stitch and\n secure locking device and was covered with a sterile dressing. The hub of the\n catheter was connected to the bag for external drainage. Meticulous\n hemostasis was maintained throughout the procedure. The patient tolerated the\n procedure well.\n\n IMPRESSION:\n\n 1. Right pyonephrosis.\n 2. Complete obstruction of the right mid ureter associated with pyonephrosis\n and proximal pyoureter.\n 3. Placement of a 10 French locking loop percutaneous nephrostomy catheter\n into the right renal pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2201-01-28 00:00:00.000", "description": "CHANGE PERC TUBE OR CATH W/CONTRAST", "row_id": 1229066, "text": " 8:26 AM\n URIN CATH REPLC Clip # \n Reason: Please attempt to dilate, pass wire, through the right naiti\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OMNIPAQUE Amt: 15\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt is a 62 yo with history of LURT in and pancreas-after-kidney transplant\n in who presents with RLQ abd pain, N/V ultimately found to have\n pyelonephritis of his native right kidney s/p perc nephrostomy tube placement.\n Course was c/b septic shock requiring pressors and respiratory failure\n requiring intubation. Now called out to for further work-up.\n REASON FOR THIS EXAMINATION:\n Please attempt to dilate, pass wire, through the right naitive kidney ureter\n ______________________________________________________________________________\n FINAL REPORT\n ATTEMPTED EXCHANGE OF RIGHT NEPHROSTOMY CATHETER WITH NU STENT; REPLACEMENT OF\n THE OLD NEPHROSTOMY WITH A NEW CATHETER\n\n INDICATION: 62-year-old male with recent septic shock from right\n hydroureteronephrosis as a result of right mid ureteral obstruction.\n\n CONTRAST: Sterile 15 mL Omnipaque 350 in the right renal collecting system.\n\n MEDICATION: IV 50 mcg fentanyl. Patient's hemodynamic status was\n continuously monitored during the procedure.\n\n OTHER MEDICATION: IV ceftriaxone.\n\n PROCEDURE AND FINDINGS: Consent was obtained from patient after explaining\n the benefits, risks, and alternatives. Patient was placed prone on the image\n table in the interventional suite. Timeout was performed as per \n protocol.\n\n Initial scout fluoroscopic image demonstrated indwelling right upper abdomen\n catheter with retention pigtail loop. Small amount of sterile contrast\n material was injected under aseptic conditions, which demonstrated filling of\n moderately dilated right renal collecting system and ureter to the level of\n its mid portion, with abrupt cutoff at the level of right common iliac artery\n stent, as was noted on the previous nephrostogram. Catheter was cut close to\n the hub to introduce a 0.035 wire, which was coiled within the right\n renal collecting system. Catheter remnant was removed to place a 7 French\n Tip sheath. After removing the inner cannula, a 5 French Kumpe catheter\n was placed over the wire to negotiate into the right proximal ureter. \n wire was exchanged for a 0.035 angled Glidewire. Kumpe catheter-Glidewire\n combination was attempted to be passed beyond the point of obstruction in the\n mid ureter; however, we were unsuccessful. During one such attempt, there was\n a tiny amount of contrast extravagation in the lateral aspect of the right mid\n ureter, which was self-limiting. Decision was made to abandon attempts at\n placing NU stent.\n (Over)\n\n 8:26 AM\n URIN CATH REPLC Clip # \n Reason: Please attempt to dilate, pass wire, through the right naiti\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OMNIPAQUE Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n After removing the Kumpe catheter, Glidewire was exchanged for wire,\n which was advanced into the right proximal ureter. After removing the 7\n French sheath, a new 10 French nephrostomy catheter was placed over the wire.\n Inner plastic stiffener and wire were removed. String was withdrawn, locked,\n and trimmed to place the retention pigtail loop in the right renal pelvis. A\n small amount of sterile contrast material was injected to confirm position.\n It was then flushed with sterile saline. Catheter was secured by 0 silk\n sutures and Flexi-Trak, and connected to an external bag. Site was\n appropriately dressed. Patient tolerated the procedure well and no immediate\n post-procedure complication was seen.\n\n Please note that at the beginning of the procedure, the old catheter was\n putting out bloody content, which was again noted after the new catheter\n placement.\n\n IMPRESSION:\n 1. Attempted conversion of right percutaneous nephrostomy catheter with an NU\n stent; however, it was not possible.\n 2. Technically successful replacement of the old 10 French percutaneous\n nephrostomy catheter with a similar but new one. It was left connected to an\n external bag.\n\n Results were discussed over the phone with Dr. , Rupam at 10 a.m. on\n .\n\n" }, { "category": "Radiology", "chartdate": "2201-01-23 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1228382, "text": " 7:57 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: New line plcmt\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with ? sepsis\n REASON FOR THIS EXAMINATION:\n New line plcmt\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: Radiograph of earlier the same date.\n\n FINDINGS: Right internal jugular vascular catheter terminates in the\n mid-to-lower superior vena cava, with no visible pneumothorax. Endotracheal\n tube is in standard position, terminating 4.4 cm above the carina. Persistent\n cardiomegaly, accompanied by pulmonary vascular congestion and worsening\n perihilar edema. Worsening atelectasis at left lung base accompanied by small\n left pleural effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2201-01-24 00:00:00.000", "description": "Report", "row_id": 99024, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 68\nWeight (lb): 151\nBSA (m2): 1.82 m2\nBP (mm Hg): 127/51\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 10:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Normal RV systolic\nfunction.\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). Minimal AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild [1+] TR. 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. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF 65%). The right ventricular free\nwall is hypertrophied. Right ventricular chamber size is normal. with normal\nfree wall contractility. The aortic root is mildly dilated at the sinus level.\nThe aortic valve leaflets (3) are mildly thickened (the noncoronary cusp is\nmoderately thickened and displays reduced systolic excursion). There is a\nminimally increased gradient consistent with minimal aortic valve stenosis.\nThe mitral valve leaflets are mildly thickened. There is borderline/mild\nposterior leaflet mitral valve prolapse. Mild (1+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nNo vegetations seen\n\n\n" }, { "category": "ECG", "chartdate": "2201-01-23 00:00:00.000", "description": "Report", "row_id": 279409, "text": "Sinus tachycardia. Borderline left axis deviation. Compared to the previous\ntracing of there are more prominent Q waves in the inferior leads.\nCannot rule out inferior wall myocardial infarction of indeterminate age.\nPoor R wave progression persists. Diffuse ST-T wave abnormalities are also\npersistent. Cannot rule out underlying myocardial ischemia. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2201-01-23 00:00:00.000", "description": "Report", "row_id": 279408, "text": "Sinus rhythm. Anteroseptal myocardial infarction of indeterminate age. Compared\nto the previous tracing of there is no diagnostic change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2105-07-08 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1199230, "text": " 2:51 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p liver transplant for HCV, EtOH cirrhosis w/ HD-dependent\n ESRD admitted w/ sepsis. Suspicion highest for pulmonary versus GI (CDiff vs\n cholangitis) source.\n REASON FOR THIS EXAMINATION:\n please place\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Placement of -intestinal tube.\n\n INDICATION: 60-year-old man status post liver transplant for HCV, alcoholic\n cirrhosis with end-stage renal disease.\n\n PROCEDURE: Patient was received with a Dobbhoff tube in the gastric fundus.\n Tube was then advanced post-pylorically with the aid of air and manipulation.\n With fluoroscopic guidance, the tube was advanced post-pylorically. 10 cc of\n Optiray contrast were then injected and fluoroscopic images confirmed the\n placement of a post-pyloric feeding tube. The tube was then flushed with 50\n cc of water.\n\n IMPRESSION: Successful placement of post-pyloric Dobbhoff feeding tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199478, "text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for aspiration. assess right effusion\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62M s/p OLT complicated by intra-abdominal hemorrhage s/p washout,\n pneumonia with right empyema, c. diff now with sepsis and GNR bacteremia now\n with desat to 70s, very congested. likely aspirated\n REASON FOR THIS EXAMINATION:\n assess for aspiration. assess right effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 62-year-old male status post orthotopic liver transplant\n complicated by intra-abdominal hemorrhage status post washout pneumonia with\n right empyema, C. diff, now with sepsis and GNR bacteremia. Assess right\n effusion.\n\n COMPARISON: Chest radiograph from at 2:00 a.m.\n\n ONE VIEW OF THE CHEST:\n\n The lungs show confluent bilateral lower lobe opacities with associated large\n effusions. A more loculated effusion in the right chest has mildly decreased\n since the exam from but is mildly increased compared to the exam\n from at 2:00 a.m. Cardiac silhouette is not well evaluated.\n The mediastinal silhouette is normal. A right IJ line terminates in the mid\n SVC appropriately. An NG tube terminates in the stomach appropriately.\n\n IMPRESSION:\n\n Mild intervertebral increase in the size of a loculated right pleural effusion\n compared to the immediate preceding examination. This effusion has decreased\n since at 10:00 a.m. Large left layering pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2105-07-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1198591, "text": " 8:58 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with RIJ placement\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Central line placement.\n\n COMPARISON: at 19:06.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous\n catheter tip terminates in the SVC. Redemonstrated is a feeding tube, which\n is partially coiled in the distal esophagus, as before. A moderate\n right-sided pleural effusion with right lower lobe collapse is again noted.\n Patchy opacity in left lung base is again visualized and may represent\n atelectasis, but infection or aspiration is not excluded. Mild pulmonary\n vascular congestion persists.\n\n IMPRESSION: Right internal jugular central venous catheter tip terminates in\n the SVC. No pneumothorax. Remainder of the chest is unchanged. Feeding tube\n remains coiled partially within the distal esophagus.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-07-03 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1198592, "text": " 9:18 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: AT BEDSIDE, please. portal vein patent? ascites?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with liver transplant, AMS, fever.\n REASON FOR THIS EXAMINATION:\n AT BEDSIDE, please. portal vein patent? ascites?\n ______________________________________________________________________________\n WET READ: SHSf FRI 10:12 PM\n 1. Patent main hepatic artery and major branches with brisk upstroke, patent\n hepatic and portal venous branches.\n 2. Echogenic focus along falciform ligament likely reflect resolving post\n surgical collection/hematoma as seen on CT .\n 3. Simple right hepatic cyst.\n 4. Coarsened hepatic echotexture with moderate to large amount of ascites as\n has been seen previously.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant with altered mental status and\n fever. Assess for portal vein patency and presence of ascites.\n\n TECHNIQUE: Liver ultrasound with Dopplers.\n\n COMPARISON: CT abdomen and pelvis, . Right upper quadrant\n ultrasound, .\n\n FINDINGS: The liver is slightly coarsened in appearance. Echogenic area in\n the left lobe measuring 3.0 x 1.8 x 1.6 cm likely reflects resolving complex\n fluid collection or hematoma in the left lobe as seen on prior CT. Right\n hepatic simple-appearing cyst is also seen measuring 2.0 cm. Main portal and\n hepatic vein and branches are patent. Main hepatic artery and branches are\n patent with brisk systolic upstrokes. Splenic vein and artery are patent with\n normal spleen measuring 9.7 cm. The gallbladder is surgically absent.\n Moderate-to-large amount of ascites is seen.\n\n IMPRESSION:\n 1. Patent portal and hepatic veins and hepatic arteries with normal systolic\n upstroke.\n\n 2. Coarsened liver with echogenic area in the left lobe compatible with a\n resolving hematoma or complex fluid collection. Simple hepatic cyst also\n seen.\n\n 3. Moderate-to-large amount of ascites.\n\n" }, { "category": "Radiology", "chartdate": "2105-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199295, "text": " 2:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p liver transplant for HCV, EtOH cirrhosis w/ HD-dependent\n ESRD admitted w/ sepsis. Suspicion highest for pulmonary versus GI (CDiff vs\n cholangitis) source.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post liver transplant, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the position of the tip of\n the Dobbhoff catheter has changed, currently the catheter is outside of the\n image borders. The course of the catheter is unchanged. Unchanged position\n of the right internal jugular access line. Unchanged bilateral pleural\n effusions, with minimally improved right basal atelectasis. Unchanged size of\n the cardiac silhouette. No newly appeared focal parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198583, "text": " 7:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis.\n\n COMPARISON: Chest radiograph and chest CT .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: A feeding tube is identified which appears\n to be coiled within the distal esophagus; however, the tip is likely within\n the stomach, but not imaged on this exam. As before, there is volume loss\n within the right lung with rightward shift of mediastinal structures and right\n lower lobe collapse. Moderate-sized right pleural effusion appears to be\n slightly increased in size with a loculated component as well as a layering\n component. There is mild pulmonary vascular congestion. Patchy opacity in\n left lung base may reflect atelectasis, but infection is not excluded. No\n pneumothorax is present.\n\n IMPRESSION:\n 1. Feeding tube appears to be coiled within the distal esophagus; however,\n the tip is likely within the stomach, but not fully imaged on this study.\n 2. Moderate-sized right pleural effusion, which is partially loculated, and\n appears slightly increased in size.\n 3. Continued right lower lobe collapse.\n 4. Mild pulmonary vascular congestion.\n 5. Patchy opacity in left lung base, which may reflect atelectasis, but\n infection or aspiration cannot be excluded.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2105-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199498, "text": " 9:47 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with ESLD/HCV\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, \n\n HISTORY: End-stage liver disease. Check ET tube placement.\n\n IMPRESSION: AP chest compared to through at 9:29 a.m.:\n\n New endotracheal tube is in standard placement. Sharp definition of the upper\n margin of the inflatable cuff suggests secretions are pooling above it.\n\n Large bilateral pleural effusions and right basal atelectasis unchanged\n acutely. No pneumothorax. A feeding tube and a nasogastric tube ends in the\n upper stomach. Right jugular line tip projects over the low SVC. Heart is\n not enlarged. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199174, "text": " 10:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p liver transplant for HCV, EtOH cirrhosis w/\n HD-dependent ESRD admitted w/ sepsis. Suspicion highest for pulmonary versus GI\n (CDiff vs cholangitis) source.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post liver transplant for HCV , cirrhosis.\n\n Comparison made with prior study, .\n\n Cardiomediastinal silhouette is unchanged, is partially obscured by pleural\n effusions. Large bilateral pleural effusions, right greater than left, have\n increased on the left side and are associated with bibasilar atelectasis, also\n increased on the left. Right central catheter tip is in the mid-to-lower SVC.\n NG tube is coiled in the stomach. The tip is in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2105-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198879, "text": " 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, ? fluid overload\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p liver transplant for HCV, EtOH cirrhosis w/ HD-dependent\n ESRD admitted w/ sepsis. Suspicion highest for pulmonary versus GI (CDiff vs\n cholangitis) source.\n REASON FOR THIS EXAMINATION:\n interval change, ? fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man status post liver transplant for HCV and ethanol\n cirrhosis, question of fluid in overload.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs show bilateral lower lobe opacities with large right and moderate\n left pleural effusion. The cardiomediastinal silhouette and hilar contours\n are normal. No pleural effusion is present. A right IJ catheter terminates\n in the mid SVC appropriately. A Dobbhoff tube terminates in the stomach\n appropriately.\n\n IMPRESSION:\n\n Large right and moderate left pleural effusion with associated atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-07-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1198636, "text": " 12:36 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Intrabad source ? colon (CDiff pos)\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with Hypotension and fever\n REASON FOR THIS EXAMINATION:\n Intrabad source ? colon (CDiff pos)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old man with hypotension and fever, query intra-abdominal\n source.\n\n TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the\n symphysis pubis following oral and intravenous contrast. Coronal and sagittal\n reformats were produced and reviewed.\n\n COMPARISON: CT abdomen and pelvis and CT chest, .\n\n CT CHEST WITH IV CONTRAST:\n\n No enlarged axillary or mediastinal lymph nodes. Visualized portions of the\n thyroid gland are unremarkable. There is moderate atherosclerotic\n calcification of the coronary arteries (2:28). The esophagus is distended,\n the Dobbhoff tube is curled on itself within the gastric lumen, passes back up\n through the esophagus is curled again and ends up in a relatively normal\n position in the distal stomach, consider repositioning. The esophagus is\n moderately distended with oral contrast, which may be related to the Dobbhoff\n tube. There are small bilateral pleural effusions. The effusion on the left\n is new compared to prior studies. There is associated atelectasis\n bilaterally, more marked on the right. No pulmonary nodules. No pericardial\n effusions.\n\n CT OF THE ABDOMEN WITH IV CONTRAST:\n\n The patient is status post liver transplant. The liver is unchanged in\n appearance compared to the prior postoperative CT. There is a linear area of\n hypoenhancement seen in segment V (2:60) and a more ill-defined hypoenhancing\n area in segment II/III (2:65). This latter lesion has decreased in extent\n compared to the prior study. The spleen is unremarkable. Both adrenal glands\n and both kidneys are unremarkable except to note some small hypoenhancing\n lesions in the upper pole of the right kidney (2:60), unchanged compared to\n the prior study. No hydronephrosis. The pancreas is unremarkable in\n appearance. No mesenteric or retroperitoneal lymphadenopathy. There is\n moderate to extensive ascites. The large bowel is diffusely abnormal with\n increased bowel wall thickness of low attenuation consistent with edema. The\n appearances are consistent with a colitis, although nonspecific, this could be\n related to the patient's known C. diff infection.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n (Over)\n\n 12:36 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Intrabad source ? colon (CDiff pos)\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The urinary bladder is decompressed by a Foley catheter. The rectum is\n abnormally edematous as is the rest of the large bowel. No pelvic\n lymphadenopathy. No free air.\n\n BONY STRUCTURES:\n\n No destructive lytic or sclerotic bony lesions.\n\n IMPRESSION:\n 1. Bilateral pleural effusions with compressive atelectasis.\n 2. Dobbhoff tube curled twice, once in the stomach, once in the esophagus.\n 3. Moderate to extensive ascites.\n 4. Diffuse colitis, nonspecific in appearance but certainly could be related\n to patient's known C. diff infection.\n\n The findings were discussed with Dr. at 1:30 p.m. in the\n radiology department.\n\n" }, { "category": "ECG", "chartdate": "2105-07-10 00:00:00.000", "description": "Report", "row_id": 229792, "text": "Sinus rhythm. Intermittent, probably rate-related right bundle-branch block.\nLow voltage. Prominent right precordial R waves, consider old true posterior\nmyocardial infarction or right ventricular hypertrophy. Compared to the\nprevious tracing of no change except right bundle-branch block is now\nintermittent.\n\n" }, { "category": "ECG", "chartdate": "2105-07-06 00:00:00.000", "description": "Report", "row_id": 229793, "text": "Sinus rhythm. Right bundle-branch block. Low voltage in the limb leads.\nThe Q-T interval is prolonged. Compared to the previous tracing of \nright bundle-branch block is new.\n\n" }, { "category": "ECG", "chartdate": "2105-07-05 00:00:00.000", "description": "Report", "row_id": 229794, "text": "Sinus rhythm. Borderline prolonged Q-T interval. Precordial ST-T wave\nchanges are non-specific. Consider ischemia. Compared to the previous tracing\nof the rhythm has changed. The rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2105-07-03 00:00:00.000", "description": "Report", "row_id": 229795, "text": "Sinus tachycardia. Incomplete right bundle-branch block. Left atrial\nabnormality. Generalized low QRS voltages. Non-specific ST-T wave changes.\nCompared to the previous tracing of diffuse T wave flattening is most\nnoticeable now in the precordial leads. Otherwise, no other significant\ndiagnostic change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769863, "text": "NICU nursing progress note\n\n\npLease refer to flowsheet for specific info.\nFEN\nO: TF of 120cc/k/d, SC 20. Bottling very well today q 4\nhours, taking 75cc and 60cc thus far. (Minimum is 44cc q 4\nhours). Wakes for feedings. No spits. Abd pink, no loops,\nactive bs.Voiding q diaper change. A: stable. P: cont to\nfollow.\nGD\nO tEmp stable in oac, active and alert with cares, MAE.\nFonts soft, flat. Good tone. CAlms with containment and\npacifier. A: AGA P: cont to support dev.milestones/ Dr.\n in and planning on doing circumcision as outpatient\nto allow infant to grow more.\nParenting\nNO contact from thus far today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769864, "text": "NPN\nMom in for infant CPR class. Watched instructional video and returned demonstration on infant mannequin. Asked appropriate questions and verbalized understanding of information. Also reviewed and demonstrated infant choking and safety issues. Mom given first aid handout and recommended other caregivers to be familiar with CPR technique.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769865, "text": "nursing note\nDisreguard above note. This was charted on wrong patient.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769866, "text": "nursing note\n\n\n1.Fluid and Nutrition:O:Total fluids 140cc/kg/day SC28 with\npromod. Tolerating well with good weight gain tonight, up 50\ngrams. PO feeding once every shift. A:35 week baby with\ngood weight gain on 28 calorie formula.P:Continue to PO feed\nas tolerated, continue with current plan.\n\n2.Growth and Developement:O:Baby remains in open crib with\nstable temp and good weight gain. PO feeding well. Alert and\nactive with care.A: Stable P:continue to offer PO feeds,\nincrease po feeds as tolerated.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769867, "text": "nursing note\n\n\nAlt in Fluid and Nutrition:O:Total fluids 120cc/kg/d sc20.\nPO feeding well. Weight up 20 grams tonight.A:stable with\ngood weight gain on 20 calorie formula. P:continue with\npresent plan.\n\n2.Growth and Developement:O:stable in open crib, with good\nweight gain. Alert and active with care, po feeding\nwell.A:35 week baby,plan to discharge tomorrowP:continue to\nmonitor weight gain, continue to offer po.\n\n4.Alt in bonding/social: o:Mom in this afternoon. Discharge\nteaching done, see discharge teaching sheet. Mom made pedi\nappointment for Friday. Mom stating she would like a bath\n before discharge to home.A:discharge\nteaching,P:discharge plan for tomorrow, Mom to bring in\ncarseat and would like bath prior.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-11 00:00:00.000", "description": "Report", "row_id": 1769868, "text": "NPN 2300-0700\n\n\n1 FEN\nCurrent weight 2.160 kg, up 20 grams. TF at of\n120cc/kg/day of SC 20. Slow with bottles, but did take\n150cc/kg/day for previous 24 hrs. Abd soft, bs +. No\nspits. Voiding and stooling.\n\n2 G&D\nTemp stable in open crib. Wakes q 4 hrs for feeds. Sucks\nvigorously on pacifier.\n\n4 social\nNo contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-11 00:00:00.000", "description": "Report", "row_id": 1769869, "text": "Neonatology Attending\nDOL 5\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP mean 49.\n\nWt 2160 (+20) on ad feeds with intake approximately 150 cc/kg/day. Voiding and stooling normally.\n\nHearing and car seat screening passed. Hepatitis B and Synagis administered. VNA arranged.\n\nA&P\n34-4/7 week GA infant, now doing well\n-For discharge home today\n-PCP through clinic (MD's name pending)\n" }, { "category": "Nursing/other", "chartdate": "2130-10-09 00:00:00.000", "description": "Report", "row_id": 1769859, "text": "NPN 0700-1900\n\n#1 Alt. in Nutrition\nO: TF increased to . 120cc/kg=44cc SpCare 20 Q 4 hrs. Abd. is round, soft with + BS, no loops. Girth stable. Frequent spits this AM, several small and 2 large. No spits since 1300. Voiding and stooling guaiac -. PO fed well at 0900 and 1330, taking 45cc. Only took 30cc for mom at 1700.\nA: Frequent spits this AM, all POs but ? whether able to meet .\nP: Continue with present feeding plan. Assess TFI and spits. Follow daily wts.\n\n#2 Alt. in Development\nO: Maintaining temp in open crib, swaddled positioned supine. Starting to stir for some feeds, sleepy at others. Alert and active with cares. PO feeding well X 2 but took less than for mom at 1700. spells.\nA: Maturing behaviors, ? adequate intake\nP: Continue to support developmental needs.\n\n#4 Alt. in Parenting\nO: Parents in at 1600. Family meeting held with MD, SW and this RN. Discussed course to present, criteria for discharge and expectations for next several days. Right now, plan is for circ. in AM and another few days of observation to ensure adequate PO intake. All questions answered. Mom still looking for pedi. Will call and let us know. Dr. in to see mom. Consent signed for circ. tomorrow. WIC forms filled out and given to mom. Also immunization booklet. Mom signed up for CPR tomorrow. Hearing screen done.\nA: Involved, loving family\nP: Keep informed and support. Continue D/C preparations.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769860, "text": "Nursing Progress Note\n\n\n#1. O: Infant remains on TF's of 120cc/k/d of SC20. All\npo. Received 107cc/k/d yesterday. Infant needs 44cc's q4hrs.\nPo fed 35-55cc's overnight. No spits thus far. Abd soft and\nround with active bowel sounds. No loops. Voiding qs. Med\ngreen stool, neg heme. Wgt this a.m. down 20gms to 2140gms.\nA: Not quite taking amts. P: Continue to encourage po\nfeeds to take 120cc/k/d.\n\n#2. O: Infant remains in open crib with stable temp. He is\nalert and active with cares. MAEW. WAking for feeds q4hrs.\nA: AGA P: Continue to assess and support developmental\nneeds.\n\n#4. No contact from tonight thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769861, "text": "Neonatology Attending\nDOL 4 / CGA 35-1/7 weeks\n\nIn room air with no cardiorespiratory events.\n\nNo murmur.\n\nWt 2140 (-20) on TFI 120 cc/kg/day SC20, tolerating well, with no further reflux overnight. Intake 107 cc/kg/day in the past 24 hours. Voiding and stooling (guiac negative).\n\nA&P\n34-4/7 week GA infant with improving feeding immaturity\n-Continue to monitor feed intake today\n-Circumcision today\n-Discharge planning in progress\n" }, { "category": "Nursing/other", "chartdate": "2130-10-10 00:00:00.000", "description": "Report", "row_id": 1769862, "text": "Neonatology Fellow Note\nExam:\nGeneral: sleeping preterm male in open crib in NAD\nHEENT: AFSF, MMM\nCV: RRR without murmur, 2+ fem pulses, CR brisk\nPulm: CTA bilaterally\nAbd: soft, NT/ND, +BS\nGU: normal preterm male external genitalia, testes descended bilaterally\nExt: WWP\nSkin: no lesions\nNeuro: arouses on exam, MAEW, normal tone, +suck\n" }, { "category": "Nursing/other", "chartdate": "2130-10-08 00:00:00.000", "description": "Report", "row_id": 1769854, "text": "NPN\nMom and 16yo son in for feeding. Mom handled infant independently. Pleased w/progress. Discussed discharge plans in detail. Reviewed feeding supply list, schedule and target amounts for each feeding. Mom asking questions about WIC. Application given to mom to fill out and return. Consent signed for PKU in am. Hep B given . Mom is to call OB and pedi to discuss circ and make initial appointment for infant. VNA referral started. Hearing screen to be done prior to discharge. Family meeting set up for tomorrow afternoon.\nCOnt to support and educate. Cont discharge planning.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-09 00:00:00.000", "description": "Report", "row_id": 1769855, "text": "NPN\n\n\n1. TF 100cc/kg/day. Intake just at at this time.\nCoordinated suck/swallow pattern. Tires after 35cc. No\nspits. Abd benign,soft. Waking early for feeds. Settles pc.\nVoiding and stooling qs. Stool heme neg.\nCOnt to offer po q3-4 hours w/ volume goals of 35-40cc.\n2. In open crib maintaining temp with hat and 2 blankets.\nSucks on fist and pacifier. Responds to swaddling and hand\ncontainment when stressed.\nCOnt to monitor stress cues and provide optimal growth and\ndevelopment.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-09 00:00:00.000", "description": "Report", "row_id": 1769856, "text": "3 Potential for sepsis\n\nREVISIONS TO PATHWAY:\n\n 3 Potential for sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-09 00:00:00.000", "description": "Report", "row_id": 1769857, "text": "Neonatology Attending\nDOL 3 / CGA 35 weeks\n\nRemains in room air with no cardiorespiratory events.\n\nNo murmur. Well-perfused.\n\nBilirubin 5.9/0.5.\n\nOff antibiotics.\n\nWt 2160 (+20) on TFI 100 cc/kg/day . Bottling at minimum but with significant reflux. Abd benign. Voiding and stooling, guiac negative.\n\nTemp stable in open crib.\n\nA&P\n34-4/7 week GA infant with resolving feeding immaturity and intolerance\n-Continue to await improvement in intake and monitor for improved tolerance. There is currently no evidence of abdominal pathology. Increase TFI to 120 cc/kg/day\n-Circumcision to be arranged. Discharge planning in progress\n" }, { "category": "Nursing/other", "chartdate": "2130-10-09 00:00:00.000", "description": "Report", "row_id": 1769858, "text": "Neonatology Fellow Note\nExam:\nGeneral: alert preterm male in open crib in NAD\nHEENT: AFSF, eyes clear, MMM\nCV: RRR without murmur, 2+ fem pulses, CR brisk\nPulm: CTA bilaterally\nAbd: soft, NT/ND, +BS\nGU: normal preterm male external genitalia with testes descended bilaterally\nExt: WWP\nSkin: no lesions\nNeuro: alert, MAEW, + suck, normal tone\n" }, { "category": "Nursing/other", "chartdate": "2130-10-07 00:00:00.000", "description": "Report", "row_id": 1769849, "text": "NPN 7a-7p\nAssessed infant at cares and agree with above note by PCA .\n\nID: Blood cultures remain pending. Infant has stable temps. Alert/active. Antbiotics given as ordered. Peripheral IV patent.\n\nInfant is breathing comfortably in RA. Sats >/=96%. No apnea/brady spells noted. No murmur. All PO's, bottling with good coordination. Abd exam stable. No spits. Voiding and stooling. Mom in several times today. Updated. Discussed possible transfer to NBN if infant cont's to fed well. Encouraged Mom to bring in carseat so that test could be done. Explained carseat testing to Mom.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-08 00:00:00.000", "description": "Report", "row_id": 1769850, "text": "NPN\n\n\n1. TF 60cc/kg/day. Taking 23-30cc this shift, all po.\nAbd benign, soft, no loops. A/G stable at 23cm. Passed small\nmec stool. Voiding qs. Active bowel sounds. Mom up for first\ntwo feeds. Infant showed good suck/swallow coordination but\nfalls to sleep toward end of feed. No spits.\nCont q4 hour feeds as tol.\n2. Maintaining temp in open crib w/ hat and 2 blankets.\nSucks vigorously on pacifier. Settles between feeds. Passed\ncarseat test. Discussed w/ mom proper use of carseat. Also\ndiscussed temp control at home. Mom verbalized understanding\nof info. Cont optimal G+D.\n3. Infant was on antibiotics for R/O sepsis. IV dislodged.\nNNP discontinued remaining antibiotics. No signs and\nsymptoms of infaction at this time.\n4. Mom in for two feeds. Encouraged to sleep through next\nfeed. Mom due to be discharged tomorrow. Infant will be\nstaying. Discussed emotional aspects of NICU stay. Mom\ncoping well. Pleased with infant's status. Preparing for\ndischarge home. Discussed feeding issues, safety issues and\npreemie issues in general. Other children are much older and\nwere full term.\nCont to suppoert and teach.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-08 00:00:00.000", "description": "Report", "row_id": 1769851, "text": "Attending Note\nDay of life 2 CGA 34 \nin room air RR 30-60 no desats\nno murmur HR 120-150 64/39 mean 48\nbili 5.9/0.5\noff abx\nweight 2140 down 50 on 60 cc/kg/day taking all po more than the minimum on SSC 20 cal/oz no spits overnight\nvoiding and stooling\nin open crib\npassed car seat test\ns/p hep B\n\nImp-making progess\nwill have hearing screen prior to discharge\nwill increase minimum to 100 cc/kg/day\n" }, { "category": "Nursing/other", "chartdate": "2130-10-08 00:00:00.000", "description": "Report", "row_id": 1769852, "text": "NPN 7a-7p\n\n\n#1: TF's increased to min100cc/k/d. Infant has been waking\nfor feeds ~q1.5-4hrs. Bottling 30-35cc SC20. Bottling with\ngood coordination. Med spit x1. Abd soft, +, no loops.\nAg stable. Voiding qs. Stooled- heme negative.\n\n#2: Infant is alert/active with cares. MAE. Waking on own\nfor feeds. Maintaining stable temps while swaddled in an\nopen crib. Will settle with pacifier and containment. A:\nAGA P:Cont to support dev needs.\n\n#3: Blood culture pending. Antbiotics d/c'ed. Infant with\nstable temps and appropriate behavior. A: stable P:Follow\nlabs and monitor.\n\n#4: Mom in for 1230 feed. Indep with diaper and feeding.\nUpdate given. Mom d/c'ed home today. Will be in later. A:\nInvolved, loving parent P:Cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-08 00:00:00.000", "description": "Report", "row_id": 1769853, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert, 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": "2130-10-06 00:00:00.000", "description": "Report", "row_id": 1769843, "text": "Case Management Note\nNotes have been reviewed. Lists of VNA's placed in chart for future d'c planning. I will cont to follow & assist w/any d'c issues.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-06 00:00:00.000", "description": "Report", "row_id": 1769844, "text": "1. Tf min 60cc/k/d Sc20 22cc q4, took 15 and 22cc po well of\nSc20 this am, abd 24cm, active bowel sounds, no loops, no\nspits, voiding, no stool, DS before 1300 feeding 54 P: pg if\nunable to po minimum volume, check lytes and bili at 24h.\n2. temp stable on servo warmer, nested with boundaries,\nactive and alert with cares, sleeping in between P; continue\nto support growth and development.\n3. on ampi and gent, question how long Mom was , cbc:\nwbc 8.3, p 35, b 0, 49, hct 53.8, plt 156 A: 48h R/O P:\nantibiotics as ordered.\n4. Mom in x2, once with oldest son, does not plan to breast\nfeed, signed consent for PKU and hep B, planning to visit\nlater and hold and feed baby P: continue to update and offer\nsupport.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-06 00:00:00.000", "description": "Report", "row_id": 1769845, "text": "1 Alt in fluid and nutrition\n2 Growth and Development\n3 Potential for sepsis\n4 Alt in bonding/social\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in fluid and nutrition; added\n Start date: \n 2 Growth and Development; added\n Start date: \n 3 Potential for sepsis; added\n Start date: \n 4 Alt in bonding/social; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-07 00:00:00.000", "description": "Report", "row_id": 1769846, "text": "NPN 1900-0700\n\n\nFEN: wt=2190g (up 15g). PO ad , 60cc/kg, SSC20.\nBottling 35-40cc q4hrs. Abdomen soft, +BS, AG stable, no\nloops, lg spits X2, voiding, sm mec stool X3. d-stick 85.\nLytes and bili sent. 142/5.3/106/23/18. 5.3/0.3.\n\nG&D: Temp stable, double swaddled with hat, on off warmer.\nAlert and active with cares. Sleeps well between. Takes\npaci. Hands to face. Received Hep B vaccine.\n\nSepsis: Continues on amp and gent as ordered. BC NGTD.\n\nSocial: Both parents in for 2100 feed. Mom held and bottled.\nDad held infant. Asking appropriate questions. Updated at\nbedside. Given back to sleep hand out.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-07 00:00:00.000", "description": "Report", "row_id": 1769847, "text": "Newborn Med Attending\n\nDOL#1. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2190 up 15, on 60 cc/k/gd SC20. BIli=5.3, Bld cx - so far.\nA/P: Cont on Ad feeds with 60 cc/kg/d. Cont abx for 48 r/o.\n" }, { "category": "Nursing/other", "chartdate": "2130-10-07 00:00:00.000", "description": "Report", "row_id": 1769848, "text": "NPN 0700-\n\n\nFEN: TF=60cc/k/day minimum SSC20 PO= 22cc's q4h. Infant\nbottled 45cc's at first feed and 35cc's at second feed. Abd\nbenign. Voiding, with small mec stools x2. No spits.\nContinue to monitor tolerance to feeds and ability to take\nin adequate nutrition.\n\nG/D: Infant moved from warmer to crib today. Swaddled, with\nhat on. Temps remain stable. Waking for feeds. Sleeping well\nbetween feeds. Alert and active. Continue to promote\ndevelopment.\n\nParents: Mom in today to visit at 0900. She came back at\n1300 to hold and bottle infant. Asking appropriate\nquestions. Plans to be discharged from hospital tomorrow.\nUpdated by RN on status of infant. Continue to update and\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-11 00:00:00.000", "description": "Report", "row_id": 1769870, "text": "Nursing Progress Note\n\n\n#1 O: now ad demand feeds, waking on own q3-4hours,\ntaking 50-60cc SSC 20 well w/o problems. will change to\nSimilac 20 for d/c home. abd benign, vdg and stooling. A:\ndoing well w/feeds P: as above.\n#2 O: temp stable in open crib, swaddled. alert w/cares,\nwaking on own and bottling well. VNA to visit Friday, to see\npedi on Monday. A: doing well, AGA P: f/u at home.\n#4 O: mom called, updated. will be in this afternoon to d/c\nbaby.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-10-11 00:00:00.000", "description": "Report", "row_id": 1769871, "text": "NURSING D/C NOTE\nInfant d/c home with mother and family at 4:15 pm--d/c teaching reviewed and mom states with information. F/u with pedi scheduled for Friday .\n" }, { "category": "Nursing/other", "chartdate": "2130-10-06 00:00:00.000", "description": "Report", "row_id": 1769842, "text": "Admission Note\nOB- , \n\nBaby is the 2175 gram product of a 34 week gestation (EDC ) born to a 43 yo G4 P3 mom whose other children are 16, 18, and 26 years old. PNS A+ antibody negative, HBsAg neg, RPR NR, Rubella Immune. Pregnancy complicated by asthma treated with ventolin and elevated blood pressure treated with labetalol. Mom also treated with methyldopa.\n\nMom GBS unknown no fever and ROM unclear because mom was leaking fluid prior to coming to the hospital.\n\nHe was born by spontaneous vaginal delivery with Apgar scores of 8 (1 min) 9 (5 min). He was dried bulb suctioned and given blow by oxygen.\nHe was taken to the NICU for further evaluation\n\nExam gen well appearing in no obvious distress\nweight 2175 (50%) length 48 cm (75%) HC 30.5 cm (25%)\nTemp 98.2 HR 164 RR 56 sat 100% in RA BP 59/33 mean 43 D-stick 69\nSkin light brown no rash\nHEENT molding of the head noted palate intact red reflex present bilaterally ant font open flat\nneck supple\nlungs clear bilaterally no grunting or flaring mild intercostal retraction\nCV regulear rate and rhythm no murmur femoral pulses 2+ bilaterally\nAbd soft with active bowel sounds no masses\nSpine midline no sacral dimple\nAnus patent\nHips stable\nGU normal preterm male testes palpable bilaterally\nExt moved symmetrically warm well perfused brisk cap refill\nNeuro good tone\n\nImp- 34 week premature infant in stable condition with risk for sepsis\nCV-stable currently will monitor\nRESP-stable in room air no issue\nFEN-will offer po feeds will consider IVF\nID-sepsis risk because of unstoppable preterm labor. Will check CBC and begin amp/gent\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2188-04-11 00:00:00.000", "description": "Report", "row_id": 1572834, "text": " TRANSFER TO FLOOR NOTE--- RESP COMPROMISE\nPLEASE SEE DETAILED ADMIT NOTE UPON TRANSFER TO MICU AS WELL.\n\nROS:\nCV: A-FLUTTER CONTS AT RATE 90'S. PP--VIA DOPPLER. BP'S REMAIN 100-120/60'S.\n\nNEURO: PT'S MENTATION WAXES AND WANES... SHE SOMETIMES ASKS WHEN SHE IS GOING BACK TO THE HOSPITAL. SHE CONSISTENTLY FOLLOWS COMMANDS.\n\nRESP: TO BE PLACED ON NASAL BIPAP OVER NOC. SHE CAN GO TO 4L NC DURING THE DAY. WITH THIS HER O2 SATS REMAIN >95%.\nWHEN SATS DO DECLINE SHE BECOMES SOMNOLENT AND ASHEN IN COLOR.\n\nGI/GU: (+) FLATUS, NO STOOL YET THOUGH. FOLEY TO GRAVITY, W/CL,Y,URINE\nTOL ICE CHIPS AND GINGERALE, AND CLEARS.\nPLAN: ADVANCE DIET AS TOL\n ASPIRATION PRECAUTIONS\n\nDISPO: CASE MNGT ON BOARD. REHABS IN SCREENING. SON IS HEALTH CARE PROXY AND PT IS NO SHOCK, NO COMPRESSIONS... BUT DO INTUBATE.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-26 00:00:00.000", "description": "Report", "row_id": 1572854, "text": "MICU NSG 7A-7P\nNEURO--PT CONTS WITH WAXING AND MS. APPEARS TO TIRE QUICKLY. MED WITH TYLENOL #3 1 TAB X1 FOR C/O LEG PAIN.\nRESP--ALT BETWEEN NC 1.5L AND BIPAP. SATS 88-98% DEPENDING ON HOW AWAKE SHE IS.\nCARD--BP MARGINAL MOST OF SHIFT. CVP DOWN TO 19. UF DECREASED TO 300ML/HR THIS AM BY RENAL, THEN AGAIN DECREASED TO 200ML/HR THIS AFTERNOON AFTER BP FALLING TO 70'S/. BP RESPONDING TO LESS FLUID REMOVAL AND NOW IN 100'S/. GOAL IS SBP >90 OR MAP > 55. CONTS WITH , LEG BLISTERS WEEPING LG AMOUNTS OF SEROUS FLUID. COCCYX/BUTTOCK AREA CANTS WITH REDDENED EXCORIATED SKIN WITH BLEEDING ULCERS. TRIPLE CREAM ALLPIED AND STARTED ON PO DIFLUCAN FOR YEAST INFECTION. SKIN FOLDS REMAIN REDDENED, NYSTATIN POWDER APPLIED.\nGU--CONTS ON DIALYSATE AT 500ML/HR, UF 200ML/HR, BLOOD PUMP 140ML/HR. HEPARIN INC TO 1200U/HR WITH 1800U BOLUS THIS AM FOR PTT<70, REPEAT PTT 93, DECREASED TO 1000U/HR, WILL NEED REPEAT PTT AT ~9PM. MAKING SCANT BROWN SLUDGY URINE.\nGI--TAKING MIN PO'S. DRANK 2 CANS OF BOOST. THIS WAS PT'S ONLY PO'S TODAY!!!! FAMILY IN AND TRYING TO PT TO EAT. BM X1, LG LIQUID BROWN STOOL.\n, HUSBAND AND FRIEND IN TO VISIT. UPDATED ON PT'S CONDITION.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-26 00:00:00.000", "description": "Report", "row_id": 1572855, "text": "REsp. Care Note\nPt wearing O2 at 1.5 L NP for most of shift. MDI's by Nursing today. Placed on full mask ventilation for about 2 hrs. today for ^ somnolence and decreased sats. Mask vent. settings CPAP 8 PSV 10 and 25% for TV 700 and RR <20. Cont with mask vent as needed.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-27 00:00:00.000", "description": "Report", "row_id": 1572856, "text": "\nPt has cont on and tol it well\nResp: pt has remained on 1.5L of O2 with sats of 93-98% overnight. She has been able to sleep little with naps here and there but she cont to be more alert and approp conversant. She is using her inhalers.\nGU:pt cont on no changes made/ or needed, blood pump rate of 140, Dialysis of 500cc, UF of 200cc/hr.Her pressures on the Prisma machine have remained pretty consistent as documented in Carvue, no clots noted. She makes ablout 10cc urine q8hrs. Her heparin cont to infuse off the machine at 1000u/hr and PTT check at 9pm was ithin therapeutic limits.\nGI: she cont to take only sips of Bosst drink, she is passing sma mts of brown OB- stool.\nSkin:her skin is unchanged as prev doucumented,her buttocks remains red and excoriated, creams and nystatin applied\nCV: her MAP from her BP has been consisted >55 and she cont in AF.\nNeuro:she cont to be more awake, approp and interactive than prev noted. She has c/o genralized pain as well as leg and back pain. So at 5am pt got x1tab of tylenol #3 with relief and she is sleeping now.\nID:she remains afebrile.\nA/P:Will cont with as ordered and monitor BP,I&O and wt.\n Follow lytes and replace if needed.\n Encourage an appetite if able, note stool amts\n Cont to keep MAP>55.\n Skin care as outlined\n Follow PTT and adjust as needed.\n Asses mental status and o2 sats for need of Bipap trial.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-25 00:00:00.000", "description": "Report", "row_id": 1572851, "text": "NPN P-MICU 7AM-7PM\nS/O: RESPIR: Maintained on O2 3L NP with RR 10-16 with O2 sats 94-96%. L/S diminished bilat. No cough noted. To go back on Bipap this evening.\n\nGU: Remains on , working well, removing 350cc/hr. BUN/CRE 74/4.6. Renal Team stated that pt will most likely be on for @ least another week, to continue to get lrge amts of fluid off. K+ 4.2.\n\nGI: Appetite continues to be very poor not taking any PO's except few sips of Gingerale or Cranberry Juice. Family not successful in encouraging her to eat more. Medical aware of extremely poor nutritional status, pt is refusing feeding tube and with her present fluid status are not considering TPN.\n\nC/V: BP 95-118/60, HR 86-90's A-fib. Appears to be tolerating . Continues on PO Amiodarone 400mg.\n\nNeuro: More alert this AM, lethargic this afternoon, responds to stimulation. Appears depressed team wants to continue to hold Psych meds.\n\nSkin: Continues with lrge amt drainage from leg blister areas, leg wrapped with absorbent dsgs changed frequently. No changes in other skin breakdown areas, buttocks area remains excoriated and bleeding in small amts.\n\nA/P: Continue with CVVHDF assess I&O's and q day wt's, monitor lytes. Assess respir status, monitor O2 sats, place back on Bipap this evening. Continue with skin care and encourage increase PO intake.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-26 00:00:00.000", "description": "Report", "row_id": 1572852, "text": "Respiratory Care:\n\nCombivent/Flovent MDI's given x 2 puffs each. Tolerated well with spacer. Pt. requiring assistance with MDI's. Bs clear and decreased bilaterally. RR 15. Pt. comfortable wearing nasal prongs @ 1.5 lpm. Adequate O2 sats. Pt. put on mask ventilation for the noc. Vent settings Psv 10, Cpap 8, Fio2 25%. Vols 800's with RR 15-17. Tolerated well until 2:30am. Pt. requested to come off. O2 sats 94% on 1.5 lpm nasal prongs. Resp status stable. Pt. appears comfortable. No further changes made. Will continue to follow with Combivent Q4-Q6prn and Flovent , mask ventilation as needed.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-26 00:00:00.000", "description": "Report", "row_id": 1572853, "text": "NURSING PROGRESS NOTE:\nPT ALERT AND ANSWERING QUESTIONS APPROP AND AWARE OF HER SURRROUNDINGS. PT C/O KNEE AND HIP PAIN AND WAS MED WITH TYLENOL #3. PT FELL ASLEEP SHORTLY AFTER BEING MED.\nPT CONT ON , TAKING OFF 350/HR AS ORDERED.\nPT GIVEN BY RESP, AND PLACED ON BIPAP OVERNIGHT BUT WAS TAKEN OFF AT 0230. PT REQUESTED TAKING OFF MASK AND GOING BACK TO NASAL CANULA. O2 SAT'S TOL WELL, RANGING 90-97%. LUNG SOUNDS CLEAR BUT DIMINISHED BILATERALLY.\nCV: BP DROPPING OCC TO THE 80'S BUT WOULD COME BACK UP INTO THE 90'S ON IT'S OWN. HR CONT TO BE IN AFIB, WITH RATES 60-70. TEMP 97.8AX. ALL SHIFT.\nFOLEY CATH INSITU STILL ONLY DRAINING SCANT AMT'S OF BROWN SLUDGY URINE.\nDSD CONT TO BE APPLIED TO LOWER EXTREMETIES. BUTTOCKS CONT TO BE GREATLY EXCORIATED AND BLEEDING.\nPT TAKING SIPS OF FLUIDS WITH MEDS WITHOUT DIFF.\nHAVE NOT SPOKEN WITH FAMILY OVERNIGHT.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-24 00:00:00.000", "description": "Report", "row_id": 1572846, "text": "NURSING NOTE MICU 7P-7A\n\nNEURO: PT AWAKE, ALERT, OX2. ABLE TO MOVE ALL EXTREMITIES.\n\nCV: HR 90-110 SINUS RHYTHM WITH NO ECTOPY. CONTINUES ON AMIODORONE GTT @ .5MG/MIN. BP 90-110. PT WITH GENERALIZED EDEMA +2. ALL PULSES PALPABLE. PT CONTINUES ON .\n\nRESP: PT RECIEVED ON 2L NC WITH SATS 93-96%. PT PLACED ON BIPAP @ 2300 FOR SLEEP APNEA. O2 SATS REMAIN 95-99%. LUNG SOUNDS DIMINISHED.\n\nGI: PT TAKING CLEAR LIQUIDS WITH NO PROBLEMS. ABDOMEN DISTENDED/FIRM DUE TO ACITIES. +BS. SMALL BROWN SOFT BM.\n\nGU: FOLEY PATENT DRAINING SMALL AMT BROWN SLUDGE URINE. TAKING OFF 350CC/HR. HEPARIN INFUSUNG THRU , AM PTT THERAPUTIC, NO CHANGE IN RATE.\n\nSKIN: BUTTOX AND COCCYX AREA EXCORIATED. ABDOMINAL FOLDS AND UNDER BREASTS REDDENED WITH SMALL OPEN AREAS. MICONAZOLE POWDER APPLIED TO AREAS. BIL LOWER EXTREMITIES WITH BLISTERS DRAINING LG AMTS SEROSANG DRAINAGE. ABSORBENT DESSINGS REAPPLIED.\n\nDISPO: PT REMAINS DNR, BUT CAN BE INTUBATED. NO CONTACT FROM FAMILY OVER NIGHT. PLAN IS TO CONT WITH AS TOLERATED. START PO DIFLUCAN FOR YEAST TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-24 00:00:00.000", "description": "Report", "row_id": 1572847, "text": "MICU nursing narrative note 7a-7p\nNeuro: Pt in and out of lethargy and following commands to not following commands. Pt is COPD, and noticed this downward trend in neuro status with increased spo2. When alert, answers questions appropriately, and when spo2 becomes too high for pt, becomes very lethargic to barely arousable. Moves upper ext. very weakly, seems to have trouble with fine motor coordination. Needed complete help with feeding and taking medications. Showed pt how to use the nurse call button and channel changer and had problems with finding the buttons with her fingers. No movement of lower ext. although was moaning in good amount of pain when lifted legs...and c/o knee pain.\n\nCV: Pt with questionable first degree block/ versus junctional?? This is an undetermined rhythm as of yet. Heaart Rates 90's to low 100's. Still remains with high edema level, even after taking off liters over several days. Afebrile. Lines: L hand hl, R AC with KVO ns at 10cc/hr, R AC picc line infusing without difficulty, L SC quenten cath with cvvh ongoing. BP ranges from 79 systolic when on R side, to 94 systolic on L side.\n\nResp: Off and on with bipap today, adjusted fio2 accordingly to mental status. started out with 40%, with spo2 98%. Switched to N/C at 5L, pt able to eat without becoming tachypneic, although as time went by lethargy increased. Then tried switching to bipap, with no increase in mental status, sats remained 98%, therefore decreased fio2 to 30%. And over period of time pt. began to awaken and answer questions as she had this morning. Then again switched to N/C at 3 liters and let pt try to eat some lunch. Remains on N/C at 3 liters with spo2 95-97%. Team aware of all changes in neuro/resp and want her on bipap over HS starting at 9pm and can be off then around 8am and throughout day to eat and drink and such.\n\nGI: Pt ate very small amounts of breakfast and lunch. Not much intake of food and drank some liquids without difficulty, but did need total assistance with feeding. No c/o n/v, burped several times. No stool this shift.\n\nGU: pt on continuously removing 350ml fluid every hour. Scant urine output and is brown sludgy\n\nSkin: Various decubs along coccyx/buttocks areas, bilateral lower calves with blisters. all have popped and draining yellow/tan drainage. Bilaterall lower legs with bad pungeant odor, changed dressings to lower ext. bilaterally due to large drainage coming from wounds.\n\nPLAN: To keep on bipap over HS until 0800 tonight and every night until new order or changes arise, assess neuro status d/t retention of co2. Plan to have Podiatry come and see pt legs/feet. Switch meds to PO as tolerated and as neuro status maintains\n\n\n" }, { "category": "Nursing/other", "chartdate": "2188-04-24 00:00:00.000", "description": "Report", "row_id": 1572848, "text": "Resp .Note\nAlternated MV->peep8/psv10/30% and Lpm NC throughtout the day. Received combivent and flovent inhalers. Had periods of RN notes. No acute distress noted. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-25 00:00:00.000", "description": "Report", "row_id": 1572849, "text": "NURSING NOTE MICU 7P-7A\n\nNEURO: PT 2/3. PT WILL FOLLOW COMMANDS. MAE WEAKLY. ABLE TO SWALLOW MEDS W/OUT DIFFICULTY. PT WAS MEDICATED W/ T3 FOR PAIN X1.\n\nCV: HR 80-100 AFIB. BP STABLE 95-110. PT CHANGED FROM IV AMIODORONE TO PO. GENERALIZED EDEMA +2. PT REMAINS AFEBRILE.\n\nRESP: PT RECIEVED ON 3L NC O2SATS 95%. PLACED ON BIPAP AT 2130. FiO2 30%. SATS 98-100%. DECREASED FiO2 TO 25% O2 SATS 93-95%. GOAL IS TO KEEP O2 SATS AROUND 95% DUE TO COPD. PT IS TO REMAIN ON BIPAP UNTIL 8AM. LUNG SOUND DECREASED. NO COUGH. PT DENIES ANY SOB.\n\nGI: PT ABD. FIRM/DISTENDED DUE TO ACITIES. BS HYPOACTIVE. NO BM. PT ABLE TO TAKE PO WITH OUT DIFFICULTY. PT CONTINUES ON PO FLAGYL FOR CDIFF.\n\nGU: PT CONTINUES ON VIA QUINTON CATH IN LSC. REMOVING 350CC/HR. HEPARIN GTT INFUSING THROUGH AT 1000UNITS/HR. PTT THIS AM THERAPUTIC, NO CHANGE MADE. FOLEY PATENT DRANING SMALL AMOUNT BROWN SLUGE URINE, 30CC/SHIFT. AM BUN/CREAT PENDING.\n\nSKIN: PT HAS AREAS IN SKIN FOLDS. MYCOSTATIN POWDER APPLIED. BIL LOWER EXTREMITIES LG OPEN BLISTERS DRAINING LG AMTS SEROUS FLUID. ABSORBENT DRESSING REAPPLIED. BUTTOX AND COCCYX AREA EXCORIATED WITH SCANT BLOODY DRAINAGE. MYCOSTATIN CREAM AND POWDER APPLIED TO ARES WITH YEAST.\n\nDISP: PT REMAINS DNR BUT ABLE TO INTUBATE. NO CONTACT WITH FAMILY OVERNIGHT. PLAN IS TO CONTINUE WITH . PT COULD FROM TPN FOR NUTRITION DUE TO PT POOR APPETITE. PLAN TO START DIFLUCAN ONCE HAVE ID APROVAL.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-25 00:00:00.000", "description": "Report", "row_id": 1572850, "text": "Respiratory Care\nRemained overnight on mask ventilation 10 psv/8 of peep, FIO2 30% down to 25% with sats 100%, tol.well.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-28 00:00:00.000", "description": "Report", "row_id": 1572861, "text": "MICU NPN 0700-:\n Neuro: Pt dozing intermittantly throughout day--arousable, A + O X 3, moving all extremities but ROM limited secondary to edema. Pt c/o intermittant \"twinging\" pain in hip joints but declines pain medication at this time.\n CV: Afebrile. Afib with controlled rate in 90's. No ectopy observed. PTT from AM labs 54--pt bolused with 1800 u heparin and gtt increased to 1200 u/hr per ss order. F/U ptt drawn at 1400--pending. Pt remains anasarcic with 3-4 + pitting edema especially in bilateral lower extremities--however, edema is much improved (weight down to 143 kg today).\n Pulm: Pt continues on 1.5 L O2 with sp02 in low 90's. When she falls deeply asleep, she is noted to have snoring respirations with corresponding decrease sp02 into mid 80's--no periods of apnea appreciated. Pt refuses nasal bipap.\n GI: Encouraging PO intake--pt only drinking few Boost shakes/puddings per day. No stool. Abd obese, soft and non tender. ENT here to eval parotid gland--reccomend wedges, warm compresses and gentle massage.\n GU/Renal: Pt continues on with ultrafiltrate of 200 cc/hr and Dialysate 500 cc/hr. Access pressures frequently rise > 200 with pt movement, coughing etc--return to baseline around 100 when pt is still. Filter pressures stable in 160's. See carevue for details. BP stable with MAP consistantly >er than 50 even while pt asleep on therapy.\n Skin: Venous stasis ulcers becoming more red, draining moderate ammounts acrid smelling serous drainage--skin care nurse not available today, will eval tommorrow. Plan to cover open areas with xeroform gauze to help prevent secondary infection. Yeast infection in groin/buttocks greatly improved on oral diflucan/nystatin paste.\n Husband, , and son, , into visit today--family discussed POC at length with renal team.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-29 00:00:00.000", "description": "Report", "row_id": 1572862, "text": "NURSING PROGRESS NOTE:\nPT CONT ON , REMOVING 200CC FLUID/HR. MACHINE OCC ALARMING EXESIVE ACCESS PRESSURE, TEAM AWARE, VISIBLE CLOTS IN CHAMBER AS WELL. WILL NOT CHG FILTER TILL IT CLOTS.\nPT TOLERATING REMOVAL RATE OF FLUID, BP MAINTAINED 90-100.\nPT ON 1LNC MOST OF NIGHT UNTIL PT FELL ASLEEP FOR LONG PERIOD AND DROPPED 02 SAT INTO THE 80'S, PLACED ON BIPAP FOR ABOUT 2 1/2 HOURS WHICH BROUGHT O2SAT'S BACK UP.\nDRSG'S ON BOTH LEGS CHG'D THIS AM AND XEROFORM GAUZE APPLIED TO OPEN EXCORIATED AREAS ON EACH LEG. BUTTOCKS IMPROVING SOMEWHAT BUT STILL HAS OPEN BLEEDING AREAS.\nPT ATTEMPTING TO HELP WITH TURNING AND SPIRITS SEEM TO BE BETTER.\nSEE FLOWSHEET FOR OBJECTIVE DATA.\nWARM PACKS APPLIED TO SWOLLEN RIGHT NECK. AREA CONT TO BE REDENED AND HARD.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 1572824, "text": "Respiratory Care:\nPt. admitted from E.D. with hypoxia and SOB. Initiated on Full Face Mask ventilation with IPS=10, peep=5 and 35% FIO2. ABG's showed adequate oxygenation with unresolved respiratory failure. Pt. demonstrating multiple missed triggers, due to her body habitus, causing continued upper airway obstruction>>inversed ventilating pressures to IPS=5, peep=10. Pt. now without missed triggers. Pt. is moving excellent VT's on IPS of 5cmH20 (600-900cc). Unable to place an a-line. Arterial gas to be done in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 1572825, "text": "CCU (MICU Border) Admission Note 7p-7a:\n\nMs. is a 56 y/o morbidly obese women with h/o CHF, cor pulmonale diagnosed , COPD, HTN who presented with hypoxia sat 79% RA per VNA. Pt discharged two days ago from for ARF.\n\nPt's ABG upon arrival to 7.18/88/231/35. K+6.1. Pt rec'd -carb, d50, insulin and kayexalate. Pt placed on pap 10/5 35%, ABG 7.23/78/63/34.\nRR high teens. Pt transfered to CCU for further treatment.\n\nPMHX: Obesity, HTN, COPD, CHF (EF WNL)\n\nAllergies: Pentathal, Demerol and Nuts.\n\nReview of Systems:\n\nNeuro: Pt arrived alert and oriented x1-2. Moving upper extremities spontaneously. Pt only able to move lower extremities slighlty on bed. Pt following commands. Pt is total care.\nPt with intermittent periods of agitation regarding mask and BP cuff. Pt stating, \"I want to die, I can't take this \".\n\nCV: SR HR 90-115. Pt hypotensive with SBP 80's pt rec'd 500cc NS bolus with effect. SBP currently 108.\nSerial CK's to be drawn, CK 16. CXR w/o evidence of CHF or pnx. Per echo pt with R sided heart failure. Pt is dig toxic with level of 2.3.\n\nPULM: Mask ventilation in place with settings of 35%. Increased peep from 5 to 10 secondary to pt obstructing her airway during sleep. Pt denies SOB. LS diminished throughout. Pt receiving nebs and MDI's by RT. No cough noted. Pt conts on solumedrol 80mg IV tid. Standing lasix dose on hold per Res last dose 80mg IV in ER. ABG in ICU 86/75/7.24/34. RR 20's. Attempts made in placement of A-line w/o success. Team to repeat ABG later this am.\n\nGI: Abd obese soft NT +BS. Pt requesting food and drink. Pt had small brown stool.\nNPO.\n\nGU: Foley cath patent draining initally cloudy yellow urine with sediment sent for ua revealing >50 WBC. BUN 54 Creat 2.6. Urine is now yellow and clear. u/o >30cc/hr.\n\nID: afebrile. Rec'd levaquin in EW. Pt to receive imipenem IV q6hr w/a form pharmacy.\nUA >50 WBC. BC x2 sent.\n**Am labs pending.\n\nSKIN: Buttocks excoriated with stage 2 breakdown. LE red and weeping serous drainage. Upper extremities with bruising.\n\nPROPH: hep sc and protonix IV.\n\nLINES: L subclavian TLC, verified by CXR.\n\nDISPO: Pt's code status needs to be discussed with patient. Pt DNR prior to admission, per report pt's son reversed .\n\nSOCIAL: Pt divorced and living with son.\nPt has home health aid and homemaker.\n\nA: Obese female with COPD presents with hypoxia/hypercarbia and change in mental status.\n\nP: Follow mental status. Await H.O. to check am ABG. Follow BP.\nNPO. Await culture and lab results.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-23 00:00:00.000", "description": "Report", "row_id": 1572844, "text": "MICU NPN 0700-:\n Neuro: Pt much more awake this morning, X 3, conversant, pleasant and appropriate. During day (off bipap), pt slightly more somnulent but continues to arouse easily and is X 3 when woken. Moving all extremities to command (weakly).\n CV: Afebrile. Pt in supraventricular rhythm with controlled rate in the 90's on amiodarone gtt at 0.5 mg/min. BP stable in low 100's. Pt continues to be grossly anasarcic but weight is down to 183 kg (from 191 on ) on CVVHD.\n Pulm: Recieved pt on bipap 10/8--switched to 2 L NC with good effect this morning. Pt maintaining sp02 in low 90's, no c/o SOB, mental status is sleepy but arousable/. Currently pt is not snoring/having periods of apnea while asleep. Plan to restart bipap for night or if pt becomes markedly more somnulent/apneic. Lung sounds diminished. No cough.\n GI: Pt able to take some limited PO's today. + gag + cough, swallowing reflex appears intact. Plan to restart PO meds later today if mental status permits. No BM. Abd remains firm/distended secondary to ascites. + bs.\n GU/Renal: Minimal UOP via foley--brown, sludge. CVVHD continues, fluid removal rate increased to 350 cc/hr with good BP/pt tollerance. Quinton site appears benign. Access/Filter pressures WNL (see care-vue). Heparin gtt continues via Prisma machine at 1000 u/hr. Pt with therapeutic PTT X 2. Next PTT due with am labs. Lytes this morning with correcting K/CR/BUN/PO4. Calcium slowly increasing--consider changing to low calcium dialysate solution if it continues trending up.\n Family: Pts son, , in to visit this . He is hopeful for his mother's complete recovery but realizes she is very sick. POC reinforced.\n Please refer to care-vue for assessments, I + O, VS etc. Thanks!\n" }, { "category": "Nursing/other", "chartdate": "2188-04-23 00:00:00.000", "description": "Report", "row_id": 1572845, "text": "MICU NPN addendum: Skin care specialists here to evaluate pt. Reccomend treatment for vaginal yeast infection with either systemic diflucan or vaginal suppositories. will f/u with team. Maceration on buttocks improving but will continue to apply nystatin powder followed by triple barrier ointment. Blisters on lower extremities continue to weep large ammounts serous drainage--exudry dressings applied. Consider podiatry consult--toenails causing breakdown on toes. See note from skin care RN for details.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-28 00:00:00.000", "description": "Report", "row_id": 1572860, "text": "NPN-MICU\nMrs. cont on her , tol it well.\nResp:she has cont on 1.5l of O2 with no C/o SOB. She is taking her inhalers fine and is maintaining O2 sats >93%. As noted above, she was unable to tolerate the nasal Bipap, she would yell and ascream and breath through her mouth.\nGU:she has cont on her with no changes made. Her access pressure is sl up and she cont to set the alarm off whenever she moves her LT shoulder. There are sl clots noted in the system and she is taking off various amts each hour. She cont to make min amts of urine.\nCV: her BP has been stable >95 with a MAP of >58 all of the shift. She cont on AF rates of 90's. Heparin drip cont at 1000U/hr.\nGI:she cont to have a poor to min appetite, only Boost drinks so far. She is also passing sm amts of OB- stool and therefore requires more turning which may be causing pressure increases in the access line of her .\nNeuro:pt cont to be more awake and interactive, very approp but intermittenly uncomfortable from her back, bottom and jaw pain.She has taken x1 tylenol #3 for pain with relief.She is moving more and helping to turn herself when asked.\nID: she is afebrile on IV AB.\nSkin:buttocks area sl less red but still very soore and raw. Triple creams with nytatin applied, gauze placed over creams for barrier protection\nP: Will conton til goal wt off. Will cont to support labs as needed. ?changing tubing as clots are forming.\n Will cont to folow BP and keep anticoagulated.\n Encourage more protein intake and food.\n Note stool amts\n Again encourage use of Bipap as needed\n Cont to asses for pain and medicate as needed.\n Note changes in cheek swelling.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-22 00:00:00.000", "description": "Report", "row_id": 1572837, "text": "Resp care note\nMask ventilation removed due to pt. vomiting. Initially placed on cool mist aerosol. Pt noted to have obstructive sleep apnea. Placed pt on NCPAP +10 with 1 L O2 bleed. Appears comfortable now, well saturated. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-22 00:00:00.000", "description": "Report", "row_id": 1572838, "text": "MICU NPN 0700-:\n Neuro: Pt with labile MS throughout day. At times, pt difficult to arouse/somnulent/boarderline unresponsive. At others, pt responding appropriately to orientation questions, following commands. Pt moves all extremities equally and to command. Team aware of MS variability. Probable relation to tenuous respiratory status--decision made to defer intubation.\n CV: Afebrile. Pt appears to be in atrial (?sinus) rhythm with rate 90's. BP stable. EKG today unchanged from previous. PO amiodarone on hold secondary to depressed mental status. Plan is to start amio gtt after PICC line is confirmed with CXR. 5 Fr. dual-lumen PICC placed (secured at 45 cm) at bedside by Dr of IR service. (lot # ). CRX pending. Pt remains grossly fluid overloaded with generalized anasarca, blistering over lower extremities. Heparin gtt (via Prisma machine) recieved at 1000 u/hr. At 12N, PTT subtherapeutic at 63. 1800 u Heparin bolus administered (IVP through peripheral) and CVVHD heparin increased to 1200 u/hr per sliding WB scale. F/U PTT to be drawn at 1800.\n Pulmonary: Recieved pt on nasal bipap with 1 L 02 bleed in. Pt with periods of apnea lasting sec with corresponding decrease sp02 into 80's despite BIPAP. At this time pt also markedly cyanotic in nailbeds/lips/eyelids. Team attempted to draw ABG, but sample was venous (see care vue). F/U ABG drawn later when pt more awake--7.25/56/59. MD spoke with pts son (health care proxy) and, at this point, his wishes are to maintain current code status of DNR with potential for intubation. He realizes if pt gets intubated, she will likely become long-term vent dependent. Based on ABG, decision made to defer intubation (as pt mentating, more awake, resolving cyanosis) and continue to support pt on bipap. Lung sounds distant/diminished throughout.\n GI: ABD firmly distended secondary to ascites. + BS, no episodes of emesis, pt denies nausea. At this point, pt is refusing NGT/dopoff--plan to save port for TPN on new PICC line. Unable to administer PO meds secondary to bipap/variable mental status. Team has d/c'd/changed to IV form appropriate medications. No stool\n GU/Renal: Recieved pt on CVVH with fluid removal rate 200 cc/hr. See care vue for access/filter/return pressures. With AM lytes K+ slightly elevated (sample with small hemolysis) and BUN/Cr greatly elevated. After renal evaluation, Dialysis added making therapy CVVHD--currently fluid removal rate=300 cc/hr, blood flow = 180 cc/hr, diaylsate = 500 cc/hr, heparin continous anticoagulation per ss. Access/filter/return pressures WNL. Some clot can be visualized in filter but it appears unchanged throughout shift. Quinton site benign. Plan to check lytes at 1800 with PTT>\n Skin: Pt with multple areas of excoriation/breakdown in perineum, folds, axilla--nystatin powder/fluffs applied. Lower extremities with several large blisters leaking serous fluid. Lower extremities wrapped in e\n" }, { "category": "Nursing/other", "chartdate": "2188-04-22 00:00:00.000", "description": "Report", "row_id": 1572839, "text": "(Continued)\n-dry to maintain dryness and minimize chance for secondary infection.\n\n" }, { "category": "Nursing/other", "chartdate": "2188-04-22 00:00:00.000", "description": "Report", "row_id": 1572840, "text": "MICU NPN addendum:\n PICC line confirmed for use by resident via cxr. - pneumothorax. One port flushed per protocol (NS/heparin) and taped for TPN. Amiodarone gtt started in other central port at 0.5 mg/min per order. Site oozing small amts blood ? secondary to heparinization. At this time pt tollerating BIPAP well and is more alert and interactive. Will continue to f/u for resp/neuro changes.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-22 00:00:00.000", "description": "Report", "row_id": 1572841, "text": "Patient was on CPAP 10 via BIPAP machine,desaturated to low 82 this afternoon then changed patient to mask ventilation 10/7.5-40%. Sat went up to 100%, gradually decreased FIO2 from 40 to 30 patient very confortable with HR 95 BP labile 94/57,sat 98%. Will inetrmittently switched patient from BIPAP machine to mask ventilation per RT discretion in consultation with RN and MD.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-23 00:00:00.000", "description": "Report", "row_id": 1572842, "text": "Resp care note\nPt remains on mask ventilation. PSV 10/8, fio2 30%. No new gases thus far. Well saturated t/o shift. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-27 00:00:00.000", "description": "Report", "row_id": 1572857, "text": "MICU NPN 0700-:\n Neuro: Pt dozing intermittantly throughout day. Arouses easily and has been completely A + O X 3. Moves all extremities weakly (decreased ROM secondary to edema). Pt c/o joint pain in hips/knees while turing only. Tylenol #3 offered but pt declines at this time.\n CV: Afebrile. Pt in afib/controlled rate. No ectopy. BP stable with MAP consistantly greater than 60. continues with acceptable access/filter/return pressures (see carevue). Pt occasionally alarming for high access pressure--? when she moves or coughs the quinton is temporarily kinked. Problem has resolved itself spontaneously. Pt continues to have generalized anasarca but with warm extremities and good peripheral pulses. Weight down to 149 KG (admission weight = 197.3 KG) today.\n Pulm: Pt continues on 1.5 L NC with spo2 91-96%. Pt without c/o SOB. She tried the nasal bipap (15/5) for about 1 hour this morning then removed it stating she would try again tonight. Lungsounds difficult to assess-distant. No cough/sputum.\n GI: Encouraging PO's today--so far pt has taken in 2 boost shakes and 1 boost pudding. She does not feel like solid foods. Abd obese, soft with + bs. Pt has one large soft brown stool this afternoon.\n GU: Foley to gravity--about 10 cc brown sludgey urine passed for 12 hour shift.\n Skin: Yeast infection in groin definately appears less inflamed today (day # 2 oral diflucan). Desitin/nystatin/lidocaine cream applied to groin and breakdown on buttocks--improving but many small stage II's noted in gluteal folds--unable to apply duoderm secondary to moisture in area--barrier cream applied.\n Other: During morning care, pt c/o pain in R cheek--large swelling palpable over R mastoid area--team has evaluated and ? blockage of parotid gland--pt started on oxacillin and juice TID (to promote salivation).\n\n" }, { "category": "Nursing/other", "chartdate": "2188-04-27 00:00:00.000", "description": "Report", "row_id": 1572858, "text": "Resp. Care Note\nPt set up with nasal BIPAP today via Respironics. Settings at spont. mode IPAP 15 EPAP 8 for 7cm PSV and 1.5L O2 bled in for sats >92%. Pt wore nasal mask for about 1 hour this morning as a trial. Plan to set up for use at night. Pt apparantly has CPAP machine at home but has not used for about 6 yrs. MDI's with nursing.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-28 00:00:00.000", "description": "Report", "row_id": 1572859, "text": "Respiratory Care:\n\nPatient put on Bipap with settings Ipap 15, Epap 8 with 1.5 liters O2 bled into mask. Pt. encouraged to wear Bipap. O2 sats 94%. Pt. tolerated x 10 mins. Pt. refused to continue to wear Bipap. Bipap taken off and pt put back on 1.5 liters nasal prongs. O2 sats 95-96%. No further changes made. Pt. appears comfortable. Will continue to follow for Bipap.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-23 00:00:00.000", "description": "Report", "row_id": 1572843, "text": "Nursing Progress Note\nNeuro: Awake, alert, x 2. Calls out at times, difficult to understand her, but easily re-. Moves all 4 extremities equally. More comfortable on rotating air bed\nResp: Continues on BiPAP continuously, sats > 96% BS decreased throughout. Removed mask a few times overnight, soft restraints not replaced\nCV: 90's Aflutter with stable BP On Amiodarone gtt at .5mg/hr\nID: Afebrile. Receiving Flagyl IV\nGI: NPO with BiPAP in place. No N/V overnight. + bowel sounds, no stool\nGU: Minimal brown sludge urine output. CVVHD continues, removing approx 300ml/hr PTT therapeutic on 1000u/hr Heparin via PRISMA, next due for PTT at 0800.\nSkin: Excoriated/macerated areas at groin, coccyx, under breasts, axillae Cleaned, Miconazole powder applied. Massive serous fluid leakage from bilat LE's. Blisters evident at both ankles ExuDry dsgs in place in attempt to prevent further maceration/breakdown\nDispo: Pt is DNR, no compressions, no defib, would be intubated if necessary. No contact with family members overnight\n" }, { "category": "Nursing/other", "chartdate": "2188-04-21 00:00:00.000", "description": "Report", "row_id": 1572835, "text": "MICU NSG ADMIT\nPT IS 56 YO WOMAN TRANS TO MICU WITH RENAL FAILURE AND CVVHD.\nPMEDHX--COPD, PULMON HTN, COR PULMONALE, OBSRTUCTIVE SLEEP APNEA, HTN, PUD, CRI, ARTHRITIS.\nALLERGIES--DEMEROL, CASHEWS.\nROS\nNEURO--PT X1 AND LETHARGIC, BUT YELLS WHEN LEGS MOVED. DECREASING ALERTNESS OVER COURSE OF EVENING, PLACED ON BIPAP.\nRESP--INITALLY ON 5L NC, BUT HAVING PERIODS OF APNEA, AND SATS DROPPING TO 87%, 92-93% WHEN CONSISTENTLY BREATHING. EVENTUALLY PLACED ON BIPAP FOR MS APNEA. LUNGS SOUNDS DECREASED THROUGHOUT.\nGI--VOMITTED X1, DID NOT APPEAR TO ASPIRATE. ABD OBESE AND SL FIRM WITH GOOD BS. NO BM.\nCARD--HR 90'S AFLUTTER, NO ECTOPY. BP 85-115/. GOAL IS TO KEEP BP > 85/. PT WITH , NAKLES WITH BLISTERS WEEPING COPIOUS AMOUNTS OF SEROUS FLUID. COCCYX/BUTTOCKS EXCORAITED. BARI-AIR BED ORDERED, BUT NOT AVAILABLE TILL . PT IS DNR.\nGU--STARTED ON SCUF AT 4PM, ULTRAFILTRATE 200CC/HR, BLOOD PUMP 180CC/HR, HEPARIN 1000U/HR (RECEIVED 2000U BOLUS). SO FAR BP TOL FLUID REMOVAL. CURRENTLY NO DIALYSIS OR REPLACEMENT FLUID, JUST FLUID REMOVAL.\nSOCIAL--NO VISITORS OR PHONE CALLS SINCE TRANS TO MICU.\n\n" }, { "category": "Nursing/other", "chartdate": "2188-04-22 00:00:00.000", "description": "Report", "row_id": 1572836, "text": "NURSING PROGRESS NOTE:\nPT RECEIVED ON 40% BIPAP WITH 02 SAT'S IN MID 90'S, LUNG SOUNDS ARE DIMIN THROUGHOUT.\nPT ALSO RECEIVED ON CVVHD IN ULTRAFILTRATION MODE. TAKING OFF 200CC FLUID EACH HOUR. BP TOLERATING THIS RATE WELL DURING THE NIGHT.\nPTT AT 2200 WAS 103, HEPARIN TURNED DOWN TO 800 UNITS/HR ACCORDING TO PROTOCOL.\nPT VERY LETHARGIC WITH MINIMAL RESPONSIVENESS. RESPONDS WITH MOANS AT TIMES WHEN YOU CALL OUT HER NAME.\nFOLEY CATHETER DRAINING SCANT AMT'S OF BROWN URINE.\nATTEMPTED TO BATH PT AND THEN VOMITED LRG AMT OF GREEN BILE INTO THE BIPAP MASK, BIPAP MASK REMOVED AND REPLACED WITH FACE MASK AT 50%. PT SEEMED TO TOLERATE THIS CHG WITH O2 SAT'S 98-100%. LUNG SOUNDS COARSE AND DIMINISHED, HAVE ASPIRATED SOME STOMACH CONTENTS. ATTEMPTED TO PLACE NGT TUBE BUT UNABLE. PT .625MG OF IV DOPERIDOL. PT GOT SOME RELIEF FROM THIS AND SETTLED DOWN FOR A SHORT TIME.\nPT C/O SEVERE JOINT PAIN ESPECIALLY WHEN SHE IS MOVED AT ALL. BED NOT COMFORTABLE FOR HER LEGS AND HIPS. WAITING FOR NEW BED.\nPT HAS MANY EXCORIATED AREAS UNDER HER ARMS, BREASTS, STOMACH FOLD AND GROIN AREA. BOTH LEGS DRAINING LRG AMT'S OF SEROUS FLUID FROM BLISTERS ON BOTH SHINS AND BOTH ANKLES. DSD'S APPLIED.\nMICONAZOL POWDER APPLIED TO SOME THE AREAS.\nTALKED ABOUT INTUBATION WITH HOUSE OFFICER AND PT TO PROTECT PT;S AIRWAY, NO DECISION MADE AT THIS TIME.\nHAVE NOT HEARD FROM HER FAMILY MEMBERS AT THIS TIME.\nUNABLE TO TAKE ANY PO MEDS DURING THE NIGHT.\nPT MORE ALERT THIS AM, STILL REQUIRING SOFT RESTRAINTS TO BOTH ARMS BECAUSE SHE PULLS OFF O2 AND PICKS AT THINGS. PT MORE AWARE OF WHERE SHE IS NOW. X 2.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-10 00:00:00.000", "description": "Report", "row_id": 1572832, "text": "FOCUS; NURSING PROGRESS NOTE.\nREVIEW OF SYSTEMS-\nNEURO- THIS AFTERNOON PATIENT IS ALERT AND ORIENTED X3.\nRESP- WAS ON BIPAP 40% FIO2 10 PEEP AND 5PS WITH SATS IN THE MID 90'S. SWITCHED AT 1600 TO 40% VM WITH SATS IN THE UPPER 90'S. RESP 16-24. BS DIMINISHED THROUGHOUT.\nCARDIAC- IN AFLUTTER. RATE AT 80-120. DID DROP HER BP TO 81/39 THIS AM. BP UP ON IT'S OWN. DECISION MADE TO ATTEMPT TO CARDIOVERT WITH ILBUTALIDE. SHE RECEIVED 3 1MG DOSES OVER 10MIN EACH. HER RATE IS IN THE 90'S AT PRESENT SHE REMAINS IN A FLUTTER. SBP HAS RANGED IN THE 90'S TO LOW 100'S.\nGI- ABD OBESE WITH POS BS. SHE HAS HAD SWABS OF H20 AS SHE IS NPO.\nGU- UO 20-30CC/HR. 80MG IV LASIX GIVEN X1. SHE IS NEG 410 SINCE MN.\nSKIN- VENOUS STASIS CHANGES ON LOWER LEGS THAT DRAIN SEROUS FLUID. BUTTOCKS EXCORIATED WITH A COUPLE OF SKIN TEARS TO WHICH DUODERM WAS APPLIED.\nID- AFEBRILE. CONTINUES ON IMIPENUM.\nDISPO- REMAINS IN THE MICU. SHE IS DNR. NO SHOCK. WOULD BE INTUBATED.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-11 00:00:00.000", "description": "Report", "row_id": 1572833, "text": " nursing note\nneuro- pt. slept most part of the night,oriented x 3,forgetfull.\nresp- on nc at 5l,no c/o sob,o2sat 94- 97%,\ncv-a-flluter,no c/o cp,bp low-in 50-60's at 00,500 cc bolus given,bp now wnl.\ngi-npo,no n/v,no bm\ngu-uo averg.40cc/hr,cl&yell.\nskin-duoderm on rt.butock changed,\ndi-max temp-98.6,on imipenem q 6hr\npt. refused heparin-sq\n" }, { "category": "Nursing/other", "chartdate": "2188-04-10 00:00:00.000", "description": "Report", "row_id": 1572830, "text": "ccu (micu border) nursing progress/transfer note 7p-4a\n\npt admitted to ccu as micu border . pt being transferred to micu. please see admission note for details.\n\nneuro: pt lethargic but arousable. receiving ativan prn for agitation. when awake, pt asking for water but also not making sense at times.\n\ncv: noted pt to be in aflutter on examination. ?how long pt has been in aflutter. hr initially 60-80's. ekg done. ho made aware. no intervention to be done at this time. bp 90-100/50's. pt's hr ^110-120's when off mask ventilation for extended period time, but returned to 70's when bipap resumed.\n\npulm: ls diminished throughout. o2 sats 93-95% on bipap. pt given rest period off mask ventilation. o2 sats stable on 50% venti mask, however ^ hr so as stated before, bipap resumed. ps 10, 5 peep, 40% fio2.\n\ngi/gu: abd obese. +bs. no stool observed at this time. pt taking small sips clear liquids. given lasix 80 mg iv with mod response. foley draining clear yellow urine.\n\naccess: pt has triple lumen central line.\n\nreport given to micu.\n\n" }, { "category": "Nursing/other", "chartdate": "2188-04-10 00:00:00.000", "description": "Report", "row_id": 1572831, "text": "PMICU NURSING ADMIT NOTE:\n Briefly, pt is a 56 yr old morbidly obese female, with h/o OSA, Cor Pulmonale, COPD, HTN, CHF, and CRI who is transferred to pmicu from CCU where she was admtited with hypoxic(RA sat 79%)/hypercarbneic resp failure, MS changes, and hyperkalemia/ARF. Admit abg: 7.18/88/231 on 80%FM.. repeat abg on bipap 10/5 35% 7.23/78/63/34. Please see CCU admit note for full details. Of note, pt had been dc'd from on after admission for ARF.\nAllergies: Demerol, nuts, pentathol\nREview of systems:\n NeurO: pt A+ O x . answering questions inconsistently, but appropriately. PERRLA, .\n RESP: pt arrives to pmicu on face mask, and replaced back on bipap 40%. RR 16, sats 93%. LS cta upper, diminished lower. receiving inhalers as ordered. PT with MRSA in sputum. cont on solumedrol.\n CV: pt in aflutter, rate 70's-90's. bp 118/48. cvp 26.\n GI: ab obese, bs+. pt on protonix.\n INteg: pt with multiple ulcerations over lower extremities... oozing serous fluid. pt on regular size mattress.. I have called to obtain larger bed.. will most likely needs large air mattress. on sq heparin.\n Fe: ivf at kvo, foley intact. urine concentrated. am labs sent, pending.\n ID: on Imipenum. afebrile.\n Code status: DNR, no shock, would be intubated.\n A/P: pt to cont on bipap.. no abg's all day.. team aware.. easily arousable, oriented as noted. ? overall plan?. needs larger bed. cont steriods, abx for now.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 1572826, "text": "Addendum to Nursing Progress Note:\n\nPt cont with intermittent agitation overnight, this am pt removed pap, leads etc off. Pt with obsene language and physically combative during nursing interventions. Pt refused oxygen and o2 sat checks.\nPt desaturated into the 70's RR 30's. H.O. present..pt agreed to go back on pap with 5min breaks. RR high 20's to low 30's. Sats >90%.\nPt alert and oriented x . Pt does not recall events of admission or while in ICU. Pt rec'd ativan .5mg IV, await effects.\n\nAwait ABG to be drawn.\n\nCPNCP.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 1572827, "text": "NURSING PROGRESS NOTE 0700-1500\nNEURO--PT SLEPT 3.5 HRS AFTER MORNING ATIVAN GIVEN. UPON WAKING UP, SHE WAS ALERT AND ORIENTED X3 WITH A SENSE OF HUMOR. SHE MOVES ARMS BUT ONLY MOVES LEGS ON BED VERY SLIGHTLY.PEARL.\n\nCARDIAC--BP 110-120. HR 80'S SR WITH OCC PAC'S. AFEBRILE. IVF INFUSING AT 75 CC HR.\n\nRESP--ON BIPAP 40%X 10/5. SPONT RESP 20-34. SAO287-95%. THIS AFTERNOON, PT BECAME AGITATED, PULLING OFF MASK. PLACED ON 4L NC BUT BECAME SOMNELENT. PLACED BACK ON MASK AND GIVEN 1.5 MG IV ATIVAN. SHE IS NOW SLEEPING AND APPEARS COMFORTABLE. NO ABG'S DRAWN BY TEAM.LUNGS DECREASED BILATERALLY.\n\nGI--HAD LIQUIDS WITHOUT DIFFICULTY. VERY LGR STOOL X2. +BS.\n\nGU-- FOLEY CATH PATENT DRAINING YELLOW SEDIMENT URINE. CX SENT THIS AM. PT HAS HAD FOLEY WITH MULTIPLE UTI'S FOR OVER 1 YR.\n\nENDO--UNREMARKABLE AT THIS TIME.\n\nSKIN--BILAT LOWER EXT ARE WITH BLISTERS AND OOZY WITH ALOT OF DEAD SKIN. ?CELLULITIS. L BREAST HAS AREA OF ? CELLULITS . BUTTOCKS WITHOUT BREAKDOWN. MULT AREAS OF ECCYMOISIS ON UPPER EXTREMITIES.\n\nCOPING--FAMILY HAS COME IN TO VISIT. PER SON WHO IS HEALTH CARE PROXY, HE WANTS MS. T TO BE INTUBATED IF IT IS NEEDED BUT ONLY FOR A SHORT TIME. HE OR MS T. WOULD WANT TO BE TRACHED IF IT CAME TO THAT. NO SHOCK OR CPR INDICATED PER SON .\n\nA--WEARING BIPAP THROUGHOUT DAY. NO ABG'S DONE.\n\nP--CON'T TO MONITOR. CHECK K+. OFFER SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 1572828, "text": "Respiratory Care Note\n\nPt remains on NIVV 10 Peep 5 IPS 40%. Vt 400-1L rr10-30. pt becoming very agitated and combative at times...pulling off the mask ans screaming. Currently pt seems comft. No changes made. Pt taken off machine for ~ 1 hr this afternoon but became very sleepy and not easily aroused. Pt placed back on mask with good effect. Will follow and titrate as needed.\n" }, { "category": "Nursing/other", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 1572829, "text": "1830 Addendum\n\nPt received 40mg of lasix at 430pm and 5pm diuresing 270ml of clear yellow urine. 2pm k 5.5 Dr aware. Multiple attempt made for Aline placement without success. Currently O2 sat fluctuates between 95-97%.\n" }, { "category": "ECG", "chartdate": "2188-04-09 00:00:00.000", "description": "Report", "row_id": 154659, "text": "Atrial fibrillation\nRight axis deviation\nRight bundle branch block\nConsider prior inferior myocardial infarct\nLow voltage\nDiffuse ST-T abnormalities\nConsistent with previous heart rate decreased\n\n" }, { "category": "ECG", "chartdate": "2188-04-16 00:00:00.000", "description": "Report", "row_id": 154660, "text": "Atrial fibrillation\nRight bundle branch block\n Inferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2188-04-19 00:00:00.000", "description": "Report", "row_id": 154661, "text": "Supraventricular rhythm. Sinus mechanism versus atrial flutter. The ventricular\nrate is 98 beats per minute. Right bundle-branch block. Inferior myocardial\ninfarction. Compared to the previous tracing of , no major change.\n\n" }, { "category": "ECG", "chartdate": "2188-04-25 00:00:00.000", "description": "Report", "row_id": 154662, "text": "Supraventricular tachycardia, probably atrial flutter\nRight axis deviation\nConduction defect of RBBB type\nLow QRS voltages in precordial leads\nConsider inferior myocardial infarct\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2188-04-27 00:00:00.000", "description": "Report", "row_id": 154663, "text": "Atrial flutter\nRight bundle branch block\nInferior infarct - age undetermined\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2188-04-28 00:00:00.000", "description": "Report", "row_id": 154664, "text": "Slow atrial flutter with variable ventricular response. Right bundle-branch\nblock. Q waves in the inferior leads suggestingprior inferior myocardial\ninfarction. Compared to the previous tracing of atrial flutter\npersists. Otherwise, no significant change.\n\n" }, { "category": "ECG", "chartdate": "2188-05-05 00:00:00.000", "description": "Report", "row_id": 154665, "text": "Slow atrial flutter versus atrial tachycardia with controlled ventricular\nresponse. Right bundle-branch block. No significant change compared to the\nprevious tracing of .\n\n" }, { "category": "ECG", "chartdate": "2188-04-08 00:00:00.000", "description": "Report", "row_id": 154439, "text": "The rhythm is uncertain - consider supraventricular tachy-arrhythmia - may be\natrial tachycardia or \"slow\" flutter with 3:1 block. Right bundle-branch block.\nconsider prior inferior myocardial infarction. Low voltage. Diffuse\nnon-specific T wave abnormalities. Since the previous tracing of \nventricular rate is more regular and slightly faster.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 753510, "text": " 1:52 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o CHF, PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n r/o CHF, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, rule out CHF, pneumonia.\n\n Frontal and lateral chest radiographs dated are compared with prior\n chest radiographs dated .\n\n The study is suboptimal in technique due to patient's body habitus. The lung\n volumes are extremely low. This limits accurate evaluation of the cardiac\n size. The mediastinal and hilar contours are probably within normal limits.\n The pulmonary vascularity appears unremarkable. There is no definite focal\n consolidation of the lung fields. There appears to be no pleural effusions.\n\n IMPRESSION: Limited study. No definite CHF or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 753538, "text": " 1:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt s/p subclavian line - cxr to eval for pneumothorax.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n Pt s/p subclavian line - cxr to eval for pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CV LINE PLACEMENT. EVALUATE FOR PNEUMOTHORAX.\n\n Tip of subclavian CV line is difficult to clearly localize on this film. It\n is likely in the left brachiocephalic vein. No pneumothorax. __Possible\n cardiomegaly but difficult to evaluate in this supine AP film in patient with\n alrge body habitus.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-08 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 753534, "text": " 10:36 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: HYPOXIA, BEDRIDDEN, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with hypoxia, on bed rest\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58yr old female bed-bound with hypoxia.\n\n BILATERAL LOWER EXTREMITY US: Limited examination due to the patient's body\n habitus. scale, color and doppler son of the right and left common\n femoral, and popliteal veins was performed. There is normal compressibility.\n Flow is grossly normal as well. The superficial femoral veins were not\n adequately visualized.\n\n IMPRESSION: Limited bilateral lower extremity US without evidence for DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 754490, "text": " 10:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 yo obese female with OSA, COPD< with worsening o2 sats. P\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n 57 yo obese female with OSA, COPD< with worsening o2 sats. Peri-intub ation.\n please evaluate cXr\n thankyou\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD. Worsening O2 saturation.\n\n COMPARISON: .\n\n Left subclavian central venous catheter is present with tip at the SVC. There\n is no pneumothorax. There is left ventricular enlargement. Mediastinal\n contour is within normal limits. Again demonstrated is upper zone\n redistribution and patchy perihilar opacities not significantly changed. There\n is no pleural effusion. The right CP angle is not included on the radiograph.\n\n IMPRESSION:\n 1) Left subclavian central venous catheter with tip at SVC without\n pneumothorax.\n 2) No significant change in pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 754534, "text": " 3:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for PICC line placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n Eval for PICC line placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line placement.\n\n CHEST AP: Comparison is made to the prior film dated .\n\n The film is of suboptimal quality. The contrast of the film is poor. There is\n evidence of moderate LV enlargement, but no evidence of upper zone\n redistribution. No evidence of pulmonary edema. No evidence of focal\n consolidation. The PICC line is poorly visualized. The visualized bony\n structures are unremarkable.\n\n IMPRESSION: Suboptimal study and the PICC line is not well visualized. Repeat\n study is recommended to confirm the exact position of the PICC line.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 754541, "text": " 5:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: obese 52 yo female s/p bedside right antecub. picc line plac\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n obese 52 yo female s/p bedside right antecub. picc line placement, with first\n post-intervention film w/o evidence of picc line tip. I spoke with teh\n radiologist, and he recommended repeating film and increasing \"kv\" (?).\n Please return to the MICU for second film ,as access is large issue at this\n point.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 58 y/o woman with obesity S/P PICC line insertion. Film\n repeated for improved exposure.\n\n COMPARISONS: .\n\n SINGLE VIEW OF THE RIGHT HEMITHORAX: A PICC line catheter is seen with tip\n terminating in the right subclavian vein just proximal to the confluence with\n the jugular vein. Also noted is the left central venous line with tip in the\n mid SVC. There has been no change in the appearance of the lungs and heart\n since the prior study.\n\n IMPRESSION: Right PICC line catheter tip in subclavian vein.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-21 00:00:00.000", "description": "P CHEST (SINGLE VIEW) PORT", "row_id": 754450, "text": " 3:26 PM\n CHEST (SINGLE VIEW) PORT Clip # \n Reason: confirm line placement for HD. Pt weighs 400 lbs.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n\n \n \n REASON FOR THIS EXAMINATION:\n confirm line placement for HD. Pt weighs 400 lbs.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement for hemodialysis.\n\n COMPARISON: .\n\n PORTABLE SUPINE CHEST RADIOGRAPH: The study is significantly limited by\n position and body habitus. The lateral chest was not included on the\n radiograph. Left subclavian central venous catheter is seen entering the left\n subclavian, visualized to the junction of the brachiocephalic vein. The more\n distal tip may not be seen due to body habitus. Pneumothorax cannot be\n excluded. The cardiac silhouette is enlarged. There is no significant change\n in pulmonary parenchyma since the previous study.\n\n IMPRESSION: Limited study. Left subclavian central catheter only visualized\n to the level of the brachiocephalic vein. Findings were discussed with house\n staff and additional radiograph recommended to better define location of tip\n of catheter.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-22 00:00:00.000", "description": "CVL/PICC", "row_id": 754525, "text": " 3:17 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Morbidly obese, tenuous access aside from dialysis catheter\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n Morbidly obese, tenuous access aside from dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Morbid obesity, MRSA and cor pulmonale, needs IV access.\n\n RADIOLOGISTS PERFORMING THE PROCEDURE:\n Drs. and . Dr. , the staff radiologist, was present and\n performed the procedure.\n\n TECHNIQUE:\n\n This procedure was done at bedside due to the size of the patient and the\n patient's clinical condition. No appropriate superficial vein was visualized.\n A prelinary ultrasound was performed of the right arm, demonstrating a patent\n brachial vein which is compressible. The skin site was then prepped and\n draped. Under local anesthesia 1% Lidocaine, a 20 gauge angiocath was placed\n in the brachial vein. A .018 guidewire was then advanced through the\n angiocath. A 5 Fr double lumen PICC was trimmed to 45 cm and advanced over the\n guidewire. The PICC line was then flushed and demonstrated good bidirectional\n flow. The wire was removed and the PICC secured to the skin.\n\n A portable chest radiograph will be performed to confirm position of the PICC.\n MEDICATIONS:\n 1% Lidocaine for local anesthesia.\n\n COMPLICATIONS:\n No evidence of immediate complications.\n\n IMPRESSION:\n Bedside placement of PICC. A portable chest radiograph is to be performed for\n confirmation of the line position. The patient's nurse was notified not to use\n the PICC until its position is confirmed.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-22 00:00:00.000", "description": "LP WRIST(3 + VIEWS) LEFT PORT", "row_id": 754507, "text": " 12:54 PM\n WRIST(3 + VIEWS) LEFT PORT Clip # \n Reason: pain, laxity, crepitus in L wrist\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n pain, laxity, crepitus in L wrist\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 year old woman with pain, laxity and crepitus in left wrist.\n\n LEFT WRIST, THREE VIEWS: There are severe destructive changes and fusion of\n the carpal bones. There is positive ulnar variance and dorsal dislocation of\n the radius and ulna with respect to the carpal bones. There is marked joint\n space narrowing and suggesting of a \"pencil-in-cup\" deformity of the MCP\n joints. There is diffuse osteopenia with more marked involvement of the\n periarticular bones.\n\n IMPRESSION: Destructive arthritis consistent with rheumatoid arthritis vs.\n Charcot joint.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "PAROTID US", "row_id": 755560, "text": " 4:18 PM\n PAROTID US Clip # \n Reason: 58 yo with right cheek swelling/increasing wbc/erythema- ple\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with morbid obesity, copd, cor pulmonale\n REASON FOR THIS EXAMINATION:\n 58 yo with right cheek swelling/increasing wbc/erythema- please eval for\n abscess/hematoma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 year old woman with morbid obesity, COPD, cor pulmonale, and\n right cheek swelling with increasing white blood cells and erythema.\n\n FINDINGS: Ultrasound of the parotid gland was performed. The tender region\n does not show areas of fluid within it. A small lymph node is seen, measuring\n 0.8 cm in diameter. The parotid gland on the right is enlarged and tender.\n Compared to the left side, the right parotid gland is markedly enlarged.\n There are no stones seen, nor any discrete fluid collections.\n\n IMPRESSION: Prominence of the right parotid gland without evidence of cystic\n regions or evidence of abscess. This might represent parotitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-30 00:00:00.000", "description": "O CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.", "row_id": 755127, "text": " 7:34 PM\n CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. Clip # \n Reason: ATTEMPTED PERMACATH PLACEMENT IN OR\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST FLUOROSCOPY WITHOUT RADIOLOGIST IN THE OR:\n\n A chest fluoroscopy without radiologist in the OR was performed. An attempt to\n place a permacath in the OR was performed. 1 minute and 16 seconds of fluoro\n time was used. No images were saved.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 755128, "text": " 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PNEUMO\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P central venous line attempt. Evaluate for pneumothorax.\n\n COMPARISON: .\n\n CHEST, SINGLE VIEW: The cardiac, mediastinal and hilar contours are stable in\n appearance. No pneumothorax is identified. The left lung is clear. However,\n the extreme left costophrenic angle has been excluded from the study. There\n is a new ill-defined opacity in the right mid lung zone. A right PICC line\n catheter tip is seen in the right subclavian vein. A left subclavian catheter\n is seen with tip at the junction of the left brachiocephalic vein and SVC. The\n soft tissue and osseous structures are otherwise unremarkable.\n\n IMPRESSION: 1) No evidence of pneumothorax. 2) Ill-defined patchy opacity\n in the right mid lung zone which could represent atelectasis with a possible\n component of fluid tracking along the fissures. Followup radiograph is\n suggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2189-10-06 00:00:00.000", "description": "Report", "row_id": 1792031, "text": "npn 1900-0730\n\n\n1. Remains in RA. Sao2 in high 90's-100%. + ic/sc\nretractions. No drifting or desats noted. Ls cl/=.\n\n3. Wt. 1.015gms. Down 10gms from yesterday. Tf cont. at\n150cc/k/d. Increasing feedings by 10cc/k/d . Now D14 now\nrunning via central picc in l foot. at 110cc/k/d or\n4.8cc/hr. Lipids remains at .8cc/hr. Enteral feedings are at\n40cc/k/d or 8cc of BM or PE20. Tolerating well. No spits or\nasp. D/s 88-99. Abd soft, no loops,+bs. Voiding 1.9cc/ki/hr\nin 12hrs and 2cc/k/hr in 24hrs.\n\n4. Remains in servo . Temps 98.2-99.6. \nweened accordingly. Remains nested in sheepskin. MAE. Fussy\nat times. All pg feedings.\n\n5. in for 2100 cars. Did not hold infant d/t had\njust had LP. Mom has lactation apppt at 1300 on .\n very loving and caring. Seem very tired.\n\n6. LP done. 10,000 wbc and 313,000 rbc. aware. Recieved\nlast dose at 2100of ampicillin. Day .\n\n7 rebound bili drawn this shift. Remains pnd. Infant .\nNo jaundice noted. Stooling well.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-06 00:00:00.000", "description": "Report", "row_id": 1792032, "text": "Neonatology note\n\n7 d.o now 18 wks PCA\nin RA, on caffeine, no spell.\nbili= 4,7\nwt= 1015 gm -10\n150 ml/kg/d with feeding at 40 ml/kg/d with EBM 20.\n\n, jaundice\nAFOF, active with exam\nRR with no murmur\nlung clear with mind retraction\nabdomen soft with no mass palpable, bowel sounds present\nnormal external female genitalia.\nnormal tone for preemie.\n\nA: ex 27 wks GA, RDS resolved, AOP, presumed sepsis resolved, hyperbilirubinemia, grade I bleed.\n\nP: continue advancing feeding, f/u bilirubin, antibiotics d/c.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-06 00:00:00.000", "description": "Report", "row_id": 1792033, "text": "Lactation Progress Note\nMet with mom re: supply issues. Mom verbalizing concern that she is only getting 4-5cc per pumping. Reviewed the pumping handout. Discussed the importance of heat, gentle massage, relaxation, and pumping a minimum of 8 times per day with no more that 4hrs between pumpings especially between midnight and 6am. Mom has a symphoney pump and is pumping 6 times/day. She is using mother's milk tea. Discussed the use of fenugreek and possibly reglan though mom does not want reglan yet. Observed mom pumping and recommended she get the next size phlange to increase breast stimulation. Encouraged rest, relaxation, and kangaroo care. Mom is keeping a pumping diary which we can review later this week. Mom does have large lobular nipples. Support and encouragement offered.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-21 00:00:00.000", "description": "Report", "row_id": 1792110, "text": "I have read and agree with above note. Mom was in for 1300 feeding and was given update on baby's progress.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-21 00:00:00.000", "description": "Report", "row_id": 1792111, "text": "Fellow PE Note\nGen- WD/WN F alert in NAD\nHEENT- NCAT, , nares patent with NGT in place, oropharynx clear\nCardiac- RRR, nl s1,s2, no murmur appreciated\nLungs- CTAB, no retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nSkin- no rash\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-21 00:00:00.000", "description": "Report", "row_id": 1792112, "text": "nursing note\n\n\n1. Baby remains in nasal conula oxygen 100% 25cc with O2\nsats >95%. Breath sounds clear and equal with mild\nretractions. No spells this shift. A: stable on low flow\nO2. P:Continue to monitor and wean as tolerated.\n\n3.Baby remains on BM30 34cc over one hour feeding time\nincreased to one hour and fifteen minuets dut to multilple\nof moderate spits. Abdomen soft and full. voiding and\nstooling, guiac neg. Weight up tonight. AP:stable on\ncurrent feeding plan. Continue to monitor.\n\n4. Baby quiet between feeds. Alert and active with care.\nTemp stable in air mode . AP:Stable, Continue to\nmonitor closely.\n\n5. Dad in to visit this evening. Held and changed\ndiaper. Asking appropriate questions. AP:Continue to\nsupport family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-22 00:00:00.000", "description": "Report", "row_id": 1792113, "text": "NPN 2300-0700\n\n\nRESP: Infant remains in NC 100%fio2, 25cc flow. RR 40-60's,\nO2 Sat >93%. Lungs are clear and equal with mild ic/scr\nnoted. Infant with one spell thus far, HR 65 O2 77 required\nmild stim. Remains on caffeine. A: Stable in NC, occasional\nspells. P: Continue to monitor resp status, wean nc as\ntolerated.\n\nFEN: CW 1355(^10). TF 150cc/k/d of BM30 w/pm (34cc q4hr pg\n1hr 15min) Abdomen soft with active bowel sounds. No loops,\nNo spits, min aspirates, girth stable. Voiding with each\ndiaper change. Sm heme neg stool x's 1 thus far this shift.\nA: Tolerating gavage feeds. P: Continue per nutritional\nplan, monitor for signs and symptoms of feeding intolerance.\n\n\nDEV: Infant remains swaddled in an air . Temps\nstable. Infant quietly alert and active with cares. Settles\nwell inbetween cares. Yellow eye drainage noted in right\neye, cleansed with warm water and erythromycin ointment\napplied as ordered. Brings hands to face for comfort, not\nyet interested in pacifier. A: AGA P: Continue to support\ndeveloment.\n\n: No contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-22 00:00:00.000", "description": "Report", "row_id": 1792114, "text": "Attending Note\nDay of life 23 PMA 30 \nin nasal cannula 13-25 cc of 100% FiO2 mild retractions RR 40-60 but can reach 70-80's\non spell in 24 hours on caffeine\nHR 150-160 BP 77/47 mean 52 \nweight 1355 up 10 grams on 150 cc/kg/day of BM 30 cal/oz with promod pg over an hour 15 minutes\nvoiding and stooling heme negative\nstable temp in \nalert and active with cares\neye ointment day \n\nImp-stable and making progress\nwill continue current management\nwill wean nasal cannula as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2189-10-22 00:00:00.000", "description": "Report", "row_id": 1792115, "text": "Fellow PE Note\nGen- WD/WN F alert in NAD\nHEENT- NCAT, , nares patent with NC and NGT in place, oropharynx clear\nCardiac- RRR, nl s1,s2, no murmur apprecitaed\nLungs- CTAB, mild retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nSkin- no rash\n" }, { "category": "Nursing/other", "chartdate": "2189-11-07 00:00:00.000", "description": "Report", "row_id": 1792181, "text": "Neo Attending\nDay 39 day, now 32.6 wk pma\nRespr RA, caffeine off \nCV: intermittent murmur\nWt 1860, up 45 gm\nFEN: BM28+PM at 150- cc/kg/day all pg\nOn fe\noff .\nHUS: bilat Gr I,\nEye: IR zone 2, . f/up in 2 weeks.\n\nAssessment: stable.\nPlan: continue current regimen.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-07 00:00:00.000", "description": "Report", "row_id": 1792182, "text": "NPN 07a-07p\n\n\nFEN\nTF 150 cc/kg/day, BM28 with Promod. Gavaged q4h/60min.\nTolerating well. No spits, min. residuals. BS active. Abd.\nsoft,round. No loops noted. Voiding, trace stool this am.\nCont. monitor PG feeding tolerance & weight.\nG&D\nIn off , temps stable. On sheepskin. & active\nwith cares. Resting comfortably inbetween. Fontanels soft,\nflat. MAEs equally. PPP x4ext. Cont. monitor growth &\ndevelopm. patterns.\n\nPOB in this am. Loving & caring. Updated, raising no\nquestions @ this time. Cont. support & educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-07 00:00:00.000", "description": "Report", "row_id": 1792183, "text": "NP EXAM\n is bundled in well perfused in RA, alerts slowly to quiet awake\n sutures approximated, eyes bright, ng in place, MMMP\nChest is eqaul clear, comfortable resp pattern\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs\nEXT: MAE, WWP\nNeuro: symmetric tone and relfexes\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-08 00:00:00.000", "description": "Report", "row_id": 1792184, "text": "3. F/N: O: Infant is on BM28 + PM, 150cc/k/d of TF, q 4 hour\nfeeds, all gavaged, over one hour each. Abd is benign. No\nspits, min asps. She gained 45g. A: Tol feeds, gaining wt.\nP: Continue w/ plan.\n\n4. G/d: O: Infant's temp is stable in an w/ the\nheat off. She is active w/ cares and settles well\nafterwards. A/P: Continue to support infant needs.\n\n5. : No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-08 00:00:00.000", "description": "Report", "row_id": 1792185, "text": "Neonatology Attending\nExam AF soft, flat, sleeping, clear bs, no murmur, benign abd\n" }, { "category": "Nursing/other", "chartdate": "2189-11-08 00:00:00.000", "description": "Report", "row_id": 1792186, "text": "Neonatology Attending\n\nDOL 40 PMA 33 weeks\n\nStable in RA. No A/B. Off caffeine since .\n\nIntermittent murmur secondary to PPS. BP 69/37 mean 52\n\nOn 150 ml/kg/d BM 28 with promod pg. Voiding. Stooling (heme neg). Wt grams (up 45).\n\n visiting and up to date.\n\nA: Stable. Recently off caffeine. No spells. Tolerating feeds and growing.\n\nP: Monitor\n Continue current regimen\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-08 00:00:00.000", "description": "Report", "row_id": 1792187, "text": "NPN 07a-07p\n\n\nFEN\nTF 150cc/kg/day, BM28 with Promod, gavaged q4h/60min.\nTolerating well. No spits, max. aspirate 1.5cc. BS active.\nAbd. soft, round. No loops noted. AG 25cm. Voiding, stooling\n(heme negative). Cont. monitor PG feeding tolerance &\nweight.\nG&D\nIn off , temps stable. & active with cares.\nResting comfortably inbetween. Fontanels soft, flat. MAEs\nequally. PPP x4ext. Cont. monitor growth & developm.\npatterns.\n\nPOB in this am. Updated @ bedside. Loving and caring. Asking\nappropriate questions. Cont. support & educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1792265, "text": "PCA Note 0700-1900\n\n\nFEN: TF 140cc/kg/day = 63cc Q4 of BM26. Tolerating PO/PG\nfeedings well with no spits and minimal aspirates thus far.\nInfant offered bottle at first two cares, took 29cc and 15cc\nwith remainder gavaged, infant coordinated but tiring\neasily. Abdomen soft/round, good BS, no loops. Voiding and\nstooling (heme negative). Desitin applied Q diaper change\nover slightly red bottom.\n\nDEV: Temps stable while swaddled in OAC. Waking for some\ncare times. and active with cares and sleeping well in\nbetween. Brings hands to face and sucks on pacifier for\ncomfort.\n\nPARENTING: Mom in for second cares, very loving and asking\nappropriate questions. Mom independent with infant's cares.\nUpdates given at bedside by RN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1792266, "text": "NPN 1900-0700\n\n\n#3FEN: Weight 2715g up 35g. TF 140cc/kg/d of BM 26= 63cc\nalt PO/PG Q 4hrs. Feeds gavaged over 75min for spits. Pt.\nhad sm spit X 1. Pt. took 15cc when bottled @ 9pm. Pt.\nwell coordinated w/ bottling but tires quickly. Abd soft &\nround, +BS, no loops. Pt. voiding & stooling, guaic neg.\nAG stable. P: cont to encourage po's & monitor FEN.\n\n#4DEV: Temps stable swaddled in OAC. Pt. awake & for\ncares. Pt. not waking for all feedings. Settles well in\nbetween w/ pacifier. MAE. . P: cont to support dev\nneeds.\n\n#5Parenting: in for 9pm cares. Both independent w/\ncares & bottling. Updates given. Both loving & invested.\nP: cont to support & update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1792267, "text": "NICU Fellow PN\nExam\nGEN; Awake, ready for feed, and in NAD\nHEENT: , soft, OP clear, MMM\nChest: CLear and equal BS, no distress\nCV: RRR, normal S1 and S2\nAbd: Soft, ND, NT, no masses, +BS\nExt: WWP, pulses normal\n" }, { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1792268, "text": "Neonatology Attending\n\nDay 59 PMA 35 wks\n\nRemains in RA. Clear breath sounds. No bradycardia. HR 160-180. BP mean 52. Pale, . Weight 2715 gms (+35). TF at 140 cc/kg/d- BM 26. Had one small spit. Minimal po volumes with alternating schedule. Benign abdomen with minimal aspirates. Stable temperature in open crib. Waking for feeds.\n\nDoing well. Monitoring closely. Gaining weight well. Encouraging po feeds. Spoke with mother yesterday.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1792269, "text": "Nursing Progress Note:\n\nFEN:\nO: Infant receiving 140cc/kg of BM 26, (63cc), every 4\nhours, po/pg. Gavaged over 1:15 d/t hx of spits. At 0900\ninfant bottled 15cc. At 1300 infant bottled 30cc. Infant\nwell coordinated using yellow , tires easily. No spits\nnoted so far this shift. Abdominal exam benign. Infant\nvoiding and passing heme negative stool.\nA: Infant progressing well with po feeds. Tolerating feeds\nwell.\nP: Cont to advance po feeds as tolerated. cont to gavage\nover 1:15 to prevent spits.\n\nDEV:\nO: Infant temp stable; swaddled in an OAC. Font s/f. Infant\na/a with cares; waking for all feeds. within normal\nlimits. Infant reaches hands to face and enjoys her\npacifier. Sleeps well between cares.\nA: Appropriate behavior for gestational age.\nP: Cont to support development.\n\nSOC:\nO: Mom in at 1pm for cares. Updated regarding infant's\nstatus and plan of care by this PCA, and RN. Mom \nin cares and responds well to infant cues. Cont to pump.\nAsking appropriate questions.\nA: Mom bonding well with infant. Active in infant care.\nP: Cont to support, educate and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-17 00:00:00.000", "description": "Report", "row_id": 1792358, "text": "Neonatology Attending\n\nDay 79 PMA 38 wks\n\nRemains in RA. Clear breath sounds. RR 30-50s. No murmur. . HR 140-160s. BP mean 61. Weight 3330 gms (unchanged). On BM 24. Waking every 3-4 hours for feeds. Took 134 cc/kg yesterday. Stable temperature in open crib. in daily.\n\nDoing well overall. Mature breathing control on monitoring. Improving feeds. Gaining weight well overall. be ready for discharge in next 2 days.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-17 00:00:00.000", "description": "Report", "row_id": 1792359, "text": "Neonatology Attending\n\nExam remarkable for well-appearing preterm infant with color, soft af, no gfr, clear breath sounds, 1/6 systolic murmur, flat soft n-t abdomen without hsm, nl perfusion, nl /activity.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-17 00:00:00.000", "description": "Report", "row_id": 1792360, "text": "Nursing Progress Note\nInfant given Synagis as ordered. Signed consent in chart.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-17 00:00:00.000", "description": "Report", "row_id": 1792361, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=min of 130cc/kg/day of BM24. Inf waking\nq4hrs thus far for PO feeds. feeds well. No spits.\nBelly soft, no loops. Voiding, . P cont to offer\nPO feeds as .\n4. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares. Sleeping well between cares. P cont\nto assess dev needs.\n5. O/A Mom in for visit and cares this AM.\nUpdate given. P plans to visit later today. Plan for\nD/C soon if cont all PO.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-18 00:00:00.000", "description": "Report", "row_id": 1792362, "text": "NPN NIGHTS\n\n\nFEN: Infant lost 20g. on min130cc/kg/d of BM24. Infant has\nnot been bottling well this shift, taking only 40cc at 2200\n(4 hrs since last bottling) after awaking on own to feed.\nInfant had very large spit while burping during bottling\nsession. Bottling session ended after this incident. Infant\ndid not wake for second feeding and was awoken at 0200, but\nonly took 35cc and was then too sleepy and began to \"gag\" on\n, which was barely in mouth at time, and arch back.\nInfant appeared sleepy; dstick checked and was 103. Infant\nput back to sleep. Noticed that infant only took 126cc/kg in\n24hrs, and will see if infant wakes naturally during rest of\nthe night shift to correct the intake. Voiding, QS\nwith soft abdomen. Small spit in crib following feeding in\naddition to large spit during first feed. P: cont to monitor\ntotal intake and make sure infant is taking in min\nrequirements.\n\nDev: Wakes for some feeds, not others. Enjoys being swaddled\nwith pacifier. Sleeps well. Criticaid placed on diaper area,\nalthough skin does not appear red or broken down.\n\nParenting: called once for update. Will be in\ntomorrow, did not specify when.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-18 00:00:00.000", "description": "Report", "row_id": 1792363, "text": "Neonatology Attending\n\nDOL 80 PMA 38 4/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 78/38 mean 52.\n\nOn min 130 ml/kg/d BM/E 24. Took 126 ml/kg yesterday. Voiding. . Wt 3310 grams (down 20).\n\nSynagis given yesterday.\n\nFamily visiting and up to date.\n\nA: Stable. No spells. Just meeting minimum po.\n\nP: Monitor\n Encourage pos\n Eye exam on Monday\n Home once feeding well with appropriate wt gain for a few days\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-05 00:00:00.000", "description": "Report", "row_id": 1792025, "text": "NPN\n\n\n#1 has cont to be in rm air, RR 40-60, LS clear and\nequal, color , mild IC/SC retractions, no AB's this\nshift. A: stable in rm air. P: no change.\n#3 Cont on 150cc/k/d TF. Presently receiving 20cc/k/d po of\nBM20, no spits or asp. IV PN & IL inf via PIC line at\n130cc/k/d. Abd soft, +BS, soft, no loops of distention. vdg\nqs, stool once. weight 1.025 up 40 grams. A: tol feeds well\nP: advance per team plan.\n#4 cont in servo , temp stable, calm with cares,\nsleeping well between. loved her binkey. A: AGA P: Cont to\nsupport development\n#5 mom and dad in to visit, mom had consult with\n , , both concerned about daughter. asking\nabout tol feeds. A: involved family P: cont to support and\ninform\n#6 cont on IV antibiotics as ordered, no S/S sepsis. A:\nstable P: cont meds as ordered.\n#7 remains sl jaundice, under phototherapy with eyes\ncovered, bili today 3.6/0.5 A: elevated bili P: ? dc\nphototherapy\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792095, "text": "NPN Addendum:\nPlease disregard above note-wrong patient\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792096, "text": "NPN Addendum:\nPlease disregard above note-wrong patient\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792097, "text": "NPN Addendum:\nPlease disregard above note-wrong patient\n" }, { "category": "Nursing/other", "chartdate": "2189-10-19 00:00:00.000", "description": "Report", "row_id": 1792098, "text": "NPN 1900-0700\n\n\nResp:Infant received in NC 100% 25-50cc. Bilateral breath\nsounds clear and equal with good aeration. Mild\nsubcostal/intercostal retractions noted. Respiratory rate\n30-70's.Continues on caffeine. No bradycardia or\ndesaturations overnight. O:Continue to assess and support\nrespiratory status.\n\nFEN:Infant's weight is 1275 grams up 30 grams. Total fluids\nat 150cc/kg/day of BM30+PM. Receiving 32cc gavage over one\nhour. Tolerating feeds well. No aspirates or spits noted.\nAbdomen benign, +bowel sounds. Voiding and stooling, guiac\nnegative stools. Continue to assess and support nutritional\nstatus.\n\nDEV:Infant maintaining temperatures, swaddled in an air\n. Awake and alert for care times, sleeping well\nbetween feeds. Appropriate for gestational age. Sucking well\non pacifier. Right eye continues to drain yellow/green\ndrainage. Ilotycin ordered by . P:Continue to assess and\nsupport growth and development. Monitor eye drainage.\n\nPAR:Dad in for 2100 feed. Took temperature and changed\ndiaper. Independent with cares. Very loving with baby.\nAsking appropriate questions. P:Continue to update and\nsupport .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-19 00:00:00.000", "description": "Report", "row_id": 1792099, "text": "Attending Note\nDay of life 20 PMA 30 \nin nasal cannula 50 cc of 100% FiO2 RR 30-70's\non caffeine\nno spells\nHr 150-170's BP 63/40 mean 52\nweight 1275 up 30 grams on 150 cc/kg/day of BM 30 cal/oz with promod pg voiding and stooling heme negative\non vit E and iron\nalert and active with cares\nyellow eye drainage getting erytho eye ointment\nevolving grade 2 with mild ventricularomegaly\n\nImp-stable making some progres\nwill continue eye ointment for 5 days total\nwill arrange HUS for the next few days\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-19 00:00:00.000", "description": "Report", "row_id": 1792100, "text": "Fellow PE Note\nGen- WD/WN F alert in NAD\nHEENT- NCAT, , nares patent with NC and NGT in place, oropharynx clear\nCardiac- RRR, nl s1,s2, no murmur appreciated\nLungs- CTAB, no retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nGU- nl female genitalia\nSkin- no lesions or rash\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-05 00:00:00.000", "description": "Report", "row_id": 1792173, "text": "Neonatology Attending Progress Note\nDOl #37\nPMA 32 4/7 weeks\nremains in RA, RR=30-70's, clear/equal\noccasional drifts at end of pg feeds\non caffeine\nno murmur, HR=150-170's, pale/\nBP 79/42 (mean=55)\nwt=1760g (inc 10g), TF=150cc/kg/d BM 28 with promod gavaged over 1 hour, no spits\n4 cc max aspirate\nvoiding, stooling--trace heme\nImp/Plan: premie infant tolerating pg feeds, benign abomdinal exam in setting of heme stool, remains stable\n--continue monitor weight\n--monitor abdominal exam\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-05 00:00:00.000", "description": "Report", "row_id": 1792174, "text": "NICU Fellow Note\nExam\nGeneral - comfortable appearing in \nHEENT - AFOS, NGT in place\nLungs - clear b/l with equal breath sounds\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended\nExtremities - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-11-24 00:00:00.000", "description": "Report", "row_id": 1792256, "text": "Nursing\n\n\n3. Feedings BM 26cal 150cc/kg/d fed po/pg. Awake and eager\nat 0900, bottled 40cc slowly and steadily. Mom in at 1300,\ninfant put to breast, latched on with help of lactation\nconsultant and nursed briefly. Fed remainder of feed by\ngavage, tolerated well without spits or aspirates. Voiding\nwell and stooled large once. A. Doing well. P. Offer\nBottle/breast when awake, gavage remainder.\n4. Temp stable in open crib. Awake and with cares.\nA. Appropriate. P. Support.\n5. Mom in at 1300, met with lactation consultant. Seems\npleased with infant's progress. A. Doing well. P.\nSupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-25 00:00:00.000", "description": "Report", "row_id": 1792257, "text": "NPN 1900-0700\n\n\n#3FEN: Weight 2625g, up 40. Tf remain at 150cc's/kg/d of\nBM26. 66cc's q 4 hours gavaged over 1 hour 20 minutes.\nInfant bottled 30cc's at 2100 care and was gavaged the\nremainder. Plan to bottle infant at 0500 care. Abdomen is\nsoft and round, +bowel sounds, no loops, min aspirates,\nmedium spit x1, voiding and stooling; heme negative. Infant\nremains on Fe and Vitamin E. A:Tolerating feeds well\nP:Continue to monitor for feeding intolerance. Encourage PO\nfeedings as tolerated.\n\n#4DEVE: Temp stable. Infant is swaddled in the OAC.\nWakes quietly for feedings. and active with cares.\nSettles well with binki. Sleeps well in between cares. MAE.\nFontanels are soft and flat. Brings hands to face. A:AGA\nP:Continue to support g/d of infant\n\n#5PARENTING: Both in to visit with infant for 2100\ncare. Independent with temp, diaper, and feeding. Very\nloving toward infant. Asking appropriate questions. Update\ngiven by RN at the bedside. A:Loving P:Continue to support\nand educate\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-25 00:00:00.000", "description": "Report", "row_id": 1792258, "text": "Neonatology Attending\n\nDay 57 PMA 35 wks\n\nRemains in RA. RR 30-60s. No bradycardia. Mild retractions. Pale, . Murmur persists. HR 130-150s. BP mean 53. Weight 2625 gms (+40). TF at 150 cc/kg/d- BM 26. Occasional large spits. Poor-fair po feeds- not taking full bottles. Benign abdomen. Passing heme negative stools. Minimal aspirates. Stable temperature in open crib.\n\nAdequate respiratory status. Continuing to monitor closely. Gaining weight well. Will decrease volume to 140 cc/kg/d. Encouraging po feeds. Adjusting iron dosing. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-28 00:00:00.000", "description": "Report", "row_id": 1792271, "text": "2300-0730\n\n\n3. FEN O: Abdomen soft, assessment benign. TF=\n140cc/kg/day. Infant taking 64cc BM 26 q 4 PO/NG\nalternating. No emesis, scant residuals. PO fed well x1,\ntaking 50cc. Drools with bottle feeding. Voiding and\nstooling with diaper changes. A: Stable, tolerating feeds\nP: Monitor for feeding intolerance. Advance feeds as\ntolerated. Encourage to PO or breastfeed when awake and\n.\n4. G&D O: is active and with cares. Wakes\nup for feeds. Temp wnl in open crib. No s/s pain or\ndiscomfort. A: Appropriate P: Monitor. Comfort\nmeasures.\n5. PARENTING O: No social contact thus far this shift P:\nSupport and update. Encourage to ask questions and voice\nconcerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-28 00:00:00.000", "description": "Report", "row_id": 1792272, "text": "Neonatology Attending Progress Note\n\nNow day of life 60, CA 6/7 weeks.\nIn RA with RR 30-60s.\nHR 150-170s BP 85/31 49\n\nWt. 2755gm up 40gm on po/pg feedings.\nNormal urine and stool output.\n\nEyes - ROP Stage I-II being followed closely - FU exam this week.\n\nAssessment/plan:\nVery nice progress overall - will plan on giving 2 month immunizations on with Pediarix.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-28 00:00:00.000", "description": "Report", "row_id": 1792273, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg/day of BM26. Inf OP feeding\n20-31cc thus far, remainder of feeds PG. Tol feeds well,\nmin asp, no spits. Belly soft, no loops. On vit E, Fe as\nordered. Voiding, stooling. P cont to offer PO feeds as\ntol.\n4. DEV O/A remains swaddled in an OAC with stable\ntemp. A/A with cares, waking for feeds. P cont to assess\nDEV needs.\n5. O/A Mom in for visit and cares. Updates\ngiven. Mom independent with care of infant. P support,\neducate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-28 00:00:00.000", "description": "Report", "row_id": 1792274, "text": " Physical Exam\nAwake and . . Breath sounds clear and equal bilaterally without retractions. No murmur, normal pulses. Abdomen soft and rounded with active BS, no HSM, or masses. Normal GU.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-29 00:00:00.000", "description": "Report", "row_id": 1792275, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, assessment benign. TF=140cc/kg/day.\nInfant taking 65 cc BM26 q4 PO/NG. No emesis, scant\naspirates. PO fed well, taking 30-45cc. Voiding and\nstooling with diaper changes. Wgt: 2.770k, ^ 15g A:\nStable feeder and grower P: Monitor for feeding\nintolerance. Advance feeds as tolerated. Encourage PO\nfeeds when awake and .\n4. G&D O: Active and with cares. Awakens for feeds.\nSucks pacifier eagerly. Temp wnl in open crib. No s/s pain\nor discomfort A: Appropriate P: Monitor. Comfort\nmeasures.\n5. PARENTING O: in to visit. Very independent\nwith giving care to . Held and fed infant. Well\nupdated with plan of care. A: Loving, concerned \nP: Support and update. Encourage to ask questions and voice\nconcerns.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-18 00:00:00.000", "description": "Report", "row_id": 1792364, "text": "NICU fellow note\nWell appearing infant sleeping in open crib.\nVSS.\nWt 3310 gm.\n, RRR.\nRRR, soft blowing murmur at LLSB, well perfused.\nCTA bilaterally, good air enry.\nSoft, NT/ND, no masses, active BS.\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792369, "text": "Nursing Progress Note:\n\nFEN:\nO: Infant receiving min 130cc/kg of BM/E 24, ad-lib (=72cc\nQ4H or =54cc Q3H). Infant cont to wake every 1/2 hours.\nTaking 50-60cc with each feed. Last 24hr total= 140cc/kg.\nInfant is well coordinated using her bottle; but tires\ntoward end of feed. No spits noted so far this shift.\nAbdominal exam benign. Infant voiding and passing heme\nnegative stool.\nA: Infant tolerating feeds well. Infant cont to reach\nminimal fluid requirements.\nP: Cont infant on current feeding plan. Cont to assess total\n24hr intake. Infant must maintain volume requirements for\nd/c.\n\nDEV:\nO: Infant temps stable; swaddled in an OAC. Font s/f. Infant\na/a with cares; waking for all feeds. within normal\nlimits. Infant reaches hands to face to comfort herself,\nshows strong head support. Enjoys her pacifier. Sleeps well\nbetween cares with boundaries.\nA: Appropriate behavior for gestational age.\nP: Pending d/c for Monday (). Infant will need carseat\ntest and hearing screen prior to d/c.\n\nSOC:\nO: Mom in this afternoon for cares. Updated regarding\ninfant's status and plan of care by RN. Some d/c teaching\ndiscussed by RN with mom. performs cares independantly.\nBottles infant well; responds appropriately to infant cues.\nCont to pump.\nA: Mom bonding well with infant. Family preparing at home\nfor infant d/c.\nP: Cont to support, educate and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792370, "text": "Nursing addendum: Examined infant and agreewith above note by Ms. , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792371, "text": "NICU Nursing Note 1500-2300\n\nFluid and Nutrition\nInfant's wt. tonoc 3360gms (+20). Total fluids\nmin.130cc/k/day; infant feeding Q3hrs. Bottles well using\nthe bottle system. Abdomen soft and nondistended,\nB.S.(+), no spits. Voiding q.s. no stool. Remains on iron\nand multivits. as ordered.\n\nDevelopment\nInfant awake and with cares. MAE, . Temp. stable\nin the crib with infant swaddled. All cares clustered.\n\nParenting\nInfant's in to visit. in\nproviding care. Infant's stated that they\nwould be back tomorrow morning to visit.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792372, "text": "NICU nursing note addendum 1500-2300\n\nInfant did stool this shift. Stool tested guiac negative.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-11 00:00:00.000", "description": "Report", "row_id": 1792056, "text": "1. remains in RA, color -palepink, RR40-70,\nclear, equal, ic/sc retractions, no bradys-on caffeine, some\ndesats related to positioning(face in bed). conntinue to\nmonitor closely.\n3. TF 160cc/k/d, feedings at 140/k of BM and D15 at 20/k\n(KO) through PICC line, plan to advance feedings to TF150\nand hep lock PICC at next cares. abd soft, no loops, active\nbowel sounds, minimal aspirates, no spits, voiding and\npassing guiac neg stool.\n4. temp stable in servo , nested in sheepskin with\nboundaries, active and alert with cares, tries to suck on\npacifier and fingers.\n5. Dad in for 1300 cares, independent with diaper changing\nand temp taking, said Mom has cold and flu. continue to\nupdate and offer support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792057, "text": "NPN\n#1\nReceived infant in RA--placed in N/C early in shift for\ndrifting sats to 80s. Infant has been in N/C 100%; 13-25cc\nwith sats mid/high 90s. BS clear= with mild retractions.\nMild tachypnea also noted with RR=50-70s. Infant has had ~3\nspells tonight-2 were desats to 40-50s;1 was with a brady\nand desat- all with apnea requiring mild stim and increased\nFIO2. Color is pale ; murmer not audible. Continues on\nCaffeine.\n\n#3\nInfant remains on TF=150cc/k of BM q4 hours via gavage.\nInfant has had a small spit x1; minimal aspirates. Abd is\nsoft and round; voiding and stooling (g-). PICC--HL'ed and\nflushed without difficulty. Wt is up 5 gms-1155.\n\n#4\nInfant remains in a heated nestled in sheepskin on\nservo. Infant was warm x1; otherwise temp has been stable.\nInfant is alert and fiesty with cares; sucks on her fingers.\nRight eye noted to have yellow drainage--warm soaks applied\nand with monitor.\n\n#5\n were in last evening. Assisted with temp and\ndiaper/ weighing. They did not hold because infant was\nhaving drifts in sats and had had a small spit on the scale.\nAlso, both have not been feeling great (minor cold\nsymptoms). Dad called x1 later to inquire if infant had had\nany further spells.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792058, "text": "PE: small preterm infant nestled in . , well perfused on NCO2. Comfortbale resp pattern. AFOF sutures approximated, eyes clewar, ng in place,MMMP\nChest is symmetric with equal clear bs\nCVL RRR,no murmur, pulses+2=\nAbd: soft, active bs, NTND cord healed.\nGU: immature female\nEXT: PICC posilflow intact, MAE, WWP\nNeuro: flexed posture with boundaries, symmetric tone and reflexes. appropiate for PMA.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792059, "text": "PE: small preterm infant nestled in . , well perfused on NCO2. Comfortbale resp pattern. AFOF sutures approximated, eyes clewar, ng in place,MMMP\nChest is symmetric with equal clear bs\nCVL RRR,no murmur, pulses+2=\nAbd: soft, active bs, NTND cord healed.\nGU: immature female\nEXT: PICC posilflow intact, MAE, WWP\nNeuro: flexed posture with boundaries, symmetric tone and reflexes. appropiate for PMA.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792060, "text": "PE: small preterm infant nestled in . , well perfused on NCO2. Comfortbale resp pattern. AFOF sutures approximated, eyes clewar, ng in place,MMMP\nChest is symmetric with equal clear bs\nCVL RRR,no murmur, pulses+2=\nAbd: soft, active bs, NTND cord healed.\nGU: immature female\nEXT: PICC posilflow intact, MAE, WWP\nNeuro: flexed posture with boundaries, symmetric tone and reflexes. appropiate for PMA.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792065, "text": "NPN 7p-7a\n\n\nResp: Infant remains in NC 02 100% fio2 13-25cc flow. Ic/Sc\nretractions noted. Brady x1 so far this shift. QSR. 2bradys\nin 24hrs. Conts on caffeiene. Ls clr/=. RR 30-70's. Cont to\nwean as tol. Cont to wean as tol.\n\nFen: Wt 1.180kg (+25gms). Conts on tf 150cc/kg of bm 20. Tol\npg feeds well gavaged over 60\". Abd soft. Active bs. No\nspits thus far. Ag stable 21cm. Trace stool. Voiding with\neach diaper change. Max aspirate 2.8cc thus far. Picc line\nheplocked. Await plan per team.\n\nDev: Temp stable in servo . Nested in sheepskin with\nboundries in place. Alert and active with cares. Sleeps well\nbetween. Dad kangarooed x75\" Infant tol well. Cont to\nsupport PKU sent. Cont to support developmental milestones.\n\nParenting: Dad in this evening. Independant with temp and\ndiaper. Updated at bedside. Held infant. Cont to support\ndevelopmental milestones.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792066, "text": "Neonatology - PRogress Note\n\nInfant is active with good tone. AFOF. He is , well perfused, no murmur auscultated. She is comfortable in NCO2. Breath sounds clear and equal. She is tolerating feeds, abd soft, active bowel sounds, voiding and stooling, heme tr pos. Hep locked PICC line in right leg intact Stable temp in . Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792067, "text": "Neonatology note\n\n14 d.o\non NC O2 at 13 ml, on caffeine, 11 spells yesterday.\nwt= 1180 gm + 25\n150 ml/kg/d with EBM 20, 1 large residual resolved.\nvoiding, stooling.\n\nA: ex 27 GA, AOP, anemia, resolving hyperbilirubinemia, PAD closed with indocin, evolving grade I.\nP: wean off Nc as tolerated, consider advcancing calorie tomorrow if no residual.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-28 00:00:00.000", "description": "Report", "row_id": 1792140, "text": "Nursing Progress Notes.\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal with mild retractions. Occasional sat drifts with\nfeeds when held. A: Doing well in room air. P: Continue to\nmonitor.\n#3 O: Total fluids 150cc/kg/day of BM30 with promod. Feeds\ngiven every 4 hours over 1 hour and 20 min. No spits, 1 x\n5cc milky aspirate. Abdomen soft, bowel sounds active, no\nloops, girth stable. A: Tolerating feeds well. P: continue\nwith current feeds.\n#4 O: Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares. A: Appropriate\nfor age. P: continue to support development.\n#5 O: Mother in to visit and care for baby this afternoon\nand plans to visit again this evening. A: Involved family.\n P: continue to keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-07 00:00:00.000", "description": "Report", "row_id": 1792311, "text": "NPN 1900-0700\n\n\nFEN: Learning to PO feed. Tolerating full enteral feeds\nwell, no spits, minimal aspirates. Abdomen soft/round, good\nbs, V&S. Continues on Iron & multivitamins.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Sucks on pacifier for comfort.\n\n: in for first cares. Updated by this RN, asking\nappropriate questions. Plans to visit with Mom for middle\ncares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-07 00:00:00.000", "description": "Report", "row_id": 1792312, "text": "Neonatology Attending\n\nDay 69 PMA 37 wks\n\nRemains in RA. RR 40-60s. No murmur. HR 140-160s. BP mean 67. Pale, . Weight 3035 gms (+40). TF at 140 cc/kg/d- BM24 with Enfamil powder. Alternating po/pg feeds. Benign abdomen. Stable temperature in open crib.\n\nDoing well overall. Will continue to monitor closely. Gaining weight well. Improving po feeds.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-07 00:00:00.000", "description": "Report", "row_id": 1792313, "text": "NICU fellow note\nWell appearing premature infant in NAD\nVSS\nWt 3035 gm\nSKIN: clear\nHEENT: , MMM, NG tube in place.\nCV: RRR, no murmur, well perfused.\nRESP: CTA bilaterally, good air entry.\nABD: Soft,NT/ND, no masses, active BS.\nNEURO: appropriate \n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-07 00:00:00.000", "description": "Report", "row_id": 1792314, "text": "NURSING PROGRESS NOTE\n\n\n3 - FEN - TF=140CC/K OF BM24. PT ALL FEEDS, ALT PO/PG\nFEEDS. SM SPIT X1, MIN ASPIRATES. ABD SOFT, +BS. PT ,\n\n\n4 - DEV - TEMP STABLE IN OAC. W/ CARES. SUCKING ON\nPACIFIER. \n\n5 - PARENT - MOM IN TO VISIT, ASSISTING W/ CARES. ASKNG\n QUESTIONS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-08 00:00:00.000", "description": "Report", "row_id": 1792315, "text": "NPN 1900-0700\n\n\nFEN: CW 3015g (down 20g). TF 140cc/k/day. Pt alt PO/PG\nwith BM 24. Infant bottled 40cc at 2100 with . Eager to\nbottle, yet tires easily. Pt was gavaged at 0100. Abd\nbenign. Voiding/ QS.\n\n\nDEV: Maintaining temps while swaddled in OAC. A/a with\ncares, sleeps well btwn. Wakes occ for feeds. Loves\npacifier, moves hands to face. , , AGA.\n\nPAR: in to visit at 2100. Updated at bedside by\nthis RN. Asking questions. with cares.\nContinue to support and update as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-04 00:00:00.000", "description": "Report", "row_id": 1792022, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:RECEIVED BABY IN NC 13CC 100% WITH SATS >94%. AFTER\nFINDING BABY MULTIPLE TIMES WITH GOOD SATS AND NC OUT OF\nNARES--BEGAN TRIAL OF RA AT 0100. BS CLEAR. RESP RATE 40-66\nWITH IC/SC RETRACTIONS, RESP RATE 80'S WITH TEMP 99.4.\nA:STABLE\nP:FOLLOW WOB AND SATS CLOSELY IN RA WITH LOW TOLERANCE TO\nRESUME NC\n\n#3F/E/N\nO:TF AT 130CC/KG. RECEIVING D12.5PN AND IL VIA PICC AT\n120CC/KG AND TROPHIC FEEDS 10CC/KG BM2CC Q4HR GAVAGE.\nABDOMEN SOFT, FULL WITH INTERMITTENT SOFT LOOPS. NO SPITS\nAND <1CC ASPIRATES. VOIDING SMALL AMTS, NO STOOL THUS FAR.\nWT DOWN 70GM. ASPIRATES BILIOUS COLORED W/BENIGN ABDOMEN--MD\nNOTIFIED AND ORDER TO CONTINUE FEEDING.\nA:TOLERATING TROPHIC FEEDS WITH SCANT BILIOUS ASPIRATES\nP:CONTINUE TO MONITOR ABD ASSESSMENT CLOSELY, FOLLOW WT AND\nU/O\n\n#4G&D\nO:IN SERVO CONTROL WITH STABLE TEMPERATURE.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. NESTED ON\nSHEEPSKIN W/BOUNDARIES. TOLERATED KC WITH MOM\n~2HR--REQUIRING WARMING LIGHTS FOR SHORT TIME. FONTANEL SOFT\nAND FLAT; SUTURES OVERRIDING. EYES REMAIN FUSED\nA:AGA\nP:CONTINEU TO MONITOR AND SUPPORT\n\n#5PARENTING\nO:MOM AND DAD IN FOR 2100 CARES. INDEPENDENT WITH TEMP AND\nDIAPER CHANGE. MOM HELD BABY X2HR. ASKING APPROPRIATE\nQUESTIONS AND UPDATED BY RN. MOM HAVING LOW MILK\nSUPPLY--GIVEN SUGGESTIONS AND TOLD TO SPEAK WITH LC OVER\nNEXT COUPLE DAYS IF SUPPLY DOES NOT PICK UP\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#6ID\nO:REMAINS ON AMP/GENT AS ORDERED. SUNDAY DAY . TEMP\nSTABLE\nA:DAY ANTIBIOTICS FOR SHIFTED CBC\nP:NEEDS LP, ?RECHECK CBC, CONTINUE ANTIBIOTICS AND FOLLOW\nCULTURE FOR GROWHT\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-04 00:00:00.000", "description": "Report", "row_id": 1792023, "text": "Neonatology\nDOL #5, CGA 28 wks.\n\nCVR: Weaned to RA overnight, currently in RA. No spells, on caffeine. Hemodynamically stable, no murmur. BP 62/38 (46).\n\nFEN: Wt 985, down 70 grams. BW 1230. TF 130 cc/kg/day, PN. Enteral feeds BM 20 at 10 cc/kg/day, started yesterday. Bilious aspirate x 1 noted, KUB normal. Voiding, no stool. Dstik 90.\n\nGI: On single phototherapy. Bili yesterday 5.5/0.5.\n\nID: On amp/gent day for presumed sepsis.\n\nNEURO: First HUS with bilateral GI IVH.\n\nDEV: In .\n\nPE: comfortable, not in distress. Skin warm, , mildly jaundiced. Fontanelles soft and flat, not shrunken. Chest clear, mild retractions. Cardiac RRR, no m. Abdomen soft, no HSM, active bs, no palpated loops. Femoral pulses 2+. Tone and activity appropriate.\n\nIMP: Former 27+ wk infant with RDS, hx of PDA, presumed sepsis, overall stable. Weaned from CPAP to RA overnight. Aspirate noted yesterday, but KUB reassuring and tolerated trophic feeds overnight. Significant weight loss from birth notable, although infant was initially somewhat edematous. GI IVH on first HUS, needs to be followed.\n\nPLANS:\n- Monitor resp status of CPAP.\n- Increase TF to 150 cc/kg/day.\n- Advance enteral feeds to 20 cc/kg/day, monitor tolerance.\n- Continue PN.\n- Continue phototherapy.\n- Lytes and bili tomorrow.\n- Continue abx.\n- LP today.\n- Repeat HUS 1 week from last.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-03 00:00:00.000", "description": "Report", "row_id": 1792163, "text": "NPN 1900-0700\n\n\nFEN: CW 1690g (^45g). TF 150cc/k/d of BM30 w/pm (42cc q4hr\npg 60min). Abdomen soft with active bowel sounds. No loops,\nNo spits, min aspirates, girth stable. Voiding w/each diaper\nchange. Sm heme neg stool thus far this shift. A: Tolerating\ncurrent feeding regimen. P:Continue per nutritional plan.\n\nDEV: Infant remains swaddled in an off . Temps\nstable. and active with cares, settles well inbetween.\nBrings hands to face for comfort, enjoys pacifier. , \nA: AGA P: Continue to support development.\n\n: No contact from thus far, both were in on\neves. Will update if call/visit.\n\nA's/B's: No apnea, bradys or desats thus far this shift.\nContinues on Caffeine.P: Continue to monitor for\na's/b's/d's.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-03 00:00:00.000", "description": "Report", "row_id": 1792164, "text": "Neonatology Attending Progress NOte:\nDOl #35\n32 2/7 weeks PMA\nwt=1690g (in 45), no murmur heard today. HR=140-170\nBP 74/40 (mean=45),\nremains on RA, RR=40-60\nno spells, on caffeine\nTF=150cc/kg/d\nBM 30 with promod\npg feeds\nvoiding, stools heme negative\non iron and vitamin E\noff \nImp/Plan: premie infant with intermittent murmur, AOP-mild, on caffeine, tolerating full feeds, doing well.\n--monitor spells, continue caffeine\n--monitor weight on current regimen\n--I spoke with family on Sunday, all questions answered.\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-03 00:00:00.000", "description": "Report", "row_id": 1792165, "text": "NICU Fellow Note\nExam:\nGeneral - NAD, in \nHEENT - AFOS, MMM, NGT in place\nLungs- CTA b/l with equal breath sounds\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended\nExt - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-11-03 00:00:00.000", "description": "Report", "row_id": 1792166, "text": "Nursing Progress Note\n\n8 Apnea and bradycardia\n\n3. FEN O/A TF=150cc/kg/day of BM30w/PM. All feeds PG\nover 1 hour. Tol well. No spits, min asp. Belly soft, no\nloops. Voiding, stooling. On Vit E, Fe. P cont to assess\nFEN needs.\n4. DEV O/A remains in an off swaddled.\nTemp stable. A/A with cares, sleeping well between cares.\nP cont to assess dev needs.\n5. O/A Mom in for visit and cares. Independent\nwith care of infant. Updates given. P support, educate.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 8 Apnea and bradycardia; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-04 00:00:00.000", "description": "Report", "row_id": 1792167, "text": "Nursing Progress Note\n\n\n3.O: Weight 1750gms up 60gms. On BM30cal with promod, 42cc's\nover 1 hour. gavaged and tolerated weoo. Total fluids at\n150cc/kg/d. Abdomen round, but soft, positive bowel sounds.\nVoiding and stooling. AG 24cm.\n A: Continues to gain weight. tolerating feeds.\n P: Continue with same plan. Monitor.\n4.O: In an with temp off. Infant swaddled with\nblanket over her. Active and for cares. Fontanels\nopen, soft and flat. Sucking on a pacifier intermittently.\n A: Gestationally appropriate.\n P: Continue with interventions. Monitor.\n5.O: No contact this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-04 00:00:00.000", "description": "Report", "row_id": 1792168, "text": "Neonatology Attenidng Progress Note:\nDOL #36\nPMA 32 3/7 weeks\nremains in RA, RR=40-60's, mild sc retx, no spells, on caffeine\nno murmur, well perfused.\nHR=150-160's, BP 80/37 mean =52\n1750g (inc 60g), TF=150cc/kg/d BM 30 with promod, all gavage over 1 hour--no aspirates, no spits\nImp/Plan: premie infant tolerating full feeds\n--continue current feeding regimen, monitor weight\n--continue rest of present management\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-25 00:00:00.000", "description": "Report", "row_id": 1792259, "text": "Nursing\n\n\n3. Feedings BM26 cal decreased to 140cc/kg/d as infant has\nhad good growth. Awake this AM so tried with bottle, infant\ntook only 10cc, seemed disinterested. Abdomen full and\nsoft, good bowel sounds. Voiding and stooling well. A.\nNot too interested in bottle. P. Decrease volume to\n140cc/kg per plan.\n4. Temp stable in open air crib. Awakens for feeds. Awake\nintermittently between feeds. and active. A. Not\nsleeping as well today. P. Support.\n5. Mom will be in at 1PM as usual. A. Loving involved\n. P. Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-15 00:00:00.000", "description": "Report", "row_id": 1792347, "text": "npn 1900-0700\n\n\n3: fen\ncurrent weight 3295gms up 35gms. total fluids remain at\n140cc/kilo/day of bm24/e 24. bm mixed with enfamil powder.\ninfant feeding q 3 hours. infant waking for some cares.\ninfant taking about half of feedings po this shift. infant\ntiring with feeds. infant abd exam benign. abd soft with no\nloops. voiding and . stool hem neg. no spits.\nminimal aspirates. continues on iron and a multivitamin.\ncontinue with current feeding plan.\n\n4: dev\ntemps stable in an oac. and active with cares. sleeps\nwell inbetween. brings hands to face. waking for some cares.\n\nsucks on pacifier. aga. continue to monitor for\ndevelopmental milestones.\n\n5: Parenting\nmom and in for care. very and involved\nfamily asking appropriate questions. updated by this rn.\nindependent with cares. continue to support family needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-15 00:00:00.000", "description": "Report", "row_id": 1792348, "text": "Neonatology Attending\n\nDay 77 PMA 38 wks\n\nRemains in RA. RR 30-50s. No murmur. Weight 3295 gms (+35). TF at 140 cc/kg/d- BM/E 24. Taking majority of volume po but requiring gavage supplementation. Stable temperature in open crib.\n\nDoing well overall. Awaiting more mature feeding. Tolerating feeds well. Monitoring.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-15 00:00:00.000", "description": "Report", "row_id": 1792349, "text": "NICU fellow note\nWell appearing premature infant in NAD\nVSS\nWt 2175 gm\n, MMM.\nRRR, no murmur, well perfused.\nCTA bilaterally, good air entry.\nSoft, NT/ND, no masses, active BS.\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-15 00:00:00.000", "description": "Report", "row_id": 1792350, "text": "FEN O/A: 140cc/kilo/day BM24 with enfamil powder. 58cc Q3\nhours PO/PG. Bottled 27, 35 and 58cc thus far this shift\nwith bottle. Abdomen is soft, , and round with no\nloops and +BS. Min aspirate. 1 large spit during 1500 feed.\nVoiding, . P: Continue to monitor and encourage PO\nfeeds.\n\nG&D O/A: Swaddled in open air crib. Temps stable. and\nactive with cares, settles well between cares. Sucks on\npacifier. P: Continue to monitor.\n\n O/A: Mom and friend in for 1200 care. Mom\nbottled infant and held. Stated that she plans to return\nwith for 2100 feed. Asked appropriate questions and\nacted lovingly towards infant. P: Continue to encourage and\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-15 00:00:00.000", "description": "Report", "row_id": 1792351, "text": "Nursing NICU Addendum Note\n\n\nI have examined this patient. I read the above note written\nby PCA and I agree with the information as\nstated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-05 00:00:00.000", "description": "Report", "row_id": 1792028, "text": "NPN 0700-1900\n\n\n1. Resp: Breathing comfortably. In RA >36hrs. RR 50-60.\nLungs clear/ equal. O2 sats 96-100%. Cont. w/ IC/SC retrx.\nCOntinues on Caffeine. , sl.ruddy, well perfused. P:\nContinue to monitor respiratory status.\n\n3. FEN: TF 150cc/kg/day. BM/PE 20(Scant BM supply) Enteral\nfeeds at 30cc/kg/day =6cc Q4hrs by NG tube. Central PICC\nline IVF D12.5 at 120cc/kg/day =5.4cc/hr. IL at 0.8cc/hr.\nIncr. 10cc/kg/day . Tolerating feeds well. Active BS.\nVoiding qs. No stool this shift. Girth stable. DS stable.\nLytes drawn this am and CO2 low, Na Bicarb x1 given as\nordered. P; Continue to assess tolerance to feeds.\n\n4. G&D: Infant remains in servo . Temps stable\nnested on sheepskin. Active w/ cares, but not waking on own.\nEyes remain fused. Sleeps well bwtn cares. AFSF. MAE. ABle\nto suck on binki when offered. F/U HUS to be done .\nP: Cont. to promote optimal G&D.\n\n5. Parenting: in this afternoon to visit, updated at\nbedside by this RN re: status and spoke w/ Dr. and \nbriefly on way out. very loving and concerned about\n. Asking appropriate q's re: BF/feeding plan; LP/Abx.\n reassured and informed that LP is scheduled to be\ndone today. P: Continue to update and support .\n\n6. ID: Infant now Day of Amp/Gent. course. BC (-). LP to\nbe done this afternoon by . Infant afebrile, acting\nappropriately, no s/s of sepsis. P: Cont. w/ Abx as ordered.\n\n7. Hyperbili: Infant recieved under single phototherapy this\nam w/ eye shields in place. Bili 3.1/0.5 . Lights DC'd at\nnoon today. Rebound bili to be drawn am. P: Continue to\nmonitor for hyperbilirubinemia.\n\nsee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-18 00:00:00.000", "description": "Report", "row_id": 1792365, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=min of 130cc/kg/day of BM24 or E24. Inf\nwaking q2-4 hrs taking 40-50cc thus far. 1 lg spit. Belly\nsoft, no loops. Voiding, . P cont to monitor inf\nPO intake, may need NGT replaced if unable to reach PO min.\n4. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares. Likes pacifier. P cont to assess\ndev needs.\n5. O/A Mom called this AM, in for afternoon\nvisit and cares. Updates given to both . \neagerly participating in care of infant. P support,\neducate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792366, "text": "NPN\n\n\n3. FEN: WT 3.340kg, up 30gr. TF at min 130cc/kg of BM 24,\nwaking q3hrs taking 60cc qfeed. Eagerly eating using \nbottles, taking 30 min to eat, difficult to burp, needs a\nrest period after 30 cc. Took in 140cc/kg/day as of MN,\nkeeping up with intake this shift. Abd soft, occasional\nsmall spits, voiding, trace stool x1.Desitin to buttocks\nprn, area without breakdown, slightly red.\nA/P; Meeting min intake requirement, starting to gain wt,\ncont to monitor intake closely, may still need NGT if she\ndoes not meet requirement and wt drops.\n\n4. Dev: Vigorous ingant, waking q3hrs overnight, eager to\neat. Sleeps in between cares, swaddled, temps WNL in crib.\nA/P: AGA premie, cont to support developmental needs.\n\n5. Parenting: in this eve for cares. Independent\nwith infant, weighing, diapering, feeding. Helped mom to\ndraw up multivits. Eager to learn care.\nA/P; Updated , cont to support, D/C target date is\nfor Monday as long as she meets her D/C criteria of gaining\nwt, consistently taking above her min, eye exam is also on\nMonday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792367, "text": "Attending Note\nDay of life 81 PMA 38 \nin room air RR 30-60 no spells\nno murmur HR 140-160's\nweight 3340 up 30 gram on min 130 cc/kg/day took in 140 cc/kg/day of BM 24 or PE 24 cal/oz\non mtv and iron\nin a crib with a stable temp\nwill have a recheck of eyes on Monday\n\nImp-stable making progress\nwill have eye exam on Monday\nwill have a car seat test and hearing screen\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-19 00:00:00.000", "description": "Report", "row_id": 1792368, "text": "Attending Note\nPhysical Exam\ngen active well appearing in no distress\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft active bowel sounds no masses or distention\nExt warm well perfused brisk cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-10-28 00:00:00.000", "description": "Report", "row_id": 1792136, "text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. RR 40-60's, O2 sat >93%. Lungs\nare clear and equal with mild scr noted. No apnea, bradys or\ndesats thus far this shift. Continues on caffeine. A: stable\nin Ra.P:Continue to monitor resp status.\n\nFEN: CW 1480 (- 15g). TF 150cc/k/d of BM30 w/pm (37cc q 4hr\npg 1hr 1min). Abdomen soft with active bowel sounds. No\nloops, Sm-med spits, girth stable, min aspirates. Voiding\nw/each diaper change, stool x's 2 (heme neg). Continues on\nvit E and FE. A: Tolerating current feeding regimen P:\nContinue per nutritional plans. Nutritional labs needed on\n.\n\nDEV: Infant remains swaddled in an oac. Temps stable. Alert\nand active with cares. Settles well in between cares. Not\nwaking for feeds. Brings hands to face for comfort. Not yet\ninterested in pacifier. , . Minimal clear R eye\ndrainaged, cleansed w/warm H20. A: AGA P: Continue to\nsupport development.\n\n: Mom and dad in for the 2100 care. Both very excited\nto see infant in an oac. Both independent with cares,\nassisted w/weighing. Asking appropriate questions. Mom held\nbaby. Stated mom will be in for the 1300 care. A: Involved,\nloving, appropriately concerned. P: Continue to\nupdate,support, educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-28 00:00:00.000", "description": "Report", "row_id": 1792137, "text": "NICU Fellow Note\nExam\nGeneral - NAD in crib\nHEENT - AFOS, NGT in place, MMM\nLungs - CTA b/l with equal breath sounds\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended, no organomegaly\nExtremities - WWP, nl cap refill, nl pulses\n" }, { "category": "Nursing/other", "chartdate": "2189-10-28 00:00:00.000", "description": "Report", "row_id": 1792138, "text": "Neonatology Attending Progress Note:\nDOL #29\n31 3/7 weeks\nremains in RA, RR=40-60's\non caffeine, no spells, HR=140-170's, intermittent murmur\n84/40 (mean=56), wt=1480g ( 15g), TF=150cc/kg/d BM 30 with promod over 1 hour 10 minutes\nsmall aspirates, voiding, stools heme negative\niron vitamin E\nImp/Plan: premie infant with AOP, maximal calories, remains stable.\n--labs tomorrow\n--HUS tomorrow\n--monitor weight on current calories\n--monitor oxygen sat off oxygen\n--monitor for spells\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-10-28 00:00:00.000", "description": "Report", "row_id": 1792139, "text": "Clinical Nutrition:\nO:\n~31 week CGA BG on DOL 29.\nWT: 1480g(-15)(~50th %ile); BWT: 1230g. Average wt gain over past week ~13g/kg/day.\nHC: 29cm(~50th %ile); last: 26.5cm\nLN: 39.75cm(20-50 %ile); last: 40.5cm\nMeds include Fe & Vit.E\nLabs due this week.\nNutrition: 150cc/kg/day as BM 30 w/ promod; pg over 70mins. Average of past 3-day intake ~133cc/kg/day, providing ~133kcals/kg/day & ~3.5g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; pg fed. Labs due this week. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is not meeting recs of ~15-20g/kg/day for WT gain & of ~1cm/wk for LN gain; TF based on 3-day average did not amount to TF allowed/day, ?reason; please monitor & record all po intake. HC gain is exceeding recs of ~0.5-1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-29 00:00:00.000", "description": "Report", "row_id": 1792141, "text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA, breathing 30-70s, LS c/=, mild\nSC retractions. O2 sats >91%. No spells/desats thus far\nthis shift. Pt is on caffeine. Cont to monitor.\n\nFEN: CW 1515g (up 35g). TF 150cc/k/day with BM30 with PM.\nPt tolerating PG feeds well over 90min for hx spits. No\nspits thus far this shift. Max asp 4cc; benign, refed. ABd\nsoft, round, no loops, active BS. AG= 22cm. Voiding QS,\nstooling heme negative. Nutrition labs drawn at 0130;\nresults pending.\n\nDEV: Maintaining temps while swaddled in OAC. A/a with\ncares, sleeps well in btwn. Likes pacifier, sucks on\nfingers. , , AGA. Yellow drainage noted R eye.\nWarm H20 soak applied.\n\nPAR: in to visit at 2100. Updated at bedside by\nthis RN. Asking approp questions. Independant with cares.\nMom held infant x 1hr; tol well. Seemed pleased that infant\nhad no drifts/desats while being held and feeding. Continue\nto support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-29 00:00:00.000", "description": "Report", "row_id": 1792142, "text": "Neonatology Attending Progress Note:\nDOL #30, PMA 31 4/7 weeks\nremains in RA\nwt=1515g (inc 35g)\nintermittent murmur, HR=160-170's,\n70/46 (mean=56)\nno spells, on caffeine, TF=150cc/kg/d\nBM 30 with promod, no spits\nvoiding, stool heme negative\nCa=11.1, AlkP=532, P=6.7\niron, vitamin E\nHUS with asymmetry left > right, ritght germinal matrix, ventricles not enlarged\ntemp low and placed back in \nPE; well appearing, , normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused. tone aga.\nImp/plan: premie infant with intermittent murmur, AOP-on caffeine, F and G, doing well\n--will speak with nutritionist re; changing formula\n--monitor for spells\n--monitor for murmur\n--I updated family over phone re: all above\n" }, { "category": "Nursing/other", "chartdate": "2189-11-16 00:00:00.000", "description": "Report", "row_id": 1792219, "text": "Nursing Progress Note 1900-0700\n\n\nF/N:Infant cont's on TF 150cc's/kg/day rec.BM28 with Promode\n57cc's gavaged over 1 hr.Infant attempted to bottle and took\n15cc's with a yellow nipple the remainder gavaged.Abd. soft\nwith pos bs,no loops or spits,minimal\naspirates.Girth=26-26.5.Voiding and stooling heme\nnegative.Weight=2.290 up 85 grams.A:Adequate Weight\nGain.Tolerating Feeds Well.P:Cont. to assess tolerance of\nfeeds and monitor weight gain.\n\nDEV:AF soft and flat. and active with cares.Sleeping\nwell b/t cares.MAE.Bringing hands to face and mouth and\nintermitently sucking on pacifier.Infant presently swaddled\nwith nested boundaries.Temp. stable in off\n.A:Appropriate for GA P:Cont. to support growth and\ndev.\n\nParenting: in tonight very independent with cares.Dad\nbottled infant for the first time reviewed cues of color and\nA's and B's.Asking appropriate questions.Cont. very loving\nand invested.A/P:Cont. to update,support,and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-16 00:00:00.000", "description": "Report", "row_id": 1792220, "text": "Neonatology Attending Progress Note:\nDOL #48\n34 1/7 weeks\nremains in RA, RR=40-60's, intermittent murmur\n, HR=150-170's, BP mean=50\n2290g (inc 85g), TF-150cc/kg/d BM 28 with promod, tolerating gavage feeds over 1 hour\ntook one bottle 15 cc overnight\nvoiding, stooling\noff \nImp/Plan: premie infant learning to po feed, murmur--asymptomatic, stable.\n--ophtho exam today\n--encourage po feeds, monitor weight\n--monitor murmur\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-10-17 00:00:00.000", "description": "Report", "row_id": 1792088, "text": "NPN DAYS\n\n\n1. Remains in NCO2 100% at 13-25cc. LS clear. RR 30-70's. On\ncaffeine, no spells. Stable in O2. Wean O2 as needed.\n\n3. TF remains at 150cc/kg. Calories to be advanced to BM28\nwith PM. Gavaged over 60 min. No spits. Abd benign. Voiding\nand stooling(heme-). Tol feeds.\n\n4. mode switched to air mode. T-shirt placed on\n and swaddled with blanket-temp stable. Active and\nalert with cares. AGA.\n\n5. in for afternoon cares with sibling. Updated,\nasking appropriate questions. Independent with cares. Will\nbe in later this eve to kangaroo. Loving family.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-17 00:00:00.000", "description": "Report", "row_id": 1792089, "text": "NEonatology- Progress Note\n\nPE: remains in her , swaddled, in nasal cannula O2, bbs cl=, rrr s1s n2o murmur, abd soft, nontender, gavage in place, V&S, afso, pale, , well perfused\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792090, "text": "PCA Note 2300-0700\n\n\nRESP: Remains on NC 100% FiO2, 13-25cc flow. Breathing\ncomfortably 30s-60s, sats 92-96%. Lung sounds clear/=\nbilaterally with mild IC/SCR noted. No spells so far this\nshift, however noted to have QSR drifting to 80s during\nfeedings.\n\nFEN: Passed birth weight tonight, weight 1.245kg (+10g). TF\n150cc/kg/day = 31cc Q4 of BM28 with promod. Tolerating full\nPG feedings (over 1 hour) well with no spits and minimal\naspirates. Abdomen soft/round, good BS, girth stable at\n22cm, no loops. Voiding and stooling (heme negative).\nContinues on Vit E and iron as ordered.\n\nDEV: Temps stable while swaddled on sheepskin in air-mode\n. Not yet waking for feedings. Alert and active with\ncares and sleeps well in between. Reaches hands to face for\ncomfort. Loves pacifier.\n\nPARENTING: in at beginning of shift, both very\nloving and asking appropriate questions. Mom held baby.\nUpdates given at bedside.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792091, "text": "NPN 2300-0700\nI have examined this infant and agree w/the assessment and plan of care as outlined by ,PCA. Infant noted to have lg amt of yellowish-green eye drainage from R eye, warm soak applied. Mom called this AM for update, spoke w/this RN. Plans to visit for 1300 care today.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792092, "text": "Neonatology\nDOing well. REmains in low flow NCO2. Comfortable appearing\nNo murmur.\n\nWT 1245 up 10 Tolerating feeds at 150 cc/k/d of 28 cal. Will increase to 30 cals and monitor tolerance.. Abdomen benign.\n\nRight eye with some drainage. Conjunctiva clear. No evidence of infection.\n\nContinue a sat present.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792093, "text": "NPN DAYS\n\n\n1. Remains in NCO2 13-50cc. LS clear. Mild retractions. RR\n30-60's. On caffeine, no spells. Monitor.\n\n3. TF at 150cc/kg. Calories to be advanced to BM30 with PM.\nGavaged over 60min. No spits. No residuals. Abd benign.\nVoiding and stooling(heme-). Tol feeds.\n\n4. Temp stable in air . Alert and active with cares.\nNested with sheepsking . AGA.\n\n5. in for afternoon cares. Updated, asking\napprpriate questions. Independent with cares. Mother held\n well. Loving family. Father to be in later this\neve.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-18 00:00:00.000", "description": "Report", "row_id": 1792094, "text": "NPN Addendum:\nFamily mtg scheduled for 2pm tomorrow. Team and aware. Mother aware through family member acting as interpretor. Interpreter services need to be contact tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-23 00:00:00.000", "description": "Report", "row_id": 1792250, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM26. Inf PO feeding as\ntol. Mom attempted to BF today, Mom had difficult time\ngetting to latch as Mom had large nipples and \nhas sm mouth. Lact consult scheduled for tomorrow at 1300\nfeed. Tol feeds well, no spits, min asp. Belly soft, no\nloops. Voiding, stooling. P cont to assess FEN needs.\n4. DEV O/ remains swaddled in an OAC with stable\ntemp. A/A with cares. Sleeping well between cares. Eye\nexam today, no change. F/U next week. P cont to assess dev\nneeds.\n5. O/A Mom in for visit and cares. Updates given.\n Mom w/ BF attempts, lact consult tomorrow. Mom\nanxious re: eye exam, Dr. spoke with Mom. P support,\neducate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-24 00:00:00.000", "description": "Report", "row_id": 1792251, "text": "NPN 07p-07a\n\n\nFEN\nCurrent weight 2585g (no change), TF 150cc/kg/day, BM26\n(PG/PO). Bottling approx. 25cc when offered, tiring\nthereafter. Coordinated suck/swallow. One small spit this\nshift thus far. Min. residuals. BS active. Abd. soft, round.\nNo loops noted. Voiding, no stool this shift thus far. Cont.\nmonitor PO/PG feeding tolerance & weight.\nG&D\nIn OAC, temps stable. & active with cares. Resting\ncomfortably inbetween. Waking for some feeds. Fontanels\nsoft, flat. MAEs equally. PPP x4ext. Cont. monitor growth &\ndevelopm. patterns.\n\nIn in pm. Loving and caring. Independent with . Asking\nappropriate questions. Cont. support & educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-24 00:00:00.000", "description": "Report", "row_id": 1792252, "text": "Neonatology Attending\n\nDay 56 PMA 35 wks\n\nRemains in RA. Clear breath sounds. RR 40-70s. No bradycardia. No murmur. HR 140-170s. BP mean 57. Weight 2585 gms (unchanged). TF at 150 cc/kg/d- BM 26- po/pg. Taking about half volume. Minimal aspirates. Occasional spits. Stable temperature. Eye exam essentially unchanged. Family up to date.\n\nDoing well overall. Feeding and gaining weight well. Encouraging po feeding. No changes for now.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-24 00:00:00.000", "description": "Report", "row_id": 1792253, "text": "Gave mother the Reglan information sheet.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-24 00:00:00.000", "description": "Report", "row_id": 1792254, "text": "Lactation Consult 1345\nMet w/ mother today to assess infant's latch and milk transfer. Infant awake and slightly drowsy; she had bottle fed and gavaged at 9am feeding. Mom reports \"just keeping up\" w/ infant's milk demand. Encouraged 8 pumps per day, mothers milk tea and possibly Reglan to increase supply if necessary. Mom's plan at home is to offer the infant a bottle 1-2X per day for father's involvement. Infant demonstrated a latch but was very sleepy during 10 min session. Some jaw mvmt. seen but no audible swallows. Encouraged kangaroo care and breast feeding 1-2X per day as infant tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-24 00:00:00.000", "description": "Report", "row_id": 1792255, "text": "Daily PE\nGeneral: Well appearing, in NAD\nSkin: Cleasr, no leasons\nHEENT: AFOFs, MMM\nCV: RRR, no ,urmur.\nResp: CTA bilaterally, good air entry.\nAbdomen: Soft NT/ND, no HSM, good BS\nGU: normal female.\nNeuro: appropriate for age\n" }, { "category": "Nursing/other", "chartdate": "2189-10-05 00:00:00.000", "description": "Report", "row_id": 1792026, "text": "Neonatology note\n\n6 d.o\nin RA since yesterday, on caffeine, no spell.\nbili= 3.6 last night, under phototherapy\nwt= 1025 gm + 40\n150 ml/kg/d with feeding at 20 ml/kg/d with EBM 20\nvoiding, stooling.\n\nAFOF, mild jaundice, \nnormal tone for preemie.\nRR with no murmur\nLung clear, mild retraction\nabdomen soft good bowel sounds, no mass palpable.\nnormal external female genitalia.\n\nA: ex 27 wks GA, RDS, PDA s/p indocin, hyperbilirubinemia, AOP, grade I IVH, presumed sepsis\nP: continue advancing feeding, f/u bilirubin, continue antibiotics for 7 days course, need LP.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-16 00:00:00.000", "description": "Report", "row_id": 1792352, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, assessment benign. TF=\n140cc/kg/day. Infnat taking 58cc BM24/SSC 24 q3 per NG/PO.\nInfant taking 50-58cc PO so far tonight. No emesis or\naspirates. Voiding and with diaper changes. Wgt:\n3.330k, ^ 35g A: Stable, tolerating feeds. Improved PO\nintake tonight.\n4. G&D O: is active and with cares. Sucks\npacifier eagerly. Temp wnl in open crib. No s/s pain or\ndiscomfort A: Appropriate P: Monitor. Comfort measures.\n5. PARENTING O: in this evening. Both are\nindependent in providing care for infant. bathed\nand fed baby. -updated. A: , concerned \nP: Support and update. Encourage to ask questions and voice\nconcerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791980, "text": "Case Management Note\nChart has been reviewed and events noted. I will place EIP & VNA options in record. Tuft's case manager will be following clinical status daily. I will cont to follow status\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791981, "text": "Clinical Nutrition\nO:\n27 week gestational age BG, AGA.\nBirth wt: 1230 g (~75th %Ile)\nHC: 26.5 cm (~50th to 75th %Ile)\nLN: 37 cm (~50th %Ile)\nLabs due to be drawn @ 24 hrs of life.\nNutrition: 80 cc/kg/day TF. NPO. UAC infusing 1/2 NS @ 0.8 cc/hr. Remainder of fluids as PN via PIV; projected intake for next 24hrs from PN ~33 kcal/kg/day, ~1.5 g pro/kg/day. GIR from PN ~5.6 mg/kg/min.\nGI: No stool yet.\n\nA/Goals:\nTolerating PN with good BS control after some initial hypoglycemia to 39. Remains NPO for now w/ UAC line. Labs due to be drawn. Initial goal for PN is ~90 to 110 kcal/kg/day, ~3 to 3.5 g pro/kg/day and ~3 g fat/kg/day. PN to be advanced per protocol and tolerance. WHen able to start enteral feeds, initial goal is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day, and ~3.2 to 3.6 g pro/kg/day. Expect PN to taper as EN feeds advance towards initial goal. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791982, "text": "0700- NPN\n\n\nRESP: Placed on HFOV at approximately 0700 this a.m. Current\nsettings MAP 13, delta P 30. Delta P was increased from 28\nat 1330 based on clinical assessment. ABG reflecting current\nsettings, 7.24(pH)/56(pC02)/53(p02)/25(tC02)/-4(BXS). Fi02\nranging from 38-100%. Requirement increased to 100% between\napproximately 1330 and 1430. Chest x-ray done at that time\nshows well-expanded lungs; fi02 variability may therefore be\nrelated to presence of intermittent PDA. Plan to decide on\nIndocin treatment based on results of pending echocardiogram\n(see CV note below). LS course and tight; suctioned prn for\nsmall-moderate amt cloudy secretions. Two doses of survanta\nhave been given; third dose will most likely be given this\nevening.\n\nCV: HR 130s-160s, no audible murmur. Precordium slightly\nactive, pulses normal. Good perfusion, brisk capillary\nrefill. Moderate generalized edema present. BPs stable with\nMAPs >28, see flowsheet. Unstable respiratory status\nindicative of PDA (see RESP note above); echocardiogram is\nbeing done at this time. Pre-ductal 02 saturation 95%,\npost-ductal 02 saturation 89%, see flowsheet. Indocin\ntreatment pending depending on echocardiogram results.\n\nFEN: NPO; TF reduced from 100cc/kg/d to 80cc/kg/d. IVFs\nPND10w infusing via PIV, 1/2NS+0.5UHep/cc infusing via UAC.\nPIV in place d/t unsuccessful attempt at placement of DLUVC.\nDsticks 65-74. Abdomen soft, round, no loops, hypoactive BS.\nVoid x1, trace meconium stool x1.\n\nDEV: Temps stable, nested with sheepskin on servo control\nwarmer. MAE, fontanels soft and flat. Infant drowzy but\nresponds appropriately to stimulation. Eyes are currently\nfused. Cluster cares maintained to reduce stimulation.\n\nPARENTING: Both parents visited on their way from DR \npostpartum floor. RN provided support and update. Parents\nasking questions, appropriately concerned. Dad visited again\nthis afternoon, updated at bedside by RN and Neonatologist.\n\nNPN CONTINUED BELOW....\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791983, "text": "0700- ADDENDUM TO NPN\n\n6 I/D\n\nI/D: Currently on Ampicillin and Gentamicin x48hr r/o\nsepsis. Differential sent this a.m. shows left shift, see\nlab for complete results and CBC. BC pending.\n\nREVISIONS TO PATHWAY:\n\n 6 I/D; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791984, "text": "Respiratory Care Note\nBaby Girl was changed to HVOF this am based on ABG: 7.19/69/59/25/-3 (on IMV 25, 25/5). Placed on MAP 13, AMP 28, HZ 15, FiO2 has ranged from .25-1.00. ABG: 7.25/52/63/24/-5. No changes made. Second dose of 5 cc's of Survanta given at 1220 pm per protocol. BS tight t/o (ETT leak noted). Had 2 episodes today of requiring increased O2, the last time 100% required. Pre-ductal Sat 95%, post-ductal Sat 89%. Having ECHO done at this time. No murmur heard. CXR showed ETT in good position, nine ribs expanded and improving lung fields. ABG: 7.24/56/53/25/-4. No changes made. Plan 3rd dose of Survanta this pm. Plan Indocin if indicated by ECHO.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791985, "text": "Respiratory Care Note\nWhen pt required 100% O2 and CXR taken, AMP was increased to\n30 per Dr. . Last ABG drawn was on MAP 13, AMP 30.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791986, "text": "Respiratory Care Note\nWhen pt required 100% O2 and CXR taken, AMP was increased to\n30 per Dr. . Last ABG drawn was on MAP 13, AMP 30.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-14 00:00:00.000", "description": "Report", "row_id": 1792214, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM28w/PM. All feeds PG\nover 1 hour. Tol well, no spits, min asp. Belly soft, no\nloops. Voiding, tr stool thus far. On Vit E and Fe. P\ncont to assess FEN needs.\n4. DEV O/A remains in an off with stable\ntemp. A/A with cares, sleeping well between cares. P cont\nto assess dev needs.\n5. O/A Mom called for updates. P plan to\nvisit this afternoon. Christening planned for this\nafternoon. P cont to support, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-14 00:00:00.000", "description": "Report", "row_id": 1792215, "text": " PHysical Exam\nPE: , , breath sounds clear/equal with comfortable WOB, no murmur, abd soft, brown pigmented nevus left ankle, active and with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-15 00:00:00.000", "description": "Report", "row_id": 1792216, "text": "Nursing Progress Note 1900-0700\n\n\nF/N:Infant cont's on TF 150cc's/kg/day.Rec.BM28 with Promode\n55cc's gavaged over 1 hr.Weight=2.205 up 45 grams.Abd. soft\nand round with pos bs,no loops or spits.Minimal\naspirates.Girth=27.Voiding and stooling heme\nnegative.A:Adequate Weight Gain P:Cont. to assess tolerance\nof feeds and monitor weight gain.\n\nDEV:AF soft and flat. and active with cares.Sleeping\nwell b/t cares.MAE.Bringing hands to face and mouth.Infant\npresently swaddled in off temp.\nstable.A:Appropriate for GA P:Cont. to support growth and\ndev.\n\nParenting:No contact from thus far.A/P:Cont. to\nupdate,support,and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-15 00:00:00.000", "description": "Report", "row_id": 1792217, "text": "Neonatology Attending Progress Note:\nDOL #47\nPMA 34 weeks\nremains in RA, RR=40-50's, sc retx, no spells\nHR=150-170's, intermittent mrumru, BP mean=51\nwt=2205g (inc 45g), TF=150cc/kg/d BM 28 with promod gavaged over one hour\nbreast feeding started\nvoiding, stools heme negative\n\nPE; well appearing, , normal S1S2, no murmur appreciated today, breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused. tone aga.\n\nImp/Plan: premie infant beginning to learn to po feed, intermittent murmur--asymptomatic\n--monitor murmur\n--monitor weight, encourage po feeds\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-15 00:00:00.000", "description": "Report", "row_id": 1792218, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM28w/PM. Feeds PG over 1\nhour, tol well. No spits, min asp. Belly soft, no loops.\nVoiding, no stool thus far. Mom put inf to breast at 1300,\nusing football hold, inf latched, few sucks. Lac consult\nscheduled for next week. P cont to assess FEN needs.\n4. DEV O/A remains swaddled in an OAC with stable\ntemp. A/A with cares, sleeping well between cares. P cont\nto assess dev needs.\n5. O/A Mom and Dad in for visit and cares.\nUpdates given. P cont to support, educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-16 00:00:00.000", "description": "Report", "row_id": 1792221, "text": "NICU Fellow Note\nExam\nGeneral - comfortable appearing in \nHEENT - AFOS, NGT in place\nLungs - CTA b/l with good air entry\nHeart - RRR no murmur heard\nAbdomen - soft, nondistended, normoactive bowel sounds\nExtremities - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-11-16 00:00:00.000", "description": "Report", "row_id": 1792222, "text": "NPN DAYS\n\n\n3. TF at 150cc/kg of BM28 with PM. Gavaged over 60min.\nMother plans to BF at 2100cares. Abd benign. Voiding and\nstooling. Spit x1 after eye exam. Tol feeds. Working on po\nfeedings.\n\n4. Transitioned from off islette to open crib this\nafternoon. Temp stable. and active with cares. AGA.\n\n5. in to visit. Independent with cares. Held infant.\nUpdated given, concerened about eye exam: mild ROP.\nFellow reviewed ROP to and updated on progress.\nLoving family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-17 00:00:00.000", "description": "Report", "row_id": 1792223, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, assessment benign. TF=150cc/kg/\nday. Infant taking 58cc BM 28 with PM q4 po/ng. No emesis,\nscant aspirates. Mom attempted to breastfeed infant, but\ndid not latch. PO fed x1, taking 30cc. Burped well.\nVoiding with diaper changes. No stool yet. Wgt: 2.300k ^\n10g A: Stable, tolerating feeds P: Monitor. Encourage\nto breast feed or bottle feed. Advance feeds as tolerated.\n4. G&D O: is active and . Awakens with\ncares, opens eyes and looks around. Temp wnl in open crib.\nSucks pacifier eagerly. No s/s pain or discomfort A:\nAppropriate P: Monitor. Comfort measures.\n5. PARENTING O: in for 2100 cares. very\nindependent giving care to . Well-updated with\nchild's plan of care. A: Loving P: Support and\nupdate. Encourage to ask questions and voice concerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-05 00:00:00.000", "description": "Report", "row_id": 1792303, "text": "Neonatology\nExam: active infant, no distress. Skin warm, dry, mildly pale. Fontanelles soft and flat. Chest clear, no g/f/r. Cardiac RRR, no m. Abdomen soft, no HSM, active BS. mildly increased, activity appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-05 00:00:00.000", "description": "Report", "row_id": 1792304, "text": "Neonatology\nDOL #67, CGA 36 wks.\n\nCVR: Remains in RA, comfortable. No spells. Hemodynamically stable.\n\nFEN: Wt 2990, up 30 grams. TF 140 cc/kg/day, BM 24 w/E powder, PO/PG. Voiding/stooling.\n\nDEV: In open crib.\n\nIMP: Former 27+ wk premature infant, doing well. Stable in RA. Still with feeding immaturity requiring PG supps. Mild ROP.\n\nPLANS:\n- Continue monitoring in RA.\n- Advance PO intake as able, monitor weight gain.\n- F/U eye exam.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792015, "text": "Neonatology Attending\nAddendum/Exam:\nPlacement of NG for feedings returned > 1 cc dk green bilious aspirate. Called to assess.\nOn exam:\nInfant , active, fiesty. AFSF. Lungs CTA, =. CV RRR, no murmur. Abd soft, +BS. Has passed meconium. Ext and well perfused.\n\nKUB: normal appearing bowel gas pattern throughout. No dilation or concerns for obstruction/NEC.\n\nWill attempt to begin enteral feedings while monitoring closely.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792016, "text": "NPN 0700-1900\nAddendum\n\nSkin: Infant has reddened area under neck. Rivers in to assess. Keeping area dry . Skin breakdown noted located on lower abdomen due to umbi tape removal. MD aware.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792017, "text": "NPN 0700-1900\nAddendum\n\nSkin: Infant has reddened area under neck. Rivers in to assess. Keeping area dry . Skin breakdown noted located on lower abdomen due to umbi tape removal. MD aware.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792018, "text": "NPN 0700-1900\nAddendum\n\nSkin: Infant has reddened area under neck. Rivers in to assess. Keeping area dry . Skin breakdown noted located on lower abdomen due to umbi tape removal. MD aware.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-02 00:00:00.000", "description": "Report", "row_id": 1792157, "text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. RR 30-60's, O2 Sat >95%. Lungs\nare clear and equal with mild scr noted. No apnea, bradys or\ndesats thus far this shift, remains on caffeine. A: Stable\nin RA P: Continue to monitor resp status.\n\nFEN: CW 1645G (^30g). TF 150cc/k/d of BM30 w/pm (41cc q4hr\npg 80min.) Abdomen soft with active bowel sounds. No loops,\nNo spits, AG stable. Max aspirate of 4.4cc of partially\ndigested breast milk. Voiding with each diaper change. Trace\nyellow stool thus far this shift. Continues on vit E and Fe.\nA: Tolerating current feeding regimen. P: Continue per\nnutritional plan.\n\nDEV: Infant remains swaddled in an off . Temps\nstable. and active with cares. Settles well inbetween\ncares. Brings hands to face for comfort, enjoys pacifier.\n, . Received Hep B vaccine. Plan for eye exam later\nthis morning. A: AGA P: Will give eye drops at 630 as\nordered, continue to support development\n\n: Both in for the 2100 care. Both very\nindependent w/temp and diaper change. Both assisted\nw/weighing. Dad held infant. Both asked appropriate\nquestions regarding care, updated by this rn. would\nlike to give a later today.A: Involved, loving,\nappropriately concerned. P: Continue to update,\nsupport,educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-02 00:00:00.000", "description": "Report", "row_id": 1792158, "text": "Neonatology\nRA. No spells. Comfortable appearing. No murmur on exam today. CV stable.\n\nWt 1645 up 30. Tolerating feeds at 150 cc/k/d of 30 cal. Abdomen benign.\n\nIn Off isollette.\n\nCOntinue a sat present.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-02 00:00:00.000", "description": "Report", "row_id": 1792159, "text": "NPN DAYS\n\n\n1. Remains in RA. LS clear. RR 30-70's. O2 sats>90. On\ncaffeine,no spells. Stable.\n\n3. TF at 150cc/kg of BM30 with PM. Gavaged over 70min. No\nspits. Abd benign. Voiding and stooling. Tol feeds.\n\n4. Temp stable in off . and active with cares.\nEye exam today: immature zone 2 f/u in 2weeks. AGA.\n\n5. Both in today. Father held held this am. Both\n independent with cares. Plan to give a tonight.\nLoving family.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-02 00:00:00.000", "description": "Report", "row_id": 1792160, "text": "1 Alt Resp Status\n8 Apnea and bradycardia\n\nREVISIONS TO PATHWAY:\n\n 1 Alt Resp Status; resolved\n 8 Apnea and bradycardia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-02 00:00:00.000", "description": "Report", "row_id": 1792161, "text": " Physical Exam\nPE: pale , , breath sounds clear/equal with comfortable WOB, very soft murmur, abd soft, sleeping.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-02 00:00:00.000", "description": "Report", "row_id": 1792162, "text": "NURSING\nPARENT\ns/o: chose not to give in light of eye exam today. Will defer to a less stressful day. A: in tune with preemie needs.\nP: Cont support and reinforce teaching.\nFEN\ns/o: Wt up 45 gms to 1690. No spits while fed over 1 hr interval.\nAbd full/soft. Void and stool q diaper change. A: Gaining on 30 cal BM P: Cont to mtr tolerance, wt gain.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-22 00:00:00.000", "description": "Report", "row_id": 1792245, "text": "NICU PCA Note\nI have examined this infant. I agree with PCA note and assessment. Inf continues on Vit E and Fe.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-13 00:00:00.000", "description": "Report", "row_id": 1792341, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg/day of BM24. Inf Sleepy this AM\nnot interested in PO feeding, PO fed 48cc at 1300. \nfeeds well. 1 spit, no asp. Belly soft, no loops.\nVoiding, . P cont to offer PO feeds as .\n4. DEV O/A remains in OAC swaddled. Temp stable.\nA/a with cares. P cont to assess dev needs.\n5. O/A Mom and in for visit and cares this\nAM. Updates given. P cont to support, educate.\nSee flowsheet for further details.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-13 00:00:00.000", "description": "Report", "row_id": 1792342, "text": " PHysical Exam\nPE: , , breath sounds clear/equal with comfortable WOB, no murmur, abd soft, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-14 00:00:00.000", "description": "Report", "row_id": 1792343, "text": "Nursing progress note\n\n\n#3 O: Wgt up 60gms. Remains on 140cc/k/d, BM/E24. Mom\nrequested to have baby fed q3h to see if she could PO full\nvolume. Baby has needed PG supplement with each feed. Abd\nsoft with active bowel sounds & no loops. Voiding & \nwith each diaper change. No spits, minimal aspirate. A:\nTolerating feeds & gaining wgt, but still needs PG\nsupplement to receive full volume. P: Cont to assess.\nEncourage PO feeds.\n#4 O: Temp stable in crib. with cares. Improving on PO\nfeeds. A: Stable. P: COnt to assess.\n#5 O: in for 9PM cares. did temp, weighed &\nchanged baby, & gave baby a bottle. Mom put baby to\nbreast briefly after PG feed. Baby latched & sucked for\n10min. Mom requested that we try q3h feeds to see if baby\ncould take full PO feed. A: family. P: Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-14 00:00:00.000", "description": "Report", "row_id": 1792344, "text": "Neonatology Attending\n\nDay 76 PMA 38 wks\n\nRemains in RA. HR 140-160s. No bradycardia. BP mean 73. Weight 3260 gms (+60). TF at 140 cc/kg/d- BM/E24. Taking three hourly feeds. Almost taking full bottles but still have by gavage. abdomen. On iron and vitamins. Not yet waking for feeds. Stable temperature. Eye exam- clock hours of stage II noted on right, some regression of stage I on left.\n\nDoing well overall. Mature breathing control on monitor. Improving feeds but not adequate for discharge. Follow up eye exam in one week.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-14 00:00:00.000", "description": "Report", "row_id": 1792345, "text": "NICU fellow note\nWell appearing premature infant sleeping in the open crib.\nVSS\nWt 3260 gm.\n, MMM.\nRRR, no murmur, well perfused.\nCTA bilaterally, good air entry.\nSoft, NT/ND, no HSM, active BS\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-14 00:00:00.000", "description": "Report", "row_id": 1792346, "text": "NPN 7a7p\n\n\nFen\nInfant on TF 140 cc/k/d of BM24 or enfamil 24. PO/PG.\nFeeding q 3 hrs per Moms request, to see if she can take the\nrequired volume. Bottled today using advent , needs to\ntake 57 cc to maintain minimum, took, 53, 51, 20 and 60 cc.\nAbd soft and round withactive BS. Voiding and . No\nloops. No spits. Waking for some feeds. Infant learning to\nPO. Monitor weight and exam.\nG/D\nInfant in OAC with stable temps. Some quiet awake times. A/A\nwith cares. MAEs. FS&F. Eye exam this am, improvement in\nleft eye. Right eye st 2, to F/U in 1 wk. AGA. Monitor and\nsupport G/D.\nParenting\nMom and aunt in for visit and cares today. Mom anxious about\neye exam. Appeared more reassured after conversation with\nthis RN. Asking appropiate questions. Intrested and\ncompetent with cares. Attending OT teaching group this eve.\nSupport and educate .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-05 00:00:00.000", "description": "Report", "row_id": 1792027, "text": "Clinical Nutrition\nO:\n~28 wk CGA BG on DOL 6.\nWT: 1025 g (+40)(~25th to 50th %Ile); birthwt: 1230 g. Wt currently down ~17% from birth wt\nHC: 27 cm (~50th to 75th %Ile); last: 26.5 cm\nLN: 37 cm (~25th to 50th %Ile); last: 37 cm\nLabs noted\nNutrition: 150 cc/kg/day TF. Feeds currently @ 20 cc/kg/day BM /PE 20, increasing 10 cc/kg/. Remainder of fluids as PN via PICC line; projected intake for next 24hrs from PN ~93 kcal/kg/day, ~3 g pro/kg/day and ~3.1 g fat/kg/day. From EN: ~20 kcal/kg/day, ~0.3 to 0.6 g pro/kg/day and ~1 to 1.1 g fat/kg/day. GIR from PN ~10.2 mg/kg/min.\nGI: Abdomen benign. Passing meconium after glycerine.\n\nA/Goals:\nTolerating feeds so far without GI problems except requiring glycerine to stool. Advancing feeds slowly and monitoring closely for signs of feeding intolerance. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Plan to give bicarbonate bolus today due to low CO2. Current PN + EN meeting recs for kcals/pro/fat and vits. FUll mineral recs will not be met until feeds reach initial goal of BM/PE 24 @ 150 cc/kg/day. Growth is meeting recs for HC gain. Not meeting wt gain and LN gain goals; expect improvement now that PN has been advanced to initial goal. WIll continue to follow w/team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-19 00:00:00.000", "description": "Report", "row_id": 1792101, "text": "NICU PCA Note\n\n\n1. Resp: O/ Pt on nasal cannula, 100% O2 at 13 cc - changed\nfrom 50 cc at 1400. Lungs C/E bilaterally. Mild\nintercostal/subcostal retractions. RR 30-70's. No spells.\nOxygen saturations mostly in the 90%'s throughout shift.\n(Please refer to flowsheet for additional Resp info). A/ Pt\nremains stable throughout shift. P/ Cont caffeine regimen;\ncont to monitor Resp status.\n\n3. FEN: O/ Voiding/stooling - hemoccult negative. Girths 23\ncm. No spits. Minimal aspirates. Abdomen benign. All feeds\ngavaged over 1 hour. (Please refer to flowsheet for amounts\nand additional FEN info). A/ Pt remins stable throughout\nshift. P/ Cont with Vitamin E and Iron regimen; cont to\nmonitor FEN status.\n\n4. G/D: O/ Temp stable in air set at 28.5 C. Alert.\nMAE. Fonts S/F. Wakes with cares, sleeps between cares.\nClearish exudate from eyes. (Please refer to flowsheet for\nadditional G/D info). A/ Pt remains stable throughout shift.\nP/ Cont with antibiotic regimen to eyes; cont to monitor G/D\nstatus.\n\n5. Parenting: O/ Mother present for 1300 cares, plans to\nreturn for 2100 cares. A/ loving, capable, and\nappropriate. P/ Cont to educate and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-20 00:00:00.000", "description": "Report", "row_id": 1792102, "text": "NPN 1900-0700\n\n\nRESP: Received infant in room air. Placed infant back on NC\n100% 25cc after frequent drifts. LS clear/=, no increased\nwork of breathing, IC/SC retractions. On caffeine, no spells\nthus far this shift.\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, good bs, girth stable, V&S\n(heme negative). On Vitamin E & Iron.\n\nG/D: Temp stable swaddled in weaning air . A&A\nw/cares, sleeps well in between. Brings hands to face for\ncomfort.\n\n: Both in to visit with first cares. Updated\nby this RN, asking appropriate questions. Independent\nw/cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791987, "text": "Respiratory Care Note\nWhen pt required 100% O2 and CXR taken, AMP was increased to\n30 per Dr. . Last ABG drawn was on MAP 13, AMP 30.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791988, "text": "Respiratory Care Note\nWhen pt required 100% O2 and CXR taken, AMP was increased to\n30 per Dr. . Last ABG drawn was on MAP 13, AMP 30.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-10 00:00:00.000", "description": "Report", "row_id": 1792051, "text": "1. remains in RA, color , BBS equal, clear, RR\n50-70, mild ic/sc retractions, on caffeine-no spells.\nconntinue to moniitor.\n3. TF 160cc/k/d, feedings of BM20 at 130cc =27cc pg q4h over\n~40 min, D15 with NaAcetate and KCl infusing through central\nPICC in rt leg at 30/k, site with dry, intact dressing. abd\nsoft, active bowel sounds, no loops, no spits, minimal\naspirates, voiding and passing guiac neg stool, DS 73. plan\nto continue to advance feedings by 10cc/k as tolerated.\n4. temp sl low x1-servo temp increased, very active and\nalert with cares, strong cry, settles well in prone position\nwith pacifier, nested in sheepskin with boundaries.\n5. here ~1300 cares, Mom pumping breast milk. plans\nto visit later. conntinue to update and offer support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-10 00:00:00.000", "description": "Report", "row_id": 1792052, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in , room air\nSkin: warm and dry; color \nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds equal, clear, well-aerated\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft no masses; + bowel sounds\nExt: P-CVL infusing right leg, dressing intact; moves all\nNeuro: symmetric tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2189-10-11 00:00:00.000", "description": "Report", "row_id": 1792053, "text": "NPN\n\n\n#1\nInfant remains in RA with sats >94%. BS clear= with mild\nretractions. Infant has had one desat to 53 requiring stim\nand BBO2 to resolve; a few other desats that were SR. No\nepisodes of bradycarida noted. Murmer not audible. Color\nis ; well perfused. remains on caffeine.\n\n#3\nInfant continues on TF=160cc/k. Infant is slowly advancing\non enteral feedings, and is presently on 140cc/k of BM q4\nhours via gavage. Infant has tolerated feeds without spits;\nmax aspirate of 3cc (non-bilious); abd is soft; voiding and\nstooling(g-). PICC remains intact with IVFs infusing as\nordered at KVO. DS=68. Wt is down 5gms-1550.\n\n#4\nInfant remains in a heated nestled in sheepskin on\nservo control. temp has been stable. Infant is alert and\nfiesty with cares; sucks on the pacifier.\n\n#5\n were in last evening. Dad took the temp and mom\n with weighing. Dad then held infant for ~an hour\nand she tolerated it well. Mom called this am for an\nupdate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-11 00:00:00.000", "description": "Report", "row_id": 1792054, "text": " progress note\nAwake and alert. Breath sounds clear and equal bilaterally with mild retractions. NG tube in place. No murmur. and well perfused. Abdomen soft and round with good bowel sounds. No HSM. Normal GU and skellital.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-03 00:00:00.000", "description": "Report", "row_id": 1792296, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg. Cal decreased to BM24 made w/\nEnf Powder. Inf PO feeding/BF as tol. Tol feeds well. 1\nsm spit, no asp. Belly soft, no loops. Voiding, stooling.\nP cont to offer PO feeds as tol.\n4. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares, not waking for feeds thus far.\nTylenol given at 0900, inf appeared sl uncomfortable due to\nimmunizations. P cont to assess dev needs.\n5. O/A Mom in for visit and cares. Updates\ngiven. D/C teaching in progress. P cont to support,\neducate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-03 00:00:00.000", "description": "Report", "row_id": 1792297, "text": "NICU Fellow note.\nWell appearing premature infabt in NAD.\nVSS\n, MMM.\nRRR, no murmur.\nCTA B, good air entry.\nAbdomen soft NT/ND.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-04 00:00:00.000", "description": "Report", "row_id": 1792298, "text": "Nursing progress note\n\n\n#3 O: Wgt up 55 gms. Rmeins on 140cc/k/d 24 cal BM w/ enf\npwdr. Abd soft with active bowel sounds & no loops. Voiding\n& stooling. Sm spit X's 1. PO feed given at 9PM by . baby\ntook 56cc. Remainder fed PG. PO fed again at 1AM. Baby took\n27cc. Remainder fed PG. A: Tolerating feeds & gaining wgt.\nP: Cont to assess.\n#4 O: Temp stable in crib. with cares. HiB\nimmunization given. PO feed fairly well with yel . A:\nStable. P: Cont to assess.\n#5 O: in for 9PM feed & also phoned for update. \ngave baby a bottle. A: Loving family. P: Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-04 00:00:00.000", "description": "Report", "row_id": 1792299, "text": "Neonatology Attending\n\nDay 66 PMA 36 wks\n\nRemains in RA. RR 30-50. No murmur. Pale, . HR 150-170s. BP mean 67. Weight 2960 gms (+55). TF at 140 cc/kg/d- BM 24. Taking half feeding volumes. Benign abdomen. Stable temperature in open crib.\n\nDoing well overall. Mature breathing control on cardio-respiratory monitoring. Gaining weight well. Spoke briefly with mother yesterday.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-04 00:00:00.000", "description": "Report", "row_id": 1792300, "text": "NICU Fellow note\nWell appearing premature infant in NAD.\nVSS\nWt 2960gm\nSkin: clear, no lesions.\nHEENT: , MMM.\nCV: CTA bilaterally, no murmur, well perfused.\nABD: Soft NT/ND, no masses, active bowel sounds.\nNeuro: normal \n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-04 00:00:00.000", "description": "Report", "row_id": 1792301, "text": "NPN DAYS\n\n\n3. TF at 140cc/kg of BM24 with enfamil powder. Working on po\nfeedings. Not interested in breastfeeding with mom this\nafternoon. Feeding gavaged over 60min. Offered bottle x2\ntoday, took - amt. Abd benign. Voiding and stooling.\nlg spit x1. Working on po feeding skills.\n\n4. Temp stable in open crib. and active with cares.\nAGA.\n\n5. Mother in for afternoon cares, father in for pm cares.\nBoth updated, asking appropriate questions. Independent with\ncares, held . Loving family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-05 00:00:00.000", "description": "Report", "row_id": 1792302, "text": "Nursing progress note\n\n\n#3 O: Wgt up 30gms. Remains on 140cc/k/d BM 24 cal made with\nEnf pwdr. Abd soft with active bowel sounds & no loops.\nMinimal aspirates, small spits with burps. PG fed at 9PM &\n5AM. PO fed at 1AM. Baby took 53cc out of total volumn of\n70cc. PG remainder. A: Tolerating feeds & gaining wgt. P:\nCont to assess. Offer PO when awake.\n#4 O: Temp stable, swaddled in crib. Quietly with\ncares. Baby PO fed at 1AM with Nuk . A: Improving on\nbottle feeds. P: Cont to assess.\n#5 O: Mom phoned for update. A: Loving family. P: Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-05 00:00:00.000", "description": "Report", "row_id": 1792305, "text": "Nursing Progress Note:\n\nFEN:\nO: Infant receiving 140cc/kg of BM 24 +E powd, (=70cc),\nevery 4 hours, po/pg. At 0900 infant took 37cc po. At 1300\ninfant took 40cc po. Infant well coordinated using her \nbottle. Tires easily toward middle of feeding. One small\nspit noted so far this shift. Minimal aspirates. Abdominal\nexam benign. Infant voiding, and passing heme negative\nstool.\nA: Infant tolerating feeds well.\nP: Cont to advance po feeds as tolerated by infant.\n\nDEV:\nO: Infant temps stable; swaddled in an OAC. Font s/f. Infant\na/a with cares; waking for most feeds. within normal\nlimits. Infant lifts head spontaneously. Bring hands to\nmouth, and enjoys her pacifier. Sleeps well between cares.\nA: Appropriate behavior for gestational age.\nP: Cont to support development.\n\nSOC:\nO: Mom in for 1300 care. Updated regarding infant's status\nand plan of care by RN. Mom in cares, and\nbottled infant well with good positioning. Responds well to\ninfant cues. Held infant after feed. Cont to pump.\nA: Mom bonding well with infant.\nP: Cont to support, educate and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-05 00:00:00.000", "description": "Report", "row_id": 1792306, "text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; PCA.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-06 00:00:00.000", "description": "Report", "row_id": 1792307, "text": "NPN 1900-0700\n\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, good bs, V&S. Continues on\niron and multivitamins.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Brings hands to face and sucks on pacifier\nfor comfort.\n\n: Both in for first cares. Updated at bedside\nby this RN, asking appropriate questions. Independent with\ncares. Discharge teaching continued.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-06 00:00:00.000", "description": "Report", "row_id": 1792308, "text": "Neonatology Attending\nPhysical Examination\nHEENT \nCHEST no retractions; good bs bilat; no adventitious sounds\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; bs active\nCNS active, resp to stim; AGA and symm\nGU normal\nINTEG normal\nMSK normal insp/palp/ROM all ext\n" }, { "category": "Nursing/other", "chartdate": "2189-12-06 00:00:00.000", "description": "Report", "row_id": 1792309, "text": "Neonatology Attending\nDOL 68 / PMA 37 weeks\n\nRemains in room air with no cardiorespiratory events.\n\nNo murmur.\n\nWt 2995 (+5) on TFI 140 cc/kg/day BM24, tolerating well. Bottling partial volumes only. Abd benign. Voiding and stooling normally.\n\nTemp stable in open crib.\n\nA&P\n27-2/7 week GA infant with feeding immaturity, resolving respiratory immaturity\n-Continue to encourage development of oral feeding skills\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792009, "text": "Nursing progress note\n\n\n#1 O: Baby remains in room air on 6cm prong CPAP. Breath\nsounds equal & clear with mild IC/SC retractions. Remains on\naffeine. No A's, B's or desats this shift. A: Stable on\nCPAP. P: Cont to assess.\n#2 O: Baby is , sl jaundiced & well perfused. No murmur\nheard. See flow sheet for BP. A: Stable. P: Cont to assess.\n#3 O: NPO. PN & IL infusing at 120cc/k/d thru PICC. Abd soft\nwith active bowel sounds & no loops. No stool this shift.\nUOPP for previous 24 hrs was 3.1cc/k/h. Wgt is down 15gms.\nA: Receiving fluid as ordered. P: Bili, Lytes, DS &\ntriglyserides to be drawn at 5AM.\n#4 O: Temp stable nested in servo . Irritable with\ncares but calms with nesting. A: Stable. P: Cont to assess.\n#5 O: Mom phoned for update. A: Loving family. P: Support.\n#6 O: Blood cultures neg to date. Remains on antibiotics. A:\nStable. P: Antibiotics as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792010, "text": "Respiratory Care\nBaby continue on prong CPAP 6, 21%. BS clear. RR mostly 40's-60's with mild retractions. On caffeine. No spells noted. Plan cont CPAP @ present, monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792011, "text": "Neonatology Attending\nAddendum/Exam:\nPlacement of NG for feedings returned > 1 cc dk green bilious aspirate. Called to assess.\nOn exam:\nInfant , active, fiesty. AFSF. Lungs CTA, =. CV RRR, no murmur. Abd soft, +BS. Has passed meconium. Ext and well perfused.\n\nKUB: normal appearing bowel gas pattern throughout. No dilation or concerns for obstruction/NEC.\n\nWill attempt to begin enteral feedings while monitoring closely.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792012, "text": "Neonatology Attending\nDay 4\nPCA 27 6\n\nCPAP6, RA. RR40-60s. No A&Bs. On caffeine. No murmur. HR 140-150s. BP 52/36, 40. Under single photot. Last bili 5.5/0.4 (down). Day of amp/gent.\n\nWt 1055, down 15 gms. TF 120. Right leg PICC. PND12.5/IL.\n146/5.5/119/12\nd/s 83\nNl voiding (3.1). No stool.\n\nIn servo .\n\nA/P:\n-- Resolving RDS. Try off CPAP today.\n-- Inc TF to 130.\n-- Would like to begin trophic feedings, but would also like to see correction in metabolic acidosis. Last check by heelstick, will check ABG 1 hour after trial extubation.\n-- Complete abx course for presumed sepsis. Needs LP.\n-- Cont photot.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792013, "text": "Neonatology Attending\nAddendum/Exam:\nPlacement of NG for feedings returned > 1 cc dk green bilious aspirate. Called to assess.\nOn exam:\nInfant , active, fiesty. AFSF. Lungs CTA, =. CV RRR, no murmur. Abd soft, +BS. Has passed meconium. Ext and well perfused.\n\nKUB: normal appearing bowel gas pattern throughout. No dilation or concerns for obstruction/NEC.\n\nWill attempt to begin enteral feedings while monitoring closely.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792014, "text": "Neonatology Attending\nAddendum/Exam:\nPlacement of NG for feedings returned > 1 cc dk green bilious aspirate. Called to assess.\nOn exam:\nInfant , active, fiesty. AFSF. Lungs CTA, =. CV RRR, no murmur. Abd soft, +BS. Has passed meconium. Ext and well perfused.\n\nKUB: normal appearing bowel gas pattern throughout. No dilation or concerns for obstruction/NEC.\n\nWill attempt to begin enteral feedings while monitoring closely.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792019, "text": "NPN 0700-1900\n\n\n#1RESP: Received patient on CPAP 6, 21%. PAtient trialed off\nCPAP at 0900 to NC at 25cc's, 100%. Patient currently\nremains on NC at 13cc's, 100%. Lung sounds are clear/=.\nInfant has mild IC/SC retractions. RR=40-60's. No spells.\nInfant continues on caffeine. ABG WNL. See flowsheet.\nA:Stable in NC P:Continue to monitor for spells, continue to\nwean as tolerated\n\n#3FEN: TF increased to 130cc's/kg/d. PN D12.5 and IL\ninfusing well through PICC line. Attempted to start feeds at\n1300, patient had 1.0cc bilious aspirate and soft loops. MD\nin to assess infant and KUB done. KUB normal MD. Plan to\nstart feeds at 10cc's/kg/d of BM20 at 1700. Abdomen is\nround, soft, a/g stable, + bowel sounds, no spits, d/stick\n86, voiding well, no stool yet this shift. U/O is\n2.6cc's/kg/hr for 8 hours A/P:Continue to monitor infant,\nplan to start feeds at 1700 as tolerated.\n\n#4DEVE: Temp stable. Infant is nested on servo control.\nFontanels are soft and flat. Brings hands to face. Alert and\nactive with cares. Slightly irritable during cares; settles\nwell with binki and boundaries. Sleeps well in between\ncares. MAE. Patient has fused eyes A:AGA P:Continue to\nsupport growth and development of infant\n\n#5PARENTING: in for afternoon visit. Asking\nappropriate questions. Very loving toward infant. Update\ngiven by RN and Dr. at the bedside. Plan to visit for\n2100 care. A:Loving P:Continue to support and educate\n\n#6ID: Infant continues on Ampicillin and Gentamycin. Day 4\nof 7. Temp stable. No signs and symptoms of infection.\nA/P:Continue to monitor for signs and symptoms of infection.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792020, "text": "NPN 0700-1900\nAddendum\n\nSkin: Infant has reddened area under neck. Rivers in to assess. Keeping area dry . Skin breakdown noted located on lower abdomen due to umbi tape removal. MD aware.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-03 00:00:00.000", "description": "Report", "row_id": 1792021, "text": "2 Alt C/V status\n\nREVISIONS TO PATHWAY:\n\n 2 Alt C/V status; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792084, "text": "Neo Attending\nPE: small well appearing preterm infant nestled in , well perfused on NCO2\n, eyes clear, ng in place. MMMP\nChest is symmetric, clear, eqaul bs\nCG: RRR, soft systolic murmur, LLSB\nPulses=2+\nAbd: soft,a ctive bs\nNeuro: flexed posture, active and responsive\n\n not interested in direct donor. Have consented to transfusion if necessary, discussed issues regarding need for transfusion. Will continue to monitor clinical status and follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-22 00:00:00.000", "description": "Report", "row_id": 1792246, "text": "NICU PCA Note\n\n\n3. FEN: O/ Abdomen benign, round and soft. Voiding/ stooling\n- hemoccult negative. No spits. Minimal aspirates. Girths 26\ncm. Maintaining nutritional requirements. Mother \nat 0900 cares. (Please refer to flowsheet for amounts and\nadditional FEN info). A/ Pt remains stable throughout shift.\nP/ Cont to monitor FEN status.\n\n4. G/D: O/ Temp stable in OAC. and active. Wakes for\nfeeds, sleeps between cares. MAE. Fonts S/F. (Please refer\nto flowsheet for additional G/D info). A/ Pt remains stable\nthroughout shift. P/ Cont to monitor G/D status.\n\n5. Parenting: O/ and sister in for 0900 cares. Plan\nto return this evening. A/ loving, capable, and\nappropriate. P/ Cont to educate and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-22 00:00:00.000", "description": "Report", "row_id": 1792247, "text": "NEO ATTEND\nDAY 54 PMA 35 WK\nRESPR: RA, RR 50-60S. CLEAR=BS.\nNO SPELLS\nCV: H/O MURMUR NONE NOW. VS STABLE.\nWT2515, UP 15 GM\n150 CC/KG/DAY BM26+PM. PO/PG. LEARNING TO PO. LACTATION CONSULTATION THIS WEEK.\n\nTOLERATING FEEDS. ABD WNL. UOP AND STOOL WNL. 1 MED SPIT.\nHAS ROP: R STAGE 2 (1-2 HR), ZONE 2/ L STAGE 1 (, ZONE 2. F/UP TOMORROW.\n\n2 MONTHS IMMUNIZATIONS SOON.\n\nPT IS STABLE. ON SUPPL FOR ~1MO. MILD ROP.\nPLAN AS NOTED ABOVE.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-23 00:00:00.000", "description": "Report", "row_id": 1792248, "text": "npn 1900-0730\n\n\n3. Wt. 2.585gms. ^70gms from yesterday. Tf cont.at 150cc/k/d\nof BM26 with PM or 65cc q 4hrs. Cont. with alt, po/pg.\nTaking 28cc po before being gavaged. Cont. to be gavaged\nover 1hr, 20min, to help decrease spitting. 1 small spit so\nfar this shift. Voiding well. 2med stool guiac- so far this\nshift. Abd girth 26-26.5cm. Max asp 5cc partially digested\nbreast milk.\n\n4. Remains in oac. Tempsstable. calms with swaddle. MAE.\nA/a. Waking for some cares. while visiting.\n\n5. in at 2100 cares. Very independant. Very loving.\nAsking appropriate questions. Pleased with \nprogress.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-23 00:00:00.000", "description": "Report", "row_id": 1792249, "text": "Neonatology Attending Progress Note:\nDOL #55\nPMA 35 1/7 weeks\nwt=2585g (inc 70g), no murmur, HR=150-18-'s, RA, RR=40-60's\nTF=150cc/kg/d BM 26 with promod po/pg\nvitamin E and iron\nvoiding, stooling\nPE: well appearing, , normal S1S2, no murmur breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused. aga\nImp/Plan: premie infant tolearing full feeds\n--d/c promod\n--monitor weight\n--encourage po feeds\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-12-12 00:00:00.000", "description": "Report", "row_id": 1792335, "text": "Nursing Progress Note\n\n\n#3. O: Infant remains on TF's of 140cc/k/d of BM24 with E20.\nPO feeding ~ volume and tires quickly. No spits. Minimal\naspirates. Abd soft and round with active bowel sounds. No\nloops. Voiding qs. No stools. Wgt is up 55gms tonight to\n3200gms. A: Tolerating feeds. P: Continue to monitor feeding\ntolerance. Encourage po feeds as tolerated.\n\n#4. O: Infant remains in open crib with stable temp. She is\n and active with cares. MAEW. A: AGA. P: Continue to\nassess and support developmental needs.\n\n#5. O: in this evening. Very independent with cares.\nASking appropriate questions. A: Involved family. P:\nContinue to inform and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-12 00:00:00.000", "description": "Report", "row_id": 1792336, "text": "Neonatology\nDOing well. REmains in RA. No spells. Comfortable apeparing.\n\nWt 3200 up 55. Tilerating feedsd at 140 cc/k/d of 24 cal. Abdomen benign. Taking approx po rest via gavage.\nCOntinue a sat present.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-20 00:00:00.000", "description": "Report", "row_id": 1792103, "text": "Attending Note\nDay of life 21 PMA 30 \nwas in room air for 5 hours then went back into nasal cannula\nsat in the 90's\non caffeine no spells\nHR 150-170's BP 77/37 mean 54\nright eye drainage on erytho ointment\nweight 1295 up 20 grams on 150 cc/kg/day of BM 30 cal/oz pg over an hour\nno spits minimal aspirates\nstools heme negative\nin air \n\nImp-making some progress\nHUS this am for evolving\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-20 00:00:00.000", "description": "Report", "row_id": 1792104, "text": "Fellow PE Note\nGen- WD/WN F alert in NAD\nHEENT- NCAT, , nares patent, oropharynx clear\nCardiac- RRR, nl s1,s2, no murmur appreciated\nLungs- CTAB, no retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nGU- nl female genitalia\nSkin- no rash or lesions\n" }, { "category": "Nursing/other", "chartdate": "2189-11-04 00:00:00.000", "description": "Report", "row_id": 1792169, "text": "NICU Fellow Note\nExam:\nwell appearing in . AFOS, NGT in place, lungs clear with min subcoastal retractions. No murmur on exam today. Extremities WWP with normal cap refill, abdomen soft\n" }, { "category": "Nursing/other", "chartdate": "2189-11-04 00:00:00.000", "description": "Report", "row_id": 1792170, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day. Cals decreased to BM28w/PM.\nAll feeds PG over 1 hour. Tol well. No spits, min asp.\nBelly soft, no loops. Voiding, stooling. Girth 24.5cm. P\ncont to assess FEN needs.\n4. DEV O/A remains in an off with stable\ntemp. A/A with cares, sleeping well between cares. P cont\nto assess dev needs.\n5. O/A Mom in for visit and cares. Updates given.\nP support, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-04 00:00:00.000", "description": "Report", "row_id": 1792171, "text": "Clinical Nutrition:\nO:\n~32 week CGA BG on DOL 36.\nWT: 1750g(+60)(~50th %ile); BWT: 1230g. Average wt gain over past week ~22g/kg/day.\nHC: 29.5cm(25-50 %ile); last: 29cm\nLN: 40cm( %ile); last: 39.75cm\nMeds include Fe & Vit.E\nLabs noted.\nNutrition: 150cc/kg/day as BM 28 w/ promod; pg over 1hr. Average of past 3-day intake ~141cc/kg/day, providing ~141kcal/kg/day & ~3.8g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; pg fed. Labs noted with slightly elevated Ca; plan to recheck next week. Current feeds & supps meeting recs for kcal/pro/vits/mins. HC gain is meeting recs. Growth is exceeding recs of ~15-20g/kg/day for WT gain; kcals just decreased. LN gain is not meeting recs of ~1cm/wk. will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-05 00:00:00.000", "description": "Report", "row_id": 1792172, "text": "NPN 1900-0700\n\n\nFEN: CW 1760g (up 10g). TF 150cc/k/day BM28 with PM.\nTolerating PG feeds well gavaged over 1hr. No spits, max\nasp 1cc. Abd benign, AG= 23cm. Voiding QS, trace stools.\n\nDEV: Maintaining temps while swaddled in OAC. A/a with\ncares, sleeps well btwn. Likes pacifier, moves hands to\nface. , , AGA.\n\nPAR: in to visit for 2100 cares. Updated at\nbedside by this RN. Asking approp questions. Independant\nwith cares. Dad held x90min; . Continue to update and\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791975, "text": "Admission Note\nOb-\nPedi- of center peds \n\nBaby girl is the 1230 gram product of a 27 week IVF gestation (EDC ) born to a 4 yo G2 P1 mom with a blood type of A + antibody negative, GBS unknown, Hep B surface Ag negative, . The Rubella and RPR of her prenatal screens were not available now. In mom's first pregenancy she develope a PE. Therefore, this pregnancy she was treated with lovenox. Here firs infant was born by C-section at term.\n\nThis pregnancy was complicated by unstoppable preterm labor. Prior to two hour prior to delivery, this pregnany was uncomplicated. Mom awoke this early am to have severe abdominal pain. She came to the hospital and was found to be 5 cm dilated with a buldging bag. She was taken for emergent C-section.\n\nThis infant emerged limp and apneic. She was intubated in the delivery room. Her Apgar scores 2 (1 min) 6(5 min) 7 (10 min). She was taken to the NICU for further management.\n\nPhysical Exam\nweight 1230 grams (75%) lenth 37 cm (50%) HC 26.5 cm (50-75%)\nTemp 97.7 HR 164 RR 32 BP 46/15mean 26 D stick 39\nHEENT-normocephalic 0.5 cm lacertion on the left parietal portion of the head, eyes fused, palate intact, ant font open flat\nskin-pink\nneck-supple\nlung-coarse breaths sounds with crackles bilaterally but good air movement\nCV regular rate and rhythm no murmur femoral pulses 2+ bilaterally\nAbd soft nondistended with soft bowel sounds\nGU normal premature female external genetalia\nHips stable\nClavicles intact\nSpine midline no sacral dimple\nNeuro decreased tone globally with decreased DTR knees bilaterally\n\nImp-27 week premature infant in guarded condition born because of unexplained preterm labor.\n\nRESP-She has the expected HMD because of her gestational age no no prenatal steriods. Will expect a long ventilatory course. will begin mechanical ventilator now. Will give survanta as well. Will wean the ventilator as tolerated\nCV-stable currently will anticipate a PDA and will watch for signs and symptons. Will also monitor for hypotension.\nFEN-She is hypoglycemic currently likely due to the stress of delivery or could also be because of sepsis. Will give a bolus of D 10 W and then will begin IVF. Will also give D5 W starter PN at 50 cc/kg/day\nWill continue to monitor blood sugar.\nID-She is at high risk for infection because of her unexplained preterm delivery. Will draw a cbc and blood culture. Will begin amp/gent for a minimum of 48 hours\nPrenatal Screen-will follow up with OB to get the missing prenatal screens.\nSocial-the family is a bit overwhelmed with rapid transition from pregnancy to premature infant. Mom is very advanced. Will plan to have a family meeting after things are more stable to discuss the clinical situation.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791976, "text": "Respiratory Care Note\nPt. is a 27 wk'er born via C/S. Pt. was intubated in the OR with a 2.5 oral tube taped at 7.75. Pt. was transferred to the NICU and placed on 25/5 R 25. FIO2 100%--attempting to wean. Pt. was treated with 4.9 cc's of Survanta. BS equal but decreased. To follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791977, "text": "Nursing Admission Note\n\n\nPt admitted to NICU after C-sec delivery. Apgars 2-6-7.\nIntub in DR brought to NICU.\n\n1. RESP: Intub in DR. settings 25/5 X25. FiO2\n80-100%. Survanta given at 0610. Lung sounds are\ndiminished. Will monitor.\n\n2. C/V: HR 164 and pt is pink. BP 46/15 X26.\n\n3. F&N: BW 1230g. NPO. PIV placed upon arrival in left\nhand. D/S 39. D10W infusing at 100cc/k/d via PIV. Umbi\nlines being placed at present. No void or stool noted.\nWill recheck D/S.\n\n4. DEV: Pt is lethargic. Eyes fused. Poor tone. Vitamin\nK gievn. Erythro held due to fused eyes. Temp 97.7 rectal\non admission.\n\nPlan babygram after umbi lines placed. F/U D/S. Will send\nCBC and blood cultures.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791978, "text": "Procedure Note\nProcedure UVC, UAC placement\nIndication: need for central access\nTime out to make sure correct patient and correct procedure\nInfant draped in sterile fashion, CVR monitor, oximeter, and on radiant warmer. Removed UVC and UAC placed by NNP Rivers because they were not in proper position. Placed UAC sutured in place at 13 cm. UVC attempted several times, but could not advance the UVC past 5 cm. Sutured UVC in place. Babygram obtained. It showed UAC in good position at T8. UVC was low in IVC. UVC was removed.\n\nInfant tolerated procedure well. There were no complication. There was minimal blood loss\n" }, { "category": "Nursing/other", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 1791979, "text": "Neonatology note\n\n27 wks GA born this am, s/p 1 dose of survanta, transitionned to HIFI MAP 13 AMP 28 O2=40-50%\n\nA: 27 wks GA, RDS, sepsis evaluation.\nP: monitor closely respiratory status, will need further surfactant replacement, empirical antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-11 00:00:00.000", "description": "Report", "row_id": 1792055, "text": "Neonatology Attending\n\nDOL 12 PMA 29 weeks\n\nStable in RA. No A/B. Occ positional desat. On caffeine.\n\nNo murmur. BP 72/46 mean 55\n\nOn 160 ml/kg/d with 140 ml/kg BM20 and 20 ml/kg D15+lytes via PICC. Advancing feeds 10 ml/kg q 12. DS 68. Voiding. Stooling. Wt 1150 grams (down 5).\n\n in and up to date.\n\nA: Stable. Spells controlled on caffeine. Tolerating feed advance.\n\nP: Monitor\n Heplock PICC\n If tolerating full feeds will d/c PICC tomorrow\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-27 00:00:00.000", "description": "Report", "row_id": 1792133, "text": "NPN 1900-0700\n\n\nResp:Infant received in room air. Bilateral breath sounds\nclear and equal with good aeration. Respiratory rates\n50-70's. Saturations 92-100%. Mild subcostal retractions\nnoted. Continues on caffeine, no spells thus far this shift.\nP:Continue to assess and support respiratory status.\n\nFen:Infant's weight today is 1495gms, up 40gms. Total fluids\nat 150cc/kg/day. Receiving BM30+pm, 37cc on a pump over one\nhour. Tolerating feeds well. Abdomen benign, +bowel sounds.\nGirth stable at 24cm. Voiding and stooling. No spits or\naspirates noted. P:Continue to assess and support\nnutritional status.\n\nDev:Infant maintaining temperatures, swaddled in an off\n. Active and alert for care times, sleeping well\nbetween feeds. Sucking on pacifier well. Appropriate for\ngestational age. Moving all extremities well. P:Continue to\nassess and support growth and development.\n\nPar:Dad in for 2100 feeding. Independent with cares. Took\ntemperature, changed diaper and placed on scale. Very loving\nwith , held her during feed. Asking appropriate\nquestions. Discussed appropriate weight for coming out of\nthe into an open crib. P:Continue to update and\nsupport .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-27 00:00:00.000", "description": "Report", "row_id": 1792134, "text": "Neonatology\nDOL #28\n31 2/7 weeks PMA\nremains in RA (x 48 hours)\nRR=50-70's, mild sc retx.\non caffeine (no spells)\nintermittent murmur, HR=140-170's, BP 71/39 (mean=50)\nwt=1495g (inc 40g), TF=150cc/kg/d BM 30 with Promod gavage over 1 hour\nno spits, minimal aspirates, voiding, stooling\nPE: well appearing, , normal S1S2, soft murmur, breath sounds clear,abdomen soft, nontender, nondistended, ext well perfused. tone aga\n\nImp/Plan: premie infant with resolving AOP, resolving lung disease, growing, murmur soft, doing well\n--continue to monitor murmur\n--monitor for spells\n--HUS this week\n--continue rest of present management\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-15 00:00:00.000", "description": "Report", "row_id": 1792078, "text": "NEonatology- Progress Note\n\nPE: remains in her , nested, in nasal cannula O2, bbs cl=, rrr s1s2no murmur, abd soft, flat, V&S, gavage in place, pale , afso, sutures slightly split, alert\n\nUpdated Dad at bedside\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792079, "text": "NPN\n\n\n#1-O: in nasal cannula, 13-25cc 100% , no spells, RR\n40's-60's, clear and equal , , on caffeine, cont to\nmonitor.\n\n#3-O: on tf 150cc/k/d BM26 = 31cc q 4 hrs PG tol well over\n1' 15\", min aspirates, no spits. abd soft, girths stable,\nactive bowel sounds. voiding qs, no stool this shift. wt up\n25 gms today to 1.220 kg.\n\n#4-o; temps stable in servo , alert and active w /\ncares. , , on sheepskin, cont to assess.\n\n#5-O; no contact this shift, visit daily.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792080, "text": "Clinical Nutrition\nO:\n~29 wk CGA BG on DOL 17.\nWT: 1220 g (+25)(~25th to 50th %Ile); birth wt: 1230 g. AVerage wt gain over past wk ~13 g/kg/day. WT ~1% below birth wt\nHC: 27 cm (~25th to 50th %Ile); last: 27 cm\nLN: 38 cm (~25th to 50th %Ile); last: 37 cm\nMeds include Fe and Vit E\nLabs not due yet\nNutrition: 150 cc/kg/day BM 26, all pg over 75 min feeds due to hx of spits. Projected intake for next 24hrs ~130 kcal/kg/day and ~3.2 g pro/kg/day.\nGI: Abdomen benign. Small occasional spit.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems except occasional small spits. Labs not due yet. CUrrent feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for LN gain. HC and wt gain should improve now that feeds are above minimum recs. continue to increase kcals; will discuss w/ team. WIll continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792081, "text": "Neo Attending\nDay 17 27.2wk GA, 29.5wkPMA\nrespr: FiO2 100%, NC 13-25 cc/ rr 40-60s. SpO2>93%. 1 desat this am.\nS/P indocin. P 150-170s. no murmur.\nHct 29.3%, Retic 3.9.\nWT 1220, up 25,\n150 bm 26 pg over 1hr. Add promod.\nno spits., neg stool.\nuop and stool wnl.\nlytes wnl. On Vit E and Fe.\nTemp stable.\nHUS: gr I bleed.\nSocial: 15 mo old, 47 yr mom.\n\nDiscuss direct donor with family.\n\nAssess: 2+wk. old infant on NC. Anemia.\nPlan as noted above.\n\nPt evaluated and discussed with team.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792082, "text": "Neo Attending\nPE: small well appearing preterm infant nestled in , well perfused on NCO2\n, eyes clear, ng in place. MMMP\nChest is symmetric, clear, eqaul bs\nCG: RRR, soft systolic murmur, LLSB\nPulses=2+\nAbd: soft,a ctive bs\nNeuro: flexed posture, active and responsive\n\n not interested in direct donor. Have consented to transfusion if necessary, discussed issues regarding need for transfusion. Will continue to monitor clinical status and follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792083, "text": "Neo Attending\nPE: small well appearing preterm infant nestled in , well perfused on NCO2\n, eyes clear, ng in place. MMMP\nChest is symmetric, clear, eqaul bs\nCG: RRR, soft systolic murmur, LLSB\nPulses=2+\nAbd: soft,a ctive bs\nNeuro: flexed posture, active and responsive\n\n not interested in direct donor. Have consented to transfusion if necessary, discussed issues regarding need for transfusion. Will continue to monitor clinical status and follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-16 00:00:00.000", "description": "Report", "row_id": 1792085, "text": "Nursing Progress Note:\n#1 - RESP: REmains in Low flow NC - 100% (13-50cc). Lungs\nclear and equal. Mild int/sub retractions. RR(50-70).\nO2Sats >90%. Remains on caffeine. 3 Spells thus far today.\nMild bradys with desats to the 50-60%. Pale to dusky with\napnea. Increased O2 needed. Hct today 29.3 with Retic of\n3.9. Most likely will need to be transfused soon.\n\n#3 - F&N: TF at 150cc/kilo/day = 31cc's q 4 hours of BM26\nwith PM. Tolerating feeds well over 50 min. One small spit\nnoted. Abdomin soft and round. GIrth 20-21cm. Max aspirate\n3cc paritally digested feed. No loops. Good BS. Voiding and\nstooling - yellow seedy stool - Guiac neg. REmains on vit e\nand iron. Lytes this am - 131/5.8/98/21.\n\n#4 - DEV: TEmps stable in servo-controlled . Alert\nand active with cares. Irritable at times. MAE. . 2 week\nHUS - with resolving bilateral Grade 1 bleed. REpeat at one\nmonth.\n\n#5 - : Mom in this afternoon. Updated at the bedside.\nIndependent with cares. Aware that infant will probably need\nto be transfused at some point soon. Updated at bedside by\nRN and NP. Mom eyed today. Given support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-17 00:00:00.000", "description": "Report", "row_id": 1792086, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN NC 25-75CC 100% WITH SATS 90-95%. BS CLEAR.\nRESP RATE 40-74 WITH MILD IC/SC RETRACTIONS. SPELL X1\nOVERNIGHT, SOME PERIODIC BREATHING NOTED WITH QSR DRIFTS\nA:SL INCREASED FIO2 REQUIREMENT WITH MORE DRIFTS\nP:CONTINUE TO MONITOR RESP STATUS CLOSELY\n\n#3F/E/N\nO:TF AT 150CC/KG BM26 W/PROMOD 31CC Q4HR GAVAGE OVER ONE\nHOUR. ABDOMEN SOFT, FULL WITH GOOD BS. 0-4CC NONBILIOUS\nASPIRATES, NO SPITS. VOIDING AND STOOLING WELL, HEME\nPOSITIIVE-- NOTIFIED. WT UP 15GM TO 1235GM (NOW ABOVE BW)\nA:TOLERATING FEEDS/CALS WELL\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, MONITOR WT GAIN\n\n#4G&D\nO:IN SERVO CONTROL WITH STABLE TEMPERATURE.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. NOTED TO BE\nDROWSY/HYPOTONIC WITH FIRST SET OF CARES--IMPROVED WHEN OUT\nON SCALE AND WNL FOR REMAINDER OF SHIFT. FONTANEL SOFT AND\nFLAT; SUTURES SMOOTH. BABY NESTED ON SHEEPSKIN W/BOUNDARIES\nA:AGA\nP:CONTINUE TO SUPPORT AND MONTIOR\n\n#5PARENTING\nO:MOM AND DAD IN FOR 9PM CARES. DID TEMP AND DIAPER\nINDEPENDENTLY. TRANSFERED BABY FROM SCALE TO MOM AND THEN\nBACK TO BED WITH SOME VERBAL CUES. VERY LOVING\nA:LOVING, INVOLVED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-17 00:00:00.000", "description": "Report", "row_id": 1792087, "text": "Neonatology Attending Note\nDOL# 18\nCGA 29 wk\n\nIn NC 25-75 cc\nRR 30-60s\n4 spells, on caffeine\n\nP 150-170s\n\nWt 1235 (up 15)\nOn 150 cc/kg BM26 with PM\n\nIn \n\nResolving Grade I IVH\n\nA: Slowly improving premature infant\nP: Advance cals to day\n Continue to monitor spells on caffeine\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-01 00:00:00.000", "description": "Report", "row_id": 1792154, "text": "Neonatology Attending Progress Note:\nPMA 32 weeks, DOL #3\nremains in RA, RR=40-60's, mild sc retx, on caffeine--no spells\nsoft intermittent murmur, HR=150-170's, BP mean=48\nwt=1615g (inc 10g), TF=150cc/kg/d BM 30 with promod, gavage over 80 minutes, voiding, stooling --heme negative\noff \nImp/Plan: premie infant with AOP, intermittent murmur, tolerating feeds, stable\n--monitor for spells on caffeine\n--monitor murmur\n--monitor weight on current regimen\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-12-12 00:00:00.000", "description": "Report", "row_id": 1792337, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF-140cc/kg/day BM24 made w/ Enfamil Powder.\nInf PO feeding 40-50cc with remainder of feeds PG. \nfeeds well. No spits, no asp. Belly soft, no loops.\nVoiding, . P cont to assess FEN needs.\n4. DEV O/A remains in an OAC with stable temp.\nA/A with cares, sleeping well between cares. P cont to\nassess dev needs.\n5. O/A Mom in for visit and cares. Updates\ngiven. Mom independent with care of infant. P cont to\nsupport, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-12 00:00:00.000", "description": "Report", "row_id": 1792338, "text": " Physical Exam\nAwake and . . Breath sounds clear and equal with no retractions. Soft intermittent murmur audible but faint, normal pulses. Abdomen soft and rounded with active BS, no HSM or masses. Normal GU.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-13 00:00:00.000", "description": "Report", "row_id": 1792339, "text": "Nursing progress note\n\n\n#3 O: Wgt unchanged. Remains on 140cc/k/d BM/E 24. Abd soft\nwith active bowel sounds & no loops. Voiding & .\nMinimal aspirates. Baby had mod spit with burping after 9PM\nfeed. A: PO taken fairly well with bottles. P: Cont to\nassess.\n#4 O: Temp stable in crib. Quietly with cares. PO\nfeeds taken fairly well. A: Stable. P: Cont to assess.\n#5 O: in for 9PM feed. A: independent with cares. P:\nSupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-13 00:00:00.000", "description": "Report", "row_id": 1792340, "text": "Neonatology Attending\n\nDay 75 PMA 38 0/7 wks\n\nRemains in RA. RR 20-40s. Clear breath sounds. No murmur. HR 120-160s. Pale, . BP mean 66. Weight 3200 gms (unchanged). TF at 140 cc/kg/d- BM/E 24. Taking half to full volume po with every feed. Stable temperature in open crib. in daily.\n\nDoing well. Monitoring for apnea. Improving feeding. Needs more mature feeding. Spoke with mother on .\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-09 00:00:00.000", "description": "Report", "row_id": 1792046, "text": "Neonatology Attending\nDOL 10 / PMA 28-5/7 weeks\n\n remains in room air with no distress. On caffeine with no apneas/bradycardias.\n\nNo murmur. BP 74/38 (51).\n\nWt 1110 (+45) on TFI 160 cc/kg/day including enteral feeds PE20/BM20 at 100 cc/kg/day, tolerating well. Abd benign. Urine output 4.1 cc/kg/hr. Stooling normally.\n\nTemp stable in servo . Alert and active.\n\nA&P\n27-2/7 week GA infant with feeding immaturity, bilateral GMH\n-Continue to advance enteral intake by 10 cc/kg/day as tolerated\n-Monitor for respiratory maturity on caffeine\n-Discontinue PN today\n-Repeat cranial ultrasound in one week\n" }, { "category": "Nursing/other", "chartdate": "2189-10-09 00:00:00.000", "description": "Report", "row_id": 1792047, "text": "Nursing Progress Note\n\n\n#1 Resp: RA, 50-70's, lungs clear, ic/sc retractions. No\nspells, on caffeine. Cont. to monitor. #3 FEN: TF\n160cc/kg/day. Enteral feeds of BM/PE20@ 100cc/kg, feeds\ngavaged over 30 minutes. No spits, abd soft, no loops,\nactive bs, voiding 3.6cc/kg/hr. Heme neg stool x2.\nAG19.5-20.5. Stable. Advance feeds 10cc/kg as tolerated.\n\n#4 DEV: temps are stable in servo . She is\nactive/alert w/cares. Sleeps well in prone position. MAE,\nfontanels soft/flat. AGA. Cont. to support dev. needs. #5\nParenting: Dad in to visit in between cares. Updated at\nbedside by RN. Understands baby's need for sleep in between\ncares. Loving parent. Cont. to support. See flowsheet for\nfurther details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-09 00:00:00.000", "description": "Report", "row_id": 1792048, "text": " Physical Exam\nPE: pinik, mild jaundice, AFOF, sutures override, breath sounds clear/equal with mild retracting, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, non tender, + bowel sounds, active.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-10 00:00:00.000", "description": "Report", "row_id": 1792049, "text": "1. Resp: O: Infant is in RA w/ RR 40-60s, occasionally 80s,\nclear ls, color, no spells. She is on caffeine. A:\nStable in RA. P: Monitor. Meds as ordered.\n\n3. F/N: O: INfant is on 160cc/k/d TF, working up on feeds.\nShe is currently at 110cc/k/d of pg feeds of BM/PE, q 4\nhours via gavage. Abd is benign. She voided 2.9cc/k/hr and\nhas been having g- stools. She gained 45g. A: Tol w/u on\nfeeds so far. P: Continue w/ plan.\n\n4. G/d: O: Infant is nestled on a sheepskin w/ bounderies,\non servo in a heated . She is active w/ cares and\nsleeps well in between. A/P: Continue to support infant\nneeds.\n\n5. : O: were in for the 9p cares. They took\nturns taking the temp, and changing the diaper. Mom held\ninfant briefly while her bed was being changed. A: Loving\n. P: Continue to support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-10 00:00:00.000", "description": "Report", "row_id": 1792050, "text": "Neonatology Attending Progress Note:\nDOl #11\nPMA 28 6/7 weeks\nremains in RA, RR=50-70's, clear/equal\n2 brady's in 24 hours, on caffeine\nno murmur, HR=150-160's BP 70/30 (mean=47)\nwt=1155g (inc 45g), TF=160cc/kg/d feeds at 120cc/kg/d PE 20/BM\nvoiding, stooling heme negative\ndstx=113\nImp/Plan: premie with AOP, on caffeine, advancing on feeds, doing well.\n--continue to advance feeds 10cc/kg \n--monitor for spells on caffeine\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-10-27 00:00:00.000", "description": "Report", "row_id": 1792135, "text": "Nursing Progress Note 0700-1900\n\n\nResp O/A: Remains in RA. Placed on NC, 25cc, x30 mins today\nwhile mom holding and feed infusing for drifts to mid-low\n80s; otherwise, occasional self-resolved drifts at rest, no\nspells noted. Lungs clear and equal. Mild sc retractions.\nRemains on caffeine. P: Continue to monitor for A/B/D's and\nadminister caffeine as ordered.\n\nFEN O/A: TF 150cc/k/d BM30 with promod, = 37cc q4h, gavaged\nover 1 hour. Abdomen full, soft, , no loops, girths 23cm\nthis shift. Active bowel sounds. Minimal aspirates. 1 small\nspit. Voiding qs, stooling heme negative. Remains on iron\nand Vitamin E. P: Continue to monitor nutritional status,\nadminister iron and Vit E as ordered. Check nutrition labs\nin a.m. on .\n\nG&D O/A: Temps stable, swaddled in off throughout\nthis shift. At 1700, transferred to OAC for T 98.9.\nSheepskin present. AGA. MAE. Font s/f. Active/alert with\ncares. Continues with small amount clear right eye drainage\nthis shift, cleansed with sterile water. P: Continue to\nmonitor and support normal infant development. Scheduled for\nhead ultrasound on Thurs.\n\nParenting O/A: Mom at bedside, participating in cares.\nUpdated by this RN. Invested and appropriate. Held infant\nx1. Plans to return with dad this evening. P: Continue to\nupdate, educate, and support NICU .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-13 00:00:00.000", "description": "Report", "row_id": 1792209, "text": "Neonatology Attending Progress Note:\nDOL # 45\nPMA 33 5/7 weeks\nremains in RA, RR=40-60's, mild retx, no spells\nno significant desats\nintermittent murmur\nHR=140-160's, BP mean=48\ncrit=24.8%, retic=12.8%\nwt=2115g (inc 55g), TF=150cc/kg/d, BM 28 with promod gavage over 1 hour, no spits, minimal aspirates, voiding\nPE: well appearing, , normal S1S2, no murmur appreciated today, breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused. tone aga.\nvitamin E and iron\nImp/Plan: premie infant tolerating full feeds, intermittent murmur, anemia of prematurity with great reticulocytosis, stable.\n--monitor weight on current regimen\n--christening on Saturday\n--monitor crit in setting of excellent retic count\n--monitor murmur\n--monitor for spells\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-13 00:00:00.000", "description": "Report", "row_id": 1792210, "text": "PCA Progress Note 0700 - 1900\n\n\nFEN - Pt tolerating feeds well with no spits and minimal\naspirates thus far. Belly is benign with good BS and no\nvisible loops. V&S heme negative.\n\nDEV - Temps remain stable swaddled in an off . A&A\nwith cares and settles well in between. Does not wake for\nfeeds. Brings hands to face and sucks on pacifier for\ncomfort. Fonts remain soft and flat.\n\nPAR - Mom in for second care. Asking appropriate questions\nand acting loving and caring. Mom held infant and tried to\nbreastfeed. Baby did not latch on very well but did have a\ngood suck reflex. Mom was updated by RN.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-13 00:00:00.000", "description": "Report", "row_id": 1792211, "text": "Nursing\nI have read and agree with above note. Spoke with mom who is exited about Christening tomorrow. Mom offered lactation consult- will sign up.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-31 00:00:00.000", "description": "Report", "row_id": 1792152, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~30-60's, no increase work of breathing noted. LS clear/=.\nShe has mild SC retractions. No A&B's noted this shift thus\nfar. A: Pt. remains stable in RA. P: Continue to monitor\nrespiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM30w/PM =40cc Q 4hrs,\ngavaged over 90min, tolerated well. Abdomen is soft, ,\n+bs, no loops/spits noted. Abdominal girth is ~23-24cm.\nShe is voiding well, no stool passed this shift thus far.\nA: Pt. is tolerateing current nutritional plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance.\n\n#4. Growth/Development O: Pt. remains in an off ,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. O: in to visit for afternoon cares.\nThey were updated at bedside on pt's current status and\ndaily plan of care. are independent in cares,\nasking appropriate questions. A: are loving and\ninvolved. P: Continue to update, support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-01 00:00:00.000", "description": "Report", "row_id": 1792153, "text": "NPN 1900-0700\n\n\nRESP: Infant remains stable in Ra. RR40-60's > 93%. Lungs\nare clear and equal w/mild scr noted. No apnea, bradys or\ndesat thus far this shift. Remains on caffeine. A: Stable in\nRa. P:Continue to monitor resp status.\n\nFEN: CW1615g( ^10g). TF 150cc/k/d of BM30 w/pm (40cc q4hr pg\n90 min.) Abdomen soft with active bowel sounds. No loops, No\nspits. Max aspirate 3.2cc of partially digest breastmilk. AG\n24.5-25. Infant voiding with each diaper change. Two heme\nneg stools thus far this shift. A: Tolerating current\nfeeding regimen, gaining weight. P: Continue per nutritional\nplan.\n\nDEV: Infant remains swaddled in an off . Temps\nstable. and active w/cares. Settles well inbetween\ncares. Brings hands to face for comfort, occ enjoys\npacifier. , . A: AGA P: Continue to support\ndevelopmental needs.\n\n: Both in for the 2100 care. Both were very\nindependent w/cares, assisted in weighing. Asked appropriate\nquestions regarding baby. Updated by this rn. Will be in to\nvisit later today. A: Involved, loving, appropriately\nconcerned. P: Continue to update,educate, support parental\nneeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-19 00:00:00.000", "description": "Report", "row_id": 1792234, "text": "NICU Fellow Note\nExam\nGeneral - comfortable appearing in crib\nHEENT - AFOS, MMM\nLungs - clear with good air entry b/l\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended\nExtremities - hyperpig lesion R lower ext, WWP\n" }, { "category": "Nursing/other", "chartdate": "2189-11-19 00:00:00.000", "description": "Report", "row_id": 1792235, "text": "Nursing Progress Note\n\n\n3. Feeds 150cc/kg/d of BM26cal with promod. Fed by gavage\non pump over one hour. Mom in, put infant to breast,\nlatched on briefly but has difficulty with size.\nAbdomen soft, good bowel sounds, large yellow stool.\nVoiding well. A. Feeding and growing. P. Alternate po/pg\nas tolerated.\n4. Awake and for feeeds, sleeps in between.\nInteractive with mom and caregivers. . A.\nAppropriate. P. Support.\n5. Mom in at 1300, did all care. Dad will be in at 2100 to\nbottle feed. A. Invested family. P. Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-01 00:00:00.000", "description": "Report", "row_id": 1792155, "text": " ON-CALL\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant swaddled in , room air\nSkin: warm and dry; color \nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR without murmur; normal S1 S2; pulses +2\nABd: soft; no masses; + bowel sounds\nExt moving all\nNeuro: symmetric tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2189-11-01 00:00:00.000", "description": "Report", "row_id": 1792156, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains in RA, O2 sats ~ 95-100%.\nRR ~30-60's, no increase work of breathing noted. LS\nclear/=. She has mild SC retractions noted. No A&B's noted\nthis shift thus far. She is on Caffeine. A: Pt. remains\nstable in RA. P: Continue to monitor respiratory status.\nMonitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM30 w/PM =40cc Q 4hrs,\ngavaged over 80 min., tolerated well. Abdomen is soft,\n, +bs, no loops/spits noted. Abdominal girht is\n~24.5cm. She is voiding, stooling QS. A: Pt. is\ntolerateing current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance.\n\n#4. Growth/Development O: Pt. remains in an off ,\nswaddled w/ stable temps. She is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. O: in to visit this afternoon for\ncares and were updated at bedside on pt's current status and\ndaily plan of care. are active and independent in\ncares, asking appropriate questions. A: Family is loving\nand involved. P: Continue to update, support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-21 00:00:00.000", "description": "Report", "row_id": 1792240, "text": "NPN 7pm-7am\n\n\nFEN: Current weight 2495gms up 90gms. TF 150cc/kg/day of BM\n26 with promod = 62cc's q4hrs. Infant is attempting to\nbottle every other feeding. At 9pm Mom gave bottle and\ninfant took 20cc's with remainder gavaged. At 1am infant was\ngavaged over 1hr. Abd soft, +bs, no loops. Voiding and no\nstool. No asp, no spits. A: Learning to bottle. P: will cont\nto monitor weight and exam.\n\nG/D: Infant is in open crib, swaddled. Temp stable. \nand active with cares. Sucks on pacifier. MAE. Fonts soft\nand flat. A: AGA P: Will cont to support dev needs.\n\n: were in for 9pm cares. They took temp and\nweighed infant. Mom offered infant bottle, is nervous. She\ndid very well. Dad held infant during gavage feed. A: loving\nand involved . P: Will cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-21 00:00:00.000", "description": "Report", "row_id": 1792241, "text": "Neonatology\nDOing well. REmains in RA. No spells. Comfortable apeparing. No mumur.\n\nWt 2495 up 90. Tolerating feeds at 150 cc/k/d of 26 cal. A bdomen benign. STill requiring gavage\n\nActive on exam. Skin w/o leisons. ABdomen benign. Cor nl. Neuro non-focal and age aprpopraite. Movingh all 4.\n\nCOntinue a sat present.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-05 00:00:00.000", "description": "Report", "row_id": 1792029, "text": " Procedure Note\nLP Procedure. Time out done with bedside nurse. Premedicated with Sucrose Pacifier. Prepped and draped. Sterile spinal needles inserted 2 times, both bloody fluid that didn't clear to CSF. Will plan to repeat the LP soon. Tolerated will by the infant.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-05 00:00:00.000", "description": "Report", "row_id": 1792030, "text": "Neonatal NP-Procedure Note\n\nProcedure: Lumbar Puncture\nIndication: R/O meningitis\n\nTime out observed. Informed consent in chart. Infant positioned and back prep'd with betadine. #24 guage introducer utilized to cannulate L4-L5 intraspace for bloody CSF, collected 2ml. Sent to lab for analysis.\n\nInfant tolerated procedure well.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-20 00:00:00.000", "description": "Report", "row_id": 1792105, "text": "NICU PCA Note\n\n\n1. Resp: O/ Pt on NC, 100% O2 at 25 cc. RR 40-80's. Lung\nsounds C/E bilaterally. Mild intercostal/subcostal\nretractions. No spells. Oxygen saturations >= 94% throughout\nshift. (Please refer to flowsheet for additional Resp info).\nA/ Pt remains stable throughout shift. P/ Cont with caffeine\nregimen; cont to monitor Resp status.\n\n3. FEN: O/ Abdomen benign. No spits. Maximum aspirate 2.2\ncc. Girths 22 cm. Voiding/stooling - hemoccult negative. All\nfeeds by gavage, over 1 hour. (Please refer to flowsheet for\nadditional FEN info). A/ Pt remains stable throughout shift.\nP/ Cont with vitamin E and iron regimen; cont to monitor FEN\nstatus.\n\n4. G/D: O/ Temp stable in covered air . Alert and\nactive. MAE. Wakes for feeds, sleeps between cares. Fonts\nS/F. Yellowish exudate from right eye, cleared with warm\nsoaks. (Please refer to flowsheet for additional G/D info).\nA/ Pt remains stable throughout shift. P/ Cont with\nerythromycin regimen to eyes; cont to monitor G/D status.\n\n5. Parenting: O/ Mother present for 1300 cares, plans to\nreturn for 2100 cares. A/ loving, capable, and\nappropriate. P/ Cont to educate and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-20 00:00:00.000", "description": "Report", "row_id": 1792106, "text": "I have read and agree with above note. I spoke with mom about head ultrasound results. Mom would like to speak with neonatoloy tonight when dad is here.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-21 00:00:00.000", "description": "Report", "row_id": 1792107, "text": "NPN\n\n\n#1\nInfant remains in N/C 100%; 25cc with sats mid/high 90s. BS\nclear= with mild retractions. No drifts or spells noted.\nColor is pale ; murmer not audible.\n\n#2\nInfant remains on TF=150cc/k of BM30 with promad q4 hours\nvia gavage. Infant has tolerated feeds well without spits\nand small non-bilious aspirates. Abd is soft and round;\nvoiding and trace stool x1. Wt is up 50gms-1345.\n\n#4\nInfant had dropped her temp x1 on eves and placed back on\nservo. Since then, infant's temp has been stable and infant\nplaced back in an air nestled in sheepskin with\nboundaries. Infant is alert with cares. Right eye with\nyellow drainage- e-mycin ointment given as ordered.\n\n#5\nNo contact noted from thus far tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-21 00:00:00.000", "description": "Report", "row_id": 1792108, "text": "Attending Note\nDay of life 22 PMA 30 \nnasal cannula 25-50 cc of 100% FiO2 RR 50-70's on caffeine\nHR 140-160's pale BP 68/44 mean 51\nweight 1345 up 50 on 150 cc/kg/day of BM 30 cal/oz with promod pg no spits no aspirate\nvoiding and heme negative stool\nin air mode \nyellow eye drainage getting erytho eye ointment day \n\nImp-stable making progress\nwill continue current management\n" }, { "category": "Nursing/other", "chartdate": "2189-10-21 00:00:00.000", "description": "Report", "row_id": 1792109, "text": "PCA Progress Note\n\n\nRESP - Pt remains stable on O2 (NC 100% 25cc). Lung sounds\nare clear and equal with mild subc/IC retractions.\n\nFEN - Pt tolerating feeds well with one spit thus far and\nminimal aspirates. Abd is benign with good BS, no visible\nloops, and stable girth. Voiding and Stooling heme negative.\n\nDEV - Temps remain stable swaddled in an air .\nDrowsy with cares and settles well in between. Does not\nwake for feeds. Brings hands to face for comfort.\n\nPAR - Mom in for second care. Mom was able to change diaper\nwithout difficulty. Asking appropriate questions, acting\nloving and caring. Plans to be back tonight with dad to\nhold the baby.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-05 00:00:00.000", "description": "Report", "row_id": 1792175, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM28w.PM. All feeds PG\nover 1 hour. Tol well. No spits, min asp. Belly soft, no\nloops. Voiding, stooling. P cont to assess FEN needs.\n4. DEV O/A remains swaddled in an off with\nstable temp. A/A with cares, sleeping well between cares.\nP cont to assess dev needs.\n5. O/A Mom in for visit and cares. Updates\ngiven. Mom independent with care of infant. P cont to\nsupport, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-06 00:00:00.000", "description": "Report", "row_id": 1792176, "text": "NPN 1900-0700\n\n\nFEN: CW 1815g (up 55g). TF 150cc/k/day BM28 with PM.\nTolerating PG feeds well over 1hr. No spits, max asp 1.2cc.\n Abd soft, round, no loops, active BS. AG= 24.5-25cm.\nVoiding QS, trace stools.\n\nDEV: Maintaining temps while swaddled in off . A/a\nwith cares, sleeps well btwn. Loves pacifier, moves hands\nto face, roots to fingers. , , AGA.\n\nPAR: in to visit for 2100 cares. Updated at\nbedside by this RN. Asking approp questions. Independant\nwith cares. Pleased with infants weight gain to 4lbs! Mom\nheld infant x60min; TW. Mom plans to be back for 1300 cares\ntoday. Continue to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-06 00:00:00.000", "description": "Report", "row_id": 1792177, "text": "Neonatology Attending Progress Note:\nDOL #38\nPMA 32 5/7 weeks\nremains on RA, RR=20-60's, occasional drifts to 80's, on caffeine\nwt=1815g on 150cc/kg/d BM 28 with promod\nno spits, iron and vitamin E\nImp/Plan: premie infant tolerating full feeds, AOP-mild.\n--will d/c caffeine, monitor for spells\n--encourage po feeds, monitor weight\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-06 00:00:00.000", "description": "Report", "row_id": 1792178, "text": "NICU Fellow Note\nExam:\nGeneral - comfortable in \nHEENT - AFOS, MMM\nLungs - CTA b/l with good breath sounds\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended\nExtremities - WWP\n" }, { "category": "Nursing/other", "chartdate": "2189-11-06 00:00:00.000", "description": "Report", "row_id": 1792179, "text": "NPN 0700-1900\n\n\n#3FEN: TF 150cc/kg/d of BM 28 w/pm= 45cc NG Q 4hrs gavaged\nover 1hr. Tolerating feeds well, no spits, min asp. Abd\nsoft & round, +BS, no loops. AG stable. Infant voiding &\nstooling, guaic neg. Continues on vit E & FeSo4. P:cont to\nmonitor FEN.\n\n#4DEV: Temps stable swaddled in off . Pt. awake &\n for cares. Settles well in between w/ pacifier. MAE.\n. AGA. P: Cont to support dev needs.\n\n#5Parenting: Mom in @ 1pm for cares. Mom asking \nquestions. Updates given. Mom held during feeding. P:\ncont to support & update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-07 00:00:00.000", "description": "Report", "row_id": 1792180, "text": "NPN\n\n\n#3F/N O- remains on feeds of BM28cal with promod at\n150cc/kg. Gavages given over 1 hour. No spits or aspirates\nnoted. Voiding and passing soft yellow stool. Wt.up 45 gms\nto 1860. A- Good wt. gain P- As per team.\n#4Dev. O- Temps remain stable in off . Infant\ndressed and swaddled. Infant and active at care times.\nInfant sucking on thumb/pacifier.A- AGA now 32 P-\nSupport dev.\n#5Family Dad in to visit for PM care. Dad able to take temp\nchange diaper and help weigh infant. A-Loving family updated\nwith status P- Teach as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-25 00:00:00.000", "description": "Report", "row_id": 1792260, "text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 57.\nWT: 2625 g (+40)(~50th to 75th %ile); birthwt: 1230 g. Average wt gain over past wk ~41 g/day.\nHC: 32.75 cm (~50th to 75th %Ile); last:29 cm\nLN: 44.5 cm (~25th to 50th %Ile); last: 43 cm\nMeds include Fe and Vit E\n not needed\nNutrition: 140 cc/kg/day BM 26, po/pg over 80 min feeds due to hx of spits. Infant po's w/ almost q feed, but tires easily and takes only ~5 to 40 cc po. Feeds just decreased today due to good wt gain. PRojected intake for next 24 hrs ~121 kcal/kg/day and 3 g pro/kg/day.\nGI: ABdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. not needed. Just starting to learn po feeding skills. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is exceeding recs for all parameters; volume of feeds decreased today in response and due to spits. WIll continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-25 00:00:00.000", "description": "Report", "row_id": 1792261, "text": "Daily PE\nGeneral: Well appearing in NAD.\nSkin: Clear.\nHEENT: AFOFS, MMM.\nCV: RRR, no murmur on todays exam.\nRESP: CTA bilaterally, good air entry.\nAdbomen: Soft NT/ND, no masses, good bowel sounds.\nGU: normal female.\nNeuro: non focal exam.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1792262, "text": "NPN 1500-2300 \n\n\nTF 140ml/kg/day. Infant had full gav at 1900 and attempted\npo for dad at 2100 taking 25ml then needing pg to finish\nvolume. When infant po fed she was well coordinated and\nsucked vigorously but lacked the stamina to finish. Voiding\nand stooling qs. Weight up 55 gm. EBM26. ABd benign, soft.\nCont current feeding regime. ALt po/pg as tol.\nIn OAC w/ stable temp. Wakes for feeds. Active and \nw/cares. Cont to promote optimal G+D.\n in for 2100 feeding. Gave infant a tub \nindependently. Dad fed infant po. Asking appropriate\nquestions. Cont to support toward discharge.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1792263, "text": "Nursing Progress Note\n\n\n#3 O: weight 2.680 up 55gms. on TF 140cc/k/d BM26. all feeds\npg tonight as infant sleepy, tol well w/o spits or asp. abd\nbenign, vdg qdiaper, stools guiac neg,Ferinsol as ordered.\nA: tol feeds well P:offer po when more awake.\n#4 O: temps stable swaddled in open crib. sleepy/\nw/cares, no po tonight. A: AGA P: encourage po feeds,\nsupport developmentally\n#5 O: no contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 1792264, "text": "Neonatology Attending\n\nDay 58 PMA 35 wks\n\nRemains in RA. RR 30-60. Clear breath sounds. Mild retractions. Soft murmur. HR 130-160. BP mean 47. Weight 2680 gms (+55) BM 26 at 140 cc/kg/d. Occasional spits. Taking about half volume feeds. Stable temperature in open crib.\n\nAdequate breathing control. Monitoring for apnea. Gaining weight well. Encouraging po feeds. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-16 00:00:00.000", "description": "Report", "row_id": 1792353, "text": "Neonatology Attending\n\nDay 78 PMA 38 wks\n\nRemains in RA. RR 30-50s. Mild retractions. No murmur. HR 130-160s. BP mean 64. Weight 3330 gms (+35). Taking BM/E24 at 140 cc/kg/d. Taking majority of feeding volume. Stable temperature in open crib.\n\nDoing well overall. Will continue to monitor. Gaining weight well. Will change to minimal volume feeds at 130 cc/kg/d. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-16 00:00:00.000", "description": "Report", "row_id": 1792354, "text": "Clinical Nutrition:\nO:\n~38 week CGA BG on DOL 78.\nWT: 3330g(+35)(~75th %ile); BWT: 1230g. Average wt gain over past week ~31g/day.\nHC: 35cm(75-90 %ile); last: 35cm\nLN: 50.75cm(75-90%ile); last: 48cm\nMeds include MVI & Fe.\n not needed.\nNutrition: ADLIB/MIN. 130cc/kg/day as BM 24 (4kcal/oz Enf powder); all po's. Projected intake for next 24hrs based on average of past 3-day intake ~144cc/kg/day, providing ~115kcal/kg/day & ~1.9g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; all po's. not needed. Current feeds & supps meeting weaned recs for kcal/vits/mins but not quite of ~2.2g pro/kg/day but gaining WT well & now adlib, thus will likely take more volumes. Growth is meeting recs for WT gain. HC gain is not meeting recs of ~0.5-1cm/wk & LN gain is exceeding recs of ~1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-16 00:00:00.000", "description": "Report", "row_id": 1792355, "text": "NCIU fellow note\nWell appearing infant in NAD.\nVSS.\nWt 3330 gm\n, MMM, NG tube in place.\nRRR, no murmur, well perfused.\nCTA bilaterally, good air entry.\nSoft, NT/ND, no masses, active bowel sounds.\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-16 00:00:00.000", "description": "Report", "row_id": 1792356, "text": "Nursing Progress Note\n\n\n3. Feeds BM24/E24 changed to ad lib demand schedule with\n130cc/kg/d minimum. Infant pulled ng tube out. All feeds\npo, bottled well taking 50-60cc q3-4hrs. One medium spit.\nAbdomen beingn. Voiding and qs. Bottom slightly\nred, desitin applied. A. Bottle feeding well, taking\nminimum requirement. P. Continue ad lib with minimum.\n4. Awake q3-4hrs, does not cry for feeding but wakes and\nroots. Temp stable in open crib. and active with\ncares. A. Doing well. P. Support developmentally.\n5. in at staggered feeding times today. Will be in\nlater tonight also. Happy with demand schedule. Understand\nthis is a trial and infant may not be able to make minimum.\nA. family. P. Support and involve in all aspects\nof care and planning.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-17 00:00:00.000", "description": "Report", "row_id": 1792357, "text": "1900-0730\n\n\n1. FEN O: Abdomen soft, examination unremarkable. Ad lib\nfeeds, taking 80cc q4h. Small spit x1 when multivitamins\nand Fe given. Voiding and with diaper changes.\nWgt: 3.330k A: Improved PO intake on demand feeds P:\nMonitor for feeding intolerance.\n4. G&D O: Active and with cares. Sucks pacifier\neagerly. Temp wnl in open crib. No s/s pain or discomfort.\nA: Apprpriate P: Monitor. Comfort measures.\n5. PARENTING O: Mom called and updated. Will call back\nin am. in to visit at 2100. Explained to that\ninfant is now on demand schedule. A: P:\nSupport and update. Encourage to ask questions and voice\nconcerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-25 00:00:00.000", "description": "Report", "row_id": 1792129, "text": "NPN 0700-\n\n\n1. Remains in RA with sats 93-100%. Occassional desats to\n70-80's, less while in prone position. Lungs clear. RR\n30-60's with mild SC retractions. No A&B's thus far.\nStable in RA with occassional desats. Continue to monitor\nfor A&B/desats.\n\n3. TF 150cc/k/d BM30 w/PM. Abdomen benign. Voiding and\nhaving heme negative stools. 2 small spits thus far. No\naspirates. Tolerating NGT feeds gavaged over 1hr. Continue\nto monitor feeding tolerance.\n\n4. Temp stable swaddled in air . Awake and active\nwith cares. MAE, brings hands to face. Tolerated kangaroo\ncare today. Continue to promote development.\n\n5. in to visit, updated on plan of care. \nindependent with infant cares. Mom able to kangaroo with\n today. planning to visit for 1700 cares.\nInvested . Continue to support, update, and educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-26 00:00:00.000", "description": "Report", "row_id": 1792130, "text": "NPN\n\n\n#1-O; in RA, rr 30's-50's, mild ic/sc retractions, clear and\nequal, no spells, no drifts. remains on caffeine.\n\n#3-O; on tf 150cc/k/d enteral feedings of BM30/pm = 36cc q 4\nhrs PG over 1 hr, tol well, no spits, abd soft, benign,\nvoiding qs, stooling soft yell, heme neg. min aspirates. wt\nup 30 gms today to 1.455 kg. Lytes, hct and retic pending\nthis am.\n\n#4-O; temps stable , swaddled in air , weaned air\ntemp x 1, , , sucking briefly on paci, alert and\nactive w/ cares, comfortable bewteen cares, cont to assess.\n\n#5-O; no contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-26 00:00:00.000", "description": "Report", "row_id": 1792131, "text": "Neonatology Attending Progress note:\nDOl #27\nPMA 31 1/7 weeks\nremains in RA now (in/out oxygen past 24 hours), RR=30-60's, mild ic/sc retx\non caffeine\nHR=150-170's, mean=50\ncrit=26.9%,\nwt up 30g 1455g, Bm 30 with promod, feeds gavaged over 1 hours, no spits/minimal aspirates\nvoiding, stools heme negative\n135/5.2/99/23\noff , stable temp\n\nPE: well appearing, , normal S1S2, murmur appreciated, loudest in axilla, breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused. tone aga.\n\nImp/Plan: premie infant with residual lung disease, AOP-on caffeine, PG feeds, intermittent murmur, doing well\n--continue to wean from oxgyen\n--monitor for spells\n--monitor murmur\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-10-26 00:00:00.000", "description": "Report", "row_id": 1792132, "text": "Nursing Progress Note\n\n\n1. Resp O/A Rec'd inf in RA. Inf remains in RA. Inf to\nNC 13cc for 1X PG feed today for drifting to 80's. No spells\nthus far, on caffeine. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of BM30w/PM. All feeds PG\nover 1 hour. Tol well. No spits, min asp thus far. Belly\nsoft, no loops. Voiding, stooling. P cont to assess FEN\nneeds.\n4. DEV O/A is in an off wtih stable temp.\n A/A with cares, sleeping well between cares. Kangaroo with\nMom today. P cont to assess dev needs.\n5. O/A Mom in for visit and cares. Updates\ngiven. Mom independent with care of infant. P cont to\nsupport, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-14 00:00:00.000", "description": "Report", "row_id": 1792212, "text": "NICU NPN\n\n\n3. F/N: INFANT REMAINS ON TF OF 150CC/K/D OF BM28W/PM\nTAKING 53CC Q4HOURS VIA GAVAGE OVER 1 HOUR. NO SPITS,\nMINIMAL ASP. ABD , VOIDING/STOOLING. A: +WT GAIN ,\nTOLERATING FEEDS P: CONT. PER FEEDING PLAN. MOM PLANNING\nTO OFFER BREAST 1XDAY, NEEDS LACTATION CONSULT.\n\n4. G/D: TEMP. STABLE IN OFF . INFNAT QUIETLY AWAKE\nAND W/CARES, SLEEPING WELL BETWEEN. DAD GAVE INFANT A\n TONIGHT WITH MINIMAL ASSIST FROM NURSING. INFNAT\nTOLERATED WELL. FAMILY PLANNING TO HAVE CHRISTENING\nTOMORROW AFTERNOON AT 4:30 IN FAMILY ROOM. A: STABLE G/D P:\n CONT. TO SUPPORT G/D.\n\n5. : DAD IN TO VISIT AND PARTICIPATED IN CARES.\nHELD INFANT X1HOUR WHILE FEED WENT IN. INVOLVED AND LOVING\n. A: STABLE P: CONT. TO SUPPORT AND TEACH .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-14 00:00:00.000", "description": "Report", "row_id": 1792213, "text": "Neonatology Attending\n\nNow day of life 46, CA 6/7 weeks.\nIn RA with RR 40-60s.\nNo apnea and bradycardia.\nHR 140-170s\n\nWt. 2160 up 45gm on 150ml/kg/d of MM28 with Promod\nFeedings well tolerated by gavage - breastfeeding has just started.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current managment with encouragment of breastfeeding.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-02 00:00:00.000", "description": "Report", "row_id": 1792292, "text": "Clinical Nutrition:\nO:\n~36 week CGA BG on DOL 64.\nWT: 2885g(+50)(50-75 %ile); BWT: 1230g. Average wt gain over past week ~37g/day.\nHC: 33.75cm(75-90 %ile); last: 32.75cm\nLN: 46.5cm(25-50 %ile); last: 44.5cm\nMeds include Fe & Vit.E\n not needed.\nNutrition: 140cc/kg/day as BM 26; po/pg. Average of past 3-day intake ~141cc/kg/day, providing ~122kcal/kg/day & ~3g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; /pg & took ~10cc, ~15cc po. not needed. Current feeds & supps meeting recs for kcal/pro/vits/mins. HC gain is meeting recs. Growth is exceeding recs of ~20-35g/day for WT gain & of ~1cm/wk for LN gain; consider decreasing kcals & changing HMF to Enfamil powder if continues to gain excess WT in the next few days. Will continue to follow w/ team & participate in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-02 00:00:00.000", "description": "Report", "row_id": 1792293, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg/day of BM26. Inf offerred PO\nevery feed. Inf BF very well today. Tol feeds well, no\nspits, min asp. Belly soft, no loops. Voiding, stooling.\nP cont to assess FEN needs.\n4. DEV O/A remains in an OAC with stable temp.\nA/A with cares, waking for feeds. P cont to assess dev\nneeds.\n5. O/A Mom in for visit and cares. Updates\ngiven. Mom independent with care of infant. Discussing D/C\ncriteria. P cont to support, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-20 00:00:00.000", "description": "Report", "row_id": 1792236, "text": "NPN NIGHTS\n\n\nFEN: 150cc/kg/d of BM26 with promod. 60cc gavaging over 1 hr\nor bottling qshift. Bottled 25cc with parent at 9pm. Gavaged\nfeeding #2. No spits so far this shift. Max asp of 6cc\nbreastmilk- refed. Abd soft. No stool so far this shift,\nvoiding QS. P: cont to offer bottle to infant as she will\naccept and monitor tolerance of feeds.\n\nDev: OAC, swaddled, maintaining temp well. in at\n9pm and bathed infant. Infant tol well without temp\ndrop. Puts hands to face and sucks pacifier. Pacifier given\nwhile gavaging feeds.\n\nParenting: supportive of baby and each other.\nIndependent with cares and as observed by PCA. Did not\nspecify when they would return but will enc phone\ncalls/visits.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-20 00:00:00.000", "description": "Report", "row_id": 1792237, "text": "Neonatology Attending Progress Note:\nDOL #52\n34 5/7 weeks PMA\nwt-2405g (in25g), intermittent murmur, HR=160-170's\nRA, RR=40-60's, no spells\nTF=150cc/gk/gd BM 26 with promod, improved pos\nvoiding, heme negative\nImp/Plan: premie infant learning to po feed, intermittent murmur, doing well\n--monitor weight, encourage po feeds\n--monitor for murmur\n--continue rest of present management\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-20 00:00:00.000", "description": "Report", "row_id": 1792238, "text": "NICU Fellow Note\nExam:\nGeneral - comfortable appearing in crib\nHEENT - AFOS, MMM\nLungs - clear with good air entry b/l\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended, normoactive bowel sounds\nExtremities - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-11-20 00:00:00.000", "description": "Report", "row_id": 1792239, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM26w/PM. Inf PO fed 15cc,\n6cc respectively, with remainder of feed gavaged. Tol feeds\nwell. No spits, min asp. Belly soft, no loops. Voiding,\nstooling. P cont to offer PO feeds as tol.\n4. DEV O/A remains in an OAC with stable temp.\nA/A with cares, sleeping well between cares. P cont to\nassess dev needs.\n5. O/A Mom in for visit and cares. Updates given.\n Mom discouraged with BF, lact consult scheduled for .\nP support, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-09 00:00:00.000", "description": "Report", "row_id": 1792322, "text": "Clinical Nutrition:\nO:\n~37 week CGA BG on DOL 71.\nWT: 3115g(+100)(50-75 %ile); BWT: 1230g. Average wt gain over past week ~33g/day.\nHC: 35cm(~90th %ile); last: 33.75cm\nLN: 48cm(50-75 %ile); last: 46.5cm\nMeds include Fe & MVI\n not needed.\nNutrition: 140cc/kg/day as BM 24 (4cal/oz Enf powder); po/pg. Average of past 3-day intake ~141cc/kg/day, providing ~113kcal/kg/day & ~1.9g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; /pg & takes volumes. not needed. Current feeds & supps meeting weaned recs for kcal/vits/mins but not quite of ~2.2g pro/kg/day but gaining good WT. Growth is meeting recs for WT gain. HC/LN gains exceeding recs of ~0.5-1cm/wk for HC gain & of ~1cm/wk for LN gain. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-21 00:00:00.000", "description": "Report", "row_id": 1792242, "text": "NPN 0700-1900\n\n\nFEN: Infant remains on a TF 150cc/k/d of BM26 w/pm (62cc\nq4hrs pg 60min) Alt po/pg. Infant bottled at 1300, she was\nwell coordinated, took 25cc's prior to tiring. Abdomen soft\nwith active bowel sounds. No loops, No spits. Voiding with\neach diaper change. No stool thus far this shift. Continues\non Vit E and FE. A: Tolerating current feeding regimen,\nlearning to po. P: Continue per nutritional plan.\n\nDEV: Infant remains swaddled in an OAC. Temps stable. \nand active with cares. Settles well inbetween cares. Brings\nhands to face and loves her pacifier. , . A: AGA P:\nContinue to support developmental needs.\n\n: , sister in for the 1300 cares for Halloween\nPictures. Dad took temp, diaper change, and dress infant.\nMom bottle baby. asked appropriate questions regarding\ninfant. Update at the bedside by this RN. A: Involved,\nloving, appropriately concerned. P: Continue to update,\nsupport, educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-21 00:00:00.000", "description": "Report", "row_id": 1792243, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: ;infant in open crib, room air\nSkin: warm and dry; color \nHEENT: gaze, fontanels open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, Gr II/VI systolic murmur left sternal border with radiation to back; pulses +2\nAbd: soft; no masses; + bowel sounds\nExt: moving all\nNeuro: ; + suck; + grasps; symmetric \n" }, { "category": "Nursing/other", "chartdate": "2189-11-22 00:00:00.000", "description": "Report", "row_id": 1792244, "text": "npn 1900-0730\n\n\n3.2.515gms. ^20gms from yestersay. Tf cont. at 150cc/k/d. of\nBM26 with PM or 63cc q 4hrs. Cont. to alt/po/pg. Taking 29cc\nat 0100 feeding. 1med spit so far this shift. Max asp. 3cc\nof partialy digested formula. Abd soft, +bs. Voiding\nstooling yellow med guiac- stool. p; cont. to monitor wt\ngain, po feeding.\n\n4. Remains in oac. Swaddled. Temps stable. A/A. Not aking\nfor cares but kicking, crying once woken. Cont. alt po/pg.\nP; cont. to support g/d.\n\n5. Mom called to say that will not be in but dad\nwill be in for 0900 feeding. Mom sounding very loving and\ncaring. p; cont. to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-10 00:00:00.000", "description": "Report", "row_id": 1792328, "text": "Nursing Progress Note 0700-1500\n\n\n3. Feeds BM24cals 140cc/kg/d tolerated well bottle/gavage.\nTook 30 then 43cc by bottle this shift. Awake for both\nfeedings. Remainder given by gavage over 30-40 minutes.\nVoiding and qs. A. Feeding and growing well,\nbottling better. P. Offer bottle when awake and .\n4. Temp stable in crib. Awake and for cares. Awake\nintermittently all morning. OT in to see, met with mom this\nPM. A. Developmentally appropriate. P. Support.\n5. Mom in this PM, met eith OT. Fed . A. \n. P. Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-10 00:00:00.000", "description": "Report", "row_id": 1792329, "text": "NICU fellow note\nwell appearing infant in NAD\nVSS\nWt 3140 gm\n, MMM.\nRRR, no murmur.\nCTA bilaterally, Good air entry.\nSoft, NT/ND, no masses\nNormal \n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1792203, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft and round, girth stable at 27.5\ncm. Assessment benign. TF=150cc/kg/day. Infant is taking\n51 cc BM 28 with PM q 4 per NGT. No emesis, scant aspi\nrates. Voiding and stooling with diaper changes. Wgt:\n2.060 ^ 100g A: Stable, tolerating feeds P: Monitor for\nfeeding intolerance. Encourage to breastfeed during feeds.\nAdvance feeds as tolerated.\n2. G&D O: is active and . Opens eyes, sucks\npacifier eagerly. Resting comfortably between cares. No\ns/s pain or discomfort. Temp wnl in , heat off A:\nAppropriate P: Monitor. Comfort measures.\n5. PARENTING O: in at the start of shift.\n able to provide care independently . Updated. A:\nLoving, concerned parent P: Support and update. Encourage\nto ask questions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1792204, "text": "Neonatology Attending Progress Note:\nDOL #44 PMA 33 4/7 weeks\n RA, RR=40-60's, mild sc retx, no caffeine since Friday, no spells x 2 days, HR=150-170s, meanBP=52, wt=2060 (inc 100g), TF=150cc/kg/d BM 28 with promod tolerating well--gavaged over 1hour.\nImp/Plan: premie infant tolerating full feeds, stable.\n--monitor murmur (not heard today)\n--labs tomorrow\n--monitor weight, continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1792205, "text": "NICU Fellow Note\nExam:\nGeneral - comfortable appearing in crib\nHEENT - AFOS, MMM\nLungs - clear b/l with equal breath sounds\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended, no organomeg\nExt - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1792206, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM28w/PM. All feeds PG\nover 1 hour. Tol feeds well, no spits. Belly soft, no\nloops. Voiding, no stool. P cont to assess FEN needs.\n4. DEV O/A remains in an off with stable\ntemp. A/A with cares, sleeping well between cares. P cont\nto assess dev needs.\n5. O/A Mom called 2X for updates. P plan\nto visit later this evening.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1792207, "text": "NICU NSG NOTE\n\nMom BF infant for first time. Infant was held in football hold with good positioning by mom. Infant latched and was eager. Lasted ~5 mins. Mom has enlarged nipples. Spoke to mom about LC. Mom interested when a slot becomes available.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-13 00:00:00.000", "description": "Report", "row_id": 1792208, "text": "NPN:\n\nRESP: Sats 93-100% in RA. RR=40-60 with SC retraction. BBS =/clear. No A&Bs over apst 24 h.\n\nCV: No murmur (hx intermittent murmur). HR=130-160. BP=68/35 (48). Color pale w/good perfusion. Hct=24.8 this a.m.; Retic pending. to be notified.\n\nFEN: Wt=2115g (+ 55g). TF=150cc/kg/d; 53cc BM-28 w/promod q 4 h via PG over 1 h. Tolerating fdgs well w/o spits; minimal residuals. Abe benign. Voiding qs; stool last eve. Vit E and FeS04.\n\nG&D: CGA=33 wk. Temp stable in off . Active and w/good tone. Swaddled, nested and resting well.\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-03 00:00:00.000", "description": "Report", "row_id": 1792294, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, assessment unremarkable.\nTF=140cc/kg/day. Infant taking 68cc BM 26 q4 PO/NG. No\nemesis or aspirates. PO fed x2, taking 28-35cc. Voiding\nand stooling with diaper changes. Wgt: 2.905k ^20g A:\nStable, tolerating feeds P: Monitor for feeding\nintolerance. Advance feeds as tolerated. Encourage to BF\nand PO feed when awake and .\n4. G&D O: is active and with cares. Temp wnl\nin open crib. Rec'd 60 day immunizations--Pediarix and\nPrevnar without incident. Tylenol given prior to IM\nadministration. Infant is comfortable and resting\ncomfortably. A: Stable P: Monitor. Comfort measures.\nAdminister HIB vaccine tomorrow. Tylenol as ordered.\n5. PARENTING O: at the start of shift. Updated.\nMom will call in am. Informed that we will start\ndoing more discharge teaching. in agreement. A:\nLoving, concerned parent P: Support and update.\nEncourage to ask questions and voice concerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-03 00:00:00.000", "description": "Report", "row_id": 1792295, "text": "Neonatology Attending\n\nDay 65 PMA 36 wks\n\nRemains in RA. RR 40-60s. No bradycardia. , well-perfused. BP mean 49. Weight 2905 gms (+20). TF at 140 cc/kg/d- BM 26. Taking half to full volumes. Tires. No spits, aspirates. Stable temperature in open crib.\n\nDoing well. Adequate breathing control. Feeding well. Gaining weight well. Will reduce calories to 24/oz today. Increasing iron dose. Will discontinue vitamin E. Adding multivitamins. Prevnar and Pediarix today. Mother up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-21 00:00:00.000", "description": "Report", "row_id": 1792380, "text": "DC note\n\n\nInfant discharge home in stable condition. By System, Resp\ninfant in RA, lungs clear and equal w/no increase in wob.\nCV: No murmur audible, HR 140-160. FEN: Infant dc'd home on\nBM/E24(made w/enfamil powder) Infant well coordinated\nbottler, waking g3-5hrs for feeds, taking 50-70cc's. Abdomen\nsoft with active bowel sounds. Voiding and , wnl.\nDEV: Infant temps remains stable in an oac. Infant is \nand active. F/u eye exam showed fading stage 1 ROP. F/u is\nin wks w/Dr. , are aware that they have to\ncall and schedule an apt. Caregroup vna contact and will\nvisit . Pedi apt scheduled for . EIP referral\nmade and Infant follow program referral faxed. have\nbeen asking appropriate questions regarding infants\ndischarge and questions have been addressed by this RN. Both\n stated that they feel ready and comfortable to bring\n home. P: DC home w/.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792003, "text": "Nursing Progress Note\n\n\n#1 Resp: rec'd pt on HIFI, extubated to CPAP 6 @ 2100. FIO2\n25-30%. rr 30-50, lungs clear, mild ic/sc retractions. On\ncaffeine, no spells. Cont. to monitor. #2 CV: map's 39-45,\npt is pink/jaundiced well perfused. no murmur heard. stable.\nCont. to monitor. #3 FEN: wt 1070(down 130). TF 100cc/kg.\nPND12.5 w/IL infusing via PICC without incident. UAC has\nsterile H20, w/ NaAcetate infusing at .8cc/hr. D stick 71,\nabd soft, hypoactive bs, voiding, med mec stool. Abd full w/\nsoft loops since baby on CPAP. Lytes 152/3.6/119/18/19.\nCont. to monitor. #4 DEV: temps stable in servo ,\n is active/irriatble w/ cares. Moved to prone position\nto settle w/ good results. MAE, fontanels soft/flat, eyes\nfused. AGA. Cont. to support dev. needs. #5 Parenting:\nmom/dad in for 2100 cares, asking appropriate questions. Mom\nvery but happy she held baby this evening. Family mtg\nplanned for 3pm tomorrow. Cont. to support. #6 ID: pt\nremains on amp/gent. No s/s sepsis. Cont. to monitor. See\nflowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-09 00:00:00.000", "description": "Report", "row_id": 1792323, "text": "Nursing Progress Note 0700-1500\n\n\n3. Feeds BM24cal with enfamil powder at 140cc/kg/d\ntolerated well by bottle/gavage. Bottled well this AM\ntaking 65ccof full 73cc volume. At 1PM bottled 22cc for mom\nthen tired. No spits or aspirates. Voiding and \nqs, abdomen benign. A. Feeding and growing. P. Continue\nwith plan.\n4. Temp stable in open crib. Awake for most feeds, \nand active. Tend to turn head to R more than L, positoned\nsupine with head to L. A. Appropriate. P. Support.\n5. Mom in most of afternoon, independent in care of .\n A. Loving family. P. Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-09 00:00:00.000", "description": "Report", "row_id": 1792324, "text": "NICU fellow note\nWell appearing premature infant in NAD\nVSS\n, MMM.\nRRR, no murmur well perfused.\nCTA bilaterally good air entry.\nSoft NT/ND, active bowel sound.\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-10 00:00:00.000", "description": "Report", "row_id": 1792325, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, exam unremarkable. TF\n=140cc/kg/day. Infant taking 73cc BM 24 q4. Breastfed well\nx1. Voiding and with diaper changes. Wgt: 3.140k,\n^25g A: Stable, tolerating feeds P: Monitor for feeding\nintolerance. Encourage PO feeds when awake and .\n4. G&D O: is active and with cares. Waking up\nfor feeds. Sucks pacifier eagerly. Temp wnl in open crib.\nNo s/s pain or discomfort A: Appropriate P: Monitor.\nComfort measures.\n5. PARENTING O: in to visit at the start of shift.\nAble to give care independently to . Well updated\nwith the plan of care for daughter. A: P:\nSupport and update. Encourage to ask questions and voice\nconcerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-10 00:00:00.000", "description": "Report", "row_id": 1792326, "text": "Neonatology Attending\n\nDay 72 PMA 37 wks\n\nRemains in RA. RR 30-50s. Clear breath sounds. No retractions. Intermittent murmur. HR 150-160s. Plae, . Weight 3140 gms (+25). TF at 140 cc/kg/d of BM 24. Improved bottling over last day. Still requiring gavage supplementation. Stable temperature in open crib.\n\nDoing well overall. Mature breathing control on monitoring. Improving feeds. Still not quite adequate for discharge.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-10 00:00:00.000", "description": "Report", "row_id": 1792327, "text": "Rehab/OT\n\nMet with mom and at the bedside. Reviewed developmental play positions. Play plan posted at the bedside. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-11 00:00:00.000", "description": "Report", "row_id": 1792330, "text": "NPN (1500-2300)\n\n\n3. F/N: Weight up 5gm. Remains on 140cc/kg/d of BM24,\ntaking a combination of PO and PG feedings. Took 35-23cc po\nthis evening with remainder given pg. Abd exam benign, vdg\nand well. One mod spit.\n\n4. Dev: and active with cares, temp stable in crib.\nWaking on own for feeds.\n\n5. Soc: in and gave tub , updated and involved.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-11 00:00:00.000", "description": "Report", "row_id": 1792331, "text": "NPN:\n\nRESP: RA. RR=40-60. BBS =/clear. No A&Bs past 24 h.\n\nCV: No murmur (hx intermittent murmur). HR=140-150s. BP=88/34 (52). Color pale w/good perfusion.\n\nFEN: Wt=3145g (+ 5g). TF=140cc/kg/d; 73cc BM-24 q 4 h via PO/PG. Bottled w/good coordination x 1 for 32cc. Tolerating fdgs well w/o spits. Abd benign. Voiding; small stool. FeS04 and ViDaylin.\n\nG&D: CGA=37 wk. Temp stable in crib. Active and w/good . Swaddled and resting well.\n\nSOCIAL: Mother called x 1 for update.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-11 00:00:00.000", "description": "Report", "row_id": 1792332, "text": "Neonatology Attending\n\nDay 73 PMA 37 wks\n\nRemains in RA. RR 40-60s. Clear breath sounds. Intermittent murmur. HR 140-150s. BP mean 52. Weight 3245 gms (+5). TF at 140 cc/kg/d- BM 24 with Enfamil powder. Alternating po/pg feeds. Stable temperature in open crib.\n\nDoing well. Mature breathing control on C-R monitor. Tolerating feeds and gaining weight. No changes for now.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-11 00:00:00.000", "description": "Report", "row_id": 1792333, "text": "NICU fellow note\nWEll appearing infant in NAD.\nVSS.\nWt 3145 gm\n, MMM.\nRRR< no murmur, well perfused.\nCTA bilaterally, good air entry.\nSoft, NT/ND, no masses, active bowel sounds.\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-12-11 00:00:00.000", "description": "Report", "row_id": 1792334, "text": "NPN DAYS\n\n\n3. TF at 140cc/kg of BM24 with enfamil powder. Abd benign.\nVoiding and . PO/PG feedings. Bottling about of\neach feeding offered. Working on po feedings.\n\n4. Temp stable in open crib. and active with cares.\nAGA.\n\n5. Mother in for afternoon cares. Updated, asking\nappropriate questions. Independent with cares. \nfamily.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-01 00:00:00.000", "description": "Report", "row_id": 1792287, "text": "PCA Progress Note\n\n\nFEN: O/Infant continued on total fluids of 140cc/k/d of BM\n26, 66cc q4. Gavaged at 0900 and PO 30cc so far this shift.\nNo spits, max aspirate was 1.4 of partially digested\nformula, re-feed through tube. Abdomen benign. Voiding and\nstooling heme(-). A/Tolerating feeds well. P/Continue to\nencourage PO feeds.\n\nDEV: O/Temps stable, swaddled in OAC. and active with\ncares. Resting comfrtably in between. MAE, . A/AGA.\nP/Continue to support dev. needs.\n\nPAR: Mom in for afternoon cares. Held and feed infant.\nIndependent with cares. VEry loving and involved. Was\nupdated by RN. Continue to keep informed and updated.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-01 00:00:00.000", "description": "Report", "row_id": 1792288, "text": "Agree with above note from , PCA. Mom in for cares. Updated at bedside. Bottle fed infant. Plans on signing consents for immunizations with later tonight. will return for 2100 cares.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-02 00:00:00.000", "description": "Report", "row_id": 1792289, "text": "2300-0730\n\n\n3. FEN O: Abdomen soft, assessment unrmarkable.\nTF=140cc/kg/day. Infant taking 67cc BM 26 PO/NG. Bottle\nfed x2, taking 50-55cc. No emesis or aspirates. Voiding\nand stooling with diaper changes. Wgt: 2.885k ^ 50g A:\nStable, tolerating feeds. Better oral intake . P: Monitor\nfor feeding intolerance. Advance feeds as tolerated.\nEncourage PO/BF when awake and .\n4. G&D O: is active and with cares. Awakens\nfor feeds. Temp wnl in open crib. No s/s of pain or\ndiscomfort A: Stable P: Monitor. Comfort measures.\n5. PARENTING O: No social contact thus far this shift P:\nKeep well updated. Encourage to ask questions and voice\nconcerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-02 00:00:00.000", "description": "Report", "row_id": 1792290, "text": "Neonatology\nDOL #64, CGA 36 wks.\n\nCVR: Remains in RA, comfortable. Lungs clear. No spells. Hemodynamically stable, no murmur.\n\nFEN: Wt 2885, up 50 grams. TF 140 cc/kg/day, BM 26, PO/PG. Voiding/stooling. Abdomen benign.\n\nHEME: Hct 26.7, retic 8.5.\n\nNEURO: Optho exam 2 days ago: St I bilaterally, f/u 2 weeks.\n\nRCHM: Due for 2 month immunizations tomorrow.\n\nIMP: Former 29+ wk infant, doing well. Stable in RA. Gradually improving PO intake.\n\nPLANS:\n- Continue as at present.\n- Advance PO as able.\n- 2 month immunizations.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-02 00:00:00.000", "description": "Report", "row_id": 1792291, "text": "NICU Fellow Physical Exam\nPlease see attending note for clinical events and plan\n\n2885g up 10g p140-160 83/55 mean 65 r30-60 RA\n\nAnterior fontanelle soft open and flat. Equal air entry with clear breath sounds bilaterally, no gruning flaring or retractions. Regular rhythm with normal rate, no murmur. Normal active bowel sounds, soft, nondistended. WArm, . Normal .\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792004, "text": "Neonatology note\n\n3 d.o\nextubated to CPAP+6 yesterday, on caffeine\nbili= 6.7, under photothera[y\non amp + gent day \n120 ml/kg/d, NPO\nwt= 1070 gm -130\nvoiding, stooling\nHUS: bilateral grade I bleed\nPIC line in place yesterday.\n\npink, jaundice\nAFOF, no cleft lips, palate, CPAP device in place\nRR with no murmur, pulses equal.\nmild retraction, clear\nabdomen soft, bowel sounds present, no mass palpable.\nactive with exam\n\nA: ex 27 wks GA, RDS, AOP, hyperbilirubinemia, presumed sepsis, PDA s/p indocin, ICH\nP: monitor respiratory status on CPAP, need f/u HUS next wk, f/u bilirubin, will need f/u with ECHO today, will need LP.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792005, "text": "1. remains on prong cpap+6 mostly RA, RR30-50, ic/sc\nretractions, BBS equal, clear, no spells, on caffeine.\n2. no murmur, HR 140-150's, mBP's in the 40's, UAC line\ndc'd-site without oozing. still with mild edema.\n3. TF 120cc/k/d D12.5PN and IL infusing through rt leg PICC\nline, NPO, abd soft, bowel sounds present, transient soft\nloops, voiding and passing sm mec stool. plan to check\nlytes, DS this afternoon.\n4. temp stable on servo , nested in sheepskin with\nboundaries, active-irritable with cares, consoled with\ncontainmment. HUS done this am.\n5. Parent meeting starting now with , SW, RN.\n6. on day ampi and gent, blood cx neg to date.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792006, "text": "Respiratory Care Note\nBaby Girl remains on +6 prong CPAP, FiO2 .21-.24. BS clear. RR 30-60's. On caffeine. No spells this shift as of this writing.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792007, "text": "Family Meeting\nMet with in the family room today. Mother is discharged home today. See family meeting check list for issues discussed. asked good questions and seem to have an understanding of the issues. Pediatrician is Dr. at Centre Peds.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792008, "text": " Procedure note\nUAC discontinued without incident.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-14 00:00:00.000", "description": "Report", "row_id": 1792074, "text": "Nursing Progress\n\n\n#1 Resp: NC 100%, 13-25cc's, no spells. 50-80's, lungs\nclear. ic/sc retractions. On caffeine. Cont. to monitor. #3\nFEN: TF 150cc/kg now on BM24, abd soft, no loops, active bs,\nvoiding, stooling (trace heme pos). AG 21. No spits, max asp\n3cc's. Started on FE, Vit E. Cont. to monitor abd exam. #4\nDev: temps stable in servo . is alert/active\nw/ cares, sleeps well between cares, brings hands to face.\nAGA. Cont. to support dev. needs. #5 Parenting: mom in for\n1300 cares, indep w/ diaper change and temp, here for room\nchange. Updated at bedside by this RN. Cont. to\nsupport/update. See flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-15 00:00:00.000", "description": "Report", "row_id": 1792075, "text": "NPN\n\n\n#1 Resp- Remains in NC 13-25cc.RR= 50-80. BS clear. mild\nretractions.Remains on caffeine. No A's or B's yet tonight.\nSee flowsheet.\n#3 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of BM24\ncals w/o spits. Minimal asps.TF=150cc/kg/day. No change in\nwt.Voiding and stooling in adeq amts.Feeds given on a pump\nover 1 hr.\n#4 dev- Alert+ active w/cares.Temp stable in servo iso.\n#5 Mom and Dad here to visit x1. Took temp and\nchanged diaper.Updated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792044, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains in RA. O2 sats ~95-98%.\nRR ~60-80's. LS clear/=. No increase work of breathing\nnoted. She has mild IC/SC retractions. No A&B's noted this\nshift thus far. She is on Caffeine. A: Pt. remains stable\nin RA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: TF 160cc/kg/d. Enteral feeds of BM/PE20 are\ncurently @80cc/kg =16cc Q 4hrs, gavaged over 30 min.\ntolerated well. IVF D15 PN and IL are infuseing @80cc/kg\nvia a PICC without incident. Advancement of enteral feeds\nheld this afternoon for an aspirate of 6cc, non-bilious.\nAbdomen is soft, , +bs, no loops. Abdominal girth is\n~20.5-21cm. She is voiding well, passed Lg guiac -stool x1.\n A: Pt. is tolerateing current nutritional plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance. Plan to asvance enteral feeds @ 1700 by\n10cc/kg as pt. tolerates.\n\n#4. Growth/Development O: Pt. remains in a\nservo-controlled , nested w/ stable temps. She is\nalert and active w/ cares, sleeps well in between.\nFontanelle soft/flat. A: AGA P: Continue to provide\nenvironment appropriate for growth and development.\n\n#5. O: Mom in to visit this am and was updated on\npt's current status and daily plan of care. Mom is active\nand involved in cares. A: Family is loving and involved.\nP: Continue to udpate, support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-09 00:00:00.000", "description": "Report", "row_id": 1792045, "text": "NPN 11p-7a\n\n\n#1 In RA with sats 92-97%. BBS clear and =. Mild retractions\npresent. RR's cont. 60-80 range. No bradys or desats. On\ncaffeine A: comfortable in RA P:Support resp needs\n\n#3 TF's 160cc/k. Enteral feeds advanced at 0500 by 10cc/k to\n100cc/k. Receiving 19cc of BM20 q 4hrs on a pump over 30\nmins. Abdominal exam unremarkable. AG 20.5-21.5cm. Small\nresiduals of 0.2-2.0cc of partially digested BM. Small\nemesis x 1.Remaining fluids of PN D15 infusing @ 60cc/k via\ncentral PICC without evidence of difficulty. UOP ~ 4.1cc/k.\nPassed trace greenish stool. A: w/u of feeds as tol P:\nAdvance feeds 10cc/k as tol, follow tolerance and belly\n\n#4 Temps slightly elevated x 1. Servo control weaned. Nested\non sheepskin with boundaries. Awake with cares and settles\nto sleep easily. A: AGA p; support developmental needs\n\n#5 Assisted mom with placing back to bed at change of\nshift. M + D planned to go home and call for an am update A:\ninvested P: cont to support and inform\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-24 00:00:00.000", "description": "Report", "row_id": 1792124, "text": "NPN 0700-\n\n\n1. Remains in 25cc NCO2, 100%. Sats 96-100%. Lungs clear.\nRR 30-70's with mild SC retractions. On caffeine, no A&B's\nthus far. Stable in low NCO2. Continue to monitor for\nA&B/desats.\n\n3. TF 150cc/k/d BM30 w/PM. Abdomen benign. Voiding and\nhad one heme negative stool thus far. Tolerating NGT feeds\nwithout spits or aspirates. Continue to monitor for feeding\nintolerance.\n\n4. Temp stable in air . Infant swaddled on\nsheepskin. Alert and active with cares. MAE, brings hands\nto face. Continue to promote development.\n\n5. Mom in to visit, updated on plan of care and independent\nwith infant cares. Mom able to kangaroo with infant today.\nInvested mom. planning to visit at 2100. Continue\nto support, update, and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-21 00:00:00.000", "description": "Report", "row_id": 1792377, "text": "NPN 1900-0700\n\n\nFEN: CW 3350g, down 10g. TF min of 130cc/kg/day of BM/E 24.\nMixed as E20 w/ 1 tsp. Enf. powder. Needs 73cc Q4hrs or 55cc\nQ3hrs. Infant is waking Q3-4 hrs and bottling 50-65cc this\nshift. Bottled well/mature feeding ability. Abd. is benign.\nPt. is voiding and . One large spit after feeding\nthis shift. Infant has been meeting TF minimum and bottling\nwell. Planning for d/c home tomorrow. P: Continue to support\ninfants FEN needs.\n\nDEV: Remains swaddled in OAC, temp stable. /active w/\ncares and waking Q3-4hrs to feed. Sleeps soundly btwn cares.\nBrings hands to face and sucks vigorously on pacifier. .\nMAE. Good . Active baby. Infant planned for d/c tomorrow\nmorning () after follow-up eye exam for ROP. Infant\npassed Car Seat test this shift (2nd screen done due to Mom\nbrought in \"wrong seat\" the 1st time). here for car\nseat test and instructed by this RN re: how to safely\nposition infant in car seat. Pt. ready for d/c. D/c exam\nplanned for morning. P: cont. w/ present interventions.\n\nParenting: in for evening cares and feeding. Updated\nat bedside by this RN. very excited for d/c. \ncompletely independent w/ cares. Mom breastfed infant for\n15min and bottle fed infant w/ no guidance necessary.\n very and feel ready and comfortable to take\n home. to make pedi appt. for this week. A:\nExperienced/capable/invested needing minimal\nteaching. state that they do not have any further\nquestions re: discharge at this time. P: Continue to update\nand support family.\n\nsee flowsheet for any further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-21 00:00:00.000", "description": "Report", "row_id": 1792378, "text": "Neonatology Attending\n\nDay 83 PMA 39 0/7 wks\n\nRemains in RA. Clear breath sounds. RR 30-50s. No murmur. HR 140-160s. , well-perfused. Weight 3350 gms (-10). On BM/E 24. Took 119 cc/kg/d and breast fed. Benign abdomen. Passing heme negative stool. On iron and vitamins. Stable temperature in open crib. Waking for feeds. Passed hearing screen and car seat study.\n\nDoing well overall. No recent apnea. Feeding well and gaining weight well overall. Ready for discharge. Follow up with Dr. being scheduled in next 2 days. Repeat eye exam and head ultrasound today prior to discharge.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-21 00:00:00.000", "description": "Report", "row_id": 1792379, "text": "NICU fellow note\nWell appearing infant in NAD,\nVSS\nWt 3350 gm.\n, MMM.\nRRR, no murmur, well perfused.\nCTA bilaterally, good air entry\nSoft, NT/ND, no masses, active BS.\nNormal .\n" }, { "category": "Nursing/other", "chartdate": "2189-10-15 00:00:00.000", "description": "Report", "row_id": 1792076, "text": "Neonatology note\n\n15 d.o, now 29 wks PCA\non NC O2 13-25 ml, on caffeien, no spell.\nbut cluster of bradycardia this am with feeding.\nwt= 1195 gm\n150 ml/kg/d with EBM 24 PG\nvoiding, stooling.\nHUS evolving grade 1 blleding this am.\n\nA: ex 27 wks GA, AOP, anemia, evolving grade 1 bleeding.\nP: continue care and advancing calorie density to 26.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-15 00:00:00.000", "description": "Report", "row_id": 1792077, "text": "NPN 0700-1900\n\n\nRESP: Infant remains on NC with a 13-25cc, Fio2 100%. Lungs\nare clear and equal with mild ic/scr noted. RR 40-70's, O2\nsat >90%. Infant O2 sat drifts to the low 80's at times.\nInfant with a cluster of spells this am, during a feed. HR\n70, O2 56 infant was pale, mottled required an increase in\nO2 and Vigorous stim to recover. Remains on caffeine. A:\nStable on NC, with occ spells. P: Continue to monitor resp\nstatus, wean nc if tolerated.\n\nFEN: Infant remains on a TF 150cc/k/d of BM26(31cc q4hr pg\n1hr15min), calories were increased today. Adomen soft with\nactive bowel sounds. No loops, Sm spit, min aspirates. AG\n20.5-21. Voiding with each diaper change. One med stool,\nheme neg today. Remains on FE and Vit E. A: Tolerating\ngavage feeds. P: Continue per nutritional plan, monitor for\nsigns and symptoms of feeding intolerance, please check\nlytes and HCT in am\n\nDEV: Infant remains comfortable in a servo controlled\n. Alert and active with cares, settles well\ninbetween. Brings hands to face for comfort and occ enjoys\npacifier. Repeat HUS was performed this am. , .\nYellow eye drainage noted in , aware, cleansing\nw/warm water. A: AGA P: Continue to support developmental\nneeds.\n\n: Mom in for the 1300 care. Independent with temp and\ndiaper change. Updated about the infant days and current\nplan of care. Mom the infant. Both baby and mom\nenjoyed. Mom asking appropriate questions regarding care.\nAppears anxious. A: Involved, loving, appropriately\nconcerned. P: Continue to educate,update, support both\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-30 00:00:00.000", "description": "Report", "row_id": 1792147, "text": "NICU Fellow NOte\nExam:\nGeneral - NAD in \nHEENT - AFOS, NGT inplace, MMM\nLungs - clear b/l with equal breath sounds\nHeart - RRR, no murmur heard\nAbdomen - soft, nondistended\nExtremities - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-10-30 00:00:00.000", "description": "Report", "row_id": 1792148, "text": "Resp O/A: RA, Sats 98-100%, occasionally to 95%. RR 40s-60s,\noccasionally to 80's. Lungs cl&=, occasional slight\nsubcostal retractions. No a's b's or d's thus far this\nshift. P: Continue to monitor.\n\nFEN O/A: 150cc/kilo/day BM30 with Promod. 39cc PG Q4 hours,\ngavaged over 90 minutes. Abdomen is soft, and round\nwith no loops and +BS. No spits, minimal aspirate. Girth\nstable, 24cm. Voiding, stooling heme negative. P: Continue\nto monitor.\n\nG&D O/A: In off on sheepskin with 1 blanket. Temps\nstable. A&P fontanells soft and flat. and active with\ncares. Wakes for feeds, sleeps well between cares. P:\nContinue to monitor.\n\nNo contact with thus far this shift.\n\nPlease see flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-30 00:00:00.000", "description": "Report", "row_id": 1792149, "text": "NPN Days\nI have examined infant and agree with above note by J. , PCA. Mother called and updated, will be in for 2100 cares.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-24 00:00:00.000", "description": "Report", "row_id": 1792125, "text": "Neonatology - Progress Note\n\n is active with good tone. . She is , well perfused, no murmur auscultated. She is comfortable in NCO2, low flow. Breath sounds clear and equal. She isl tolerating enteral feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in . Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-25 00:00:00.000", "description": "Report", "row_id": 1792126, "text": "NPN\n\n\n#1 remained in low flow O2 NC until 05:00 after SaO2\n98-100 NC removed, SaO2 remains 95-96 since O2 off. LS clear\nand equal, Mild subcostal retractions color . A: trial\noff O2 P: monitor, return to NC as needed.\n#3 remains on 150cc/k/d BM30pro tol pg's well, no spits, min\nasp. Abd benign, soft, +BS, no loops or distention, vdg qs,\nstool x's 3 heme neg. weight up 25 grams A: tol feeds P: no\nchange at present.\n#4 stable in low heat , sleeps between feeds, calm\nwith cares, sucks some on pacifier. A: AGA P: cont to\nsupport development\n#5 mom and dad here to visit, dad held for 45 min.\nmom informed of NC removal A: involved famiy P: cont to\nsupport and inform\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-25 00:00:00.000", "description": "Report", "row_id": 1792127, "text": "Neonatology Attending Note\nDay 26\nPCA 31\n\nRA since this AM. RR30-70s. Mild sc rtxns. No murmur. HR 150-170s. Pale/. BP 68/38, 50. Wt 1425, up 25 gms. TF 150 BM30 w promod. Tol well. Nl voiding and stooling. In .\n\nGrowing preterm infant w immature feeding, and req . Cont present management.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-25 00:00:00.000", "description": "Report", "row_id": 1792128, "text": " Physical Exam\nPE: pinkk , breath sounds clear/equal with mild retracting, no murmur, well perfused, abd soft, non distended, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1792198, "text": "NPN:\n\nRESP: Sats 95-98% in RA. RR=40-60 with SC retraction. BBS =/clear. No A&Bs over past 24 h.\n\nCV: No murmur (hx intermittent murmur). HR=160s. BP=69/32 (45). Color pale w/good perfusion.\n\nFEN: Wt=1960g (- 5g). TF=150cc/kg/d; 49cc BM-28 w/promod q 4 h via PG over 1 h. Tolerating fdgs well w/o spits; minimal residuals. Abd benign. Voiding; yellow stool. Vit E and FeS04.\n\nG&D: CGA=33 wk. Temp stable in off . Active and w/good tone. AF soft, flat. Swaddled, nested and resting well. PKU done.\n\nSOCIAL: No contact w/.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1792199, "text": "Neonatology Attending Progress Note:\nDOL #43\nPMA 33 3/7 weeks\nwt=1960g ( 5g)\nintermittent murmur, HR=150-160's, 69/32 (mean=45)\nremains on RA, RR=40-60's\nno spells, off caffeine, TF=150cc/kg/d\nBM28 with promod, voiding, stools heme negative\nno spits\niron and Vitamin E\nImp/Plan: premie infant with fair weight gain past 2 days, mild apnea of prematurity--resolving, tolrerating full feeds.\n--monitor weight, consider increasing calories if continues with fair weight\n--monitor for spells off caffeine\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1792200, "text": "NICU Fellow Note\nExam:\ncomfortable apearing in , lungs clear b/l with equal breath sounds, no murmur heard on exam, abdomen benign - soft and nontender, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-10-31 00:00:00.000", "description": "Report", "row_id": 1792150, "text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. RR 30-60's, O2 sat >95%. Lungs\nare clear and equal with mild scr noted. No apnea, bradys or\ndesats noted thus far this shift. Remains on Caffeine. A:\nStable in Ra. P: Continue to monitor resp status.\n\nFEN: CW 1605g (^50g). TF 150cc/k/d of BM30 w/pm (40cc q4hr\npg 90min.) Abdomen soft with active bowel sounds. No loops,\nNo spits. AG 24. Voiding with each diaper change, Stool x's\n1 (heme neg). Remains on Vit E and FE. A: Tolerating pg\nfeeds, gaining weight P: Continue per nutritional plan.\n\nDEV: Infant remains swaddled in an off . Temps\nstable (98.0-98.4) Infant is and active with cares.\nSettles well inbetween cares. Brings hands to face for\ncomfort and occasionally enjoys her pacifier. A: AGA P:\nContinue to support development.\n\n: Infants in at 2100. Both very independent with\ninfant. Both assisted with weighing. Mom held infant\nduring her feed. Both asking appropriate questions,\nall questions answered by this RN and were updated\nabout the infants overall status. Mom and dad are planning a\nchristening on in the family resource room A:\nInvolved, loving, appropriately concerned. P: Continue to\nupdate,support,educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-31 00:00:00.000", "description": "Report", "row_id": 1792151, "text": "Attending Note\nDay of life 31 \n DOL 32\nin room air RR 30-60\nsat above 95\non caffeine no spells\nHR 150-160's BP 70/36 mean 44\nweight 1605 up 50 on 150 cc/kg/day BM 30 cal/oz with promod pg over 90 min\non vit E and iron\nvoiding and stooling heme negative\n\nImp-stable making progress\nwill continue current calories\nwill consent for Hep B\n" }, { "category": "Nursing/other", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 1792228, "text": "Clinical Nutrition:\nO:\n~34 week CGA BG on DOL 50.\nWT: 2340g(+40)(50-75 %ile); BWT: 1230g. Average wt gain over past week ~23g/kg/day.\nHC: 29cm( %ile); last: 30.5cm\nLN: 43cm(~25th %ile); last: 42cm\nMeds include Fe & Vit.E\nLabs noted.\nNutrition: 150cc/kg/day as BM 26 w/ promod; po/pg & took ~15cc. Average of past 3-day intake ~150cc/kg/day, providing ~130kcal/kg/day & ~4g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; /pg & took ~15cc po x1. Labs noted & within acceptable ranges. Current feeds & supps meeting recs for kcal/pro/vits/mins. LN gain is meeting recs. Growth is exceeding recs of ~15-20g/kg/day for WT gain. HC gain is not meeting recs of ~0.5-1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 1792229, "text": "SOCIAL WORK\nThis family has been followed by , LICSW during my absence and was finally able to meet mother today. She appeared relaxed and enjoying her visit, RN reports no social issues of concern. Offered my availability for support/resources and will continue to be available as needed.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1792201, "text": "Clinical Nutrition:\nO:\n~33 week CGA BG on DOL 43.\nWT: 1960g(-5)(50-75 %ile); BWT: 1230g. Average wt gain over past week ~15g/kg/day.\nHC: 30.5cm(25-50 %ile); last: 29.5cm\nLN: 42cm(~25th %ile); last: 40cm\nMeds include Fe & Vit.E\nLabs due this week.\nNutrition: 150cc/kg/day as BM 28 w/ promod; pg over 1hr. Average of past 3-day intake ~150cc/kg/day, providing ~140kcal/kg/day & ~4g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; pg fed. Labs due this week. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is meeting recs for WT/HC gains. LN gain is exceeding recs of ~1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1792202, "text": "NPN 0700-1900\n\n\nF&N: TF-150cc/k/d of BM28 w/ promod. Tolerating feeds over\n1hr. One spit this afternoon. ABd is round and soft\nw/active bowel sounds and no loops. AG is stable at 26cm.\nAspirates <1cc. On Vit. E and Iron as ordered.\nA/P: Monitor weight on 28 cals.\n\nDEV: Temp has been stable in an off . Infant is\nswaddled. Infant is and active w/ cares. Tone is\nwnl.\n\n: Mom in to visit- updated at bedside. Mom is\nindependent w/ cares and held during her feed and\nindependently put her back to bed. Mom is anxious to have\n home.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-30 00:00:00.000", "description": "Report", "row_id": 1792281, "text": "Neonatology Attending\n\nDay 62 PMA 36 wks\n\nRemains in RA. RR 30-60. No murmur. HR 130-160s. BP mean 60. Weight 2810 gms (+40). TF at 140 cc/kg/d- BM 26. Offered bottle with each feed and taking half to full volumes.\n\nDoing well overall. Mature breathing control. Monitoring. Encouraging po feeds. Eye exam today. Immunizations due in three days. Plan to recheck Hct tomorrow. Mother up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-30 00:00:00.000", "description": "Report", "row_id": 1792282, "text": "Fellow Note\nPE:\nwell appearing infant, and in NAD.\nAFOS, conj clear. OP clear with MMM.\nCTA B without GFR.\nRRR without murmer. 2+ pulses LE.\nNT ND soft, no HSM.\nMAEW. appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-30 00:00:00.000", "description": "Report", "row_id": 1792283, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg/day of BM26. Inf PO feeding\n32-45cc thus far, remainder of feeds gavaged. Tol feeds\nwell. Min asp, 1 sm spit. Belly soft, no loops. Voiding,\nstooling. P cont to offer PO feeds as tol.\n4. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares, sleeping well between cares. Eye\nexam today, stage 1 both eyes F/U in 2 weeks. P cont to\nassess dev needs.\n5. O/A Mo in for visit and cares. Updates given.\n P Both plan to be in for 2100 cares.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 1792230, "text": "Nursing\n\n\n3. Feeds 150ml/kg/d, calories decreased to 26 today. Fed\nover 1hr on pump, tolerated well with no spits or\nsignificant aspirates. Abdomen full and soft, stool x1,\nvoiding qs. Nursed once, latched on briefly. A. Gaining\nweight well. Beginning oral feeds. P. Continue to\nencourage latch on once/day, bottle once/shift if able.\n4. In open crib, temp 98+, swaddled with hat on. and\nactive when awake. Slept between cares. A. Appropriate.\nP. Support.\n5. Mom in this afternoon, met with lactation consultant.\nPleased with infant's overall progress. A. Invested\nfamily. P. Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 1792231, "text": "nursing note\n\n\n3. remains on total fluids 150/kg/d. PO fed this\nevening taking 24cc,pg remainder. Abdomen soft.voiding and\nstooling, one small spit noted. AP:Po fed well, continue to\noffer po feeding as tolerated.\n\n4.Temp stable in open crib. and active, calm easily\nwith pacifier. A:stable 34+ week infant.P:continue to\nmonitor closely.\n\n5. Dad in this evening. Diapered, changed and fed .\nLoving family. AP:continue to support family, discharge\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-19 00:00:00.000", "description": "Report", "row_id": 1792232, "text": "2300-0700 NPN\n\n\nFEN: Weight 2380, up 40gms. TF 150cc/kg/d BM26 with pm,\npo/pg. Infant was offered bottle once this shift and took\nonly 5cc. No spits, min asp. Abdomen soft, round, no loops,\nactive BS. Voiding and stooling.\n\nDEV: Temps stable, dressed and swaddled in open crib. MAE,\nfontanels soft and flat. and active with cares,\nsleeping between cares. AGA.\n\nPARENTING: No contact from thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-19 00:00:00.000", "description": "Report", "row_id": 1792233, "text": "Neonatology Attending Progress Note:\nDOL #51\nPMA 34 4/7 weeks\nremains in RA, RR=30-60's, mild retx\nsoft intermitetn mrumru, HR=150-160's, 75/37 (mean-49)\nwt=2380g (up 40g), TF=150cc/kg/d BM 26 with promod , bottling 1x/shift\nImp/Plan: premie infant leraning to po feed, murmur-monitoring.\n--continue to follow murmur\n--monitor weight, encourage po feeds.\n--continue rest of present managemetn\n" }, { "category": "Nursing/other", "chartdate": "2189-12-08 00:00:00.000", "description": "Report", "row_id": 1792316, "text": "Neonatology Attending\n\nDay 70 PMA 37 wks\n\nRemains in RA. RR 40-60s. No retractions. No bradycardia. No murmur. HR 140-150s. Pale, . BP mean 60. Weight 3015 gms (-20). TF at 140 cc/kg/d- BM 24 with Enfamil powder. Taking half volume feeds and receiving gavage supplementation. Benign abdomen. Stable temperature in open crib.\n\nDoing well overall. Mature breathing pattern. Monitoring. Gradually improving feeding. Gaining weight well overall. No changes planned for now.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-08 00:00:00.000", "description": "Report", "row_id": 1792317, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg/day of BM24. Inf PO feeding as\n. Inf P fed 40cc at 0900, remainder of feed gavaged.\nInf BF at 1300, full feed gavaged. feeds well. No\nspits, no asp. Belly soft, no loops. Voiding, . P\ncont to offer PO feeds as .\n4. DEV O/A remains in OAC swaddled withstable\ntemp. A/A with cares, sleeping well between cares, stirring\nquietly before feeds. P cont to assess dev needs.\n5. O/A Mom in for visit and cares. Updates given.\nMom independent with care of infant. P cont to support,\neducate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792038, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS >93%. RESP RATE 60-80 WITH MILD\nIC/SC RETRACTIONS. ELEVATED RESP RATE NOTED WITH ELEVATED\nTEMP. BS CLEAR. BRADY X1--ON CAFFEINE\nA:STABLE\nP:CONTINUE TO MONITOR FOR SPELLS, MONITOR RESP STATUS\n\n#3F/E/N\nO:TF AT 160CC/KG. ADVANCED TO 80CC/KG ENTERAL FEEDS BM/PW20\n16CC Q4HR GAVAGE AND IVF D15PN AND IL VIA PICC AT 80CC/KG.\nABDOMEN SOFT, FLAT WITH GOOD BS. NO SPITS AND <1CC\nASPIRATES. AG 20-21CM. VOIDING WELL; NO STOOL THUS FAR. WT\nUP 35GM (STILL BELOW BW)\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO ADVANCE AS ORDERED, MONITOR TOLERANCE TO\nFEEDS AND WT GAIN\n\n#4G&D\nO:IN SERVO CONTROL . ELEVATED TEMP X1 WHEN PROBE\nCOVER LOOSE--NEW COVER AND TEMP STABLE SINCE. ACTIVE/MAE\nWITH CARES; SLEEPING WELL BETWEEN. NESTED ON SHEEPSKIN\nW/BOUNDARIES. FONTANEL SOFT AND FLAT; SUTURES SMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO: IN FOR 2100 CARES. INDEPENDENT WITH TEMP/DIAPER\nCHANGE. MOM STATED SHE HAS NOTICED SOME INCREASED MILK\nPRODUCTION--LC FOLLOWING.\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792039, "text": " Physical Exam\nNeonatology note\n\n9 d.o\nin RA, on caffeine, 2 spells yesterday.\nwt= 1065 gm + 25\n160 ml/kg/d with feeding at 80 ml/kg/d with EBM, PG, no isssue.\n\nPE: agree with assessment by .\n\nA: 27 wks GA, RDS resolving, AOP, anemia, grade I bleed, HUS done today result pending.\nP: continue advancing feeding.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792040, "text": " Physical Exam\nNeonatology note\n\n9 d.o\nin RA, on caffeine, 2 spells yesterday.\nwt= 1065 gm + 25\n160 ml/kg/d with feeding at 80 ml/kg/d with EBM, PG, no isssue.\n\nPE: agree with assessment by .\n\nA: 27 wks GA, RDS resolving, AOP, anemia, grade I bleed, HUS done today result pending.\nP: continue advancing feeding.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792041, "text": " Physical Exam\nNeonatology note\n\n9 d.o\nin RA, on caffeine, 2 spells yesterday.\nwt= 1065 gm + 25\n160 ml/kg/d with feeding at 80 ml/kg/d with EBM, PG, no isssue.\n\nPE: agree with assessment by .\n\nA: 27 wks GA, RDS resolving, AOP, anemia, grade I bleed, HUS done today result pending.\nP: continue advancing feeding.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792042, "text": " Physical Exam\nNeonatology note\n\n9 d.o\nin RA, on caffeine, 2 spells yesterday.\nwt= 1065 gm + 25\n160 ml/kg/d with feeding at 80 ml/kg/d with EBM, PG, no isssue.\n\nPE: agree with assessment by .\n\nA: 27 wks GA, RDS resolving, AOP, anemia, grade I bleed, HUS done today result pending.\nP: continue advancing feeding.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-08 00:00:00.000", "description": "Report", "row_id": 1792043, "text": " Physical Exam\nPE: , mild jaundice, active in an incubator, AFOF, sutures slightly overiding, breath sounds clear/equal with good air entry, mild intercostal and subcostal retracting, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with age appropriate tone.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-01 00:00:00.000", "description": "Report", "row_id": 1792284, "text": "NPN 7pm-7am\n\n\nFEN: Current weight 2835gms up 25gms. TF 140cc/kg/day of BM\n26 =66cc's q4hrs. Infant is attempting to bottle each feed\nif awake. At 9pm she took 20cc's and at 1am took 35cc's.\nInfant paces well she just tires out. Remainder gavaged over\n35-45mins. Abd soft, +bs, no loops. No spit, min asp.\nVoiding and stooling heme neg. A: Working on feeding. P:\nWill cont to monitor weight and exam.\n\nG/D: Infant is in open crib, swaddled. Temp stable. \nand active with cares. Sucks on pacifier. Sleeps well\nbetween cares. A: Growing premie. P: will cont to support\ndev needs.\n\n: were in for 9pm cares. They are\nindependent. Take temp, change diaper, put infant on scale.\nMom gave infant bottle. She is nervous with infant but able\nto read infant ques with having had enough trying to feed.\n held infant for gavage feed. Mom plans to put infant to\nbreast today. A: Very loving and involved. P: Will cont to\nsupport and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-01 00:00:00.000", "description": "Report", "row_id": 1792285, "text": "Neo Attend\nDay 63 now 36.2 wk pma\nrespr: ra, rr 30-60s, clear =bs.\ncv: soft murmur, p 130-160s, bp 81/54\nTF 140 cc/kg/day of BM26. PO>PG\nglucose screen stable. uop and stool wnl\nHct = 26.7% with excellent retic of 12.7% ( retic pending).\nOn Fe and Vite E.\nweaned to crib.\ninfant needs 2 mo immunizations.\nEye exam : ROP: R stage 1, zone 2 (6hr); L stage 1, zone 2(7 hrs).\n\nstatus stable, learning to po feed.\nContinue regimen as noted above.\nPt evaluated and discussed with fellow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-01 00:00:00.000", "description": "Report", "row_id": 1792286, "text": "NICU Fellow Note\nPhysical Exam:\nWeight 2.835 kg\nVSS\nGen-Alerts with exam, , active\nHEENT-AF soft, MMM, NG tube in place\nCV-RRR nl S1 S2 no murmur nl pulses\nChest-Lungs clear bilat, good air entry\nAbd-Soft, BS present, no HSM\nExt-WWP\nNeuro-nl , reflexes for GA\n\nPlease see attending note above for assessment and plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-20 00:00:00.000", "description": "Report", "row_id": 1792373, "text": "NPN 2300-0700\n\n\nFEN: CW 3360 g, up 20g. Infant on TF min of 130cc/kg/day of\nBM24 or Enfamil 24 cals(Making E24 by w/ powder per mom's\nwishes)= 54cc Q3hrs or 73cc Q4hrs. Infant waking Q3-4hrs.\nTook 65ccc at 0200 w/ good coordination w/ Bottle\nsystem (at bedside). Infant is tolerating feedings well. No\nspits. Abdomen exam benign. Voiding, no stools tonight. On\nIron and multi-vitamin. P: Continue to support FEN needs.\nInfant req. to meet TF min for possible D/C Mon. .\n\nDEV: Remains swaddled in OAC. Temps stable. and active\nw/ cares and sleeps well bwtn. Waking Q3-4 hrs for feeds.\nBrings hands midline and sucks vigorously on pacifier for\ncomfort. . MAE. wnl. Eyes have ROP: (R)eye=Stage 2,\n(L)eye=Stage 1, to be rechecked this mon. . Infant\nneeds hearing screen prior to d/c. Infant currently having\ncar seat screening, result pending. Mom will make Pedi appt.\nP: continue to promote optimal G&D.\n\nParenting: No contact from thus far this shift. P:\ncontinue to update and support and prepare for d/c.\n\nsee flowsheet for further details.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-20 00:00:00.000", "description": "Report", "row_id": 1792374, "text": "Neonatology Attending\n\nDay 82, PMA 38 6\nRA. RR30-50s. No A&Bs. h/o int murmur. HR 140-160s. BP 89/55, 68. Wt 3360, up 20. BM/E24. All po. well. Nl voiding and . In open crib.\n\nA/P: Plan for discharge tomorrow after eye exam. No changes to current plan.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1791996, "text": "Nursing Progress Note\n\n\n#1 Resp: pt remains on HFOV map 9, delta p 20, abg at 0100\n7.25/47/76/22/-6, no changes made. FIO2 25-33%, mostly 25%.\nLungs coarse, minimal secretion from ett. Stable. Cont. to\nmonitor. #2 C/v: no murmur heard, rec'd 3rd dose of 1st\ncourse of Indocin. To have echo in am. MAP's 36-38, pt is\npink/jaundiced, well perfused. Stable. cont. to monitor. #3\nFEN: wt 1200 (down 25). FR 80cc/kg. UAC has sterile H2O w/\nNaAcetate infusing @ .8cc/hr. PN D12.5 infusing via PIV in R\nhand. D stick 62, lytes 150/4.6/114/19 (22). U/O\n4.1cc/kg/hr. Abd soft/flat, no loops, girth 22. Minimal bs,\nsm mec stool passed. Cont. to monitor. #4 Dev: temps stable\nnested on sheepskin on open warmer. is active w/\ncares, eyes are fused. Settles well w/ hand containment.\nMAE. AGA. Cont. to support dev. needs. #5 Parenting: mom/dad\nin prior to care time. Updated at bedside by this RN. Asking\nappropriate questions. Loving toward infant. Family mtg\ntomorrow 2pm. Cont. to support/update. ID: BC neg to date,\npt continues on amp/gent. temps stable. No overt s/s sepsis.\nCont. to monitor. #7 Bili: bili drawn at 0100. 6.4/0.4.\nSingle photo started , eyeshields on. Cont. to\nmonitor. See flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1791997, "text": " Physical Exam\nPE: pink, jaundiced, generalized edema, AFOF, scalp edema, eyes fused, orally intubated, breath sounds cleaer to coarse/equal with good air entry, mild retracting, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, non tender, + bowel sounds, UAc in place, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1791998, "text": "Neonatology note\n\n2 d.o\non HIFI MAP9 AMP20 24%O2\ncompleted course of indocin last night.\nNPO\nwt= 1200 gm -25\n100 ml/kg/d with IV.\nbili= 6.4, under phototherapy\non amp+gent day \nvoiding, stooling.\n\nPE: agree with assessment.\n\nA: ex 27 wks GA, RDS, hyperbilirubinemia, presumed sepsis.\nP: consider repeating ECHO, weaning off HIFI as tolerated, continue phototherapy, f/u bilirubin, HUS tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1791999, "text": "Procedure Note: P-CVL\nIndication: long-term central venous access.\n\nSigned parental consent in chart.\n\nProcedural time-out observed. Pre-medicated with Fentanyl 2 mcg/kg IV.\n\n#1.9 BD catheter pre-shortened to 23 cm and advanced to 20 cm via introducer in right saphenous vein at the ankle. Catheter draws and flushes easily. Secured with sterile occlusive dressing. Aseptic technique with betadine/alcohol skin prep. Infant tolerated procedure well, no complications. X-ray confirms tip position in IVC.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1792000, "text": "Respiratory Care\nPt cont on HFOV. Weaned to MAP 8, Amp 18. Fo2 .25. bs clear, rr 40-60. sx for sm amt. abg on MAP 9, AMP 20: 7.26/43/56/22/-7. cxr- well expanded bilaterally. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1792001, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains on HiFy Map 8, DeltaP 18\n(since 1600). FIO2 24-30%. RR ~40-60's/70's. LS clear/=.\nShe was suctioned for minimal amount of secretions. CXR\ndone. No A&B's noted this shift. Patient loaded on\nCaffeine this evening. Please refer to pt. chart for\nfurther information and bl.gas/CXR results. A: Pt. remains\nstable on HiFy. P: Continue to monitor respiratory status.\n Monitor for A&B's. Continue to wean FIO2 as pt. tolerates.\n\n#2. CV Status O: Pt. remains jaundiced, warm and well\nperfused. HR ~130-160's, mo murmur noted. Follow up ECHO\ndone this afternoon, results pending. BP means all WNL.\nShe conitnues to be edematous throughout. A: stable P:\nContinue to monitor CV Status.\n\n#3. FEN O: Pt. is NPO. TF 100cc/kg/d. UAC is infuseing\nSterile H2o+NA Acetate @ .8cc/hr without incident. R.foot\nPICC is infuseing D12.5 and IL without incident. Abdomen is\nsoft/flat. Abdominal girth is 21.5cm. She is voiding well,\nno stool noted this shift thus far. A: Pt. is tolerateing\ncurrent nutritional plan. P: Continue w/ current feeding\nplan. Monitor for s/s of intolerance.\n\n#4. Growth/Development O: Pt. remains in an open warmer,\nnested w/ stable temps. She is alert and active w/ cares,\nirritable at times in between. Fontanelle soft/flat. Eyes\nremain fused. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n#5. O: in to visit throughout the shift.\nThey were updated at bedside on pt's current status and\ndaily plan of care. asking appropriate questions.\nMom very today, wasn't up for a family team meeting\nr/t her emotional status. Social work in to see mom. A:\nFamily is loving and involved. P: Continue to update,\nsupport and educate. Plan to have Family team meeting\ntomorrow @ 1500.\n\n#6. ID O: This is Day #3 of 7 days of IV Amp+Gent. Pt.\nis alert, active and appropriate. No s/s of infection\nnoted. A: stable P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 1792002, "text": "Respiratory Care\nBaby extubated to cpap 6 @ 2100.Sx prior to extubation for mod cldy secs.FIO2 ranges from 26-38%BS clear throughout.ABG @ 0300 7.26/43/63/28/-7 with no changes made at this time.No spells documented thus far this shift,on caffeine.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-08 00:00:00.000", "description": "Report", "row_id": 1792318, "text": "NICU fellow note\nWell appearing in NAD, sleeping in open crib\nVSS\n, MMM\nRRR, no murmur, well perfused\nCTA bilaterally, good air entry\nSoft, NT/ND, no masses, active bs\nnormal \n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-08 00:00:00.000", "description": "Report", "row_id": 1792319, "text": "Parent CPR Class - infant's participated in the Parent CPR class that was offered this afternoon. They watched the video and then used the manikins to demonstarate use of CPR and choking relief techniques. Questions answered.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-09 00:00:00.000", "description": "Report", "row_id": 1792320, "text": "NPN 1900-0700\n\n\nFEN: Learning to PO feed, tolerating well - no spits,\nminimal aspirates. Offered bottle with middle cares with\ninfant taking approx. half volume. Abdomen soft/round, good\nbs, voiding, trace stool. Continues on iron & multivitamins.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Brings hands to face and sucks on pacifier\nfor comfort.\n\n: No contact thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-09 00:00:00.000", "description": "Report", "row_id": 1792321, "text": "Neonatology Attending\n\nDay 71 PMA 37 wks\n\nRemains in RA. Clear breath sounds. RR 30-50s. Mild retractions. . Soft murmur persists. HR 140-150s. BP mean 48. Pale, . Weight 3115 gms (+100). TF at 140 cc/kg/d- BM 24 with Enfamil powder. Taking half volumes po with every other feed. Occasional spit. Stable temperature in open crib.\n\nDoing well overall. Adequate breathing control. Feeding improving. Gaining weight well. No changes for now.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-07 00:00:00.000", "description": "Report", "row_id": 1792034, "text": "NPN 1900-0700\n\n6 I/D\n\nRESP: Infant remains in RA, RR 50-70s. LS c/=, mild IC/SC\nretractions. O2 sats >95%. 1 spell thus far this shift.\nHR 71, O2 sat 90% while feeding; required mild stim for\nresolvement. Pt is on caffeine.\n\nFEN: BW 1230g CW 1030g (up 15g). TF 160cc/k/day. EF\ncurrently at 60cc/k/day with BM/PE20; advancing by 10cc/k\n. Central PICC R foot patent and infusing PN D15 + IL at\n100cc/k/d. Tolerating feeds well. Min asp, no spits. Abd\nbenign. AG=20-21.5cm. Voiding QS, lg stools x2. Stool at\n0100 noted to be heme positive. aware. Continue to\nmonitor. Lytes, trig, BUN & creat drawn at 0100; results\npending.\n\nDEV: Maintaining temps while nested in servo . A/a\nwith cares, sleeps well btwn. Tries to suck on pacifier.\nMoves hands to face. , , AGA.\n\nID: pt completed 7 day atbx. Temps stable. Issue\nresolved.\n\nBILI: Infant not currently under phototx lights. Rebound\nbili yesterday 4.7/0.4. Pt , sl Jaundiced. Bili drawn\nat 0100; results pending.\n\nREVISIONS TO PATHWAY:\n\n 6 I/D; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-07 00:00:00.000", "description": "Report", "row_id": 1792035, "text": "Neonatology note\n\n8 d.o, 28 wks PCA\nin RA, 1 spell last night, on caffeine.\nbili= 4.3\nwt= 1030 gm + 15\n1690 ml/kg/d with feeding at 60 ml/kg/d with EBM \\PE 20\n\n\nAFOF, , jaundice\nmild retraction, clear lungs\nRR with no murmur, pulses equal all 4\nAbdomen soft no mass palpable, bowel sounds present\nnormal tone for preemie\n\nA: ex 27 wks GA, RDS resolved, AOP, resolving hyperbilirubinemia, grade 1.\nP: advance feeding, f/u HUS tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-07 00:00:00.000", "description": "Report", "row_id": 1792036, "text": "Nursing Progress\n\n\n#1 Resp: RA, 50-70's, lungs clear, ic/sc retractions. One\nspell req. mild stim. On Caffeine. Stable. Cont. to monitor.\n#3 FEN: TF 160cc/kg. Enteral feeds @ 70cc/kg of BM/PE20. Abd\nsoft, no loops, active bs, voiding 5.0cc/kg, no stool. No\nspits. IVF @ 90cc/kg of PND15 w/IL infusing via central\nPICC. Stable. Advance enteral feeds 10cc/kg . #4 DEV:\ntemps stable nested in servo . is\nalert/active w/ cares. Settles well between cares. MAE,\nfontanels soft/flat. Eyes open. AGA. Cont. to monitor. #5\nParenting: mom/dad in for 1300 cares, participating in\ncares, very loving toward infant. Asking appropriate\nquestions, pleased w/ baby's progress. Cont. to\nsupport/update. #7 Hyperbilirubinemia: pt is slightly\njaundiced, 2nd rebound 4.3/0.5. Problem resolved. \nflowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-07 00:00:00.000", "description": "Report", "row_id": 1792037, "text": "7 Hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-23 00:00:00.000", "description": "Report", "row_id": 1792119, "text": "Attending Note\nDay of life 24 PMA 30 \nin room air since yesterday sat 92-100% self resolved drifts\nRR 50-60 no spells in 24 hours on caffeine\nHR 160-170 BP 72/50 mean 56\nweight 1375 up 20 on 150 cc/kg/day of BM 30 cal/oz pg over an hour 15 minutes\nno spits minimal aspirate\nvoiding and heme negative stools\nstable temp in air \nalert and active with cares\nday of erythro eye ointment\non iron and vit E\n\nImp-stable\nwill continue current calories\nwill d/c eye ointment today\nwill have a head ultrasound next week\nwill have hep B next week\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-23 00:00:00.000", "description": "Report", "row_id": 1792120, "text": "Nursing Progress Note\n\n\n1. Resp O/A Rec'd inf in RA. Inf returned to NC 100%\n13cc for frequent drifting to 70-80's this am. No spells,\non caffeine. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of BM 30w/PM. All feeds PG\nover 1hr 15 min. Tol well, no spits, min spits thus far.\nBelly soft, no loops. Infant voiding, stooling. On Fe and\nVit E as ordered. P cont to assess FEN needs.\n4. DEV O/A remains swaddled in air with\nstable temp. Quietly A/A with cares. Sleeping well between\ncares. Erythro ointment D/C'd as ordered. P cont to assess\ndev needs.\n5. O/A Mom and Dad in for visit and cares. Updates\ngiven. gave infant a today with minimal\nassistance from this RN. Mom kangaroo'd infant today. P\nsupport, educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-23 00:00:00.000", "description": "Report", "row_id": 1792121, "text": "Fellow PE Note\nGen- WD/WN F alert in NAD\nHEENT- NCAT, , nares patent with NC in place, oropharynx clear\nCArdiac- RRR, nl s1,s2, no murmur\nLungs- CTAB, mild retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nSkin- no rash\n" }, { "category": "Nursing/other", "chartdate": "2189-10-24 00:00:00.000", "description": "Report", "row_id": 1792122, "text": "1. Resp: O: Infant is on O2 via nc, 100%, 25cc flow. RR\n30-60s, ls clear, no spells. Infant only desats when she has\nthe nc prongs out of her nose. A: Infant still needs a whiff\nof O2. P: Monitor. Wean as tol.\n\n3. f/N: O: Infant is on 150cc/k/d of BM30 + promod, fed q 4\nhours via gavage over 1 hour and 15min. Abd is benign. She\nis voiding and stooling g- stools. Min asps, no spits. She\ngained 25g. A: Tol feeds, gaining wt. P: Continue w/ plan.\n\n4. G/d: O: infant is alert and active w/ cares. A:\nAppropriate for G/A. P: Continue to support infant needs.\n\n5. : O: Dad was in to visit and spent time getting\ninfant foot prints to send to his dad in . (He also\ndid infant care.) A: Loving, involved Dad. P: Continue to\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-24 00:00:00.000", "description": "Report", "row_id": 1792123, "text": "Neonatology\nDOL #25, CGA 30 wks.\n\nCVR: Continues in NC 25 cc, RR 30-50s, overall comfortable. No spells, on caffeine. Hemodyanmically stable.\n\nFEN: Wt 1400, up 25. TF 150 cc/kg/day, BM 30 w/PM. Voiding/stooling. Abdomen benign.\n\nDEV: In .\n\nIMP: Former 27 wk infant with RDS, overall doing well. Low oxygen requirement. Tolerating enteral feeds, gaining weight.\n\nPLANS:\n- Continue as at present.\n- Wean NC as able.\n- Continue current enteral regimen.\n- HUS this week.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-20 00:00:00.000", "description": "Report", "row_id": 1792375, "text": "Neonatology - Progress Note\n\n is active with good . . She is , well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. She is tolerating ad-lib feeds. Abd soft, active bowel sounds, voiding and . Stable temp in open crib. Eye exam scheduled for tomorrow, then discharge to follow. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-20 00:00:00.000", "description": "Report", "row_id": 1792376, "text": "Nursing Progress Note\n\n\n3. Awoke and fed well q2.5-4hrs, taking 45-80cc well with\n feeder. Feeds e24 or BM24cals. No spits. Voiding\nand qs. Desitin applied to bottom, slightly\nreddned. Abdomen benign. A. Feeding and growing. P.\nReady for discharge in AM.\n4. Temp stable in open crib. and active with cares,\nfollows face with eyes. Wakes spontaneously for all feeds.\nA. Developmentally appropriate. P. Support.\n5. called twice today, at home getting ready to\nbring baby home tomorrow. Will visit later this evening.\nA. getting ready for d/c tomorrow. P. Finish\ndischarge teaching tonight. Car seat test needs to be\nrepeated as brought in wrong car seat.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792068, "text": "Lactation Progress Note\nSpoke with mom briefly this afternoon. Mom reports her supply has increased tremendously this week. She is pumping 7-8 times per day and getting 300-400cc/day. Support and encouragement offered. Asked mom to contact us if she has any questions or concerns.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792069, "text": "Nursing Progress Note\n\n\n1. Continues on N/C O2 at 13cc 100% with O2 sats 90-100.\nLungs clear and well aerated. Color , mild retractions.\nA. Diong well in low- flow O2. P. Wean cannula as\ntolerated.\n3. Fluids 150cc/kg/d of BM 20cal via ng over one hour.\nAbdomen soft with active bowel sounds, soft transient loops.\n No distension, girth stable at 20.5cm. Guiac positive\nstools noted x2, KUB done at 1400, read as normal, feeds\ncontinued. Aspirates 0-3cc. A. Heme + stools, KUB benign.\n P. Continue with feeding plan, monitor closely.\n4. In servo . Very active at start of shift,\nkicking off servo probe, temp high. Blanker placed over\ninfant for coontainment and boundaries raised, infant\nsettled to sleep. A. Better with more containment. P.\nContinue with support.\n5. in during KUB. Asking appropriate questions,\ninformation given. Will be back to kangaroo at . A.\nInvested . P. Support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792070, "text": "Procedure Note: P-CVL removal\nP-CVL removed without incident.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-13 00:00:00.000", "description": "Report", "row_id": 1792071, "text": "NICU NSG NOTE\n\n\n#1. Resp. O/ Conts on NC 13cc. RR 60-70's with occassional\ntransient tachypnea to 80's. LS clear and equal. Mild\nIC/SubC retractions. On caffeine. No spells. A/ Stable in\nmin O2. P/ Cont to monitor resp status closely.\n\n#3. FEN. O/ WT up 15g. TF 150cc/k/d. Receiving q4h volumes\nBM20 via gavage over 1h. Abd soft and round. Voiding and\nstooling. Stool trace heme pos. No loops or spits. Max asp\n3cc. A/ Tolerating feeds. P/ Cont to monitor for feeding\nintolerances. Daily wts.\n\n#4. G&D. O/ Awake and alert with cares. Temps stable in\nservo . MAE. Nested on sheepskin. Cares clustered.\nKangaroo'd x1h--tolerated it well. A/ AGA. P/ Cont to\nsupport developmental needs of infant.\n\n#5. Parenting. O/ Mom and dad in for cares. Independant.\nUpdated at bedside. Dad kangaroo'd x1h. A/ Updated and\ninvolved. P/ Cont to provide info and support to family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-14 00:00:00.000", "description": "Report", "row_id": 1792072, "text": "NPN\n\n\n#1-O; remains in nasal cannula 100% 13cc, no spells, no\ndrifts this shift. clea and equal RR 50's-70's, ic/sc\nretractions, on caffeine\n\n#3-O: on tf 150cc/k/d full enteral feeds of BM20 = 31cc q 4\nPG over 1 hr tol well, no spits, min aspirates, girths\nstable, abd soft, benign, voiding q diaper and one mod\nyellow seedy stool. wt up 15 gms to 1.195 kg. today.\n\n#4-O;very alert and active, AFOF, MAE, no spells , on\nsheepskin. cont to assess.\n\n#5-O; mom called x 1, updated, will be in today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-14 00:00:00.000", "description": "Report", "row_id": 1792073, "text": "Neonatology note\n\n15 d.o\non NC O2 13 ml, no spell, on caffeine.\nwt= 1195 gm + 15\n150 ml/kg/d with EBM 22 pG\nstool positive, KUB unremarkable, not bilious aspirate 3-4ml.\n\nin , , jaundice.\nAFOF, no cleft lips, palate\nnormal tone, appropriate response with exam\nRR with no murmur\nmild retraction, clear lungs\nabdomen soft, bowel sounds present.\n\nA: ex 27 wks GA, RDS, AOP, resolving hyperbilirubinemia, grade I.\nP: advancing to 24 cal/oz and monitor tolerance.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-22 00:00:00.000", "description": "Report", "row_id": 1792116, "text": "Clinical Nutrition:\nO:\n~30 week CGA BG on DOL 23.\nWT: 1355g(+10)(25-50 %ile); BWT: 1230g. Average wt gain over past week ~17g/kg/day.\nHC: 26.5cm( %ile); last: 27cm\nLN: 40.5cm(50-75 %ile); last: 38cm\nMeds include Fe & Vit.E\nLabs due next week.\nNutrition: 150cc/kg/day as BM 30 w/ promod; pg over 75mins. Average of past 3-day intake ~141cc/kg/day, providing ~141kcal/kg/day & ~3.8g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; pg fed. Labs due next week. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is meeting recs for WT gain. HC gain is not meeting recs of ~0.5-1cm/wk & LN gain is exceeding recs of ~1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-22 00:00:00.000", "description": "Report", "row_id": 1792117, "text": "Nursing Progress Note\n\n\n1. Resp O/A Rec'd inf in NC. Inf remains in NC 13cc\n100%. No spells thus far, on caffeine. IC/SCR noted. P\ncont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of BM30w/PM. All feeds PGover\n1 hr 15 min. Tol well. No spits, no asp thus far. Belly\nsoft, no loops. Voiding, stooling guiac -. P cont to\nassess FEN needs.\n4. DEV O/A Temp stable swaddled in air . A/A\nquiet during cares. Sleeping well between cares. R eye yel\ndrainage, warm soaks, erythro ointment applied as ordered.\nP cont to assess dev needs.\n5. O/A Mom in for visit and cares. Updates given.\n P plan to visit this evening.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-23 00:00:00.000", "description": "Report", "row_id": 1792118, "text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. RR 50-60's occ in 70's. O2sat\n>92%. Lungs are clear and equal with mild ic/scr noted. No\napnea, bradys or desats thus far this shift. Continues on\ncaffeine. A: Stable in Ra. P: Continue to monitor resp\nstatus.\n\nFEN: CW 1375g (^20). TF 150cc/k/d of BM30 w/pm (34cc q4hr pg\n1hr 15min). Abdome soft with active bowel sounds. No loops,\nno spits, girth stable, min aspirates. Voiding with each\ndiaper change. Stool x's 2, heme neg. A: Tolerating current\nfeeding regimen, gaining wgt. P: Continue per nutritional\nplan.\n\nDEV: Infant remains swaddled in an air . Temps\nstable. Alert, active during cares, settles well inbetween.\n, . Right eye with yellow drainage, erythromycin\nointment applied as ordered. Brings hands to face for\ncomfort and occ interested in pacifier. A: AGA P: Continue\nto support developmental needs.\n\n: Mom and dad in for the 2100 cares. Both are\nvery loving and affectionate towards infant. Both ask\nappropriate question regarding care. Updated by this RN. Mom\nand dad took part in the cares and weighing. Mom \ninfant for >1hr. Both enjoyed. Mom and Dad looking forward\nto giving the baby a later today. will be in at\n1p. A: Involved, loving, appropriately concerend. P:\nContinue to support, educate, update .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-10 00:00:00.000", "description": "Report", "row_id": 1792193, "text": "NPN 07p-07a\n\n\nFEN\nCurrent weight 1965g (no change), TF 150cc/kg/day, BM28 with\nPromod, gavaged q4h/60min. Tolerating well. No spits. Min.\naspirates. BS active. Abd. soft, full. AG 26cm. Voiding,\nstooling (heme negative). Cont. monitor PG feeding tolerance\n& weight.\nG&D\nIn off , temps stable. & active with cares.\nREsting comfortably inbetween. Fontanels soft, flat. MAEs\nequally. PPP x4ext. Cont. monitor growth & developm.\npatterns.\n\nNo contact thus far. Cont. support & educate.\nA&B\nNo spells this shift thus far. Occ. desats into 80's noted\n(while resting & with feeds), QSR. Cont. monitor for\nchanges.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-10 00:00:00.000", "description": "Report", "row_id": 1792194, "text": "NICU Fellow Note\nExam:\nGeneral - comfortable in \nHEENT - AFOS, NGT in place\nLungs - clear b/l with equal breath sounds\nHeart - RRR, I/VI soft systolic murmur\nAbdomen - soft, nondistended\nExtremities - WWP, nl cap refill\n" }, { "category": "Nursing/other", "chartdate": "2189-11-10 00:00:00.000", "description": "Report", "row_id": 1792195, "text": "Neonatology Attending Progress Note:\nDOL #42\nPMA 33 2/7 weeks\nwt= (no change)\nintermittent murmur, HR=140-170\nBP 72/39 mean=48\nremains in RA, mild , no spells but drifts to 80's\nvoiding, stool heme negative\nTF=150cc/kg/d, BM28 and promod, all pg\nImp/Plan: preme infant with intermittent murmur, tolerating full feeds\n--monitor sats\n--monitor murmur\n--monitor for feeding intolerance, monitor weight\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-10 00:00:00.000", "description": "Report", "row_id": 1792196, "text": "FEN O/A: 150cc/kilo/day BM28 with Promod. 49cc Q4 hours PG\nover 60 minutes. Abdomen is soft, and slightly full. No\nloops, +BS. Aspirates 3 and 5cc thus far this shift,\npartially digested breast milk. Girth 25.5-26cm. Voiding, no\nstool thus far this shift. P: Continue to monitor.\n\nG&D O/A: Swaddled in off . Temps stable. 1 QSR sat\ndrift today, sat 78%, no dip in HR. Brown birth mark noted\non right ankle. Sleeps well between cares. Slightly\nlethargic during cares. Sucks on thumb. A&P fontanells soft\nand flat. P: Continue to monitor.\n\n O/A: Mom in for 1300 care. Asked appropriate\nquestions, loving towards infant. Held infant for 1 hour.\nStates that she and Dad plan to return for 2100 care. P:\nContinue to encourage and support.\n\nPlease see flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-10 00:00:00.000", "description": "Report", "row_id": 1792197, "text": "NICU NSG NOTE\n\n\n#3. FEN. O/ Wt down 5g. TF 150cc/k/d BM28 with PM. Receiving\nq4h volumes via gavage over 1h. Abd exam benign. Voiding and\nstooling. Sm spit x1. No loops. 2-5cc asps. AG 26. A/\nTolerating feeds. P/ Cont to montior for feeding\nintolerances. Daily wts.\n\n#4. G&D. O/ Awake and with cares. Temps stable in off\n. Nested and swaddled. Cares clustered q4h. Held by\ndad. A/ AGA. P/ Cont to support developmental needs of\ninfant.\n\n#5. Parenting. O/ Mom and dad in for cares. Independant.\nUpdated at bedside. Looking forward to Christening this\nweekend. A/ Updated and involved. P/ Cont to provide info\nand support to family.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-30 00:00:00.000", "description": "Report", "row_id": 1791992, "text": "0700- NPN\n\n\nRESP: Continues on HFOV; current settings MAP 10, delta P\n24, fi02 21%. Settings weaned throughout the day, see\nflowsheet for details. Most recent blood gas drawn at 1100,\n7.33(pH)/39(pC02)/55(p02)/21(tC02)/-4(BXS). Plan to continue\nto wean as tolerated and monitor blood gases. LS course,\nwell-aerated; suctioned x1 for small amt clear secretions\nvia ETT.\n\nCV: HR 130s-160s, no audible murmur. Second dose of first\ncourse of Indocin given this a.m, TW. BPs stable with MAPs\n32-36. Infant is pink and well-perfused, peripheral pulses\nnormal. Precordium slightly active. See lab for CBC and\ndifferential drawn this a.m.\n\nFEN: NPO; TF 80cc/kg/d. IVFs PND12.5w infusing via PIV,\nsterile water with 1/2NaAc + 0.5Uhep/cc infusing via UAC.\nSee lab for this morning's electrolytes. DStick 100. Remains\nedematous. Abdomen soft, round, no loops, hypoactive BS.\nVoiding, no stool at this time.\n\nDEV: Temps stable, nested with sheepskin on servo control\nwarmer. MAE, fontanels soft and flat. Active with cares,\nsleeping between cares. Settles easily. Eyes remain fused.\nAGA.\n\nPARENTING: No contact from at this time. Plan to\nschedule family meeting when visit.\n\nI/D: Day 2 out of a planned 7 day course of Ampicillin and\nGentamicin, tx presumed sepsis. Repeat differential sent\nthis a.m. shows no left shift, see lab. BC pending. Plan to\ncheck Gentamicin levels at third dose.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-29 00:00:00.000", "description": "Report", "row_id": 1792143, "text": "PCA Note 0700-1900\n\n\nRESP: Remains stable in RA, breathing comfortably 30-50s,\nsats 94-500% at rest. Lung sounds clear/= bilaterally with\nmild SC retractions noted. No spells so far this shift.\nRemains on caffiene as ordered.\n\nFEN: TF 150cc/kg/day (38cc Q4 of BM30 with promod) all PG.\nAbdomen soft/round, good bs, AG stable at 22cm, no loops.\nInfant had small spit x1 thus far and a max, benign aspirate\nof 2cc. Voiding and stooling (heme negative). Continues on\niron and Vit E as ordered.\n\nDEV: Received infant in OAC. Infant had cool temp at 0900\n(97.4 rectal) and was placed into air-mode , temp\nrechecked and was WNL. shut off at 1300 after temp\nof 99.4. Temps now stable while swaddled in off .\n and active with cares and sleeping well in between.\nBrings hands to face and sucks on pacifier for comfort.\nSmall amount of yellow drainage noted from right eye, eye\ncare given. Head ultrasound performed this AM.\n\nPARENTING: Mom in for second cares, very loving and asking\nappropriate questions. Mom independent with infant's cares,\nheld baby during gavage feeding. Updates given at bedside by\nRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-29 00:00:00.000", "description": "Report", "row_id": 1792144, "text": "NPN\n\n\n#1 remains in room air with occasional quick self\nresolving drifts to the high 80's.LS clear and equal , mild\nsc retractions noted.caffeine given as ordered.\n#3 Remains on BM30kcal/oz with weight gain tonight of 40\ngrams. Weight is 1555. Tolerated feeds over 90 minutes\nvdg /no stool.\n#5 Mom and dad in for 9pm feeding. Loving towards .\nUpdated at the bedside. Dad held for feeding. Mom and\ndad requested they be allowed to have a Christening for\n on at 4:30 pm. Approved by \n that can use family resource room and have\nno more then 10 guests.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-30 00:00:00.000", "description": "Report", "row_id": 1792145, "text": "NPN:\n\nRESP: Sats 96-100% in RA. RR=50-60s with SC retraction. BBS =/clear. Occasional sat-drifts (85) w/quick recovery. No A&Bs over past 24 h. Remains on Caffeine.\n\nCV: Soft murmur @ LUSB. HR=140-160s. BP=71/34 (47). Color pale w/good perfusion. Hct ()=26.1, Retic=5.8.\n\nFEN: Wt=1555g (+ 40g). TF=150cc/kg/d; 39cc BM-30 w/promod q 4 h via gavage over 90 minutes. Tolerating fdgs well w/o spits; minimal residuals. Abd benign. Voiding ; yellow stool. FeS04 and Vit E.\n\nG&D: CGA=31 wk. Temp stable in off . Active and w/good tone. Nested in sheepskin and resting well. AF soft, flat. Eye exam next week.\n\nSOCIAL: No contact w/.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-30 00:00:00.000", "description": "Report", "row_id": 1792146, "text": "Neonatology Attending Progress Note:\n31 5/7 weeks PMA\nremains in RA, mild sc retx, caffeine, no spells\nsoft intermittent murmur, HR=150-170's, BP 71/34 (mean=47)\nwt=1555g (inc 40g), TF=150cc/kg/d BM 30 with promod, tolerating feeds over 90 minutes, no spits, voiding, stools heme negative.\nImp/Plan: premie with AOP-on caffeine, intermittent murmur,right germinal matrix, doing well\n--monitor for spells, continue caffeine\n--monitor murmur\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-10-04 00:00:00.000", "description": "Report", "row_id": 1792024, "text": "NPN 0700-1900\n\n7 Hyperbilirubinemia\n\n#1Resp: pt. remains in stable in RA, RR 40-70's, sats >\n95%. Pt. comfortably tachypneic at times. LS clear\nbilaterally w/ IC/SCR. NO spells or desats so far this\nshift. Pt. continues on caffeine. P: cont to monitor resp\nstatus.\n\n#3FEN: TF increased to 150cc/kg/d of PN/IL & enteral feeds.\n PND 12.5/IL @ 130cc/kg/d infusing well through central\nPICC. Enteral feeds of BM 20cal/oz advanced to 20cc/kg= 4cc\nNG Q 4hrs. Pt. tolerating feeds well, no spits, min asp.\nAbd soft & full, +BS, no loops. AG stable. Pt. voiding qs,\nno stool so far this shift. P: cont to monitor for feeding\nintolerances & check lytes in am.\n\n#4DEV: Temps stable nested in sheepskin in servo .\nPt. awake & alert for cares. Settles well in between w/\npacifier. MAE. AFSF. Eyes remain fused. P: cont to\nsupport dev needs.\n\n#5Parenting: Dad in today asking approp questions. Updates\ngiven. Mom called this afternoon asking similar questions.\nMom having difficulty w/ milk production. Encouraged mom to\ncontinue pumping 8x day, drink lots of fluids, & try mothers\nmilk tea. Lactation consult scheduled for tuesday @ 1pm.\nMom plans on visiting tonight for 9pm cares. P: cont to\nsupport & update.\n\n#6ID: Pt. continues on ampi & gent, now day 5 of 7. Pt.\nawaiting LP. P: cont to monitor for s/s of infection.\n\n#7Bili: Pt. continues under single phototherapy. Eye\nshields in place. P: check bili in am.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-09 00:00:00.000", "description": "Report", "row_id": 1792188, "text": "3. F/N: O: Infant is on 150cc/k/d of BM 28 + promod, q 4\nhour feeds, all gavaged, over one hour each feed. Abd is\nbenign, no spits, min asps. She is voiding and had a large,\ng- stool. She gained 60g. A: Tol feeds, gaining wt. P:\nContinue w/ plan.\n\n4. G/d: O: Temp is stable in the w/ the heat off.\nInfant is active w/ cares and sucks on a binkie. A/P:\nContinue to support infant needs.\n\n5. : O: were in to visit, do cares and hold\ninfant. They are independent w/ cares. A: Loving, involved\n. P: Continue to support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-09 00:00:00.000", "description": "Report", "row_id": 1792189, "text": "Fellow Exam Note\nGen: awake, , NAD, active in \nHeent: , EOMI, ngft in place, MMM, o/p clear\nCor: no murmur\nLungs: cta b/l\nAbd: soft, nt, nd, +bs, no hsm\nExt: warm, good cap refill, 2+ fem pulses\nGU: nl female\nSkin: no lesions\n" }, { "category": "Nursing/other", "chartdate": "2189-11-09 00:00:00.000", "description": "Report", "row_id": 1792190, "text": "Neonatology Attending Progress Note:\nDOL #41\n33 1/7 weeks PMA\nremains in RA, RR=30-60's, clear/equal, mild retx\nno spells\nintermittent murmur, HR=150-180's overnightm, BP 63/32 (mean=47)\nwt=1965g (inc 60g), TF=150cc/kg/d BP 28 with promod, all gavage over 1 hour\nmax aspirate 1 1/2 cc\nvoiding, stools heme negative, no spits\noff \nImp/Plan: premie infant tolerating full feeds, intermittent murmur--cardiovascularly stable, doing well\n--continue current feeding regimen, monitor weight\n--monitor murmur\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2189-11-09 00:00:00.000", "description": "Report", "row_id": 1792191, "text": "NPN 0700-1500\n\n\n#3 O: TF= 150cc/kg/d. Infant receiving 49cc's of BM28 with\npromod q 4h via gavage over 1h. Abdomen benign; voiding,\ntiny stool. No spits, max aspirate of 1.0cc. A: Tolerating\nfeeds. P: Cont to monitor.\n\n#4 O: Maintaining temp in an \"off\" . Dressed in\nt-shift and swaddled in blanket. Awake and with cares;\nsleeping well between. Brings hands to face for comfort. A:\nAGA. P: Cont to support development.\n\n#5 O: No contact as yet. A/P: Cont to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-09 00:00:00.000", "description": "Report", "row_id": 1792192, "text": "NPN\n\n\n#3 O: Baby remains on 150cc/K/day via 49cc\nBM28PM every 4hrs given over 1hr. Voiding and stooling.\nVitamin E given as ordered. A: Tol NG feeds. P: Cont to feed\nas tol.\n#4 O: Baby with care. Very with visit.\nTemp stable dressed and swaddled in off , A: AGA. P:\nCont interventions. Keep in for\na while longer for growth. Mother verbalized that she\npreferred in due to fluctuations in room\ntemps.\n#5 O: in for several hrs. Dad gave baby a with\nmothers help. Mother held baby swaddled for over 1hr. A:\nInvolved . P; Cont teaching, inform, support and\nencourage .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1792270, "text": "NICU Nursing Progress Note\n\nI have examined infant and agree with observations described above by PCA .\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-29 00:00:00.000", "description": "Report", "row_id": 1792276, "text": "NICU Attending Note\n\nDOL # 61 = 36 weeks PMA learning to PO feed, no new concerns.\n\nAgree with full .\n\nCVR/RESP: RRR without murmur, skin and well perfused, BS clear/=, RA, no A/B. Will continue to monitor.\n\nFEN: Abd benign, weight today 2770, up 15 gm on TF of 140 mL/kg/day, MM26 PO/PG, improving PO's. Fe,Vit E, tolerated well, voiding and stooling, Will continue current diet. When fully PO feeding, will be ready for discharge to home.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-29 00:00:00.000", "description": "Report", "row_id": 1792277, "text": "Nursing Progress Note:\n\nFEN:\nO: Infant receiving 140cc/kg of BM 26, (=65cc), every 4\nhours, po/pg. Infant took 30cc with each feed, by bottle,\nusing a nuk . Well coordinated, tires quickly, and\ngets remainder by gavage. No spits noted this shift.\nAbdominal exam benign. Minimal aspirates. Infant voiding,\nand passing heme negative stool.\nA: Infant tolerating feeds well. Progressing well with po's.\nP: cont to offer infant bottle with each feed, when awake\nand .\n\nDEV:\nO: Infant temp stable; swaddled in an OAC. Font s/f. Infant\na/a with cares, waking for most feeds. within normal\nlimits. Infant reaches hands to face and enjoys her\npacifier. Sleeps well between cares with boundaries.\nA: Appropriate behavior for gestational age.\nP: Cont to support development.\n\nSOC:\nO: Mom, and 2yo sister in to visit at 1300. \n with cares, and mom bottled infant well with\ngreat positioning. Very responsive to infant cues while\nbottling. asking appropriate questions. Mom cont to\npump.\nA: bonding well with infant. Active in infant care.\nP: Cont to support, educate and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-29 00:00:00.000", "description": "Report", "row_id": 1792278, "text": " Physical Exam\nAwake and . and well perfused. . Breath sounds clear and equal with slight retractions. No audible murmur, normal pulses. Abdomen soft and rounded with active BS, no HSM or masses. Normal GU.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-29 00:00:00.000", "description": "Report", "row_id": 1792279, "text": "0700- NPN\nI agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-30 00:00:00.000", "description": "Report", "row_id": 1792280, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, assessment unremarkable.\nTF=140cc/kg/day. Infant taking 66 cc BM26 q4 PO/NG. Infant\nPO feeding 40-50cc using NUK . No aspirates or\nemesis. Voiding and stooling with diaper changes. Wgt:\n2.810k ^40g A: Stable feeder and grower. Improving PO\nintake P: Advance feeds as tolerated. Monitor for feeding\nintolerance. Encourage PO feeds when awake and .\n4. G&D O: is active and with cares.\nPeriodically wakes up for feeds. Temp wnl in open crib. No\ns/s pain or discomfort. Eye exam in am A: Appropriate P:\nMonitor. Comfort measures. Eye gtts at 0830.\n5. PARENTING O: in to visit. Provides care\nindependently. Well-updated with plan of care. A: Loving\nparent P: Support and update. Encourage to ask questions\nand voice concerns.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-30 00:00:00.000", "description": "Report", "row_id": 1791989, "text": "Respiratory Care\nBaby rec'd on HFOV with MAP 13, amp 30, 15 Hz, 30%. ABG: 7.29/44/69/22/-4; amp weaned in increments to 26. ETT retaped without incident. Baby repositioned @ 2400. for mod amt white secretions. BS clear. Rec'd 1st dose Indocin- no murmur noted @ 2400. ABG @ 0230: 7.26/50/59/23/-4; no further changes made. Fi02 has weaned to .21 through the night. Will cont to follow closely, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-30 00:00:00.000", "description": "Report", "row_id": 1791990, "text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCONTINUES ON HFV AT MAP 13, AMPLITUDE 26. NO O2\nREQUIREMENT. GOOD SPONTANEOUS EFFORT. CXR AT 0625. LAST\nABG 7.28/50, NO CHANGES MADE.\n2. CV\nNO MURMUR HEARD. PRECORDIUM ACTIVE, PULSES NL. COLOR PINK,\nJAUNDICED. BP MEANS STABLE 29-34.\n3. F/N\nTONIGHT'S WEIGHT DOWN 5 GRAMS TO 1.225KG. IS EDEMATOUS.\n24 HOUR ELECTROLYTES PENDING. TOTAL FLUIDS AT 80CC/KG,\nD12.5PN INFUSING VIA PIV. GLUCOSE 81/77. VOIDING 1.6CC/KG\nFOR 12 HOURS. NO STOOL. NO AUDIBLE BOWEL SOUNDS ON EXAM.\n4. G&D\nEYE FUSED. ACTIVE WHEN DISTURBED. REPOSITIONED AT 2400.\nSERVO WEANED.\n5. PARENTS\nDAD IN X2 DURING EVENING, ASKING APPROPRIATE QUESTIONS. MOM\nCALLED AND UPDATED.\n6. ID\nON AMPICILLIN AND GENTAMYCIN. CBC AND DIFF\nREPEATED/PENDING.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-30 00:00:00.000", "description": "Report", "row_id": 1791991, "text": "Neonatology note\n1 d.o\non HIFI MAP 11 AMP 26 RA, s/p 3 doses of survanta.\nECHO showed presence of PDA, no on indocin\nwt= 1225 gm -5\n80 ml/kg/d, NPO\n\nreddish color, good perfusion, edematous lloking in the lower extremities.\nAFOF, no cleft lips, palate\nHerat: RR with no murmur, pulses equal, not bouncing.\nair entry good with hand bag.\nabdomen soft, no mass palpable, bowel sounds present.\nnormal external female genitalia.\n\nA: 27 wks GA, RDS, sepsis evaluation (presumed sepsis), PDA, hyperbilirubinemia.\nP: continue course of indocin, monitor closely lytes, continue antibiotics (consider 7 days due to left shift , with reddish color and edematous looking), wean setting as tolerated.\nspoke with mother at bedsides.\nwill need to repeat ECHO after indocin.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-30 00:00:00.000", "description": "Report", "row_id": 1791993, "text": "0700- ADDENDUM TO NPN\n were in to visit for about an hour this afternoon. Update provided by RN as well as by M.D. appropriately concerned about infant and were both teary-eyed during the time they were here. A family meeting has been scheduled for tomorrow afternoon at 2p.m. SW is aware.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-30 00:00:00.000", "description": "Report", "row_id": 1791994, "text": "Respiratory Care\nPt cont on HFOV. Weaned to settings MAP 9, AMP 20. FIO2 .24. abg on AMP 24 7.33/36/69/20/-6. bs clear, rr 40's sx for mod amt. Completing 1st course indocin tonight. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 1791995, "text": "Respiratory Care\nBaby remains on HiFi MAP 9 AMP 20 fio2 ranges from 24-33%.Weighed and turned @ 2200 BS clear throughout,sx for sm cldy secs..ABG 7.25/47/76/22/-6 with no changes made at this time.On indocin.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792061, "text": "Neonatology note\n\n\n13 d.o, now 29 wks GA\non NC 25 ml O2, 5 spells yesterday, on caffeine.\nwt= 155 gm + 5\n150 ml/kg/d with EBM 20, PG, occasional spit and residual.\n\nA: ex 27 wks GA, RDS resolved, AOP, anemia, hyperbilirubinemia resolved, grade 1 bleed, mild ventriculomegaly.\nP: monitor spell, consider advancing calorie density tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792062, "text": "PE: small preterm infant nestled in . , well perfused on NCO2. Comfortbale resp pattern. AFOF sutures approximated, eyes clewar, ng in place,MMMP\nChest is symmetric with equal clear bs\nCVL RRR,no murmur, pulses+2=\nAbd: soft, active bs, NTND cord healed.\nGU: immature female\nEXT: PICC posilflow intact, MAE, WWP\nNeuro: flexed posture with boundaries, symmetric tone and reflexes. appropiate for PMA.\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792063, "text": "Nursing Progress Note\n\n\n#1 Resp: NC 100%, 25-37cc's. Lungs clear/equal. IC/SC\nretractions. 1 spell. On caffeine. RR 30-80's. Stable.\nMonitor resp. status closely. #3 FEN: TF 150cc/kg of BM20.\nAbd soft, no loops, active bs, voiding, stooling heme neg.\nAspirate of 9cc's non bilous, refed and rechecked 20 minutes\nlater- 3.8cc's. Feed gavaged over 1 hour. No spits. .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-10-12 00:00:00.000", "description": "Report", "row_id": 1792064, "text": "#3 Cont. to monitor tolerance of feeds. #4 DEV: temps stable\nin servo . is active/irritable w/ cares.\nSettles well in prone position. MAE, fontanels soft/flat.\nCont. to support dev. needs. #5 Parenting: dad called x1,\nmom in for 1300 cares. Updated at bedside by this RN, mom\n stating \"having an off day\". Cont. to support/update.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-17 00:00:00.000", "description": "Report", "row_id": 1792224, "text": "Neonatology Attending Progress Note:\nDOL #49\n34 2/7 weeks\nremains in RA, RR-40-60's, mild sc retx, no spells\nintermittent murmur, HR=150-160's, Bp 71/31 (mean=46)\nwt=2300g (inc 10g), TF=150cc/kg/d 28 cal BM with promod\nvoiding, stooling, 2 bottles past 48 hours.\nImp/Plan: premie infant learning to po feed, intermittent murmur, stable\n--monitor murmur\n--encourage po feeds, monitor weight\n" }, { "category": "Nursing/other", "chartdate": "2189-11-17 00:00:00.000", "description": "Report", "row_id": 1792225, "text": "Nursing\n\n\n3. Feedings 150cc/kg/d of BM 28 cal with promod q4hr ng on\npump over 50 mins. Tolerated well, one moderate spit when\n holding. Abdomen soft. Large stool x1. Voiding\nqs. A. Feeding, gaining well. P. Continue with plan.\n4. Temp stable in open crib. Slept between cares, \nwhen awakened. A. Doing well. P. Support.\n5. Both in for 1300 feeding, both held\ninfant. Mom put to breast briefly, but she did not\nlatch on. Mom was waiting for lactation consultant to come\nby but she was unavailable. I gave mom a whield\nwhich she will try at next BF. A. Mom would like lactation\nconsult. P. Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 1792226, "text": "1900-0730\n\n\n3. FEN O: Abdomen soft, assessment unremarkable. TF=\n150cc/kg/day. Infant taking 59 cc BM 28 with PM q4 per\nNG/PO. Dad fed infant x1, taking 15cc. No emesis, scant\naspirates. Voiding and stooling with diaper changes. Wgt:\n2.340k ^ 40g A: Stable, tolerating feeds P: Monitor for\nfeeding intolerance. Encourage PO and breastfeeding when\nawake and .\n4. G&D O: is active and . Wakes up before\nfeeding is due. Soothed with pacifier. Temp wnl in open\ncrib. No s/s pain or discomfort A: Appropriate P:\nMonitor. Comfort measures.\n5. PARENTING O: Dad in to visit. Updated. Held and fed\ninfant A: Loving parent P: Support and update. Encourage\nto ask questions and voice concerns.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-18 00:00:00.000", "description": "Report", "row_id": 1792227, "text": "Neonatology Attending Progress Note:\nDOL #50\n34 3/7 weeks PMA\nremains on RA, no spells, RR=30-60's, mild sc retx\nintermittent murmur, HR=150-160's, pale/\nBP 75/37 (mean=49)\nwt=2340g (inc 40g), TF=150cc/kg/d BM 28 with promod still gavage, beginning to bottle feed\nno significant aspirates, voiding, large stool\nopen crib\nPE; well appearing, , normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused. tone aga.\nimp/plan: premie infant learning to po feed\n--monitor weight, encourage po feed, will decrease to 26 calories\n--will need repeat HUS pre-discharge\n--lactation consult next week\n" }, { "category": "Nursing/other", "chartdate": "2189-12-06 00:00:00.000", "description": "Report", "row_id": 1792310, "text": "NPN 0700-\n\n\n3. TF 140cc/k/d BM24 w/enfamil powder= 70cc Q4hr. Abdomen\nbenign. Voiding and had a heme negative stool. Able to\nbottle 55cc very slowly and tired easily. Gavaged 1300\nfeed, infant sleepy. Mom planning to visit at 1700 to\nbreast feed. Tolerating NGT/PO's without spits or\naspirates. Continue to encourage PO's as tolerated.\n\n4. Temp stable swaddled in open crib. and active\nwith cares, rest well inbetween cares. MAE, brings hands to\nface and mouth. Continue to promote development.\n\n5. planning to visit for 1700 cares. No contact\nthus far.\n\n\n" }, { "category": "Echo", "chartdate": "2189-10-02 00:00:00.000", "description": "Report", "row_id": 79494, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease. Focused, serial f/u.\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Congenital, focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Echo", "chartdate": "2189-10-01 00:00:00.000", "description": "Report", "row_id": 79495, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease. Serial f/u.\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Congenital, focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Echo", "chartdate": "2189-09-29 00:00:00.000", "description": "Report", "row_id": 79496, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Radiology", "chartdate": "2189-10-02 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 880519, "text": " 7:36 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT ASSESS FOR INTRACRANIAL HAEMORRHAGE OR OTHER ABNORMALITY\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation\n REASON FOR THIS EXAMINATION:\n rule out intracranial hemorrhage or other abnormality\n ______________________________________________________________________________\n FINAL REPORT\n CRANIAL ULTRASOUND.\n\n Images were obtained in coronal and sagittal planes through the anterior\n fontanelle. There are areas of heterogeneous increased echogenicity related\n to the caudothalamic grooves bilaterally consistent with germinal matrix\n hemorrhage. Findings are more conspicuous on the right. There is no\n ventriculomegaly. No definite intraventricular hemorrhage is seen. Immature\n sulcation pattern is seen consistent with the patient's prematurity. No gross\n parenchymal abnormality is seen.\n\n Mastoid views demonstrated normal-appearing fourth ventricle.\n\n IMPRESSION: Grade I germinal matrix hemorrhage, right greater than left.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-10-01 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 880435, "text": " 3:18 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: EVALAUTE LUNGS, CONFIRM p-cvl TIP POSITION\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 27 gestation\n ON hfov\n p-cvl ORIGINATING RIGHT SAPHENOUS VEIN\n REASON FOR THIS EXAMINATION:\n EVALAUTE LUNGS\n CONFIRM p-cvl TIP POSITION\n ______________________________________________________________________________\n FINAL REPORT\n\n\n BABYGRAM.\n\n Endotracheal tube is 1 cm above the carina. The lungs are well aerated with\n diffuse granularity consistent with surfactant deficiency. Umbilical arterial\n line terminates at T8. A right femoral PICC line terminates at the level of\n T12.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-30 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 880203, "text": " 6:05 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: lung expansion\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant on hifi, now 24 hours old\n REASON FOR THIS EXAMINATION:\n lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 6:21 A.M.\n\n HISTORY: Infant on HiFi, now 24 hours old.\n\n Comparison is yesterday at 1:48 p.m.\n\n The endotracheal tube is unchanged in position.\n\n Lungs are hyperinflated. Findings of mild surfactant deficiency, unchanged.\n UA catheter unchanged in position. Heart size is stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-29 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 880122, "text": " 1:48 PM\n BABYGRAM (CHEST ONLY) PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: preemie, RDS\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, on HIFI\n REASON FOR THIS EXAMINATION:\n preemie, RDS\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON ,1:48 P.M.:\n\n HISTORY: Respiratory distress syndrome, on HIFI.\n\n COMPARISON: 8:45 a.m. from .\n\n The endotracheal tube terminates 1-2 cm above the carina. The lungs are\n hyperinflated. Mild granular air space opacification is again seen,\n consistent with mild Surfactant deficiency, perhaps improved allowing for\n differences in technique. UA catheter terminates at T8, as before. Heart\n size is normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-29 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 880040, "text": " 6:55 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: ETT, UVC, and UAC placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 27 gestation\n REASON FOR THIS EXAMINATION:\n ETT, UVC, and UAC placement\n ______________________________________________________________________________\n FINAL REPORT\n 7:08 HOURS.\n\n CLINICAL HISTORY: Premature infant. Assess ET tube, UVC and UAC placement.\n\n FINDINGS: A supine radiograph of the chest and abdomen demonstrates the\n presence of an endotracheal tube with its tip in satisfactory position below\n the thoracic inlet and above the carina. There is a UAC with its distal tip\n at the level of T12. The UVC is coiled on itself with its distal tip pointing\n inferiorly at the level of L2/L3. Lung volumes are moderately increased.\n There is extensive bilateral ground glass opacity within the lungs in keeping\n with RDS. There is moderate gaseous distention of the stomach. The bowel gas\n pattern is otherwise unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-29 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 880062, "text": " 8:45 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # \n Reason: UAC, UVC placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 27 gestation\n REASON FOR THIS EXAMINATION:\n UAC, UVC placement\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM ON AT 8:45.\n\n CLINICAL HISTORY: Premature infant. Assess UAC AND UVC placement.\n\n FINDINGS: A supine radiograph of the chest and abdomen demonstrates the\n endotracheal tube tip just above the level of the carina. The UAC tip is\n located at the level of T8 and the UVC at the level of T12-L1, presumably\n within the intrahepatic portion of the liver. Lung volumes are moderately\n increased. Heart size is normal. There is a moderate-to-severe ground-glass\n appearance of the lung parenchyma bilaterally in keeping with RDS. The\n abdominal bowel gas pattern is unremarkable apart from moderate gaseous\n distension of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2189-10-29 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 883915, "text": " 7:44 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: Follow up HUS at 1 month of age, R/O abnormality\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation, following mild ventriculomegaly, evolving\n GMH\n REASON FOR THIS EXAMINATION:\n Follow up HUS at 1 month of age, R/O abnormality\n ______________________________________________________________________________\n FINAL REPORT\n NEONATAL PORTABLE HEAD ULTRASOUND ON \n\n HISTORY: 27 weeks gestation with germinal matrix hemorrhage.\n\n COMPARISON: .\n\n Again seen is a small right germinal matrix hemorrhage which is unchanged to\n slightly smaller and has a slightly more echogenic rim. There is ventricular\n asymmetry, left greater than right. However, both measure within normal\n limits. The left ventricle measures 6.8 mm and the right ventricle measures\n 4.0 mm. Resistive indices do not demonstrate significant change with\n compression.\n\n No new abnormalities. Brain otherwise appears normal for the patient's\n gestational age.\n\n IMPRESSION: Evolving germinal matrix hemorrhage with mild ventricular\n asymmetry.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-21 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 890957, "text": " 9:06 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: History of IVH and ventricular assymetry\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation, following mild ventriculomegaly, evolving\n GMH\n REASON FOR THIS EXAMINATION:\n History of IVH and ventricular assymetry\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Ex 27-week infant with history of right germinal matrix\n hemorrhage.\n\n Compared to an examination dated , the right germinal matrix\n hemorrhage has resolved. The size of the ventricles is similar to previously\n with the left lateral ventricle measuring approximately 5 mm and the right\n lateral ventricle measuring 4 mm. The asymmetry is similar. No new\n hemorrhage is identified. Sulci and gyri appear otherwise symmetric.\n Midline structures and the posterior fossa appear unremarkable.\n\n IMPRESSION:\n 1. Stable asymmetry in the size of the lateral ventricles.\n 2. Resolved germinal matrix hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2189-10-15 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 882250, "text": " 7:38 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT ASSESS FOR IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation, s/p pda rx w/ indometh\n REASON FOR THIS EXAMINATION:\n Follow up IVH\n ______________________________________________________________________________\n FINAL REPORT\n CRANIAL ULTRASOUND:\n\n This study is compared with the examination of . Further evolution of the\n germinal matrix hemorrhage is evident. The hemorrhage on the right has\n decreased in overall size and echogenicity. It is now apparent as a\n hypoechoic focus at the caudothalamic groove with a somewhat hyperechoic rim.\n Pulse size is diminished as compared with the earlier study. The frontal \n of the right lateral ventricle is decreased in size and is now slit like. On\n the left, there is some minimal residual increased echogenicity in the\n caudothalamic groove, but a discrete hemorrhage is no longer apparent.\n Anterior of the lateral ventricle has decreased in size and is now\n normal. No other foci of hemorrhage are identified. The extra-axial spaces\n are normal.\n\n IMPRESSION: Evolving bilateral germinal matrix hemorrhage. No\n ventriculomegaly. Utricular asymmetry.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-10-08 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 881330, "text": " 7:16 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: screen for IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation, s/p pda rx w/ indometh\n REASON FOR THIS EXAMINATION:\n screen for IVH\n ______________________________________________________________________________\n FINAL REPORT\n CRANIAL ULTRASOUND\n\n Images were obtained in the coronal and sagittal planes through the anterior\n fontanelle and in the axial plane through a mastoid approach. The study is\n compared with the prior examination of . Again noted is evidence of\n bilateral germinal matrix hemorrhage, right greater than left. The hemorrhage\n on the right is showing sharper definition with a mildly hypoechoic center.\n It is somewhat better defined on this study, in part related to slight\n enlargement of the ipsilateral ventricle. The germinal matrix hemorrhage on\n the left is again inconspicuous, but is now more sharply defined due to mild\n ventriculomegaly, greater than on the right. There is no evidence of\n intraventricular hemorrhage. The parenchyma remains normal.\n\n IMPRESSION: Evolving bilateral germinal matrix hemorrhage, right greater than\n left. Mild ventriculomegaly, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-10-20 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 882865, "text": " 7:03 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: r/o IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation, following mild ventriculomegaly, evolving\n GMH\n REASON FOR THIS EXAMINATION:\n r/o IVH\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE NEONATAL HEAD ULTRASOUND:\n\n HISTORY: This is a 20 day old infant born at 27 weeks with a history of right\n germinal matrix hemorrhage and ventriculomegaly.\n\n Comparison is made to multiple prior studies including and .\n\n FINDINGS: Since the prior study, there is a stable appearance of the evolving\n right germinal matrix hemorrhage measuring approximately 1 cm x .5 cm. This\n has not significantly changed in size since the prior study on . In the\n interval, there has been mild increase in the ventriculomegaly most\n prominently seen within the frontal region. The left lateral ventricle\n remains slightly larger than the right lateral ventricle. There is no new\n evidence of intraventricular hemorrhage. There is no significant change within\n the resistive indices in the anterior cerebral arteries with and without\n compression. The cerebral and cerebellar architecture remains premature in\n echo texture.\n\n IMPRESSION: Stable appearance of evolving right germinal matrix hemorrhage.\n However, there has been mild increase in the ventriculomegaly, left greater\n than right. This is most prominent within the frontal horns bilaterally.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2189-10-13 00:00:00.000", "description": "P BABYGRAM AP ABD ONLY PORT", "row_id": 882011, "text": " 1:53 PM\n BABYGRAM AP ABD ONLY PORT Clip # \n Reason: r/o pneumotosis/abnormal bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with heme + stools.\n REASON FOR THIS EXAMINATION:\n r/o pneumotosis/abnormal bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM TAKEN PORTABLY AT 14:22 HOURS AND COMPARED TO AT 14:21 HOURS\n\n FINDINGS: Nasogastric catheter overlies the stomach. PICC line entering from\n the right leg, tip is at the T12 vertebral body. The heart is normal in size.\n Lungs show mild diffuse haziness, unchanged. Abdominal gas pattern is\n unremarkable without evidence of free or intramural air. No bony or soft\n tissue abnormalities are seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-10-03 00:00:00.000", "description": "BABYGRAM AP ABD ONLY", "row_id": 880695, "text": " 1:55 PM\n BABYGRAM AP ABD ONLY Clip # \n Reason: check bowel loops\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with 27 gestation\n slightly full abdomen\n bilious aspirate\n REASON FOR THIS EXAMINATION:\n check bowel loops\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention. Evaluate bowel gas.\n\n PORTABLE ABDOMEN, 2:21 P.M., .\n\n Compared to the study obtained two days earlier, a nasogastric tube has been\n placed. There is mild gaseous distention of the bowel, but no specific\n features of obstruction. Right groin catheter remains in place. On the\n current study, the tip projects to the base of the right atrium. This could\n be projectional and related to the patient's hip flexion. Nonetheless,\n attention to this on followup is suggested.\n\n The visualized lung bases are clear, with mild changes of lung prematurity\n again seen. No other changes.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2148-02-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1008521, "text": " 9:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with falling o2 sats, decreased BS on left\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man, with acute hypoxia and decreased breath sounds\n on the left.\n\n COMPARISON: at 5:00 a.m.\n\n SINGLE UPRIGHT VIEW OF THE CHEST AT 9:20 A.M: An endotracheal tube terminates\n 7 cm from the carina, a nasogastric tube has its side port just distal to the\n GE junction, and a left subclavian catheter terminates at the junction of the\n left brachiocephalic vein with the superior vena cava.\n\n Since the prior radiograph of 24 hours earlier, an extensive opacity now\n obscures the left hemidiaphragm and the retrocardiac region. This is likely\n due to a combination of pleural effusion and segmental collapse in the left\n lower lobe, one cause of which could be mucus plugging.\n\n Additionally, new airspace opacities are seen in the perihilar regions\n bilaterally, suggestive of pulmonary edema. However, the pulmonary\n vasculature is not engorged, and the heart is not increased in size.\n Multifocal pneumonia could have this appearance, but typically does not\n develop within 24 hours.\n\n There is no pneumothorax.\n\n IMPRESSION:\n 1. New left pleural effusion and segmental collapse of the left lower lobe,\n possibly due to mucus plugging.\n 2. New bilateral perihilar airspace opacity, possibly due to pulmonary edema,\n although the pulmonary vasculature is not engorged. Multifocal pneumonia is\n less likely given the rapid development.\n 3. No pneumothorax.\n\n Findings discussed with the medical service caring for this patient at the\n time of examination.\n\n" }, { "category": "Radiology", "chartdate": "2148-02-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1008317, "text": " 8:34 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: left subclavian line placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with large subdural hematoma\n REASON FOR THIS EXAMINATION:\n left subclavian line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:15 P.M. ON \n\n HISTORY: Large subdural hematoma. Left subclavian line placement.\n\n IMPRESSION: AP chest compared to :42 p.m.\n\n ET tube, left subclavian line, nasogastric tube are in standard placements.\n Increased caliber of mediastinal vessels and upper lobe pulmonary vasculatures\n suggest increasing intravascular volume, but no pulmonary edema or pleural\n effusion is seen. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-02-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1008346, "text": " 5:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: order per organ bank\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with massive SDH\n REASON FOR THIS EXAMINATION:\n order per organ bank\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 54-year-old man with massive subdural hematoma, organ bank.\n\n FINDINGS: In the interim, there is essentially no change in the ___of the\n mediastinal vessels and upper lobe pulmonary vasculature suggesting an\n increase in intravascular volume. However, no pulmonary edema or pleural\n effusion is noted. The heart size is normal.\n\n The endotracheal tube is in 4cm from the carina. Left subclavian central line\n terminates at the SVC and a feeding tube distal tip is out of view.\n\n IMPRESSION:\n\n 1) Persistent mild vascular volume.\n\n" }, { "category": "Radiology", "chartdate": "2148-02-27 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1008255, "text": " 12:33 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n TRAUMA CHEST\n\n INDICATION: Trauma.\n\n COMPARISON: None available.\n\n FINDINGS: The ET tube is 7 cm from the carina. The lungs are clear. The\n cardiomediastinal silhouette is normal.\n\n IMPRESSION: Normal exam, ET tube in standard position.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-02-28 00:00:00.000", "description": "Report", "row_id": 1659585, "text": "NPN7p-7a\n\n54yr male s/p fall hitting head on coffee table. Large right frontal/parietal SDH with 15mm shift. DNR, pt progressing toward brain death, pt is a registered organ donor. Organ bank involved in case.\n\nneuro- pt cont to have no neuro exam, no movement, no cough, gag, or corneal reaction. pupils 5mm non-reactive. has not recieved and pain med or sedation. ethanol level this am neg. benzo cont to be pos. pt on ativan at home. mannitol started last night. NA 148/osmo 318. pt poiklothermic. requiring cooling and now warming to keep temp wnl.\n\nCV- ST-SR rate now 89 NSR. pt cont to require neo to keep map >60. neo weaned as tol. currently at 1.5 mcg/kg/min. heparin held last night per in house attending. med to be discussed on rounds. P-boots on.\n\nresp- cont vent support. AC 40% TV 600 rate 12 peep5. abg wnl. lung sounds clear. no sputum sx. pp 22. pt cont to take a few breaths went vent on hold. (4/min)\n\nGI- abd soft. NGT to sx. bloody output. BS absent. on pepcid.\n\nGU- incresed u/o due to mannitol. na 148/ serum osmo 318. bun beginning to raise. creat wnl. 700cc neg from midnight. CVP 7.\n\nskin- intact\n\nendo- insulin gtt.\n\nsocial- spoke at length with wife, social work, organ bank, and resident about pt condition. pt 3 children in to visit ages 11,13,14. condition was explained to them. ( see social work note). Wife realistic but in shock. family went home to rest will be back this am. wife would like to be present for apnea testing this am.\n\nplan- brain death testing this am. If pt not brain dead possible DCD.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-02-28 00:00:00.000", "description": "Report", "row_id": 1659586, "text": "Respiratory Care:\n\nPt remain orally intubated & sedated on full ventilatory support. We weaned FIO2 this morning. BS are dim midly and clear. RSBI was attempted, Pt taking ~4bpm. We are sxtn for scant secretions, no gag noted. Plan: brain dead/ apnea test to be done this morning. See Careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-28 00:00:00.000", "description": "Report", "row_id": 1659587, "text": "Nursing Progress Note\nSee careview for exact data.\n\nNeuro: Pt no sedated. Exam remains poor. Pt does not open eyes. Pupils 4-5 mm, fixed, NR bilaterally. Absent corneals, cough, and gag. Pt does not move any extremeties to noxious stimuli. Pt does show spontaneous breathes when vent switched to c-pap. No s/s pain. Mannitol dc'd today hypernatremia.\n\nCV: NSR/ST, rare ectopy. HR 90-100's. Pt requiring neo and vasopressin gtt's to maintain adequate BP control. SBP 80-130's maintaining MAP's >70. Pt also responding well to fluid boluses as pt appears to be intravascularly dry. ?DI. Sodium elevated today, at highest 162. Pt receiving free water through NGT, and in IVF with good reversal effect. Lytes repleted as ordered.\n\nResp: CMV 600x12/5/40. abg wnl. No vent changes made today. LSCTAB, dim in bilat bases. Sats 96-100%. RR 12. Pt sx'd for min amts thick yellow secretions.\n\nGI: Abd soft, ND. BS absent. -BM. NGT now clamped for free h2o boluses.\n\nGU: Foley initially draining lrg amts lt yellow urine. UOP now slowing with vasopressin gtt.\n\nEndo: Pt on insulin gtt. BS did drop at one point to 63, received 12.5gms dextrose, and insulin gtt stopped. Gtt now restarted for aggressively climbing sugars.\n\nID: Pt poikiothermic, warming blanket provided intermittently throughout day.\n\nSkin: intact.\n\nSocial: Wife in today. Meeting held with Dr and NEOB. would like to make pt a donor. Plan made to wait and see if pt will progress to brain death overNOC. If brain death does occur testing will take place tomorrow morning. has expressed that it is very important for her to be presnt during the apnea test. If brain death does not occur, a time will be set tomorrow afternoon to extubate and attempt a DCD.\n\nPlan: Maintain stable hemodynamics, fluid bolus and titrate neo gtt as needed to maintain MAP>70. Monitor and replete lytes as ordered, esp q2hr na. Cont free h2o boluses q4hrs. Am labs per NEOB in front of Red Book (contact info in redbook as well if questions). Cont to offer support to family during this difficult time.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-28 00:00:00.000", "description": "Report", "row_id": 1659588, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 600x 12 5P 40%.\nNo other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 1659589, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue, Multiple vent changes per ABGs. No RSBI due to high Fi02. Continue to provide full vent support at this time.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-27 00:00:00.000", "description": "Report", "row_id": 1659583, "text": "Resp care\nPt intubated from ED, s/p ICH. Current vent settings: A/C 600 x 16 5P 100%. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-27 00:00:00.000", "description": "Report", "row_id": 1659584, "text": "Nursing Admission Note\n54 yo male s/p witnessed fall last night, +ETOH. Per wife pt hit head on coffee table and she helped him up to the chair (4am) where he slept for the remainder of the night. When wife attempted to arouse pt this morning he was unresponsive. EMS found pt in Vfib/PEA arrest. Epi/atropine given. Pt regained HR and BP en route to . Head CT at OSH showed lrg R SDH in frontal and parietal lobes with 15mm midline shift. Pupils fixed and dilated. No corneals. No movement in extremeties. Pt transfered to for further care.\n\nUpon arrival aline placed for closer BP monitoring. Pt very hypothermic 90 degrees F. Pt warmed with bairhugger to eventual hyperthermia of 102.0. At approx 1800, pt became increasingly tachycardic with HR climbing to 120-130's. SBP 200-210's, then dropping within 5 minutes to 70's w/o intervention. Pt started on neo gtt to maintain BP. ?Herniation. Family meeting held, pt is DNR. NEOB presently on unit.\n\nNeuro: Pt not sedated. Pupils 4mm, NR bilaterally. Corneals absent. Cough and gag absent. No movement in any extremety to nailbed pressure. Pt initially overbreathing vent, now no overbreathing after herniation. Pt is +for benzos so cannot begin braindeath testing.\n\nCV: NSR/ST, rare pvc's. HR 70-130's. SBP 100-120's, maintain MAP>65 by titrating neo gtt. Pt also received 1L fluid bolus with good effect. Mag 1.4, repleted with 6gms mag sulfate. +PP.\n\nResp: cmv 600x12/5/50. abg showing meta acidosis. Sats 100%. RR 16. LSCTAB. Sx'd for no secretions.\n\nGI: Abd soft NT, ND. NGT to LCS, mod amts bloodly drainage. +BS. -BM.\n\nGU: Foley draining adequate amts CYU.\n\nEndo: BS elevated, insulin gtt ordered.\n\nID: Pt initially hypothermic, warmed with bairhugger, now hyperthermic.\n\nSkin: intact.\n\nSocial: Per wife pt drinks ETOH daily. Recently pt was prescribed ativan by PCP and attending AA in effort to quit drinking. Pt lives at home with wife and three children ages .\n\nPlan: ?possible flowscan to declare braindeath. Maintain hemodynamics. Cont to follow up with family/SW/NEOB for plan for end of life care.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 1659590, "text": "1900-present\nS: see carevue for specifics\nO: Neuro: unresponsive, pupils fixed and dilated- NR 5mm bilaterally- negative corneals, no gag, no cough, no spontan movement.\n" }, { "category": "Nursing/other", "chartdate": "2148-02-29 00:00:00.000", "description": "Report", "row_id": 1659591, "text": "addendum\nCVS: DNR, BP 90-110's/50-70's. on neo gtt currently at 4mcg/kg/min- goal MAP >65. NSR-ST- 500cc LR bolus given for tachycardia and low u/o with good effect K repleted and Mg repleted. NA q2hrs, Na decreasing during night, free water flushes and D5W IV infusion.Resp: multiple vent changes throughout the shift. now CMV 100%, Peep 10. LS upper coarse- clear diminished lower. sats 91-98%. Suctioned for thick green/yellow secretions both nasally and orally, and through ett. GI: BS absent,lrg loose BM- NGT-NPO free water flushes Q4hrs. GU vasopressin gtt was at 1.2 mcg/kg/min and then dc'd- was for goal u/o >100 cc /hr. Endo: on insulin gtt.\nPlan: NEOB involved.- apnea test today ***wife wants to be present. MAP>65, u/o >100/hr. NA Q2hrs, wife will be in today. NEOB here to assess patient.\n" }, { "category": "ECG", "chartdate": "2148-02-27 00:00:00.000", "description": "Report", "row_id": 215526, "text": "Sinus rhythm with A-V conduction delay. Left atrial abnormality. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2151-10-29 00:00:00.000", "description": "Report", "row_id": 235929, "text": "Sinus tachycardia. Right bundle-branch block. No previous tracing available\nfor comparison.\n\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 1101832, "text": " 3:05 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: eval for fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man MVC trauma unrestrained driver\n REASON FOR THIS EXAMINATION:\n eval for fx/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, , AT 1519 HOURS.\n\n HISTORY: Post-motor vehicle collision. Unrestrained driver sustaining\n trauma.\n\n COMPARISON: CT of the pelvis performed immediately prior.\n\n FINDINGS: The sacrum is obscured by contrast within the patient's bladder.\n Extensive surgical clips are identified in the pelvis. The pelvis is intact\n without fracture or dislocation. The sacrum and sacroiliac joints are\n unremarkable. Degenerative changes are noted at the lumbosacral junction.\n Bilateral femoral heads are appropriately located with no fracture of the\n proximal femurs identified.\n\n IMPRESSION: No fracture seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-11-01 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1102141, "text": " 7:47 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: etiology of seizure. Pt is unresponsive but has had CT of wh\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL ADDENDUM\n D/w Dr. by Dr.. Apparently, the pt.'s mental status dramatically\n improved and CSF negative for infection; Possibilities include metastatic\n lesions/ infection by slow growing organisms/viral with seizure related\n changes/paraneoplastic syndrome.\n\n\n 7:47 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: etiology of seizure. Pt is unresponsive but has had CT of wh\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with unresponsiveness, suspect seizure activity and cerebral\n edema\n REASON FOR THIS EXAMINATION:\n etiology of seizure. Pt is unresponsive but has had CT of whole body\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw MON 3:23 PM\n Extensive FLAIR hyperintense areas in the frontal lobes and left temporal lobe\n pred. the cortex; a smaller focus in the left frontal subcortical white\n matter; these can be seen with seizure, drug- induced , encephalitis, etc. a\n small enhancing lesion in the right frontal lobe. Given the presence of this\n lesion, addiitonal inflammatory/infective etiologies and less likely\n metastatic lesions are in the DD as well. Short term F/u as clinically\n indciated and correlation with labs rec.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male patient, with unresponsiveness, suspected\n seizure activity, cerebral edema, to evaluate for intracranial abnormalities.\n\n COMPARISON: No prior MR studies. CT head done on .\n\n TECHNIQUE: MR of the head without and with IV contrast per seizure protocol.\n\n FINDINGS: Study is somewhat limited due to the patient motion-related\n artifacts.\n\n On the FLAIR sequence, there are extensive areas of increased signal intensity\n in the cerebral cortex, in the frontal lobes on both sides, as well as the\n left temporal lobe and also in the left frontal subcortical white matter\n precentral in location - cortex and the subcortical white matter (series 3,\n image 17).\n\n On the post-contrast images, there is a small enhancing lesion noted in the\n right frontal lobe, periventricular anterior to the frontal , better seen\n on the spin echo post-contrast sequence (series 18, image 8) measuring 0.6 x\n 0.8 cm. No other areas of abnormal enhancement are noted. While minimal\n restricted diffusion is possible in the left frontal subcortical white matter\n region, it is not convincing on the ADC sequence.\n\n The ventricles are normal. Mild prominence of the parietal extra-axial CSF\n spaces is noted posteriorly.\n\n There is possible extension of the FLAIR hyperintensity, from the bifrontal\n regions, on to the hypothalamus and not adequately assessed on the present\n study.\n The major intracranial arterial flow voids are noted.\n (Over)\n\n 7:47 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: etiology of seizure. Pt is unresponsive but has had CT of wh\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The hippocampi are small on both sides; however, evaluation limited due to\n artifacts.\n\n IMPRESSION:\n\n Extensive areas of FLAIR hyperintensity in the cortex, in the frontal lobes on\n both sides as well as left temporal lobe, with another focus in the left\n frontal subcortical white matter; a 0.8 x 0.6 mm round enhancing lesion noted\n in the right frontal lobe anterior to the frontal . The differential\n diagnosis for the FLAIR hyperintense areas includes seizure- associated\n phenomena, drug induced, other etiologies like encephalitis, viral in\n etiology. However, given the small enhancing lesion in the right frontal\n lobe, superimposed inflammatory or infective etiologies, less likely\n neoplastic etiology like metastasis are also in the differential diagnosis.\n Followup evaluation in a few days can be considered to assess the stability of\n the FLAIR signal abnormalities based on the clinical condition. Correlate with\n labs to confirm the nature of the enhancing lesion.\n\n\n" }, { "category": "Respiratory ", "chartdate": "2151-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490692, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: NO\n Procedure location: EW\n Reason: sz\ns,unable to protect airway\n Tube Type\n ETT:\n Position: 20cm at teeth\n Route: po\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 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: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n ~80yo M adm for MS changes/sz\ns. Pt intubated, vent supported-\n changed to PSV overnight without event. See flowsheet for further pt\n data. Will follow. Wean to extubate if tolerable.\n 04:03\n" }, { "category": "Respiratory ", "chartdate": "2151-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490610, "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: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\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: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2151-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490596, "text": "Altered mental status (not Delirium)\n Assessment:\n Sedated on Propofol gtt, Pupils 2mm and sluggish. MAE non-purposefully\n off sedation, withdraws to painful stim. Does not follow commands or\n open eyes. No seizure activity noted. Stiff collar in place from EW.\n Lung sounds diminished throughout, minimal secretions. WBCs 18 and\n lactate 9 in EW.\n Action:\n Begun on IV abx, neuro checks, safety precautions.\n Response:\n No change.\n Plan:\n Cont. to monitor closely, neuro checks, f/u ABG and labs, IV abx.\n" }, { "category": "Physician ", "chartdate": "2151-10-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 490598, "text": "Chief Complaint: found down\n HPI:\n The patient is an unidentified 80? y.o. male who was found down between\n two cars this morning. There was reported \"seizure-like\" activity at\n the scene, and though could not speak, was mumbling to EMS. IN the ED\n the patient was tremulous and not speaking. He became combative and\n was therefore intubated. Intial vitals in the ED showed a heart rate\n of 140 and blood pressure 210/120 with adequate oxygen saturation.\n Labs were notable for a lactate of 9.6 and white count of 17.6. CT\n head was negative, CT torso was significant for potential aspiration\n pneumonia. C-Spine was normal. The patient continued to shake after\n intubation and was given ativan 2mg x2 which caused the tremors to\n stop. After intubation vitals were; T 98.6 HR 116 BP 147/96 RR 28\n 100% on AC 600/14 PEEP 5, FiO2 50%.\n The patient had 2 peripheral IV's placed.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 04:21 PM\n Levofloxacin - 05:02 PM\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Other medications:\n unknown\n Past medical history:\n Family history:\n Social History:\n unknown\n unknown\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 05:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 89 (89 - 96) bpm\n BP: 124/81(90) {120/73(90) - 124/81(107)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 424 mL\n PO:\n TF:\n IVF:\n 424 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 84 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.32/42/118//-4\n Ve: 12.1 L/min\n PaO2 / FiO2: 197\n Physical Exam:\n Vitals: T:96.6 BP:124/81 P:89 R:14 O2: 98% FiO2 50%\n General: sedated, unresponsive, intubated.\n HEENT: pupils 2mm, reactive, Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n .\n Labs:\n See below\n .\n Micro:\n .\n Images:\n CT chest: Bilateral basal lung changes ,mostly related to\n aspiration.No other acute pathology detected\n .\n C-spine: no fractures.\n .\n : head CT: No acute intracranial hemorrhage or major vascular\n territorial infarct.Chronic microangiopathic disease.Soft tissue\n opacification of bilateral ethmoid sinuses and nasal passages.No\n fractures\n .\n EKG: sinus tachycardia at rate 125, normal axis, prolonged QRS, RBBB,\n TWI in III, aVF.\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A10/9/ 05:47 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 23\n Other labs: Lactic Acid:1.4 mmol/L\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: This is a 80 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection.\n .\n # Altered mental status: was initially found down but was conscious,\n was able to murmur, and was found to have tremulous movements. urine\n and serum toxicology screens are negative. CT head is without acute\n intracranial process, though potentially may show cerebral edema.\n Elevated white count makes infection a possibility. Elevated lactate in\n absence of hypotension may indicate mycoclonic seizures. Will pursue\n neuro evaluation to rule out seizure.\n -load with fosphenytoin 20mg/Kg tonight\n -fosphenytoin 100mg IV TID starting tomorrow.\n -ampiric abx coverage for meningitis, vanc, ceftriaxone, ampicillin\n -f/ head CT read\n -LP once official head CT read\n -Head MRI wihtout contrast given ARF\n -EEG\n -ativan PRN\n -trend cardiac enzymes\n -telemetry\n -blood, urine, sputum Cx\n -trend lactate.\n -neuro recs\n .\n #Lactic acidosis: in setting of hypertension makes septic shock\n unlikely. Has resolved with intubation and propofol. potentially be\n from myoclonic activity given setting of tremulous movements. Will pan\n culture and start empiric antibiotics.\n -urine, blood, sputum cx.\n -vanc, ceftriaxone, ampicillin\n .\n # Leukocytosis: CBC Differential is pending. be infection vs.\n acute stress reaction from seizure.\n -trend cbc\n -empiric abx\n -LP\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripherals X2\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 18 Gauge - 04:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 491028, "text": "Chief Complaint: This is a 72 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection. Now extubated, stable.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:00 PM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:35 PM\n pt. combative and agitated got out of bed and was abusive to staff\n attempting to hit nurses. Bloody all over from pulling out IV and foley\n catheter may have been stepped on by him causing bloody\n drainage--irrigated with small improvement and Lido uroject used for\n pain.\n -extubated just after noon, no complications. Mildly agitated,\n frustrated with Foley. Slightly groggy, but alert and responsive.\n -No cervical midline tenderness, C-collar removed.\n -At 1:30, the patient became increasingly combative with nurse, got up\n out of bed, pulled IV, took off his clothes. Was taken back to bed\n without a fall, cleaned up, and calmed down. No injuries other than\n bleeding from IV site, stopped with pressure.\n -During 1:30 episode the patient stepped on his Foley tubing, then\n complaining of pain at the base of the penis afterward. Tried several\n times to flush Foley without success.\n -Foley was DC-ed, removed smoothly, with clot adhering to and\n completely obstructing the tip. Moderate bleeding from urethral meatus\n after Foley removal.\n -Unable to pass 3-way catheter\n urology tried also without success.\n -Haldol 2.5 given with good effect - patient became more calm.\n -LP results back - 0 WBC, 1 RBC. Antibiotics DC-, continue\n acyclovir for now.\n -patient's son arrived to hospital at 1900, did not know much about his\n medical history, other than that he has gout. He also says he thinks\n that the patient has had a seizure before in the past.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 05:02 PM\n Ceftriaxone - 06:55 AM\n Ampicillin - 02:00 PM\n Vancomycin - 04:00 PM\n Acyclovir - 04:24 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 09:29 PM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Fosphenytoin - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (98.9\n HR: 78 (73 - 102) bpm\n BP: 115/64(77) {98/46(64) - 176/119(131)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 3,496 mL\n 548 mL\n PO:\n TF:\n IVF:\n 3,436 mL\n 548 mL\n Blood products:\n Total out:\n 2,165 mL\n 0 mL\n Urine:\n 2,065 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,331 mL\n 548 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (500 - 530) mL\n PS : 5 cmH2O\n RR (Set): 19\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///25/\n Ve: 9.8 L/min\n Physical Examination\n Alert, oriented, calm, comfortable. Very pleasant.\n Strength 5/5 in all extremities, CN intact.\n Lungs CTAB.\n RRR, no MRG.\n Abdomen soft, non-tender.\n Labs / Radiology\n 206 K/uL\n 13.0 g/dL\n 99 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 110 mEq/L\n 144 mEq/L\n 39.9 %\n 10.1 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n 03:00 PM\n 04:15 AM\n WBC\n 16.6\n 12.0\n 10.1\n Hct\n 44.6\n 43.5\n 39.9\n Plt\n 235\n 202\n 206\n Cr\n 1.2\n 1.3\n 1.7\n 1.6\n TropT\n 0.14\n 0.27\n 0.15\n TCO2\n 23\n Glucose\n 146\n 108\n 142\n 99\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:391/12/0.15, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 72 y.o. man found down, with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection.\n .\n # Altered mental status: Most likely seizure, possible acute infarct,\n meningitis, encephalitis. Pt had elevated lactate and white count.\n Lactate is now resolved making seizure process likely.\n -fosphenytoin 100mg IV TID\n - d/c antibiotics for bacterial coverage given LP results. continue\n acyclovir\n - Head MRI without contrast given ARF - order written\n -EEG ordered\n -telemetry\n -blood, urine, sputum Cx\n -neuro recs from , will see him today\n #Agitation: After extubation was persistently agitated, with episodes\n of combativeness, aggression. Appeared to be alert, but very angry and\n frustrated. Haldol given, 2.5 mg with very good effect - much more\n calm without excessive sedation.\n #Foley trauma: During period of agitation soon after extubation the\n patient stood up and in the process pulled on his Foley, causing pain\n and hematuria. The catheter was flushed multiple times without\n clearing, obstruction felt during attempt. Finally the catheter was\n removed, with moderate-sized clot adhering to and completely\n obstructing the tip. Both the nurse and resident attempted to place\n 3-way catheter, then urology also attempted without success.\n -moderate bleeding from meatus after Foley removal, but stopped.\n -no obstruction, urinating well.\n # Elevated troponins - With elevated CK, CKMB and troponins. CKMB -I\n Negative. Likely had an NSTEMI on the scene of the acident. Troponins\n trended, yesterday afternoon trending down.\n - Statin, BB\n - held ASA given coffee ground in suction, will trend Hct and\n reasses. Hct reduced slightly today but stable.\n - Cardiology aware\n #Lactic acidosis: in setting of hypertension makes septic shock\n unlikely. Has resolved with intubation and propofol. potentially be\n from myoclonic activity given setting of tremulous movements. Empiric\n antibiotics now stopped, leukocytosis resolved, afebrile, no clear\n source.\n - f//u urine, blood, sputum cx.\n - continue acylovir for now.\n # Leukocytosis: Now resolved. Likely acute stress reaction from\n possible seizure. Could also be c/w infection, but no other indicators\n for infection.\n -trend cbc\n - acyclovir, add abx as cultures return\n - LP clear\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripheral, DC-ed one peripheral yesterday.\n .\n # Code: presumed full\n .\n # Communication: wife, son. The son came in yesterday evening,\n discussed with him.\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor\n" }, { "category": "Physician ", "chartdate": "2151-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 491043, "text": "Chief Complaint: ?Seizure, resolved respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Delirium/agitation has cleared significantly\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:00 PM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:35 PM\n pt. combative and agitated got out of bed and was abusive to staff\n attempting to hit nurses. Bloody all over from pulling out IV and foley\n catheter may have been stepped on by him causing bloody\n drainage--irrigated with small improvement and Lido uroject used for\n pain.\n -->multiple attempts to place 3-way foley unsuccessful, but now able to\n void on his own\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 05:02 PM\n Ceftriaxone - 06:55 AM\n Ampicillin - 02:00 PM\n Vancomycin - 04:00 PM\n Acyclovir - 04:24 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 09:29 PM\n Fosphenytoin - 04:24 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per ICU team\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 Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: No(t) Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 74 (74 - 102) bpm\n BP: 137/100(109) {98/46(64) - 176/119(131)} mmHg\n RR: 17 (7 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 3,496 mL\n 977 mL\n PO:\n 120 mL\n TF:\n IVF:\n 3,436 mL\n 857 mL\n Blood products:\n Total out:\n 2,165 mL\n 200 mL\n Urine:\n 2,065 mL\n 200 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,331 mL\n 777 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (530 - 530) mL\n PS : 5 cmH2O\n RR (Set): 19\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: ///25/\n Ve: 9.8 L/min\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\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 conversive\n Labs / Radiology\n 13.0 g/dL\n 206 K/uL\n 99 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 110 mEq/L\n 144 mEq/L\n 39.9 %\n 10.1 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n 03:00 PM\n 04:15 AM\n WBC\n 16.6\n 12.0\n 10.1\n Hct\n 44.6\n 43.5\n 39.9\n Plt\n 235\n 202\n 206\n Cr\n 1.2\n 1.3\n 1.7\n 1.6\n TropT\n 0.14\n 0.27\n 0.15\n TCO2\n 23\n Glucose\n 146\n 108\n 142\n 99\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:391/12/0.15, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: This is a 72 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection.\n # Altered mental status: Now extubated and with normal mental status.\n Unclear why he lost consciousness - sz still seems to be most likely\n possibility. Cont anti-sz meds. Will need an MRI at some point - can\n potentially do as an outpatient given patient's claustraphobia. EEG.\n Will discuss follow-up plans with neurology team.\n #NSTEMI: Troponins trending down. TTE.\n #Respiratory Failure: Now extubated\n #Hematuria: No further bleeding, passing urine\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2151-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 491044, "text": "Chief Complaint: This is a 72 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection. Now extubated, stable.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:00 PM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:35 PM\n pt. combative and agitated got out of bed and was abusive to staff\n attempting to hit nurses. Bloody all over from pulling out IV and foley\n catheter may have been stepped on by him causing bloody\n drainage--irrigated with small improvement and Lido uroject used for\n pain.\n -extubated just after noon, no complications. Mildly agitated,\n frustrated with Foley. Slightly groggy, but alert and responsive.\n -No cervical midline tenderness, C-collar removed.\n -At 1:30, the patient became increasingly combative with nurse, got up\n out of bed, pulled IV, took off his clothes. Was taken back to bed\n without a fall, cleaned up, and calmed down. No injuries other than\n bleeding from IV site, stopped with pressure.\n -During 1:30 episode the patient stepped on his Foley tubing, then\n complaining of pain at the base of the penis afterward. Tried several\n times to flush Foley without success.\n -Foley was DC-ed, removed smoothly, with clot adhering to and\n completely obstructing the tip. Moderate bleeding from urethral meatus\n after Foley removal.\n -Unable to pass 3-way catheter\n urology tried also without success.\n -Haldol 2.5 given with good effect - patient became more calm.\n -LP results back - 0 WBC, 1 RBC. Antibiotics DC-, continue\n acyclovir for now.\n -patient's son arrived to hospital at 1900, did not know much about his\n medical history, other than that he has gout. He also says he thinks\n that the patient has had a seizure before in the past.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 05:02 PM\n Ceftriaxone - 06:55 AM\n Ampicillin - 02:00 PM\n Vancomycin - 04:00 PM\n Acyclovir - 04:24 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 09:29 PM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Fosphenytoin - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (98.9\n HR: 78 (73 - 102) bpm\n BP: 115/64(77) {98/46(64) - 176/119(131)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 3,496 mL\n 548 mL\n PO:\n TF:\n IVF:\n 3,436 mL\n 548 mL\n Blood products:\n Total out:\n 2,165 mL\n 0 mL\n Urine:\n 2,065 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,331 mL\n 548 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (500 - 530) mL\n PS : 5 cmH2O\n RR (Set): 19\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///25/\n Ve: 9.8 L/min\n Physical Examination\n Alert, oriented, calm, comfortable. Very pleasant.\n Strength 5/5 in all extremities, CN intact.\n Lungs CTAB.\n RRR, no MRG.\n Abdomen soft, non-tender.\n Labs / Radiology\n 206 K/uL\n 13.0 g/dL\n 99 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 110 mEq/L\n 144 mEq/L\n 39.9 %\n 10.1 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n 03:00 PM\n 04:15 AM\n WBC\n 16.6\n 12.0\n 10.1\n Hct\n 44.6\n 43.5\n 39.9\n Plt\n 235\n 202\n 206\n Cr\n 1.2\n 1.3\n 1.7\n 1.6\n TropT\n 0.14\n 0.27\n 0.15\n TCO2\n 23\n Glucose\n 146\n 108\n 142\n 99\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:391/12/0.15, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 72 y.o. man found down, with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection. Agitated yesterday, but today completely calm, pleasant,\n reports feeling his usual self.\n .\n # Altered mental status: Most likely seizure given very high lactate,\n immediate resolution, no infectious signs. Etiology for possible\n seizure unclear.\n -fosphenytoin 100mg IV TID\n - d/c antibiotics for bacterial coverage given LP results. Will also\n stop acyclovir today.\n - Would like to get head MRI to further evaluate\n patient says today\n that he absolutely cannot tolerate a closed MRI. Would consider\n possible open MRI as outpatient?\n -EEG ordered\n will discuss with neurology about management\n potentially get EEG, how to arrange outpatient workup vs further\n inpatient testing.\n -telemetry\n #Agitation: After extubation was persistently agitated, with episodes\n of combativeness, aggression. Appeared to be alert, but very angry and\n frustrated. Haldol given, 2.5 mg with very good effect - much more\n calm without excessive sedation. This morning completely calm,\n pleasant. Remembers yesterday\ns events, but apologized for behavior.\n #Foley trauma: During period of agitation soon after extubation the\n patient stood up and in the process pulled on his Foley, causing pain\n and hematuria. The catheter was flushed multiple times without\n clearing, obstruction felt during attempt. Finally the catheter was\n removed, with moderate-sized clot adhering to and completely\n obstructing the tip. Both the nurse and resident attempted to place\n 3-way catheter, then urology also attempted without success.\n -moderate bleeding from meatus after Foley removal, but stopped now,\n urine clear.\n -no obstruction, urinating well. Able to use urinal this morning, no\n incontinence.\n # Elevated troponins - With elevated CK, CKMB and troponins. CKMB -I\n Negative. Troponins trended, yesterday afternoon trending down.\n - Statin, BB\n -Hct reduced slightly today but stable - 40.\n #Lactic acidosis:. As above\n likely from seizure or seizure-like\n activity. Empiric antibiotics now stopped, leukocytosis resolved,\n afebrile, no clear source.\n - f//u urine, blood, sputum cx.\n # Leukocytosis: Now resolved. Likely acute stress reaction from\n possible seizure. Could also be c/w infection, but no other indicators\n for infection.\n - cbc WNL today\n - acyclovir, add abx as cultures return\n - LP clear\n .\n # FEN: No IVF, replete electrolytes, regular diet today\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripheral.\n .\n # Code: full\n .\n # Communication: wife, son. The son came in yesterday evening,\n discussed with him.\n .\n # Disposition: to floor today.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491001, "text": "TITLE:\n Altered mental status (not Delirium)\n Assessment:\n Afebrile vss.Awake, alert , oriented to self, vaguely to place(\n hospital). Agitated at times refusing care and meds. Neuro exam\n otherwise unremarkable, pserl , w normal strength, no pronator\n drift or weakness noted, no seizure activity.\n Resp: on rm air sats 92-95% bbs clear but diminish bibasilar, strong\n prod cough ? color sputum(swallows sputum)\n Gu- Voiding\nclear pale urine w intermit clots and fresh blood in\n urine.\n Gi-bowel snds + abd soft distended.Taking small amts po w meds.\n Action:\n Urology consulted, scoped at bedside, urethral stricture noted, Pt\n voiding before, during and after exam w/o difficulty, urine stream pale\n clear urine w bld and clots passed after void. Per urology rec\n defer placement of foley cath d/t pt ability to void w/o retention at\n this time (** MD will need 12french if nec to cath at future time).\n Lidocaine urojet to urethra w gd effect.\n Neuro- agitated, refusing care despite incontinent of lg amts of urine\n . Pt yelling\n stop trying to hurt me!\n Despite reassurance pt\n increasingly agitated- Haldol 2.5mg iv x 1.Sats dwn to 89-90 off O2\n while sleeping-> cool aerosol placed at 50%\n Son in to visit, updated on pt condition by MD and attempts to complete\n MRI screen form unsuccessful d/t son unaware of pt\ns full medical hx.\n AM labs sent\n Response:\n agitation resolved w haldol. Pt calmer, although remains confused to\n date and place ( knows in hospital\ndenies despite reminders that he is\n in )After haldol -resting in naps, cooperative w care and\n treatments, agreeable to taking meds and nsg interventions(lab draws\n and assist w hygiene care).\n O2 sat improved w ofm at 50%.Continues to be incontinent of urine at\n times,urine pale clear w decr amts of penile bldy drainage and clots.\n Labs wbc wnl @ 10. hct stable @ 39.\n Plan:\n Cont to monitor vdg, watch for bladder distention. ? psych consult to\n eval periods of agitation and rec\ns for med management. ? MRI today\n after cleared medically. ? c/o to floor > ? adv diet, tolerating cl\n liqs w po meds.\n" }, { "category": "Physician ", "chartdate": "2151-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490812, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:00 PM\n LUMBAR PUNCTURE - At 10:45 PM\n LUMBAR PUNCTURE - At 01:59 AM\n - found cell phone with pt's belongings and called family, pt's name is\n or . Has son in wife in called \n ; she has just been d/c'd from hospital and will come in\n today\n - called Pharmacy in for med list pt only on Allopurinol\n - LP performed\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 04:21 PM\n Levofloxacin - 05:02 PM\n Ampicillin - 02:08 AM\n Ceftriaxone - 06:55 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:06 AM\n Fosphenytoin - 04:45 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 08:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 73 (64 - 96) bpm\n BP: 104/60(70) {77/49(55) - 138/84(107)} mmHg\n RR: 17 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 1,228 mL\n 1,546 mL\n PO:\n TF:\n IVF:\n 1,228 mL\n 1,546 mL\n Blood products:\n Total out:\n 565 mL\n 1,130 mL\n Urine:\n 565 mL\n 1,030 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 663 mL\n 416 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 674 (623 - 674) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 18 cmH2O\n SpO2: 96%\n ABG: 7.32/42/118/23/-4\n Ve: 10.2 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Cardiovascular: Gen: intubated, sedated. responds minimally to pain.\n does not respond to command.\n CV: RRR, nl S1 and S2\n Lungs: CTAB\n Abd: NT/ NT ABS\n Ext: 1+ edema bilaterally\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 202 K/uL\n 14.2 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 105 mEq/L\n 137 mEq/L\n 43.5 %\n 12.0 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n WBC\n 16.6\n 12.0\n Hct\n 44.6\n 43.5\n Plt\n 235\n 202\n Cr\n 1.2\n 1.3\n TropT\n 0.14\n 0.27\n TCO2\n 23\n Glucose\n 146\n 108\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:451/18/0.27, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: Cardiac enzymes\n 03:06AM 18* 4.0 0.27*1\n 06:24PM 15* 3.9 0.14*2\n 11:51AM <0.013\n Imaging: CT chest: Bilateral basal lung changes ,mostly related\n to aspiration.No other acute pathology detected\n .\n C-spine: no fractures.\n .\n : head CT: No acute intracranial hemorrhage, edema, masses, mass\n effect, or\n major vascular territorial infarction. The -white matter\n differentiation\n is well preserved. White matter hypodensities are noted in bifrontal\n white matter, consistent with chronic microangiopathic ischemic\n disease. The\n ventricles and sulcal spaces appear normal in caliber and\n configuration. The\n basal cisterns are widely patent.\n - XRAY of pelvis - no actue fracture\n Microbiology: 11:00PM\n Report Comment:\n TUBE #4\n ANALYSIS\n WBC, CSF 0 #/uL\n CLEAR AND COLORLESS\n RBC, CSF 1* #/uL 0 - 0\n Polys 0 %\n 34 CELL DIFFERENTIAL\n Lymphs 41 %\n Monocytes 56 %\n Atypical Lymphocytes 3 %\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 80 y.o. man found down, with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection.\n .\n # Altered mental status: Ddx includes seizure, acute infarct,\n meningitis, encephalitis. Pt has elevated lactate and white count.\n Lactate is now resolved making seizure process likely.\n -fosphenytoin 100mg IV TID\n - d/c antibiotics for bacterial coverage given LP results. continue\n acyclovir\n - Head MRI without contrast given ARF\n -EEG\n -ativan PRN\n -telemetry\n -blood, urine, sputum Cx\n -neuro recs\n - d/c sedation\n # Elevated troponins - With elevated CK, CKMB and troponins. CKMB -I\n Negative. Likely had an NSTEMI on the scene of the acident. Continue\n to follow CE.\n - Statin, BB\n - holding ASA given coffee ground in suction, will trend Hct and\n reasses\n - Cardiology aware\n #Lactic acidosis: in setting of hypertension makes septic shock\n unlikely. Has resolved with intubation and propofol. potentially be\n from myoclonic activity given setting of tremulous movements. Will pan\n culture and start empiric antibiotics.\n - f//u urine, blood, sputum cx.\n - continue acylovir\n # Leukocytosis: CBC Differential is pending. be infection vs.\n acute stress reaction from seizure. No bands, again making bacterial\n infectin less likely.\n -trend cbc\n - acyclovir, add abx as cultures return\n - LP not suggestive of infection\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripherals X2\n .\n # Code: presumed full\n .\n # Communication: wife, son\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 18 Gauge - 04:35 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491123, "text": "This is a 72 y.o. man found down , with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection. Agitated , but today completely calm, pleasant,\n reports feeling his usual self.\n SICU events:\n Altered mental status: Most likely seizure given very high\n lactate, immediate resolution, no infectious signs. Etiology for\n possible seizure unclear. Would like to get head MRI to further\n evaluate\n patient says today that he absolutely cannot tolerate a\n closed MRI. Would consider possible open MRI as outpatient?EEG ordered\n team will discuss with neurology about management\n potentially get\n EEG, how to arrange outpatient workup vs further inpatient\n testing. Agitation: After extubation was persistently agitated,\n with episodes of combativeness, aggression. Appeared to be\n alert, but very angry and frustrated. Haldol given, 2.5 mg with very\n good effect - much more calm without excessive sedation. This morning\n completely calm, pleasant. Remembers yesterday\ns events, but\n apologized for behavior.\n Foley trauma: During period of agitation soon after\n extubation the patient stood up and in the process pulled on his Foley,\n causing pain and hematuria. The catheter was flushed multiple times\n without clearing, obstruction felt during attempt. Finally the\n catheter was removed, with moderate-sized clot adhering to and\n completely obstructing the tip. Both the nurse and resident attempted\n to place 3-way catheter, then urology also attempted without success.\n Moderate bleeding from meatus after Foley removal, but stopped now,\n urine clear. Using urinal without problems. Urology following, pt. has\n moderate post-void residuals and urology has been notified. He needs to\n f/u with Urologist. He has persistent leakage and has been wearing\n attends at home.\n Elevated troponins - With elevated CK, CKMB and troponins.\n CKMB -I Negative. Troponins yesterday afternoon trending down.\n Lactic acidosis: likely from seizure or seizure-like\n activity. Empiric antibiotics now stopped, leukocytosis resolved,\n afebrile, no clear source.\n Leukocytosis: Now resolved. Likely acute stress reaction\n from possible seizure. Could also be c/w infection, but no other\n indicators for infection. LP clear-off antibiotics and Acyclovir.\n He is alert and oriented x3, ambulating well, started\n regular diet without problems, IVF \nd-has . Sats 92-96% on RA.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 98.8 kg\n Daily weight:\n 101.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: unknown, pt. found down\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:65\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 2,321 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 04:15 AM\n Potassium:\n 3.9 mEq/L\n 04:15 AM\n Chloride:\n 110 mEq/L\n 04:15 AM\n CO2:\n 25 mEq/L\n 04:15 AM\n BUN:\n 19 mg/dL\n 04:15 AM\n Creatinine:\n 1.6 mg/dL\n 04:15 AM\n Glucose:\n 99 mg/dL\n 04:15 AM\n Hematocrit:\n 39.9 %\n 04:15 AM\n Finger Stick Glucose:\n 104\n 04:00 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: CC729\n Date & time of Transfer: @ 1900\n ------ Protected Section ------\n Wallet, bag of pills patient\ns son brought in , glasses, dentures(in)\n and clothes transferred with pt. His son took cell phone and car keys\n home.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:12 ------\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491130, "text": "TITLE:\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 98.8 kg\n Daily weight:\n 101.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: htn, gout\n CV-PMH:\n Additional history: unknown, pt. found down\n Surgery / Procedure and date: prostate ? When. Pt states received\n surgical care in .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:69\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 2,321 mL\n 24h total out:\n 850 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 04:15 AM\n Potassium:\n 3.9 mEq/L\n 04:15 AM\n Chloride:\n 110 mEq/L\n 04:15 AM\n CO2:\n 25 mEq/L\n 04:15 AM\n BUN:\n 19 mg/dL\n 04:15 AM\n Creatinine:\n 1.6 mg/dL\n 04:15 AM\n Glucose:\n 99 mg/dL\n 04:15 AM\n Hematocrit:\n 39.9 %\n 04:15 AM\n Finger Stick Glucose:\n 104\n 04:00 PM\n Valuables / Signature\n Patient valuables: Cell phone sent home with son .\n valuables:\n Clothes: Sent home with: Son\n / :\n money / /credit cards given to cc7 RN to place in safe.\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu\n B\n Transferred to: CC729\n Date & time of Transfer: 20:45\n" }, { "category": "Physician ", "chartdate": "2151-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 490800, "text": "Chief Complaint: Repiratory Failure, Loss of Consciousness\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 LP done overnight\n Switched to PSV overnight\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:00 PM\n LUMBAR PUNCTURE - At 10:45 PM\n LUMBAR PUNCTURE - At 01:59 AM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 04:21 PM\n Levofloxacin - 05:02 PM\n Ceftriaxone - 06:55 AM\n Ampicillin - 08:16 AM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 04:45 AM\n Heparin Sodium (Prophylaxis) - 08:16 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 Respiratory: mechanical ventilation\n Genitourinary: Foley\n Heme / Lymph: No(t) Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (64 - 96) bpm\n BP: 112/69(79) {77/49(55) - 138/84(107)} mmHg\n RR: 9 (9 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 1,228 mL\n 1,844 mL\n PO:\n TF:\n IVF:\n 1,228 mL\n 1,784 mL\n Blood products:\n Total out:\n 565 mL\n 1,230 mL\n Urine:\n 565 mL\n 1,130 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 663 mL\n 614 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 500 (500 - 674) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.32/42/118/23/-4\n Ve: 9.5 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 14.2 g/dL\n 202 K/uL\n 108 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 105 mEq/L\n 137 mEq/L\n 43.5 %\n 12.0 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n WBC\n 16.6\n 12.0\n Hct\n 44.6\n 43.5\n Plt\n 235\n 202\n Cr\n 1.2\n 1.3\n TropT\n 0.14\n 0.27\n TCO2\n 23\n Glucose\n 146\n 108\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:451/18/0.27, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: This is a 80 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection.\n # Altered mental status: No studies at this point that shed light on\n the source. Need head MRI, EEG. Neuro following. LP without WBCs.\n Cont anti-sz meds.\n #Lactic acidosis: Now improved\n #NSTEMI: Does have mildy elevated troponin likely in setting of\n demand. EKG normal. Cont to trend. TTE\n #Respiratory Failure: Wean sedation and extubate. Needs c-spine\n clinically cleared post-extubation\n Remainde3r of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 18 Gauge - 04:35 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Have found family through his cell phone -\n son is aware\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2151-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490788, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:00 PM\n LUMBAR PUNCTURE - At 10:45 PM\n LUMBAR PUNCTURE - At 01:59 AM\n - found cell phone with pt's belongings and called family, pt's name is\n or . Has son in wife in called \n ; she has just been d/c'd from hospital and will come in\n today\n - called Pharmacy in for med list pt only on Allopurinol\n - LP performed\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 04:21 PM\n Levofloxacin - 05:02 PM\n Ampicillin - 02:08 AM\n Ceftriaxone - 06:55 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:06 AM\n Fosphenytoin - 04:45 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 08:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 73 (64 - 96) bpm\n BP: 104/60(70) {77/49(55) - 138/84(107)} mmHg\n RR: 17 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 1,228 mL\n 1,546 mL\n PO:\n TF:\n IVF:\n 1,228 mL\n 1,546 mL\n Blood products:\n Total out:\n 565 mL\n 1,130 mL\n Urine:\n 565 mL\n 1,030 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 663 mL\n 416 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 674 (623 - 674) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 18 cmH2O\n SpO2: 96%\n ABG: 7.32/42/118/23/-4\n Ve: 10.2 L/min\n PaO2 / FiO2: 236\n Physical Examination\n Cardiovascular: Gen: intubated, sedated. responds minimally to pain.\n does not respond to command.\n CV: RRR, nl S1 and S2\n Lungs: CTAB\n Abd: NT/ NT ABS\n Ext: 1+ edema bilaterally\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 202 K/uL\n 14.2 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 105 mEq/L\n 137 mEq/L\n 43.5 %\n 12.0 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n WBC\n 16.6\n 12.0\n Hct\n 44.6\n 43.5\n Plt\n 235\n 202\n Cr\n 1.2\n 1.3\n TropT\n 0.14\n 0.27\n TCO2\n 23\n Glucose\n 146\n 108\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:451/18/0.27, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: Cardiac enzymes\n 03:06AM 18* 4.0 0.27*1\n 06:24PM 15* 3.9 0.14*2\n 11:51AM <0.013\n Imaging: CT chest: Bilateral basal lung changes ,mostly related\n to aspiration.No other acute pathology detected\n .\n C-spine: no fractures.\n .\n : head CT: No acute intracranial hemorrhage, edema, masses, mass\n effect, or\n major vascular territorial infarction. The -white matter\n differentiation\n is well preserved. White matter hypodensities are noted in bifrontal\n white matter, consistent with chronic microangiopathic ischemic\n disease. The\n ventricles and sulcal spaces appear normal in caliber and\n configuration. The\n basal cisterns are widely patent.\n - XRAY of pelvis - no actue fracture\n Microbiology: 11:00PM\n Report Comment:\n TUBE #4\n ANALYSIS\n WBC, CSF 0 #/uL\n CLEAR AND COLORLESS\n RBC, CSF 1* #/uL 0 - 0\n Polys 0 %\n 34 CELL DIFFERENTIAL\n Lymphs 41 %\n Monocytes 56 %\n Atypical Lymphocytes 3 %\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 80 y.o. man found down, with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection.\n .\n # Altered mental status: was initially found down but was conscious,\n was able to murmur, and was found to have tremulous movements. urine\n and serum toxicology screens are negative. CT head is negative for\n edema or acute infarct. Elevated white count makes infection a\n possibility. Elevated lactate in absence of hypotension may indicate\n mycoclonic seizures. Will pursue neuro evaluation to rule out seizure.\n Lactate resolved, making seizure likely.\n -load with fosphenytoin 20mg/Kg tonight\n -fosphenytoin 100mg IV TID starting tomorrow.\n - d/c antibiotics for bacterial coverage given LP results. continue\n acyclovir\n -Head MRI wihtout contrast given ARF\n -EEG\n -ativan PRN\n -telemetry\n -blood, urine, sputum Cx\n -neuro recs\n - taper sedation\n # Elevated troponins - With elevated CK, CKMB and troponins. CKMB -I\n Negative. Likely had an NSTEMI on the scene of the acident. Continue\n to follow CE.\n - Statin, BB\n - holding ASA given coffee ground in suction, will trend Hct and\n reasses\n - Cardiology aware\n #Lactic acidosis: in setting of hypertension makes septic shock\n unlikely. Has resolved with intubation and propofol. potentially be\n from myoclonic activity given setting of tremulous movements. Will pan\n culture and start empiric antibiotics.\n - f//u urine, blood, sputum cx.\n - continue acylovir\n # Leukocytosis: CBC Differential is pending. be infection vs.\n acute stress reaction from seizure. No bands, again making bacterial\n infectin less likely.\n -trend cbc\n - acyclovir, add abx as cultures return\n - LP bland\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripherals X2\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 18 Gauge - 04:35 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491107, "text": "This is a 72 y.o. man found down , with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection. Agitated , but today completely calm, pleasant,\n reports feeling his usual self.\n SICU events:\n Altered mental status: Most likely seizure given very high\n lactate, immediate resolution, no infectious signs. Etiology for\n possible seizure unclear. Would like to get head MRI to further\n evaluate\n patient says today that he absolutely cannot tolerate a\n closed MRI. Would consider possible open MRI as outpatient?EEG ordered\n team will discuss with neurology about management\n potentially get\n EEG, how to arrange outpatient workup vs further inpatient\n testing. Agitation: After extubation was persistently agitated,\n with episodes of combativeness, aggression. Appeared to be\n alert, but very angry and frustrated. Haldol given, 2.5 mg with very\n good effect - much more calm without excessive sedation. This morning\n completely calm, pleasant. Remembers yesterday\ns events, but\n apologized for behavior.\n Foley trauma: During period of agitation soon after\n extubation the patient stood up and in the process pulled on his Foley,\n causing pain and hematuria. The catheter was flushed multiple times\n without clearing, obstruction felt during attempt. Finally the\n catheter was removed, with moderate-sized clot adhering to and\n completely obstructing the tip. Both the nurse and resident attempted\n to place 3-way catheter, then urology also attempted without success.\n Moderate bleeding from meatus after Foley removal, but stopped now,\n urine clear. Using urinal without problems. Urology following, pt. has\n moderate post-void residuals and urology has been notified. He needs to\n f/u with Urologist. He has persistent leakage and has been wearing\n attends at home.\n Elevated troponins - With elevated CK, CKMB and troponins.\n CKMB -I Negative. Troponins yesterday afternoon trending down.\n Lactic acidosis: likely from seizure or seizure-like\n activity. Empiric antibiotics now stopped, leukocytosis resolved,\n afebrile, no clear source.\n Leukocytosis: Now resolved. Likely acute stress reaction\n from possible seizure. Could also be c/w infection, but no other\n indicators for infection. LP clear-off antibiotics and Acyclovir.\n He is alert and oriented x3, ambulating well, started\n regular diet without problems, IVF \nd-has . Sats 92-96% on RA.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 98.8 kg\n Daily weight:\n 101.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: unknown, pt. found down\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:65\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 2,321 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 04:15 AM\n Potassium:\n 3.9 mEq/L\n 04:15 AM\n Chloride:\n 110 mEq/L\n 04:15 AM\n CO2:\n 25 mEq/L\n 04:15 AM\n BUN:\n 19 mg/dL\n 04:15 AM\n Creatinine:\n 1.6 mg/dL\n 04:15 AM\n Glucose:\n 99 mg/dL\n 04:15 AM\n Hematocrit:\n 39.9 %\n 04:15 AM\n Finger Stick Glucose:\n 104\n 04:00 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: CC729\n Date & time of Transfer: @ 1900\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101795, "text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with intubation\n REASON FOR THIS EXAMINATION:\n ?tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 1212 HOURS.\n\n HISTORY: Intubation.\n\n COMPARISON: None.\n\n FINDINGS: Consistent with the given history, an endotracheal tube is evident\n terminating at the thoracic inlet approximately 9.2 cm proximal to the carina.\n A nasogastric tube is also in place coiling within the gastric fundus with the\n distal tip at the pylorus. Lung volumes are markedly diminished with\n resultant bronchovascular crowding at the bases. There is cephalization of\n flow likely in part due to supine position. Central vascular congestion is\n therefore evident however no frank edema is appreciated. There is no\n consolidation. There is a tortuous aorta. The cardiac silhouette is within\n normal limits for size. A small left pleural effusion cannot be excluded.\n\n IMPRESSION: Endotracheal tube high. Consider advancing 4 cm for more optimal\n placement. Nasogastric tube in satisfactory position. Central vascular\n congestion without overt edema or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1101796, "text": " 12:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?acute change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with found dow, unresponsive combative\n REASON FOR THIS EXAMINATION:\n ?acute change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc FRI 12:52 PM\n No acute intracranial hemorrhage or major vascular territorial infarct.Chronic\n microangiopathic disease.Soft tissue opacification of bilateral ethmoid\n sinuses and nasal passages.No fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man found unresponsive, combative, to evaluate for\n acute intracranial pathology.\n\n COMPARISON: No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images were acquired through the brain. No\n contrast was administered.\n\n FINDINGS: No acute intracranial hemorrhage, edema, masses, mass effect, or\n major vascular territorial infarction. The -white matter differentiation\n is well preserved. White matter hypodensities are noted in bifrontal white\n matter, consistent with chronic microangiopathic ischemic disease. The\n ventricles and sulcal spaces appear normal in caliber and configuration. The\n basal cisterns are widely patent.\n Bilateral mastoid air cells, external auditory canals appear clear.\n\n IMPRESSION: No acute intracranial hemorrhage or acute major vascular\n territorial infarction detected. However, if there is continued clinical\n concern for acute ischemia/infarction, an MRI with DWI would be more\n sensitive.\n\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1101797, "text": " 12:16 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with found dow, unresponsive combative\n REASON FOR THIS EXAMINATION:\n ?fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc FRI 1:09 PM\n No fractures of C-spine.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 80-year-old man,found unresponsive, to rule out cervical spine\n fracture.\n\n TECHNIQUE: Contiguous axial images were acquired through the cervical spine.\n No contrast was administered. Coronal and sagittal reformats were generated\n and reviewed.\n\n COMPARISON: No prior studies for comparison.\n\n FINDINGS: No acute cervical spine fractures detected. The atlantoaxial and\n atlanto-occipital joint appears normal. There is normal cervical spine\n orientation. There is a congenital non-fusion of the posterior arch of C1.\n\n Multilevel moderate degenerative disease noted in the cervical spine.\n Multilevel anterior and posterior osteophytes, predominantly at C4, C5, C6,\n and C7 vertebral bodies, causing mild spinal canal narrowing at these levels.\n There is reduction in the disc height at C4-C5, C5-C6, C6-C7, and C7-T1\n levels. No abnormality noted in the cervical prevertebral soft tissues.\n\n Again noted is endotracheal tube, terminating at the level of the vocal cords,\n recommended further advancement of the tube.\n\n The visualized lung apices show emphysematous changes.\n\n IMPRESSION:\n 1. No acute cervical spine fracture.\n 2. Multilevel degenerative disease with posterior osteophytes at C4, C5, C6,\n C7, and T1 levels, causing mild spinal canal narrowing at that level. The\n presence of these osteophytes may predispose the patient to have cord injury,\n depending on the type of trauma. Recommended MRI of C-spine, if the patient\n has signs of cord injury.\n\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1101799, "text": " 12:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with found dow, unresponsive combative\n REASON FOR THIS EXAMINATION:\n ?trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc FRI 1:45 PM\n Bilateral basal lung changes ,mostly related to aspiration.No other acute\n pathology detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man was found unresponsive, combative, to rule out\n trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images were acquired through the chest, abdomen, and\n pelvis, after administration of intravenous contrast. Coronal reformats were\n generated and reviewed.\n\n FINDINGS:\n\n CT CHEST WITH CONTRAST: The airways are patent up to the subsegmental levels\n bilaterally. Bilateral symmetric dependent opacities are noted in the basal\n segments, could represent dependent atelectatic changes. However, considering\n the intubated status and presence of material in the right main stem bronchus\n (2:24), aspiration cannot be ruled out.\n\n Diffuse bilateral centrilobular emphysematous changes are noted. No pleural\n effusion or pneumothorax detected. There is no pericardial effusion. The\n heart and the great vessels appear unremarkable, except for atheromatous\n disease of the aorta. A few calcified right hilar nodes are noted, related to\n prior granulomatous disease exposure. No significant mediastinal or hilar\n lymphadenopathy detected. Again noted is the high position of the\n endotracheal tube, about 7.5 cm from the tracheal bifurcation.\n\n CT OF THE ABDOMEN WITH CONTRAST: A small 7-mm hypoattenuating lesion is seen\n at the hilum of the liver, too small to characterize, most probably represents\n a hepatic cyst. The gallbladder appears unremarkable. There is no intra- or\n extra-hepatic biliary dilatation. The adrenal glands appear unremarkable.\n Mild fatty infiltration of the pancreas. The spleen appears slightly smaller\n in size, correlates with the clinical history of hypotension.\n\n Both kidneys show normal opacification and excretion of contrast. No\n hydroureteronephrosis. The left kidney has a hypoattenuating lesion in the\n interpolar region, most probably represents a renal cortical cyst.\n\n Nasogastric tube is seen in the stomach. The visualized stomach, small bowel\n (Over)\n\n 12:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appears unremarkable. No intra-abdominal free fluid or air is present. There\n is diffuse atherosclerotic disease of the abdominal aorta with non-calcific\n plaques, without aneurysmal dilatation of the aorta. No significant\n retroperitoneal lymphadenopathy. A few 5-mm non specific mesenteric lymph\n nodes are noted.\n\n CT OF THE PELVIS WITH CONTRAST: The bladder appears distended and is\n unremarkable. Multiple surgical clips are noted on bilateral pelvic\n sidewalls, with nonvisualization of the prostate, indicating prior prostatic\n surgery. Distal sigmoid shows multiple diverticulae, without evidence of\n acute diverticulitis. No pelvic free fluid. There is no significant pelvic\n lymphadenopathy.\n\n OSSEOUS STRUCTURES AND SOFT TISSUES: Multilevel degenerative changes are\n noted with grade 1 anterolisthesis of L5 over S1 with bilateral pars\n interarticularis defect at that level. Also noted is degeneration of the\n L5-S1 disc. No suspicious lytic or sclerotic bone lesion is detected.\n\n IMPRESSION:\n\n 1. No evidence of acute thoracic or abdominal traumatic injury.\n\n 2. Bilateral basal opacities in the lung could represent dependent\n atelectatic changes. Considering the presence of fluid in the right main\n bronchus in this intubated patient, aspiration cannot be ruled out. Diffuse\n emphysematous changes of both lungs.\n\n 3. High position of the endotracheal tube, 7 cm from the carina. Recommended\n advancement of the tube.\n\n 4. Hypoattenuating 7-mm liver lesion, too small to characterize, most\n probably represent hepatic cyst.\n\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490892, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490743, "text": "TITLE:\n Altered mental status (not Delirium)\n Assessment:\n Intubated, sedated on propofol. Stiff collar in place.On cmv mode fio2\n 60% tv- rr- peep 5 BBS diminished. Temp 96.6 orally\n Neuro-pupils 2-4mm brisk reactive. Withdraws to nailbed pressure.\n Impaired gag, Intact cough, intact corneals\n Ogt to lws w sm amts thick tan to brwn drng. Foley cath placed w clear\n yellow urine.\n Action:\n Heme/ID-Wbc elevated 18-12. Received ceftriax, ampicillin, acyclovir.\n Lumbar puncture done and samples sent to micro lab. Hypothermic\n blankets applied\n Neuro-neuro checks q2h & Daily wakeup done with propfol off ->, spont\n movement of all extrems, not following commands., does not open eyes\n spontaneously or to command.. Propofol resumed & titrated to sedate\n attempt to wean to 50mcg/kg poorly tolerated-> tachypneic and low Min\n ventilation when sedation lightened..\n Resp-Decreased to cpap w peep5 ps 10 fio2 to 50% Vap bundle and q4h\n suct for small amts of tan to clear secretions.\n Gi- npo ogt w small amts tan/brwn drng, active bowel sounds +.\n Gu- marginal uop x2 with bdline BP treated w 500cc NS\n Social/ (son lives in Fl.)contact by Dr and\n update given. Pt\ns pharmacy provider list= allopurinol.\n Response:\n Neuro exam unchanged. Normothermic w warm blankets. Tolerating cpap w\n O2 sats stable > 96% and stv 500-600ml. Brth sounds remain diminished.\n Uop improved w fld bolus, now with uop > 200cc/hr\nmonitor closely for\n possible DI\n Plan:\n Cont freq neuro exams. Check for results of LP. Pulm toilet.. ? wean\n from vent to extub later today. MRI once checklist completed by family.\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490906, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and following commands off sedation. He was easily extubated.\n Alert and oriented x3 but became progressively more aggressive,\n combative and very insulting. He became abusive with staff at the time,\n saying he would only speak to the doctor and not the nurse. He was more\n cooperative with the MICU team but still non-compliant with care. He\n became so agitated at one point that he climbed out of bed, pulling out\n his peripheral IV and stepping on his foley catheter. His urine output\n slowed down and only clotted frank red blood draining from foley.\n Action:\n Haldol given with some effect after second dose. He complained of pain\n due to trauma from the foley catheter being pulled. Lidocaine uroject\n with effect. Foley irrigated without effect and continued low output.\n Bladder scan without significant urine retention\n197ml. Foley catheter\n pulled with large amount of penile bleeding-saturated 1 pink pad, 2\n blue chucks and\n of . Attempted to place three way catheter to\n provide bladder irrigation after consulting with Urology, without\n success.\n Response:\n Continues alert and oriented x3 and now more cooperative and calm.\n Apologized to nursing staff for being rude.\n Plan:\n F/u with urology regarding replacing foley. MRI when family able to\n fill out screening form.\n" }, { "category": "Physician ", "chartdate": "2151-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 490973, "text": "Chief Complaint: This is a 80 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection. Now extubated, stable.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:00 PM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:35 PM\n pt. combative and agitated got out of bed and was abusive to staff\n attempting to hit nurses. Bloody all over from pulling out IV and foley\n catheter may have been stepped on by him causing bloody\n drainage--irrigated with small improvement and Lido uroject used for\n pain.\n -extubated just after noon, no complications. Mildly agitated,\n frustrated with Foley. Slightly groggy, but alert and responsive.\n -No cervical midline tenderness, C-collar removed.\n -At 1:30, the patient became increasingly combative with nurse, got up\n out of bed, pulled IV, took off his clothes. Was taken back to bed\n without a fall, cleaned up, and calmed down. No injuries other than\n bleeding from IV site, stopped with pressure.\n -During 1:30 episode the patient stepped on his Foley tubing, then\n complaining of pain at the base of the penis afterward. Tried several\n times to flush Foley without success.\n -Foley was DC-ed, removed smoothly, with clot adhering to and\n completely obstructing the tip. Moderate bleeding from urethral meatus\n after Foley removal.\n -Haldol 2.5 given with good effect - patient became more calm.\n -LP results back - 0 WBC, 1 RBC. Antibiotics DC-, continue\n acyclovir for now.\n -patient's son arrived to hospital at 1900, did not know much about his\n medical history, other than that he has gout. He also says he thinks\n that the patient has had a seizure before in the past.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 05:02 PM\n Ceftriaxone - 06:55 AM\n Ampicillin - 02:00 PM\n Vancomycin - 04:00 PM\n Acyclovir - 04:24 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 09:29 PM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Fosphenytoin - 04:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (98.9\n HR: 78 (73 - 102) bpm\n BP: 115/64(77) {98/46(64) - 176/119(131)} mmHg\n RR: 23 (7 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.6 kg (admission): 98.8 kg\n Total In:\n 3,496 mL\n 548 mL\n PO:\n TF:\n IVF:\n 3,436 mL\n 548 mL\n Blood products:\n Total out:\n 2,165 mL\n 0 mL\n Urine:\n 2,065 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,331 mL\n 548 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (500 - 530) mL\n PS : 5 cmH2O\n RR (Set): 19\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///25/\n Ve: 9.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 206 K/uL\n 13.0 g/dL\n 99 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 110 mEq/L\n 144 mEq/L\n 39.9 %\n 10.1 K/uL\n [image002.jpg]\n 05:47 PM\n 06:24 PM\n 03:06 AM\n 03:00 PM\n 04:15 AM\n WBC\n 16.6\n 12.0\n 10.1\n Hct\n 44.6\n 43.5\n 39.9\n Plt\n 235\n 202\n 206\n Cr\n 1.2\n 1.3\n 1.7\n 1.6\n TropT\n 0.14\n 0.27\n 0.15\n TCO2\n 23\n Glucose\n 146\n 108\n 142\n 99\n Other labs: PT / PTT / INR:12.2/27.7/1.0, CK / CKMB /\n Troponin-T:391/12/0.15, Differential-Neuts:81.4 %, Lymph:9.0 %,\n Mono:7.7 %, Eos:1.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 80 y.o. man found down, with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection.\n .\n # Altered mental status: Most likely seizure, possible acute infarct,\n meningitis, encephalitis. Pt had elevated lactate and white count.\n Lactate is now resolved making seizure process likely.\n -fosphenytoin 100mg IV TID\n - d/c antibiotics for bacterial coverage given LP results. continue\n acyclovir\n - Head MRI without contrast given ARF - order written\n -EEG ordered\n -telemetry\n -blood, urine, sputum Cx\n -neuro recs from , will see him today\n #Agitation: After extubation was persistently agitated, with episodes\n of combativeness, aggression. Appeared to be alert, but very angry and\n frustrated. Haldol given, 2.5 mg with very good effect - much more\n calm without excessive sedation.\n #Foley trauma: During period of agitation soon after extubation the\n patient stood up and in the process pulled on his Foley, causing pain\n and hematuria. The catheter was flushed multiple times without\n clearing, obstruction felt during attempt. Finally the catheter was\n removed, with moderate-sized clot adhering to and completely\n obstructing the tip. Both the nurse and resident attempted to place\n 3-way catheter, then urology also attempted without success.\n -moderate bleeding from meatus after Foley removal, but stopped.\n -no obstruction, urinating well.\n # Elevated troponins - With elevated CK, CKMB and troponins. CKMB -I\n Negative. Likely had an NSTEMI on the scene of the acident. Troponins\n trended, yesterday afternoon trending down.\n - Statin, BB\n - held ASA given coffee ground in suction, will trend Hct and\n reasses. Hct reduced slightly today but stable.\n - Cardiology aware\n #Lactic acidosis: in setting of hypertension makes septic shock\n unlikely. Has resolved with intubation and propofol. potentially be\n from myoclonic activity given setting of tremulous movements. Empiric\n antibiotics now stopped, leukocytosis resolved, afebrile, no clear\n source.\n - f//u urine, blood, sputum cx.\n - continue acylovir for now.\n # Leukocytosis: Now resolved. Likely acute stress reaction from\n possible seizure. Could also be c/w infection, but no other indicators\n for infection.\n -trend cbc\n - acyclovir, add abx as cultures return\n - LP clear\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripheral, DC-ed one peripheral yesterday.\n .\n # Code: presumed full\n .\n # Communication: wife, son. The son came in yesterday evening,\n discussed with him.\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 20 Gauge - 07:42 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491100, "text": "This is a 72 y.o. man found down , with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection. Agitated , but today completely calm, pleasant,\n reports feeling his usual self..\n SICU events:\n Altered mental status: Most likely seizure given very high\n lactate, immediate resolution, no infectious signs. Etiology for\n possible seizure unclear. Would like to get head MRI to further\n evaluate\n patient says today that he absolutely cannot tolerate a\n closed MRI. Would consider possible open MRI as outpatient?EEG ordered\n team will discuss with neurology about management\n potentially get\n EEG, how to arrange outpatient workup vs further inpatient\n testing. Agitation: After extubation was persistently agitated,\n with episodes of combativeness, aggression. Appeared to be\n alert, but very angry and frustrated. Haldol given, 2.5 mg with very\n good effect - much more calm without excessive sedation. This morning\n completely calm, pleasant. Remembers yesterday\ns events, but\n apologized for behavior.\n Foley trauma: During period of agitation soon after\n extubation the patient stood up and in the process pulled on his Foley,\n causing pain and hematuria. The catheter was flushed multiple times\n without clearing, obstruction felt during attempt. Finally the\n catheter was removed, with moderate-sized clot adhering to and\n completely obstructing the tip. Both the nurse and resident attempted\n to place 3-way catheter, then urology also attempted without success.\n Moderate bleeding from meatus after Foley removal, but stopped now,\n urine clear. Using urinal without problems. Urology following, pt. has\n moderate post-void residuals and urology has been notified. He needs to\n f/u with Urologist. He has persistent leakage and has been wearing\n attends at home.\n Elevated troponins - With elevated CK, CKMB and troponins.\n CKMB -I Negative. Troponins yesterday afternoon trending down.\n Lactic acidosis:. As above\n likely from seizure or\n seizure-like activity. Empiric antibiotics now stopped, leukocytosis\n resolved, afebrile, no clear source.\n # Leukocytosis: Now resolved. Likely acute stress reaction from\n possible seizure. Could also be c/w infection, but no other indicators\n for infection.\n - LP clear-off antibiotics and Acyclovir.\n .\n # FEN: No IVF, replete electrolytes, regular diet today\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripheral.\n .\n # Code: full\n .\n # Communication: wife, son. The son came in yesterday evening,\n discussed with him.\n .\n # Disposition: to floor today.\n .\n ICU Care\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491103, "text": "This is a 72 y.o. man found down , with elevated lactate and\n leukocytosis, hypertension, tremor, and intubated for airway\n protection. Agitated , but today completely calm, pleasant,\n reports feeling his usual self.\n SICU events:\n Altered mental status: Most likely seizure given very high\n lactate, immediate resolution, no infectious signs. Etiology for\n possible seizure unclear. Would like to get head MRI to further\n evaluate\n patient says today that he absolutely cannot tolerate a\n closed MRI. Would consider possible open MRI as outpatient?EEG ordered\n team will discuss with neurology about management\n potentially get\n EEG, how to arrange outpatient workup vs further inpatient\n testing. Agitation: After extubation was persistently agitated,\n with episodes of combativeness, aggression. Appeared to be\n alert, but very angry and frustrated. Haldol given, 2.5 mg with very\n good effect - much more calm without excessive sedation. This morning\n completely calm, pleasant. Remembers yesterday\ns events, but\n apologized for behavior.\n Foley trauma: During period of agitation soon after\n extubation the patient stood up and in the process pulled on his Foley,\n causing pain and hematuria. The catheter was flushed multiple times\n without clearing, obstruction felt during attempt. Finally the\n catheter was removed, with moderate-sized clot adhering to and\n completely obstructing the tip. Both the nurse and resident attempted\n to place 3-way catheter, then urology also attempted without success.\n Moderate bleeding from meatus after Foley removal, but stopped now,\n urine clear. Using urinal without problems. Urology following, pt. has\n moderate post-void residuals and urology has been notified. He needs to\n f/u with Urologist. He has persistent leakage and has been wearing\n attends at home.\n Elevated troponins - With elevated CK, CKMB and troponins.\n CKMB -I Negative. Troponins yesterday afternoon trending down.\n Lactic acidosis: likely from seizure or seizure-like\n activity. Empiric antibiotics now stopped, leukocytosis resolved,\n afebrile, no clear source.\n Leukocytosis: Now resolved. Likely acute stress reaction\n from possible seizure. Could also be c/w infection, but no other\n indicators for infection. LP clear-off antibiotics and Acyclovir.\n He is alert and oriented x3, ambulating well, started\n regular diet without problems, IVF \nd-has . Sats 92-96% on RA.\n" }, { "category": "Nursing", "chartdate": "2151-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491090, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490750, "text": "TITLE:\n Altered mental status (not Delirium)\n Assessment:\n Intubated, sedated on propofol. Stiff collar in place.On cmv mode fio2\n 60% tv- rr- peep 5 BBS diminished. Temp 96.6 orally\n Neuro-pupils 2-4mm brisk reactive. Withdraws to nailbed pressure.\n Impaired gag, Intact cough, intact corneals\n Ogt to lws w sm amts thick tan to brwn drng. Foley cath placed w clear\n yellow urine.\n Action:\n Heme/ID-Wbc elevated 18-12. Received ceftriax, ampicillin, acyclovir.\n Lumbar puncture done and samples sent to micro lab. Hypothermic\n blankets applied\n Neuro-neuro checks q2h & Daily wakeup done with propfol off ->, spont\n movement of all extrems, not following commands., does not open eyes\n spontaneously or to command.. Propofol resumed & titrated to sedate\n attempt to wean to 50mcg/kg poorly tolerated-> tachypneic and low Min\n ventilation when sedation lightened..\n Resp-Decreased to cpap w peep5 ps 10 fio2 to 50% Vap bundle and q4h\n suct for small amts of tan to clear secretions.\n Gi- npo ogt w small amts tan/brwn drng, active bowel sounds +.\n Gu- marginal uop x2 with bdline BP treated w 500cc NS\n Social/ (son lives in Fl.)contact by Dr and\n update given. Pt\ns pharmacy provider list= allopurinol.\n Response:\n Neuro exam unchanged. Normothermic w warm blankets. Tolerating cpap w\n O2 sats stable > 96% and stv 500-600ml. Brth sounds remain diminished.\n Uop improved w fld bolus, now with uop > 200cc/hr\nmonitor closely for\n possible DI\n Plan:\n Cont freq neuro exams. Check for results of LP. Pulm toilet.. ? wean\n from vent to extub later today. MRI once checklist completed by family.\n ------ Protected Section ------\n CV- nsr no ectopics.Ck with Mb and Troponins elevated, Dr \n notified->12 lead ekg done- no acute significant changes noted.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:26 ------\n" }, { "category": "Physician ", "chartdate": "2151-10-30 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 490910, "text": "Chief Complaint: found down\n HPI:\n The patient is an unidentified 80? y.o. male who was found down between\n two cars this morning. There was reported \"seizure-like\" activity at\n the scene, and though could not speak, was mumbling to EMS. IN the ED\n the patient was tremulous and not speaking. He became combative and\n was therefore intubated. Intial vitals in the ED showed a heart rate\n of 140 and blood pressure 210/120 with adequate oxygen saturation.\n Labs were notable for a lactate of 9.6 and white count of 17.6. CT\n head was negative, CT torso was significant for potential aspiration\n pneumonia. C-Spine was normal. The patient continued to shake after\n intubation and was given ativan 2mg x2 which caused the tremors to\n stop. After intubation vitals were; T 98.6 HR 116 BP 147/96 RR 28\n 100% on AC 600/14 PEEP 5, FiO2 50%.\n The patient had 2 peripheral IV's placed.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 04:21 PM\n Levofloxacin - 05:02 PM\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Other medications:\n unknown\n Past medical history:\n Family history:\n Social History:\n unknown\n unknown\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 05:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 89 (89 - 96) bpm\n BP: 124/81(90) {120/73(90) - 124/81(107)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 424 mL\n PO:\n TF:\n IVF:\n 424 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 84 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.32/42/118//-4\n Ve: 12.1 L/min\n PaO2 / FiO2: 197\n Physical Exam:\n Vitals: T:96.6 BP:124/81 P:89 R:14 O2: 98% FiO2 50%\n General: sedated, unresponsive, intubated.\n HEENT: pupils 2mm, reactive, Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n .\n Labs:\n See below\n .\n Micro:\n .\n Images:\n CT chest: Bilateral basal lung changes ,mostly related to\n aspiration.No other acute pathology detected\n .\n C-spine: no fractures.\n .\n : head CT: No acute intracranial hemorrhage or major vascular\n territorial infarct.Chronic microangiopathic disease.Soft tissue\n opacification of bilateral ethmoid sinuses and nasal passages.No\n fractures\n .\n EKG: sinus tachycardia at rate 125, normal axis, prolonged QRS, RBBB,\n TWI in III, aVF.\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A10/9/ 05:47 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 23\n Other labs: Lactic Acid:1.4 mmol/L\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: This is a 80 y.o. man found down, with elevated\n lactate and leukocytosis, hypertension, tremor, and intubated for\n airway protection.\n .\n # Altered mental status: was initially found down but was conscious,\n was able to murmur, and was found to have tremulous movements. urine\n and serum toxicology screens are negative. CT head is without acute\n intracranial process, though potentially may show cerebral edema.\n Elevated white count makes infection a possibility. Elevated lactate in\n absence of hypotension may indicate mycoclonic seizures. Will pursue\n neuro evaluation to rule out seizure.\n -load with fosphenytoin 20mg/Kg tonight\n -fosphenytoin 100mg IV TID starting tomorrow.\n -ampiric abx coverage for meningitis, vanc, ceftriaxone, ampicillin\n -f/ head CT read\n -LP once official head CT read\n -Head MRI wihtout contrast given ARF\n -EEG\n -ativan PRN\n -trend cardiac enzymes\n -telemetry\n -blood, urine, sputum Cx\n -trend lactate.\n -neuro recs\n .\n #Lactic acidosis: in setting of hypertension makes septic shock\n unlikely. Has resolved with intubation and propofol. potentially be\n from myoclonic activity given setting of tremulous movements. Will pan\n culture and start empiric antibiotics.\n -urine, blood, sputum cx.\n -vanc, ceftriaxone, ampicillin\n .\n # Leukocytosis: CBC Differential is pending. be infection vs.\n acute stress reaction from seizure.\n -trend cbc\n -empiric abx\n -LP\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: peripherals X2\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:33 PM\n 18 Gauge - 04:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n I agree with the note above, including the assessment and plan. Please\n see my note from for further details.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:02 ------\n" } ]

[ { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1546501, "text": "SICU NURSING NOTE 7P-7A\nREVIEW OF SYSTEMS\n\nNEURO: PT ON DILAUDID GTT FOR PAIN AND PROPOFOL TO LIGHTLY SEDATE. OPENS EYES TO VOICE. FOLLOWING ALL COMMANDS. MAE. COMMUNICATING BY WRITING NOTES AND MOUTHING WORDS. AOX3 WITH OCC EPISODES OF REORIENTATION NEEDED.\n\nCV: HEMODYNAMICALLY STABLE. HR 80'S SR. NIPRIDE GTT STARTED D/T SLIGHT HTN D/T PT BEING LIGHT. +PP WITH SKIN WARM AND DRY. CVP 5-9\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. SX FOR MINIMAL THICK YELLOW. REMAINS ON PS 8 WITH GOOD EFFECT. CHEST TUBE LEFT WITH SMALL AMT TO SEROSANG. FLUID. SMALL LEAK NOTED.\n\nGI: REMAINS NPO. SOFTLY DISTENDED ABD WITH HYPO. BS. NO STOOL OR FLATUS NOTED. NGT DRAINING SMALL AMT OF BROWN MATERIAL.\n\nGU: U/O ADEQUATE. LYTES REPLETED.\n\nHCT: STABLE AT 25. INR 1.2\n\nENDO: no issues\n\nID: TMAX 100.9. CONTS ON IV CEFAZOLIN.\n\nSKIN: DSG TO THORACOTOMY SITE INTACT.\n\nSOCIAL: MOTHER CALLED AND UPDATED ON STATUS.\n\nA: S/P THORACOTOMY AFTER MVA\nP: EXTUBATE TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-20 00:00:00.000", "description": "Report", "row_id": 1546504, "text": "ctic/sicu transfer note\n\n This is a very fortunate 46 yr old man that was involved in a mva on where he was a restrained driver. . He was ambulatory at scene and decliened to go to hospital. Felt fine for ~ 24 hrs until he felt sharp back pain and sob was transferred to ew by amb. cxr showed left hemothorax. Chest tube placed with immediate return of 3.5L of blood with sbp down to 50. emergently to or now s/p left thoracotomy and evacuation of blood. control of intercostal and intervertebral bleeds, required crossclamping for ~ 1/2hr. required 20u prbc, 12 ffp, 4u cellsaver, and 3 plat. Pt arrived to sicu early am requiring neo and then nipride for bp control. On pt extubated at 9:30 a and has done well. Now stable for discharge to floor.\n\nr.o.s.: neuro: pt alert, o x 3, mae's, f/c's.\n\ncv: hr 80's nsr, no ectopy, lytes repleted, bp control was on lopressor iv yet restarted on hydrochlorthiazide this am and to receive his zestril this pm. sbp 130-150. pulses palp. skin w & d.\n\nresp: lungs clear sl diminished at bases, enc to c & db, good effort, fair cough. no sob, able to wean o2 off maintaining sats > 96%. left ct to water seal post cxr done awaiting . draining serosang dnge.\n\ngi: abd soft, n/d, n/t, no n/v, tol 2gm salt diet. no bm.\n\ngu: foley draining qs yellow urine.\n\nskin: left thoracotomy dsg intact.\n\nact: pt oob with 2 assist amb ~20 steps total then up in chair for ~ 3 hrs. tol well.\n\nsocial: wife and mother in to visit, asking approp questions, support provided.\n\na/p: cont to monitor, increase act, pulm toilet, 2 gm na diet, q 12hr hct, next due at 2a, support, stable for transfer to floor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1546497, "text": "RESP CARE NOTE\nPT RECEIVED FROM OR S/P LT CHEST EXP FOR EVAC OF HEMOTHORAX & REPAIR OF BLEED. MASSIVE BLOOD PRODUCT AND FLUID RESUS REQ, EBL IS QUITE SIGNIFICANT HOWEVER AMT IS UNKNOWN. PT & SEDATED, INTUBATED W/ #7.0 ETT. MECH VENTED VIA PB7200 VENT. VT DECR TO 500 FOR PROTECTIVE LUNG STRATEGY. A/C 500 X 16, 50%, 5PEEP. ABG ON 700 X 12 7.34/44/167/-. BS SL COARSE BILAT, SXN ETT FOR NO SEC RETURN. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1546498, "text": "SICU ADMISSION NOTE 315A-730A\n MR. IS A 47YO MALE WHO WAS INVOLVED IN MVA ON WHERE HE WAS HIT BY TRUCK THEN HIT BY CAR. PT WAS WALKING AT SCENE AND DECLINED TO GO TO HOSPITIAL. WIFE PICKED PT UP AT SCENE AND BROUGHT HIM HOME. ON PT DEVELOPED SOB AND BACK/FLANK PAIN SO HE CAME TO EW TO BE EVALUATED. ARRIVAL PT SBP 80 AND PT DIAPHORETIC. CXR REVEALED L SIDED HEMOTHORAX. CT PLACED AND IMMEDIATELY PUT OUT 3.5 LITERS OF BLOOD WITH SBP DROPPING TO 50. PT RESUSCITATED WITH BLOOD AND FFP AND EMERGENTLY SENT TO OR.\n\nOR: L THORACOTOMY, EVACUATION OF BLOOD, AND CONTROL OF BLEEDING INTERCOSTAL VESSELS AND PERIVERTEBRAL VESSELS.\nINTAKE: 20U PRBC OUTPUT: U/O 400CC\n EBL 6000\n 12U FFP\n 4U CELLSAVER\n 3 PLATELETS.\n 6.5L CRYSTALLOIDS\n\nPT CROSSCLAMPED FOR APPROX. 1/2 HOUR.\n**********************************************************************\nPMHX: NEUROFIBROMALOSIS, EX LAP AND LOA FOR SBO, AND HTN.\nMEDS: ?\nALLE: NKDA\nSOCIAL: LIVES WITH WIFE IN \n**********************************************************************\n\nREVIEW OF SYSTEMS\n\nNEURO: PT ARRIVED FROM OR AND ALLOWED TO WAKE. WHEN LIGHT PT MOVES ALL EXTREMETIES AND FOLLOWING ALL COMMANDS. SEDATED ON PROPOFOL AND DILAUDID GTT. Q1 NEURO CHECKS DONE. MAINTAIN LOGROLL PRECAUTIONS.\n\nCV: HEMODYNAMICALLY LABILE. HR 80-90 SR WITH NO ECTOPY. INITIALLY SBP 150-160 SO NIPRIDE GTT STARTED TO KEEP SBP<120. NIPRIDE THEN WEANED AND PT BECAME HYPOTENSIVE SO NEO GTT STARTED TO KEEP MAP>65. +PP WITH SKIN WARM AND DRY. L RADIAL ALINE INTACT. R FEMORAL NONFUNCTION ALINE WHICH CT WILL REMOVE TODAY. LEFT FEMORAL TRAUMA LINE INTACT. PIV X2.\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. MAINTAINED ON A/C WITH ADEQUATE ABG. BECAUSE OF HIGH RISK OF ARDS VENT SETTINGS CHANGED TO DECREASE VT AND INCREASE RR. SX FOR SMALL AMT OF BLOOD TINGED SPUTUM. CXR DONE. SATS 100%. LEFT CHEST TUBE TO 20 SX WITH SMALL LEAK NOTED. DRAINING MOD AMT OF SANG. FLUID. NO CREPITUS NOTED AT SITE.\n\nGI: ABD SOFT WITH HYPOACTIVE BS. NGT DRAINING SCANT BILIOUS MATERIAL. NO STOOL OR FLATUS NOTED. IVR LR AT 100CC/HR.\n\nGU: U/O ADEQUATE. K AND MG REPLETED\n\nHEME: HCT STABLE AT 28. INR 1.4 WHICH CT AND TRAUMA DID NOT WANT TO RX.\n\nENDO: NO ISSUES.\n\nID: FLAT WBC. AFEBRILE. CONTS ON IV ANCEF.\n\nSKIN: THORACOTOMY INCISION INTACT.\n\nSOCIAL: WIFE AND MOTHER BOTH CALLED AND UPDATED BY THIS RN ON EVENTS.\n\nA: S/P MVA\nP: CONT FULL SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1546499, "text": "NEURO; Pt remains on small 30mcg propofol an .5 dilaudid. Pt easily arousable, able communicate with gestures and writing, orientated x 3. Asked who won the game last night. Pain well controlled with some discomfort turning. Pt cooperative and restraints removed, pt very cautious of lines and tubes. MAE well and assists with turning.\n RESP; Pt remains vented on PS 8 with adeq ABGs. Lungs clear with diminished bases and scant thin white secretions. CT x 2 to 20cm sx, small air leak, no crepitus and seroussang drainage appr 250cc for shift.\n CV; SR, no ectopy, requiring small amts neo to maintain MAP>65. Lytes repleted as needed. Tmax 100.2. Skin W&D and intact, + perp pulses, mild generalized edema and mod orbital edema. HCT drop from 27 to 21 in 6 hrs, MD aware and Tx 2 u PRBCs. Received 2u FFP for INR 1.4.\n GI/GU; Abd soft and nontender with very faint +BS. NGT to lws with 400cc gastric drainage. Foley patent with appr 100cc/h clear yellow urine.\n Wife and mother visited, spoke with HO.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1546500, "text": "RESP CARE NOTE\nPt remians on minimal vent support, PSV 8/5 40%. Gases acceptable. Sx minimal secretions. Will follow, assess for extubation in am.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1546502, "text": "ctic/sicu nursing note\n\ns/o: neuro: a & ox 3, mae's, f/c's, after extubated asking approp questions, propofol off and dilaudid gtt changed to pca - pt using approp with good effect.\n\ncv: hr 80-90's nsr, lytes ok, bp stable off nipride, at times bp up to sbp 180's with movement then settles back to s 140-150. pulses palp skin w & d.\n\nresp: pt extubated at 9:30a pt doing great, sats 98 -100%, no sob, pt with productive cough yet unable to expectorate occass swallows. left ct with small leak this am now no sir leak noticed. cont 20cm sxn. draining serosang dnge. pt enc to c & db, good effect needs some enc.\n\ngi: abd soft, n/d, ngt dc'd, no n/v, tol swabs, will advance to cl.\n\ngu: foley draining qs yellow urine\n\nact: pt oob with 2 assist able to pivot to chair, tol well. sat for 1hr then able to stand and pivot back to bed.\n\ncomfort: pt using dilaudid pca with good relief from pain.\n\nskin: left thoracotomy dsg intact.\n\nsocial: wife and mother in to visit, very supportive, asking approp questions.\n\nheme: hct q 6h stable. 24.9\n\nendo no issues.\n\na/p: monitor hemodynamics, pulm toilet, increase act, increase dat, ? amb tomorrow, monitor hct, dilaudid pca, as per plan\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-20 00:00:00.000", "description": "Report", "row_id": 1546503, "text": "CTIC/SICU Progress Note\nS/O: Neuro: Intact and comf on dilaudid PCA.\n CV: BP 140-160/70 on iv lopressor 5 mg q6hrs.\n Resp: 4lNP with SAO2 100%.\n Renal: UO 50-100 on D51/2NS with 20 kcl. Lytes repleted.\n Heme: Hct 23.5, plt 65, pneumoboots. CT draining serosang.\n ID: Tmax 101.7, now 100. WBC 5.7, on kefzol.\n GI: CL liqs, zantac, passing flatus.\n Endo: GLu~130.\n Skin: Intact, neurofib lesions.\n Rehab: Moving well in bed.\nA: Doing well.\nP: Advance activity. Cut down IV fluid and watch hct. Transfer to floor.\n\n\n" }, { "category": "ECG", "chartdate": "2120-02-17 00:00:00.000", "description": "Report", "row_id": 140241, "text": "Sinus rhythm. Prominent R waves in leads VI-V2 with early transition. Compared\nto the previous tracing of no diagnostic interim change. Clinical\ncorrelation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2120-02-17 00:00:00.000", "description": "Report", "row_id": 140242, "text": "Sinus rhythm. Prominent R waves in leads VI-V2 with early transition.\nNon-specific intraventricular conduction delay with notched QRS complexes. No\nprevious tracing available for comparison. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2120-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750820, "text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P LEFT SC TLC PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p thoracotomy\n REASON FOR THIS EXAMINATION:\n S/P LEFT SC TLC PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Follow up thoracotomy.\n\n There is no appreciable change in the appearance of the chest since the\n previous chest x-ray at 4:37 AM on .\n\n IMPRESSION: Satisfactory postoperative appearance.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750860, "text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess hemothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p thoracotomy\n REASON FOR THIS EXAMINATION:\n reassess hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P thoracotomy, assess hemothorax.\n\n COMPARISONS: .\n\n SUPINE PORTABLE CHEST: ETT is present with tip 3 cm above the carina. Two\n left sided chest tubes are present. There is no pneumothorax and there is\n interval improvement of left subcutaneous emphysema. NGT is present with tip\n in the stomach. Cardiac silhouette and mediastinal contour are unchanged.\n There is interval increase in size of small left pleural effusion. Bibasilar\n and subsegmental atelectasis is unchanged.\n\n IMPRESSION:\n\n Interval increase in size of small left pleural effusion, otherwise no\n significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750793, "text": " 10:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p mva now w/ hemothorax and CT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with HX X 1 DAY OF BACK AND CHEST PAIN R/O AORTIC DISSECTION\n REASON FOR THIS EXAMINATION:\n s/p mva now w/ hemothorax and CT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 year old man with a one day history of back and chest pain\n following MVA. Presents with a hemothorax following chest tube placement.\n\n COMPARISONS: at 20:39 hours.\n\n PORTABLE AP CHEST: There is a new chest tube in the left hemithorax, with its\n tip projecting over the left hilar region. There is persistent almost complete\n opacification of the left lung. There is stable mediastinal shift to the\n right. The right CP angle is not included in this study.\n\n IMPRESSION: Left chest hemothorax and status post left sided chest tube\n placement. No other change from the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750803, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess CT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p thoracotomy\n REASON FOR THIS EXAMINATION:\n assess CT position\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST, 4:37 AM.\n\n HISTORY: Thoracotomy, trauma with hemothorax.\n\n The left 6th rib has been partially resected. There is a fracture of the\n lateral aspect of the left 5th rib, and there is subcutaneous emphysema. There\n are two chest tubes in the left hemithorax. the large hemothorax has been\n almost completely evacuated since the prior chest x-ray. An ETT terminates 5\n cm above the carina. There is subsegmental atelectasis at the right lung\n base. The heart is slightly enlarged. There are no other significant\n findings.\n\n IMPRESSION; Evacution of large left hemothorax following thoracotomy with\n subsegemental atelectasis at the right lung base and insertion of a second\n chest tube.\n\n Left-sided rib fractures.\n\n ETT 5 cm above carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750790, "text": " 8:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 47 Y/O MALE C/O BACK AND CHEST PAIN R/O AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with HX X 1 DAY OF BACK AND CHEST PAIN R/O AORTIC DISSECTION\n REASON FOR THIS EXAMINATION:\n 47 Y/O MALE C/O BACK AND CHEST PAIN R/O AORTIC DISSECTION\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Back and chest pain for one day.\n\n PORTABLE CHEST: A single upright view obtained at 8:39 pm shows near-complete\n opacification of the left hemithorax and rightward mediastinal shift. The\n dome of the left hemidiaphragm is not obscured and is not elevated. The right\n lung is clear. No fractures are identified. There is no prior exam for\n comparison.\n\n IMPRESSION: Near-complete opacification of left hemithorax, likely due to\n hemothorax, with rightward mediastinal shift. A chest CT is recommended for\n further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750910, "text": " 6:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p hemothorax....demonstrate complete evacuation?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p thoracotomy\n REASON FOR THIS EXAMINATION:\n s/p hemothorax....demonstrate complete evacuation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P thoracotomy for hemothorax. Evaluate status of hemothorax.\n\n CHEST SINGLE VIEW TIME 7:09: The patient has been extubated. Two chest tubes\n are unchanged in position since time 5:38. There is no pneumothorax.\n Patchy bibasilar opacities are unchanged. A small left effusion is also\n stable. Heart size is at the upper limits of normal.\n\n IMPRESSION: There is no pneumothorax. A small left effusion and probable\n bibasilar atelectasis are unchanged from .\n\n" }, { "category": "Radiology", "chartdate": "2120-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750951, "text": " 2:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube on water seal, r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p thoracotomy w/ chest tube on water seal.\n REASON FOR THIS EXAMINATION:\n chest tube on water seal, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP SUPINE CHEST, :\n\n CLINICAL INDICATION: Evaluate for a pneumothorax in a patient with a chest\n tube on water seal.\n\n COMPARISON: \n\n Two left-sided chest tubes are present with their tips direct towards the left\n apex and sideholes within the left hemithorax. No appreciable pneumothorax is\n present. The bibasilar atelectasis has improved compared to . There\n is slight residual atelectasis at the left lung base. There is slight\n elevation of the left hemidiaphragm. The heart size is slightly enlarged,\n allowing for AP technique. Mediastinal and hilar contours are normal. The\n pulmonary vascularity is within normal limits. The soft tissue and osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1) No evidence of pneumothorax.\n 2) Two left-sided chest tubes with tips positioned near the left apex.\n 3) Improvement of bibasilar atelectasis, with slight residual left basilar\n atelectasis.\n 4) Slight elevation of the left hemidiaphragm.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2165-10-14 00:00:00.000", "description": "Report", "row_id": 1575279, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Intact\nCV: Afebrile crit stable. S/P bilat extremity u/s..neg for any additional thrombus. Tolerating OOB well.\nResp: Pt placed on 5L NC ABG with Pa02 68. MD is aware. Stated Pa02 68 okay 02sat 92-95%. Lungs clear to diminished at the bases.\nGI/GU: + Obese switched to reg diet. Foley patent drng minimal u/o Bun/creat WNL.\nEndo: RISS tightened.\nID: No abx\nMisc: Psych c/s today per family request.\nPlan: ICU one more day. OOB as tolerated. Cont to monitor resp status\n" }, { "category": "Nursing/other", "chartdate": "2165-10-15 00:00:00.000", "description": "Report", "row_id": 1575280, "text": "NURSING UPDATE\nCV: NSR, NO ECTOPY. NORMOTENSIVE. HEME LABS WNL.\n\nGU: URINE OUTPUT STILL DIMINISHED 10-15CC/H, URINE MURKY. DR NOTIFIED AND NURSE REQUESTED ORDER FOR U/A C&S, REQUEST DECLINED BY SAME HO DUE TO PT PRESENTING WITH NORMAL TEMP AND WBC. BUN/CREAT REMAIN WNL @ 14/0.7 RESPECTIVELY.\n\nRESP: BREATH SOUNDS CLEAR, DIMINISHED @ BASES. SATS 91-96% ON 5L O2 NASAL/PRONGS. ABG WITHIN ACCEPTABLE PARAMETERS.\n\nENDO: SLIDING SCALE REVISED AGAIN AND BLOOD GLUCOSE RX Q4H OVERNOC TO GET LEVELS UNDER CONTROL. GOOD EFFECT - GLUCOSE DOWN TO 135 THIS AM.\n\nPT MONITORED CONTINUOUSLY.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-15 00:00:00.000", "description": "Report", "row_id": 1575281, "text": "Focus Condition Update\nPlease see flowsheet for specific information\n\nNeuro: Pt alert and oriented x3, MAE's, follows commands. PERRLA. Denies pain. Paxil restarted for depression.\nCV: NSR with no ectopy noted. SBP 120-150, HR 70-95. A-line positional, dressing changed.\nResp: LCTA, dim in bases. Sating 90-100% on 5 liters O2 via NC.\nGI: BS+, abdomen obese, non-tender. no BM this shift. MRI of abdomen scheduled routine for tomorrow.\nGU: UO low, amber colored and cloudy. Fluid bolus given this a.m. without effect.\nEndo: RISS\nSocial: Social work in to see patient today. Dtr at patients bedside.\nPlan: Continue to monitor UO\n MRI in a.m.\n Monitor and replete labs as needed\n Continue with SICU POC, contact HO with changes.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-16 00:00:00.000", "description": "Report", "row_id": 1575282, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nStable night. U/O improving with increased IVF. Pt slept well overnight. Possible trnf today. pt will need MRI of abd today.\nCont with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2165-10-16 00:00:00.000", "description": "Report", "row_id": 1575283, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS. HEMODYNAMICALLY STABLE, AWAITING MRI OF LIVER, CAN TRANSFER TO FLOOR WHEN BED AVAILABLE.\nNEURO: ALERT, ORIENTED X3\nCV: AFEBRILE. HR 80-90'S NSR, SBP 90-120\nRESP: BS CLEAR BUT DIMINSHED IN BASES. NC AT 2 LITERS WITH SAT >92%\nGI: TOL DIET WELL,\nGU: UO IMPROVING, IVF AT 150CC/HR\nENDO: BS ELEVATED IN 200'S- TX'D WITH SLIDING SCALE. PO MEDS RESUMMED TODAY\n\n" }, { "category": "Nursing/other", "chartdate": "2165-10-13 00:00:00.000", "description": "Report", "row_id": 1575277, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nPt arrived s/p IVC filter placement + CT for bilat PE and liver hematoma. Pt alert and oriented. Currently on 6L NC with adequate sat's. Hypotensive on arrival bolused with 1.5l of NS and aline placed. BP now stable 100-110's. HR NSr-ST no noted ectopy. Lungs clear to diminished at the bases. Pt is very pleasant and follows commands appropriately.\nPlan: Cont to monitor HCT's. Cont to monitor for increased s/s of resp distress. Cont with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2165-10-14 00:00:00.000", "description": "Report", "row_id": 1575278, "text": "NURSING UPDATE\nCV: VSS. MAG REPLETED. ALINE IN RT RADIAL PRESENTING DAMPENED WAVE AND UNABLE TO WITHDRAW BLOOD. NEW ALINE PLACE IN LT RADIAL.\n\nRESP: PA02 71 @ , INTUBATION CONSIDERED BY TEAM, BUT PT RECEIVING O2 6L N/PRONGS AT THIS TIME. 02 DELIVERY CHANGED TO 100% NRB AND ABGS IMPROVED - 7.44/38/98/27/1 @ 0300. LUNG SOUNDS DIMINSHED @ BASES BUT OTHERWISE CLEAR. SATS 94-97%.\n\nENDO: GLUCOSE ELEVATED, TREATED PER SLIDING SCALE, NOT EFFECTIVE, WILL NEED REVISION.\n\nRENAL: HUO 10-25CC CONC AMBER. CATH PATENCY VERIFIED. FLUID BOLUS 500X2 AND 1L X1 INFUSED, INEFFECTIVE TO THIS TIME. BUN AND CREAT WNL.\n\nPLAN: RESPIRATORY AND RENAL STATUS BEARS CLOSE MONITORING. SLIDING SCALE REQUIRES REVISION.\n\nPT MONITORED CONTINUOUSLY.\nSEE CARVUE FOR DETAILED DATA.\n\n\n" }, { "category": "ECG", "chartdate": "2165-10-22 00:00:00.000", "description": "Report", "row_id": 206248, "text": "Sinus rhythm. Left axis deviation. Low voltage. Late transition. No previous\ntracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2165-10-17 00:00:00.000", "description": "MRI ABDOMEN W/O & W/CONTRAST", "row_id": 936187, "text": " 1:30 PM\n MRI ABDOMEN W/O & W/CONTRAST Clip # \n Reason: please perform MRV of HEPATIC VEINS to evaulate for clot/sou\n Admitting Diagnosis: PULMONARY EMBOLUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman 4 weeks s/p lap Chole with known PE & subcapsular hematoma.\n upper and lower US neg for clot\n REASON FOR THIS EXAMINATION:\n please perform MRV of HEPATIC VEINS to evaulate for clot/source of PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Four weeks status post laparoscopic cholecystectomy with known\n pulmonary embolism, subcapsular hematoma. Perform MRV of hepatic veins to\n evaluate for clot or source of pulmonary embolism.\n\n TECHNIQUE: Multiplanar MR imaging of the abdomen was performed, including 2D\n time-of-flight images through the hepatic veins.\n\n FINDINGS: There is an large subcapsular hematoma along the lateral aspect of\n the liver, measuring approximately 17.3 cm AP x 10 cm TV x 23.4 cm SI,\n resulting in significant leftward shift of the hepatic parenchyma and\n compression upon the IVC. There is patency and appropriate directional flow\n of the hepatic veins.\n\n There is no evidence of intra- or extra-hepatic biliary ductal dilatation.\n There appears to be a small right-sided pleural effusion. Visualization of\n the left adrenal gland and pancreas appears unremarkable.\n\n Low signal within the inferior vena cava after administration of gadolinium at\n the infrarenal level likely represents an IVC filter.\n\n Evaluation of 3D acquired volumetric images of the abdomen is degraded by\n motion.\n\n IMPRESSION:\n 1. Large lateral subcapsular hematoma along the lateral aspect of the liver.\n 2. No evidence of thrombus within the hepatic veins, which show appropriate\n directional flow.\n\n" }, { "category": "Radiology", "chartdate": "2165-10-13 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 935498, "text": " 4:12 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: please evaluate liver with non-contrast scan\n Field of view: 45\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with B PE, ? liver hematoma\n REASON FOR THIS EXAMINATION:\n please evaluate liver with non-contrast scan\n CONTRAINDICATIONS for IV CONTRAST:\n recent IV study\n ______________________________________________________________________________\n WET READ: JJMl SUN 4:50 AM\n large subcapsular collection producing mass effect upon the right lobe of the\n liver. density values range from 15-22. considerations include a chronic\n subcapsular hematoma or a biloma.\n\n spiculated soft tissue density in left breast, near an apparent surgical\n defect.\n\n exophytic cystic lesion at upper pole of left kidney with suggestion of a\n hyperdense rim.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of bilateral pulmonary embolism with ? liver hematoma.\n\n ABDOMINAL ULTRASOUND WITHOUT CONTRAST: There is right lower lobe atelectasis\n versus consolidation. There is a large low density collection adjacent to the\n right lobe of the liver that appears to conform to the liver capsule and\n produces mass effect upon the right lobe. Hounsfield unit attenuation values\n range from 15 to 22. The patient is status post cholecystectomy. Pneumobilia\n is noted. There is stranding adjacent to this large collection extending\n along the right paracolic gutter.\n\n The spleen and pancreas are unremarkable. The adrenal glands are normal.\n There is a 10.6 cm exophytic cystic lesion at the upper pole of the left\n kidney that appears to have a high density rim and possible septation.\n Contrast material was present within the kidneys from the patient's recent\n contrast-enhanced CT scan. There is no intra-abdominal free air. Visualized\n loops of bowel are grossly unremarkable.\n\n Note is made of a spiculated area of soft tissue attenuation in the left\n breast that appears to correspond to an area of a surgical defect anteriorly.\n\n Bone windows reveal no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n\n 1. Large subcapsular collection producing mass effect upon the right lobe of\n the liver with Hounsfield unit attenuation values ranging from 15 to 22.\n Considerations include a chronic subcapsular hematoma, or a subcapsular biloma\n in this patient that is status post cholecystectomy.\n (Over)\n\n 4:12 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: please evaluate liver with non-contrast scan\n Field of view: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Spiculated soft tissue density in the left breast that appears to be near\n surgical defect. Correlation with the patient's history and mammogram is\n recommended.\n\n 3. 11 mm exophytic lesion at the upper pole of the left kidney with the\n suggestion of a high density rim and a possible septation. Correlation with\n the patient's other outside imaging is recommended. Further evaluation with\n an ultrasound or MRI could also be performed to further characterize this\n lesion.\n\n" }, { "category": "Radiology", "chartdate": "2165-10-13 00:00:00.000", "description": "INTERUP IVC", "row_id": 935503, "text": " 5:59 AM\n IVC GRAM/FILTER Clip # \n Reason: place IVC filter\n Admitting Diagnosis: PULMONARY EMBOLUS\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * INTERUP IVC 2ND ORDER OR> VENOUS SYSTEM *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * C1769 GUID WIRES INCL INF C1880 VENA CAVA FILTER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with B PEs\n REASON FOR THIS EXAMINATION:\n place IVC filter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old woman with bilateral pulmonary emboli. Question of a\n subcapsular hepatic hematoma. Asked to place an IVC filter.\n\n RADIOLOGISTS: (radiology resident) and \n (attending radiologist). Dr , the attending radiologist was present\n and supervising throughout the procedure.\n\n TECHNIQUE/FINDINGS: A written informed consent was obtained prior to the\n procedure. The patient was brought into the radiology suite and placed supine\n on the angiographic table. A preprocedure timeout was performed. The right\n groin was prepped and draped in standard sterile fashion. Under\n ultrasonographic guidance, a suitable puncture site was determined. Uneventful\n single wall venipuncture of the right common femoral vein was performed. A\n 0.035 inch Bentson guidewire was advanced through the needle into the inferior\n vena cava. The needle was removed off the wire and a 5 French Omniflush\n catheter was steered into the left external iliac vein. Hand injection\n demonstrated appropriate positioning. Subsequently, a power injection\n inferior vena cavogram was performed. Review of the images demonstrated no\n caval anatomic variations, a single inferior vena cava, without intraluminal\n filling defects. The level of the renal veins was determined.\n\n Based on the diagnostic findings, it was determined that an IVC filter\n placement was indicated. The in situ catheter and sheath were removed over\n the wire, and the IVC filter sheath was advanced over the wire. A Gunther\n Tulip filter was then delivered uneventfully to the lower margin of the L2\n vertebral body, inferior to the renal veins. It was successfully deployed and\n the sheath was removed. Final abdominal radiograph demonstrated good\n positioning and deployment of the IVC filter. Hemostasis was achieved using\n digital compression for a total of 5 minutes. There was no residual bleeding\n or hematoma in the right groin. The patient tolerated the procedure well and\n there were no immediate postprocedure complications.\n\n IMPRESSION: Successful placement of a Gunther Tulip IVC filter. This filter\n can be removed within 14 days of placement if medically indicated.\n\n (Over)\n\n 5:59 AM\n IVC GRAM/FILTER Clip # \n Reason: place IVC filter\n Admitting Diagnosis: PULMONARY EMBOLUS\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2165-10-19 00:00:00.000", "description": "US HEPATOTOMY DRAIN ABSCESS/CYST", "row_id": 936451, "text": " 10:03 AM\n US HEPATOTOMY DRAIN ABSCESS/CYST; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n GUIDANCE FOR ABSCESS ()\n Reason: Evaluate for drainage, and if possible, drain percutaneously\n Admitting Diagnosis: PULMONARY EMBOLUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with subcapsular liver hematoma s/p lap chole.\n REASON FOR THIS EXAMINATION:\n Evaluate for drainage, and if possible, drain percutaneously.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL: Hepatic subcapsular fluid collection in a patient four weeks out\n from laproscopic cholecystectomy. Pulmonary embolism.\n\n LIMITED HEPATIC ULTRASOUND: A large subcapsular fluid collection is\n identified with low-level internal echoes, measuring approximately 19 by 14\n cm in the transverse plane.\n\n ULTRASOUND-GUIDED DRAINAGE: The risks, benefits, and alternatives of the\n procedure were explained to the patient. All patient questions were answered\n to her satisfaction, and written informed consent was obtained.\n\n A preprocedure timeout was performed. Following localization under ultrasound,\n the area was prepped and draped in a sterile fashion. Local anesthesia was\n performed with approximately 12 mL of 1% lidocain. The fluid collection was\n localized with ultrasound. Under son guidance, an 8 French Navare\n catheter was advanced through a tongue of liver into the fluid collection.\n Approximately 2100 mL of cloudy yellow fluid was aspirated. Samples were sent\n for cultures and laboratory testing. Repeat ultrasound showed the subcapsular\n fluid collection to be markedly decreased in size. The pigtail was formed, and\n the was fixed to the skin surface with an adhesive clip.\n\n The patient tolerated the procedure well, and there were no immediate post\n procedure complications. Moderate conscious sedation was provided by the\n nursing staff, which included divided doses fentanyl and Versed. The patient's\n hemodynamic parameters were continously monitored.\n\n Dr. was present throughout the entire procedure.\n\n IMPRESSION: Successful ultrasound-guided drainage of a subhepatic abscess.\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 10:03 AM\n US HEPATOTOMY DRAIN ABSCESS/CYST; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n GUIDANCE FOR ABSCESS ()\n Reason: Evaluate for drainage, and if possible, drain percutaneously\n Admitting Diagnosis: PULMONARY EMBOLUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2165-10-14 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 935677, "text": " 2:08 PM\n BILAT LOWER EXT VEINS; BILAT UP EXT VEINS US Clip # \n -59 DISTINCT PROCEDURAL SERVICE; -76 BY SAME PHYSICIAN\n : H/O SADDLE PE PLEASE PERFORM 4 EXT ULTRASOUND TO R?O DVT\n Admitting Diagnosis: PULMONARY EMBOLUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with recent saddle pulmonary embolus\n REASON FOR THIS EXAMINATION:\n please perform 4 extremity ultrasound to rule out DVT\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bilateral upper and lower extremity venous Doppler ultrasound.\n\n CLINICAL HISTORY: 65-year-old woman with recent saddle pulmonary embolus.\n Post-placement of IVC filter. Rule out DVT.\n\n No prior studies available for comparison.\n\n FINDINGS: Grayscale and color Doppler ultrasound was performed of the\n bilateral upper and lower extremities.\n\n The bilateral common femoral, superficial femoral, and popliteal veins are\n widely patent and demonstrate normal compressibility, augmentation and phasic\n flow. No evidence of intraluminal thrombus.\n\n The bilateral internal jugular, subclavian vein, axillary, brachial, basilic\n and cephalic veins are widely patent and demonstrate normal compressibility,\n augmentation and phasic flow. No evidence of intraluminal thrombus.\n\n IMPRESSION: No evidence of deep venous thrombosis of bilateral upper and\n lower extremity venous system.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2166-10-22 00:00:00.000", "description": "Report", "row_id": 1325787, "text": "CSRU Admission Note\n\nMrs. is a 64 year old woman s/p left pneumonectomy and aortic arch repair who was readmitted to yesterday w/ c/o sob and pain. This evening with significant SOB, tachycardia, and rigors. Dropping O2 sats. Transferred to CSRU for further management.\n\nNKDA\n\nNeuro: Anxious on arrival d/t feelings of SOB. After resp status improved, pt still requesting something to make her \"relax\". H/O anxiety noted. ativan to cont. Oriented x 3. MAE equally.\n\nCV: HR up to 150's NST on arrival with stable BP. HR down to 120's with improved resp status. SBP dropping to high 60's. Md aware. A line placed. Neo gtt started to maintain MAP > 60 after placement of left sublavian catheter confirmed by CXR. Cardiac echo neg for tamponade. Receiving 1u PRBC's slowly MD request.\n\nResp: BS with faint wheezes throughout on arrival. Currently clear. Left pleural tube placed with return of 2l bloody dng. CT to dry suction. No airleak/crepitus noted. Sporadic dng throughout night. RR initially in 40's with pt appearing anxious and air hungry. RR down to 20's within approx 10 mins of pleural tube placement. ABG with resp alkalosis-MD aware. Weaned to 4l np.\n\nGI: Abd soft, hypoactive BS. No nausea.\n\nGU: Foley placed per orders. Clear yellow urine.\n\nID: Afebrile since arrival to floor. No rigors noted. Pleural fluid sent for cx. Repeat urine sent after foley in. Vanco and zosyn cont.\n\nSkin: Sternal incision OTA, no dng. Bruising noted at coccyx which patient states is d/t previous lumbar puncture. Skin intact.\n\nComfort: Ativan for anxiety. c/o at CT insert site. MSO4 given in small doses d/t low BP. Slept during night.\n\nA: Resp distress relieved with placement of left pleural tube and dng of bloody fluid. Low BP.\n\nP: Ativan for anxiety. Reassurance. Neo as per orders. Dry suction to pleural tube. Monitor CT o/p. Mso4 prn. Check cultures. IV ABX.\n" }, { "category": "Nursing/other", "chartdate": "2166-10-22 00:00:00.000", "description": "Report", "row_id": 1325788, "text": "CSRU 0700 - 1300\n\nNEURO: A/O X 3, MAE, anxious at times, needs reassurance.\n\nCV: NSR with no ectopy, on neo. gtt. to maintain MAP >60, BP in the 80's/50's, asymptomatic, afebrile, PP+.\n\nRESP: RUL,RLL clear to auscultation, LUL,LLL absent BS, left pleural CT was to balanced drainage, dc'd after CT of the chest, + cough and expectorated thick sputum, no SOB, 02 @ 3L via NC, sats 100%.\n\nGI: Abd. soft, BS +, NPO except for meds.\n\nGU: Foley patent, draining clear yellow urine.\n\nPAIN: Receiving motrin ATC and PRN X 1 for pain with good relief.\n\nPLAN: Monitor respiratory status, encourage pulmonary toilet, pain management, maintain MAP > 60, wean neo. as tolerated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-10-22 00:00:00.000", "description": "Report", "row_id": 1325789, "text": "cardiology consulted,see progress notes. tte->global hypokinesis w ef 25-30%,? etiology. attempted dopa @ 2 in order to wean neo but w tachycardia > 120. milrinone started low dose & neo increased to maintain map > 90.digoxin begun.tremendous diuresis w lasix 10 mg.plan to hold next dose m.d.K+ repleted as needed.bs clear on rt.c & r thick tan after getting oob. antibiotics continue.cultures from pending voice slighty hoarse but improving per pt. felt to be related to prior intubation.sternal incision ota,thoracotomy dsg intact. ct site dsg d & i.continues to c/o pain & anxiety despite recieving atc ibuprofen & ativan.mso4 given x 1 prior to getting oob w relief of pain @ ct site.\n" }, { "category": "Radiology", "chartdate": "2166-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 803310, "text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check for mediastinal position\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with l pneumonectomy\n\n REASON FOR THIS EXAMINATION:\n check for mediastinal position\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: S/P Left pneumonectomy. ck for mediastinal position.\n\n CHEST, AP PORTABLE. Comparison is made to prior film of one day prior.\n\n There has been no significant change since prior film. The heart is shifted\n somewhat to the left, consistent with left pneumonectomy. The right lung\n remains clear. Subcutaneous emphysema is still present on the left side.\n\n IMPRESSION; No significant change.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2166-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 802946, "text": " 8:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt in RR distress\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with l pneumonectomy\n\n REASON FOR THIS EXAMINATION:\n pt in RR distress\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n Comparison to prior exam of .\n\n FINDINGS: The patient is post-left pneumonectomy. The left hemithorax has\n filled with fluid and there is appropriate shift of the mediastinum to the\n right. There is a small right pleural effusion. The right lung is otherwise\n clear. There is no pneumothorax. The right sided vasculature is less\n distinct than on the prior exam.\n\n IMPRESSION: 1) Post-left pneumonectomy. Clear right lung. Possible early\n edema. Recommend followup films.\n\n" }, { "category": "Radiology", "chartdate": "2166-10-22 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 803002, "text": " 10:39 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o aortic pseudoaneurysm s/p intrapericardial pneumonectomy\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with lung cancer s/p chemo and xrt now s/p pneumonectomy\n with fevers\n REASON FOR THIS EXAMINATION:\n r/o aortic pseudoaneurysm s/p intrapericardial pneumonectomy with soft tissue\n mass on cxr\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left pneumonectomy and tumor resection. Now with left\n pleural effusion and fevers.\n\n FINDINGS:\n\n There is slight thickening of the pulmonary interstitium on the right and a\n small right pleural effusion. Clinical correlation for findings of congestive\n heart failure is recommended. There is a bleb located anteriorly in the right\n middle lobe.\n\n There is a left hydropneumothorax and a left-sided chest tube in place. There\n has been a left pneumonectomy. It should be noted that there is some high\n density within the pleural fluid consistent with blood.\n\n After the injection of contrast, there is no evidence of an aortic dissection\n or pseudoaneurysm.\n\n There is pneumomediastinum and probably pneumopericardium. However, this is\n not unexpected, given the patient's surgical history. There has been ligation\n of the left pulmonary artery, and there is extensive mediastinal infiltration,\n which is also probably on a postoperative basis.\n\n Post-contrast CT abdomen:\n\n On the arterially enhanced images there is no gross abnormality of the liver,\n spleen, pancreas, adrenals, or kidneys. The gallbladder is present.\n\n No lytic or blastic destructive osseous lesions.\n\n IMPRESSION:\n\n 1. No evidence of aortic pseudoaneurysm, as clinically questioned.\n 2. Clinical correlation recommended for findings in the right lung suggestive\n of pulmonary edema.\n\n (Over)\n\n 10:39 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o aortic pseudoaneurysm s/p intrapericardial pneumonectomy\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2166-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 802955, "text": " 10:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CXR check placement\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with l pneumonectomy\n\n REASON FOR THIS EXAMINATION:\n s/p CXR check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left pneumonectomy. Check current status.\n\n FINDINGS: A single AP supine view. Comparison study dated .\n A left chest tube is mildly inserted in the mid zone, its tip overlying the\n left hilar region. There appears to be a significant reduction in size of the\n previous large left-sided pleural effusion, but there is now a fairly large\n collection of gas in the pleural cavity overlying the left upper zone and mid\n zone. A band like opacity extends upward from the left hilar region towards\n the thoracic apex. This could be an extension of the effusion in the\n posterior cul- de- sac. The heart and mediastinum have returned to a more\n midline position than before.\n\n IMPRESSION: The left hemithorax now contains a moderate-sized collection of\n air and liquid following insertion of the chest tube. Follow up images will\n clarify any further changes.\n\n" }, { "category": "Radiology", "chartdate": "2166-10-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 802813, "text": " 11:23 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o fistula\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with lung cancer and increased SOB, s/p pneumonectomy \n\n REASON FOR THIS EXAMINATION:\n r/o fistula\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Lung cancer with shortness of breath. S/P pneumonectomy. Rule\n out fistula.\n\n FINDINGS: Following the left pneumonectomy there is a large fluid collection\n in the left hemithorax, increased since the prior study with some displacement\n of the heart and mediastinum to the right. A fluid level is noted at the\n extreme apex. The right lung appears well inflated and structurally\n unremarkable. Minimal blunting of the right costophrenic angle is noted.\n\n IMPRESSION: Increasing volume of left effusion following the pneumonectomy.\n Very small residual apical pneumothorax on this side.\n\n" }, { "category": "Radiology", "chartdate": "2166-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 803096, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS MEDIASTINAL BALANCE\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with l pneumonectomy\n\n REASON FOR THIS EXAMINATION:\n ASSESS MEDIASTINAL BALANCE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P left pneumonectomy.\n\n FINDINGS: Study is compared to previous examination of and again\n shows postoperative changes from left pneumonectomy and some pneumothorax in\n the left pleural cavity. There is shift of the heart and mediastinal\n structures to the left due to volume loss. The right lung is clear. Since the\n previous study, there has been removal of the left chest tube.\n\n IMPRESSION: Interval removal of the left chest tube.THE LEFT pneumothorax may\n be slightly smaller\n S/P left pneumonectomy. The right lung is clear.\n\n" }, { "category": "Nursing/other", "chartdate": "2166-10-25 00:00:00.000", "description": "Report", "row_id": 1325796, "text": "NPN:\n\nNeuro: Alert and oriented X3, MAE. Steady on feet. OOB to commode q2-3hrs.\nCV: 80's SR with no VEA. Started on captopril-lopressor cont -BP stable. K,Mg and Ca repleted. Palp pedal pulse.\nResp: R ess CTA. O2 sats>94% on roomair. Cough prod sm amts clear secretions. RR-16-22.\nGU: Voiding lg amts. Cr .7\nGI: Tol reg diet. Abd softly distended with +BS. Small amts of loose stool with each void. Still need cdiff to be sent.\nID: Cont on Vanco and Piperacillin.\nEndo: Glucoses WNL.\nActivity: OOB to commode q 2-3 hrs. MOves well-steady on feet-just needs assist with wires.\nComfort: Medicated X1 with motrin for L inc tightness with effect.\nA: Stable.\nP: Transfer to 2 to cont further rehab.\n\n" }, { "category": "Nursing/other", "chartdate": "2166-10-22 00:00:00.000", "description": "Report", "row_id": 1325790, "text": "increasing disparity btwn a line & cuff bp. titrating neo to cuff pressure. ambulated around bed w/o difficulty or sob.spo2 > 95% on room air.continues w low cvp,poor skin turgor,lg. huo.\n" }, { "category": "Nursing/other", "chartdate": "2166-10-23 00:00:00.000", "description": "Report", "row_id": 1325791, "text": "NPN:\n\nNeuro: Alert and oriented x3, MAE. Conversing appropriately...slept 1-2 hr naps. Requesting ativan in am..given at 530am MD.\nCV: 90's SR with rare PVC. K repleted. BP maintained > 90-cont on milrinone and neo. Cuff and a line correlating more closely overnight.\nPalp pedal pulse.\nResp: Lungs CTA on R, L absent, On RA most of night but sats dipped to 90-91 so 2l nc placed with sats> 95%.\nGU: Foley to gd with cont vigorous diuresis which has slowed this am . Cr stable .7. AM Lasix held r/t prev response per Dr .\nGI: Abd soft, NT, ND..no N/V. Tol liquids overnight.\nID: WBC 2.7, Remains on Piperacillin & Vanco. Peak vanco level >46-Tm aware. Afebrile.\nComfort: Medicated with motrin as ordered with some effect-required MS 2 IV for comfort.\nIncisions: Per carevue.\nA: BP maintained > 90 on Neo and milrinone.\nP: Cont per present plan-wean neo as tolerated. Cont IV antibx as ordered\n\n" }, { "category": "Nursing/other", "chartdate": "2166-10-23 00:00:00.000", "description": "Report", "row_id": 1325792, "text": "NEURO ALERT ORIENTED FOLLOWS ALL COMMANDS NO DEFECITS NOTED\n\nC/V NSR ST NEO WEANING TOL WELL ALINE OUT CUFF PRESSURE SAME MILRINONE CONTINUED\n\nRESP NC 2L SATS 98% RA SATS 94% BS CLEAR ON R NOT HEARD ON L SIDE NO SOB NOTED\n\nGU/GI FOLEY OUT 8AM VOIDED COMMODE WITHOUT DIFFICUTLY BM X2 LIQUID STOOL TAKING SMALL AMTS PO MEALS WITH ENCOURAGMENT TAKING LIQUIDS WELL\n\nACTIVITY OOB TO CHAIR AND COMMODE WITH ONE ASSIST TOL WELL AMBULATED X1 WITHOUT DIFFICUTLY TOL WELL\n\nPLAN CONTINUE TO WEAN NEO AS TOL MAINTAIN MILRINONE CONTINUE TO MONITOR RESP STATUS\n" }, { "category": "Nursing/other", "chartdate": "2166-10-23 00:00:00.000", "description": "Report", "row_id": 1325793, "text": "NEURO: ALERT, INTACT\nCARDAIC: MP SR TO ST, SB/P ^ 100, WEANING IV NEO TO KEEP SB/P ^ 80. MILRANONE AT .20.\nRESP: CS DIMINISHED IN RT BASE.\nGI/GU: TOLERATING LIQUIDS, HAS NOT VOIDED SINCE 1900.\nID: NO ISSUES.\nPAIN: DENIES.\n" }, { "category": "Nursing/other", "chartdate": "2166-10-24 00:00:00.000", "description": "Report", "row_id": 1325794, "text": "I JUST CANNOT GET COMFORTABLE\nO. NEURO PT ALERT ORIENTED X3 MAE FC OOB TO COMMODE WITH MIN. ASSIST\nGIVEN MSO4 2MG IV X1 FOR INCISIONAL PAIN\nRESP RM AIR O2 SATS > 95% RUL RLL CLEAR LUL LLL ABSENT COUGHING PRODUCTIVE\nCARDIAC HR 93-103 NSR WITHOUT ECTOPY BP 90/28- 116/53 MILRINONE .2MCG/KG/MIN AND NEO .05 MCG/KG/MIN SKIN W+D PP+2 HCT\nGI TAKING FLUIDS DARK BROWN STOOL MEDIUM X1 ABD SNT BS+\nGU U/O VOIDING WELL BUN 9 CR .7\nID AFEBRILE WBC 2.7\nA. LUNG CA\nHYPOTENSION DECREASE EF\nP. CONT TO WEAN NEO CONT MILIRONE\n" }, { "category": "Nursing/other", "chartdate": "2166-10-24 00:00:00.000", "description": "Report", "row_id": 1325795, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE\n\nCV: NSR with no ectopy, weaned off milranone and neo. gtts. BP has been stable, started on PO lopressor, afebrile, PP+.\n\nRESP: RUL,RLL lungs clear, on room air with sats. 98%, coughing up small amounts thick white sputum.\n\nGI: Abd. soft, BS+, loose stool X 2\n\nGU: OOB to commode, voiding clear yellow urine.\n\nACT: Ambulated in hallway X 2, tolerated well.\n\nPLAN: Continue to monitor CV and respiratory status, keep SBP>80, pain management, encourage pulmonary toilet.\n" }, { "category": "Radiology", "chartdate": "2166-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 802959, "text": " 11:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check central line placement (L subclavian)\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with l pneumonectomy\n\n REASON FOR THIS EXAMINATION:\n check central line placement (L subclavian)\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P left pneumonectomy. Ck central line.\n\n AP PORTABLE CHEST: A new left subclavian central line has been inserted and\n its tip is well positioned in the mid-SVC. The left chest tube remains in\n good position in the mid-zone. The residual left-sided pleural effusion and\n air collection is again noted not significantly changed. The unfolded aortic\n profile is noted overlying the left upper zone. Sternal sutures are again\n noted.\n\n IMPRESSION: Satisfactory placement of new left subclavian line. Appearances\n are otherwise, essentially unchanged.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2166-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 803202, "text": " 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with l pneumonectomy\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy.\n\n VIEWS: AP portable chest radiograph. Comparison with .\n\n FINDINGS: There is evidence of surgical emphysema within the left axilla not\n seen on prior exam due to technique. The left central line is unchanged in\n position. The right lung remains clear. There is persistent shift of the\n heart and mediastinal structures to the left due to volume loss. This study\n is otherwise unchanged.\n\n IMPRESSION: Left pneumonectomy. Postsurgical changes. No significant change\n from prior study.\n\n" }, { "category": "Echo", "chartdate": "2166-10-21 00:00:00.000", "description": "Report", "row_id": 60891, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Right ventricular function. Tamponade.\nHeight: (in) 64\nWeight (lb): 120\nBSA (m2): 1.58 m2\nBP (mm Hg): 89/46\nHR (bpm): 142\nStatus: Inpatient\nDate/Time: at 21:57\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: The left ventricular cavity size is top normal/borderline\ndilated. There is severe regional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - hypokinetic; mid anterior - akinetic;\nbasal anteroseptal - hypokinetic; mid anteroseptal - akinetic; mid inferior -\nhypokinetic; mid inferolateral - hypokinetic; basal anterolateral -\nhypokinetic; mid anterolateral - hypokinetic; anterior apex - akinetic; septal\napex- akinetic; inferior apex - akinetic; lateral apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mitral\nregurgitation is present but cannot be quantified.\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. The patient is\ntachycardic (HR>100bpm).\n\nConclusions:\nThe left ventricular cavity size is top normal/borderline dilated. There is\nsevere regional left ventricular systolic dysfunction. Resting regional wall\nmotion abnormalities include anterior, anteroseptal and apical\nakinesis/hypokinesis. Right ventricular chamber size is normal. Right\nventricular systolic function appears depressed. The aortic valve leaflets are\nmildly thickened. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Mitral regurgitation is present but cannot be fully\nquantified (may be mild but views suboptimal). There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (tape reviewed) of , left\nventricular function is now severely impaired.\n\n\n" }, { "category": "ECG", "chartdate": "2166-10-22 00:00:00.000", "description": "Report", "row_id": 116475, "text": "Sinus rhythm\nNonspecific ST-T wave changes\nLateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of , there is new lateral T wave inversion.\nConsider ischemia/infarction.\nClinical correlation required\n\n" }, { "category": "ECG", "chartdate": "2166-10-20 00:00:00.000", "description": "Report", "row_id": 116476, "text": "Sinus tachycardia\nShort PR interval\nNonspecific ST-T wave changes\nSince last ECG, no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2176-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976538, "text": " 2:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia, r/o free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with 2 days of abd pain, distention.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia, r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Two days of abdominal pain and distention.\n\n COMPARISON: None.\n\n PORTABLE CHEST: Cardiomediastinal silhouette is unremarkable. Lungs are\n clear and there is no consolidation, pleural effusion or pneumothorax.\n Hyperlucency of the lungs may represent underlying emphysema though\n evaluation is limited on this single view. Degenerative changes of the\n thoracic spine are noted.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2176-09-21 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 976562, "text": " 7:37 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o obstruction, other acute pathology\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with 2 days of abdominal pain, distention, vomiting.\n REASON FOR THIS EXAMINATION:\n r/o obstruction, other acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SAT 9:59 PM\n Limited study to to lack of IV contrast and low energy technique. Moderate\n ascites with multiple peritoneal and mesenteric masses likely representing\n peritoneal carcinomatosis from an unkown primary. Bilateral hydronephrosis,\n left greater than right, likely obstructed by pelvic masses which are\n incompletely characterized. Right liver mass lesion incompletely\n characterized. Gastric mucosa near fundus thickened but incompletely\n characterized.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, distension, and vomiting.\n\n COMPARISON: Renal ultrasound .\n\n TECHNIQUE: Non-contrast axial images of the abdomen and pelvis were obtained\n with oral contrast only. Low dose technique limits evaluation. Multiplanar\n reformatted images were also submitted for review.\n\n CT ABDOMEN WITHOUT CONTRAST: The lung bases demonstrate bibasilar atelectasis\n with small bilateral effusions. Scattered atherosclerotic coronary\n calcifications are observed.\n\n Overall evaluation is limited without contrast, however, a moderate-to-large\n amount of intra-abdominal ascites tracks superiorly along the distal esophagus\n and into the paracolic gutters bilaterally. Additionally, there are\n multiple poorly characterized mesenteric and omental masses, many of which\n approach 5 cm in size.\n\n Non- contrast evaluation of the liver demonstrates at least one large\n hypodense focus within segment VI (2:26) measuring approximately 29 x 29 mm.\n No definite other hepatic lesions are seen, though evaluation is limited.\n There is suggestion of periportal edema. The gallbladder is surrounded by\n fluid and appears partially collapsed. The spleen, pancreas. and adrenal\n glands are unremarkable. There are post- surgical changes of the stomach\n consistent with patient's history of partial gastrectomy. Within the fundus,\n the mucosa appears irregular and thickened, though evaluation is limited.\n Non-contrast evaluation of the kidneys demonstrates bilateral, left greater\n than right, moderate-to-severe hydronephrosis and hydroureter. There is no\n evidence of free air. The abdominal aorta demonstrates atherosclerotic mural\n calcification but is of normal caliber. Intra-abdominal loops of small bowel\n are distended but nondilated.\n\n (Over)\n\n 7:37 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o obstruction, other acute pathology\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITHOUT CONTRAST: Left greater than right hydroureter quickly\n tapers though point of obstruction is not visualized. There is no definite\n urinary tract calcuilus. The distal large bowel does not contain contrast\n which limits evaluation. There is at least one large calcified uterine\n fibroid and additional fibroids are suspected given the lobulated appearabce\n of the uterus. Air within the bladder likely representing recent Foley\n manipulation.\n\n Bone windows reveal no worrisome lytic or sclerotic lesions. There is diffuse\n osteopenia with evidence of healed rib fractures of the right 11th and 12th\n ribs posteriorly. There is thoracolumbar spondylosis with a compression\n deformity of the L1 vertebral body with greater than 50% loss of height of\n unknown chronicity.\n\n IMPRESSION:\n 1. Multiple abdominal omental and mesenteric masses with a large volume of\n ascites, likely peritoneal carcinomatosis. Primary malignancy is not\n identified. Omental masses would be amenable to percutaneous biopsy.\n 2. Bilateral left greater than right hydronephrosis and hydroureter tracking\n down into pelvis without clear visualization of the point of obstruction.\n 3. Hypodense hepatic segment 6 mass, may represent metastasis.\n 4. Suggestion of mucosal thickening and irregularity of the gastric fundus,\n though evaluation extremely limited. Correlate with endoscopy.\n 5. L1 compression deformity of unknown chronicity.\n 6. Leiomyomatous uterus.\n\n" }, { "category": "Radiology", "chartdate": "2176-09-21 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 976539, "text": " 2:56 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with 2 days of abd pain, distention.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL SERIES, .\n\n COMPARISON: Comparison with prior abdominal ultrasound dated .\n\n CLINICAL HISTORY: An 87-year-old woman with abdominal pain for two days,\n distention, rule out obstruction.\n\n FINDINGS: Single AP view of the abdomen is obtained. Bowel gas pattern is\n nonspecific, revealing no evidence of dilated small or large bowel. There is\n no definite evidence of free air. An area of amorphous calcification is seen\n overlying the pelvis, which may be related to degenerating fibroid.\n Degenerative changes are noted in the spine, with possible compression at L1\n though this is poorly assessed on AP view. There is sclerosis and irregularity\n involving the SI joints, which may be related to sacroiliitis. The hip joints\n appear unremarkable.\n\n IMPRESSION:\n 1. No evidence of bowel obstruction.\n 2. Degenerative changes in the spine and SI joints, with possible compression\n at L1. Correlation with lateral view is advised.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2176-09-21 00:00:00.000", "description": "RENAL U.S.", "row_id": 976564, "text": " 7:41 PM\n RENAL U.S. Clip # \n Reason: ? hydronephrosis, ? stone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with acute renal failure, Cr 7, no urine on FOley insertion,\n p/w diffuse pain\n REASON FOR THIS EXAMINATION:\n ? hydronephrosis, ? stone\n ______________________________________________________________________________\n WET READ: ARHb SAT 8:10 PM\n Bilateral moderate to severe hydronephrosis. Moderate free fluid. Hepatic\n lesion incompletely characterized. Recommend CT to exclude pelvic mass as\n cause for hydro.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure.\n\n COMPARISON: Abdominal ultrasound .\n\n FINDINGS: The right kidney measures 11.3 cm. The left kidney measures 9.5\n cm. There is new moderate-to-severe hydronephrosis bilaterally, left greater\n than right, however, no definite obstructing lesion is identified. No stone\n or renal mass is seen. There is a moderate amount of perihepatic and\n perisplenic free fluid as well as fluid within the lower quadrants\n bilaterally.\n\n An approximately 2.9 x 3.6 x 2.9 cm predominantly hypoechoic lesion within\n segment VI of the liver posteriorly is noted. The bladder is not well seen and\n is likely empty.\n\n IMPRESSION:\n 1. In the setting of moderate-to-severe bilateral hydronephrosis,\n retroperitoneal or pelvic mass is a concern and CT of the abdomen and pelvis\n is recommended.\n 2. Moderate ascites.\n 3. Incompletely characterized right hepatic lesion could also be further\n evaluated with CT.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-09-23 00:00:00.000", "description": "Report", "row_id": 1666997, "text": "Nsg.notes 0700-1900hrs.\n\nPt continued with comfort meassures.having generalised pain,treated with morphine IV .IVF dc'd,KVO on.later PIV got infiltrated,KVO dc'd,tried for a new line,failed,called for iv nurse,she said she will be coming.started on s/L morphine for comfort.family stayed with pt throughout the shift.vital signs remained stable.talking and understands.continue comfort measures.call out when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 1666998, "text": "MICU NPN 7P-7A\nPT . FAMILY AT BEDSIDE, BUT LEFT FOR THE NIGHT. GRANDDAUGHTER CALLED FOR UPDATE. PATIENT APPEARS COMFORTABLE WITH EFFORTLESS RESPIRATORY STATUS. WILL OPEN EYES TO VOICE AND LOOK AT SPEAKER. GIVEN 0.5MG MORPHINE IV PRIOR TO AND AFTER TURNING THIS MORNING FOR INCONTINENT CARE. REMAINS A CALL OUT.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 1666999, "text": "PATIENT ON COMFORT MEASURES ONLY.\nOPENS EYES TO CALL, RESPONDS TO COMMANDS INCONSISTENTLY, VOICED COUPLE OF WORDS. STARTED ON MORPHINE DRIP AT 1MG/HR, RR 14 TO 16/MIN WITH AGONAL/ ACIDOTIC PATTERN OF BREATHING. Patient appears to be more comfortable. FAMILY AT BEDSIDE .UPDATED ON PATIENTS STATUS. SON WAS UPSET ON STARTING THE MORPHINE DRIP, EDUCATION PROVIDED WITH GOOD EFFECT. PCP AT BEDSIDE , DISCUSSED ALL CONCERNS INCLUDING THE MORPHINE DRIP WITH THE FAMILY.\nPLAN TO TANSFER OUT TO THE FLOOR WHEN BED IS AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-22 00:00:00.000", "description": "Report", "row_id": 1666994, "text": "Nursing Progress Note 1900-0700\n\nThis is an 87 year old female with end stage alzhemiers disease, spinal stenosis, chronic back pain, osteoporosis, gastric ulcers, compression FXs who presented to the EW today for diffuse body pain, her lab results showed ARF with hyperkalemia as well as a metabolic acidosis. She was RX with Dex/insulin/CA & Kayexelate. A renal US showed bilateral hydronephrosis. A subsequent CT of her abdomen showed mutiple lesions along with ascites that was concerning for a metistatic process. She was fluid challenged in the EW with 3 liters of NS, but remainned anuric. She was given a total of 2 mg of morphine for pain and 1 mg ativan for anxiety/aggitation. She was transferred to the MICU for ? emergent hemodialysis vs emergent nephrostomy tube placement in IR. Upon arrival to MICU family meeting held with Dr. , Dr. , Husband and children. In light of CT findings and advanced alzheimers DZ family declined aggressive RX of ARF, made the pt DNR/DNI and is moving towards palliative care.\n\nNeuro: Alert, oriented to self only. Following commands inconsistently. Calling out in pain with any stimulation saying \"leave me alone\". But appears comfortable and slept most of time since arrival. No need for PRN morphine this shift\n\nResp: Lungs clear, RR 16-22 respirations even and unlabored sats 98-100 on RA\n\nCardiac: Tele SR 80's without ectopy, hemodynamically stable. no edema + 2 pt/dp\n\nGI: Abdomen firm distended, tender to touch. + BS in 4 quadrents. Kept NPO\n\nRenal: Foley without output\n\nID: afebrile, no current issues\n\nFEN: started on NS @ 70 cc/hr for maintence fluid. No RX of lytes ordered\n\nSkin: Intact, toes blue and dusky\n\nAccess: Very difficult stick, has one # 22, Venous access team stuck pt mutiple times for current access.\n\nSocial: Husband in family spokesperson. Currently DNR/DNI moving towards CMO. Social Work consulted ordered Re: Family Support\n\nPlan:\n\n1. Morphine PRN for pt comfort\n2. Maintence fluids\n3. Social work consult emotional support to pt and family\n4. Routine ICU monitoring and care\n" }, { "category": "Nursing/other", "chartdate": "2176-09-22 00:00:00.000", "description": "Report", "row_id": 1666995, "text": "Neuro: Startles easily. At times seems anxious with care. Tearful at times. Alert, sleeping intermittently. Morphine 0.5mg IVPx1 when pt became restless, grimacing. Unable to reliably communicate discomfort or needs although she does verbalize clearly. Moves all extremities.\n\nCV: NSR rate 80's. BP was stable in 120-130's systolic. MD order to D/C tele, vital signs. Patient .\n\nResp: Lung sounds clear, no cough. Frequent oral care for mouth breathing. SAT 100% on room air.\n\nGI: Abdomen distended. +BS. No stool.\n\nGU: Has foley cath, essentially anuric.\n\nPatient has been bathed. Turning Q 3-4hrs for comfort. Becomes upset with turns, back care, because per family she hates to be cold. Heat turned up in room, socks and blankets placed on patient. Patient screams as though in pain when touched with cold hands or lotion. Lotion warmed in hot water. Family remained at bedside throughout shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-09-23 00:00:00.000", "description": "Report", "row_id": 1666996, "text": "Nursing Progress Note 1900-0700 hours:\n** Pt is . Family went home last evening after visit with family. Pt has appeared comfortable with care and intervention given as needed. Cont to assess on-going needs.\n" }, { "category": "ECG", "chartdate": "2176-09-21 00:00:00.000", "description": "Report", "row_id": 147470, "text": "Sinus rhythm\nAtrial premature complexes\nLow limb lead QRS voltages - are nonspecific and may be within normal limits\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2200-04-22 00:00:00.000", "description": "Report", "row_id": 1552296, "text": "TSICU NPN\nO: ROS\nNeuro: awake, easily arousable from sleep. pearl 3mm bilat. mae and consistently follows commands. No futher episodes of vomiting overnoc. Mso4 2mg x1 for worsening ha w/ gd effect. Started mannitol given x2.\n\ncv: stable.\n\nresp: 2lnc w/ stable 02sats. srr 10-20. ls clear.\n\nrenal: lytes wnl. foley catheter inserted d/t mannitol. adequate u/o.\n\ngi: abd soft. denies nausea. npo after mn for or today. cont ivf at 100cc/hr.\n\nheme: stable\n\nID: afebrile\n\nSkin: intact\n\nSH: Friend/ roomate in to visit. Pt did phone his mom in and tell her what was planned.\n\nA: stable neuro vital signs. ha persists.\n\nP: Cont mannitol. q1hr nvs. Pt will go to the or for burr holes and evacuation today.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-22 00:00:00.000", "description": "Report", "row_id": 1552297, "text": "7a-7p\nFULL ASSESSMENT AND VITAL SIGNS ON CAREVUE.\n\nNEURO: A&O X3. PERL 3MM. MAE. NO CHANGE THROUGHOUT THE DAY. MANNITOL AND PHENYTOIN GIVEN AS ORDERED. C/O HEADACHE. MORPHINE GIVEN PRN WITH ACCEPTABLE RESULTS.\n\nCV: VITAL SIGNS STABLE. HR 59 BP 130/63.\n\nRESP: NC 2L O2. SATS MAINTAINED >97%.\n\nGI/GU: NPO. IV HYDRATION 0.9% NaCl @ 100MLPH. URINE OUTPUT >60MLPH. BOWEL SOUNDS. NO BOWEL MOVEMENT. BLOOD SUGARS WITHIN LIMITS NOT REQUIRING INSULIN COVERAGE.\n\nSOCIAL: PT HAS HAD FRIENDS SUPPORTING HIM ALL DAY AS HE IS ANXIOUS ABOUT HIS PENDING SURGERY.\n\nPT HAS BEEN AWAITING OR ALL DAY AS AN ADD ON CASE FOR BURR HOLES AND EVACUATION OF SDH. CONSENTS SIGNED/ INTERPRETER USED FOR SURGICAL CONSENT DUE TO COMPLEX INFORMATION.\n\nPLAN: CT HEAD\n OR FOR BURR HOLES AND EVACUATION OF SDH.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-23 00:00:00.000", "description": "Report", "row_id": 1552298, "text": "Nursing Progress Note\n1900-0730\n\n24 year old male admitted on s/p snowboarding accident on . Pt was seen in ED on following initial injury, Returned on with headache and emesis subsequent Head CT revealed L SDH with mass effect and shift d/c'd to home with dilantin, Nimodipine, and tylenol returned to on /06 with c/o increasing headache repeat Head CT showed worsening of bleed and shift of L SDH\n\nEvents: Pt brought to OR at for burr holes and evacuation of L SDH uneventful, returned post-op at 2230, Head CT x2 overnoc\n\nNeuro: q1 hour neuro checks throughout most of the noc, pt slow to wake up post-op, but appropriate. Pupils equal and reactive to light, moves all extremities spontaneously and to commands. Aware of month, year, and situation, repeating questions related to outcome of surgery and pain medication, reassurance given, pt calms with reassurance and information about plan of care. Head CT post-op at 0200.\n\nCV: Sinus brady 50-70's throughout the night, no ectopy noted. BP stable 120's. Positive pulses to all extremities, no edema noted. Hct stable this am at 36\n\nResp: Lung sounds clear, weaned post-op to 2L per NC encouraged deep breathing with neuro checks to promote adequate pulmonary toilet.\n\nGI/GU: bowel sounds present x4 NPO overnoc, Foley with marginal UOP averaging 40/hr, concentrated urine. MD notified this am in rounds, plan to decrease fluid and start po intake this am, will assess results of UOP following initiation of po intake.\n\nEndo: FSG within normal limits\n\nSkin: Incision to left head covered with surgical drsg, sanguinous drainage noted at 0200, no further increase in bleeding noted since then, shadow remains on drsg, staff note says will address drsg in am. Head of bed at 15 degrees per order last noc, tolerated well, will slowly increase HOB throughout the day. Pt refused to move due to pain with activity overnoc. No pressure areas noted with turning for procedures.\n\nLabs: Mag 1.8 replaced with 2 grams Mag\n\nPain: complains of pain at pre-op with minimal relief from Morphine. Pain post-op at 0000 total of 4 mg Morphine given with good relief, current rating of 2 mg Morphine given at 0630 with good relief noted per pt. Continue to encourage verbalization of increasing or changing pain, medicate as needed to maintain adequate level of pain relief.\n\nSocial: Friends to bedside post-op last noc, updated on care, no calls overnoc\n\nPlan: Continue to monitor neuro status q 2 hours, monitor for changes in neuro status\n Monitor for adequate pain relief and encourage verbalization of change or increase in level of pain\n Monitor for adequate UOP and encourage po intake as pt is able this shift.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-21 00:00:00.000", "description": "Report", "row_id": 1552293, "text": "TSICU NSG ADMISSION NOTE\nO: 24 Y/O MALE WHO IS S/P SNOWBOARD ACCIDENT ON . CAME TO EW AND WAS EVALUATED AND SENT HOME. RETURNED W/ C/O HA AND EMESIS. HEAD CT SHOWED L SDH W/ MASS EFFECT AND SHIFT. TREATED CONSERVATIVELY AND WAS SENT HOME ON DILANTIN, NIMODIPINE AND PRN TYLENOL. RETURNED TO EW TODAY W/ 3 DAY HX SEVERE HA W/ NO RELIEF. HEAD CT TODAY SHOWED NEW INCREASE IN SDH W/ 13MM SHIFT AND HYPODENSITY IN FRONTO-PARIETO-TEMPORAL LOBES. HEMODYNAMICALLY AND NEUROLOGICALLY STABLE IN EW. TRANSFERRED TO TSICU ABT 4AM FOR NEURO CHECKS AND CONT EVALUATION.\n\nROS:\nNEURO: PT ARRIVE ON STRETCHER AND AMBULATED TO BED W/ SLOW STEADY GAIT. C/O SEVERE HA W/ PRESSURE BEHIND HIS EYES. PEARL 5MM BILAT, MAE W/ NORMAL,EQUAL STRENGTH. FOLLOWS COMMANDS AND ABLE TO RECOUNT ALL EVENTS LEADING UP TO ADMISSION. DILANTIN LEVEL ON ADMISSION 3.3. STARTED DILANTIN 100MG Q8HRS AND LOADED W/ 1GM DILANTIN. DENIES ANY NAUSEA/VOMITING, BLURRED VISION.\n\nCV: HEMODYNAMICALLY STABLE, BRADYCARDIC W/ HR 45-50. SBP 120/70.\n\nRESP: LS CLEAR THROUGHOUT. 02SAT 97% ON RM AIR.\n\nRENAL: NO IDENTIFIED ISSUES. PT HAS NO FOLEY. HAS NOT VOIDED SINCE ARRIVAL BUT DENIES ANY URGE TO URINATE. LYTES PND. IVF STARTED AT 100CC/HR.\n\nGI: NPO. DENIES NAUSEA.\n\nHEME: HCT STABLE. INR 1.1.\n\nID: AFEBRILE.\n\nSKIN: INTACT.\n\nSH: FRIEND IS CONTACT PERSON. ARE IN AND WERE AWARE OF INITIAL TRAUMA. THEY HAVE NOT BEEN NOTIFIED RE: THIS ADMISSION.\nPT PLANS TO CALL THEM IN AM AFTER PLAN IDENTIFIED.\n\nA: NEUROLOGICALLY INTACT BUT CONT W/ SEVERE HA.\n\nP: CONT TO MONITOR NVS. REPEAT HEAD CT TODAY. I/O, NPO, BEDREST. CONT DILANTIN AND RECHECK LEVEL. PT PLANS TO CALL TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-21 00:00:00.000", "description": "Report", "row_id": 1552294, "text": "NPN\nN: NEUROLOGICALLY INTACT. NO DEFICITS. A/OX3. PERRL 3MM/BRISK. C/O HA AND PRESSURE \"BEHIND EYES.\" MEDICATED WITH 2-4MG MSO4 PRN WITH SOME EFFECT. REPEAT HEAD CT DONE THIS AM.\nCV: HD STABLE. SEE CAREVUE FOR SERIAL VS.\nR: LUNGS CLEAR BILAT AND RA SATS 95-98% RR TEENS.\nGI: TOL CLEAR LIQS. C/O NAUSEA THIS AM. RESOLVED WITHOUT NEED FOR MED.\nNO VOMITING. CONT NS AT 100CC/HR.\nGU: VOIDING IN URINAL CLEAR YELLOW.\nID: AFEBRILE\nSOC: PROVIDED EMOTIONAL SUPPORT AND ENCOURAGEMENT TO PATIENT. HE IS VERY WORRIED THAT HE NEED SURGERY AND THAT HE IS ALONE HERE WITH IN . PLANS TO CALL THIS AFTERNOON TO LET THEM KNOW OF THIS ADMISSION.\nA/P: CONT TO MONITOR CLOSELY AND MEDICATE FOR PAIN PRN.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-21 00:00:00.000", "description": "Report", "row_id": 1552295, "text": "addendum to previous nsg entry- 7a-7p\n\n1700-PT NAUSEOUS AND VOMITED ~200CC. C/O FEELING LIGHT HEADED WITH WORSENING PRESSURE BEHIND EYES. NP CHIP MCCINTOSH CALLED AND CAME TO ASSESS PT. GIVEN 4MG MSO4 WITH SOME RELIEF. NO OTHER CHANGE IN NEURO STATUS NOTED.\n" } ]

[ { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 380874, "text": "48y/o with ESRD with HD 3x's a week who presents with abdominal and\n chest pain, N/V, and general malaise. C/o symptoms for last 2 weeks\n also including SOB, cough, diarrhea. States he has gone to HD because\n he has been ill. Appetite has been poor. K+ 6.9, BUN 111, creat 22.2.\n Elevated lipase and amylase. Peaked T's on EKG. Given calcium\n gluconate, bicarb, D50, Kayxelate, and insulin to treat K+. K+ later\n 6.2 then 5.5. Non IV but PO contrast abdomen/pelvis CT done, nothing\n acute to explain pain. Hypoglycemic to 50, given 1 amp D50 and back to\n 129. Started on D5.45NS @75cc/hr. Hemodynamically stable. AAO x3.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n HR 70-80\ns NSR with peaked T\ns. No ectopy. Has LUE AV fistula with\n +bruit and thrill. Anuric.\n Action:\n Given 30gms kayxelate x1. Monitoring potassium levels closely.\n Response:\n K+ 5.4 (VBG) 5.7 (corvasc) upon arrival. Brown, liquid stool x3 s/p\n kayxelate. This morning K+ pending.\n Plan:\n Plan for HD first thing in the AM. Monitor K+.\n Pain control (acute pain, chronic pain)\n Assessment:\n Initially c/o lower abdominal pain, tolerable, , has stated this\n has been constant. Bowel sounds positive, abdomen soft and obese,\n tender to palpation.\n Action:\n CT done but showed nothing acute to explain pain. Monitoring pain,\n abdominal exam.\n Response:\n Slightly elevated amylase may be indicative of a mild pancreatitis.\n Pain remains even after eating. Describes at crampy and gassy (had\n received kayxelate). This morning pain , given 650mg tylenol.\n Plan:\n Monitor for worsening pain. No IVF for now. Consider imaging if\n conservative measures not effective.\n Hypoglycemia\n Assessment:\n Blood sugar 125 upon arrival to MICU. Received on D5.45NS @75cc/hr.\n Action:\n Stopped IVF\ns. Allowed patient to eat and drink. Monitoring blood\n sugars.\n Response:\n AM blood sugar 65.\n Plan:\n MD aware, no intervention at this time. Continue to follow\n fingersticks.\n v Alert and oriented x3. Able to ambulate to bed, get up to\n commode without difficulty.\n v HR 70-80\ns SR, BP 130-150\ns/90-100\ns. Will start his\n antihypertensives in the morning unless he has a spike in his BP.\n v Lung sounds clear, on 2L nasal prongs, RR 10-18 with sats >95%.\n Occasional strong, nonproductive cough. No SOB at this time.\n v Afebrile, no current ID issues.\n v Will be called out this morning, possibly before HD.\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 380942, "text": "Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Am K+ down to 5.4 after kayexalate, insulin & dextrose\n Action:\n Hemodialysis done today x 3 hrs via L AV fistula\n Response:\n Tolerated HD well\n Plan:\n TX to floor after HD, PM lytes\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abdominal pain this am, no N/V, large loose stool x1, mildly\n elevated lipase & amylase\n Action:\n Po Tylenol for pain x 1, HD done this am x 3 hrs, on renal diet\n Response:\n Abdominal pain improving\n Plan:\n Continue to follow abdominal pain, if abdominal pain worsens may keep\n pt NPO\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 380903, "text": "HPI:\n Mr. is a 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, decreased PO intake, nausea,\n difficulty breathing and diffuse abdominal pain. He was in his usual\n state of health until two weeks prior to presentation. Last dialysis\n was two weeks ago. He received dialysis at Frecenius dialysis (, , Sa). He does not have a particular reason for skipping\n dialysis. He continued to feel worse and worse. On the day of\n presentation he noted that his breathing was worse and he decided to\n come to the emergency room.\n In the ED, initial vs were: T 97.3 BP 149/103 P 80 R 19 O2 sat 100% on\n RA. Patient was given kayexylate 30 mg, calcium gluconate 10 mg, 1 amp\n sodium bicarbonate, 10 units IV insulin and 1 amp D50 IV x 2. He had a\n CT abdomen without contrast which was negative for acute process. CXR\n did not show significant volume overload.\n On arrival to the emergency room he has no specific complaints. No\n fevers, chills. He has noticed diffuse chest pain which he has had in\n the past. He has mild difficulty breathing improved with supplemental\n oxygen. Diffuse bilateral lower quadrant abdominal pain. Mild\n non-productive cough. Mild diarrhea, no constipation. No melena or\n hematochezia. Mild lower extremity edema present. No leg pain. No\n confusion. No known weight gain.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Am K+ down to 5.4 after kayexalate, insulin & dextrose\n Action:\n Hemodialysis done today x 3 hrs via L AV fistula\n Response:\n Tolerated HD well\n Plan:\n TX to floor after HD, PM lytes\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 380904, "text": "HPI:\n Mr. is a 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, decreased PO intake, nausea,\n difficulty breathing and diffuse abdominal pain. He was in his usual\n state of health until two weeks prior to presentation. Last dialysis\n was two weeks ago. He received dialysis at Frecenius dialysis (, , Sa). He does not have a particular reason for skipping\n dialysis. He continued to feel worse and worse. On the day of\n presentation he noted that his breathing was worse and he decided to\n come to the emergency room.\n In the ED, initial vs were: T 97.3 BP 149/103 P 80 R 19 O2 sat 100% on\n RA. Patient was given kayexylate 30 mg, calcium gluconate 10 mg, 1 amp\n sodium bicarbonate, 10 units IV insulin and 1 amp D50 IV x 2. He had a\n CT abdomen without contrast which was negative for acute process. CXR\n did not show significant volume overload.\n On arrival to the emergency room he has no specific complaints. No\n fevers, chills. He has noticed diffuse chest pain which he has had in\n the past. He has mild difficulty breathing improved with supplemental\n oxygen. Diffuse bilateral lower quadrant abdominal pain. Mild\n non-productive cough. Mild diarrhea, no constipation. No melena or\n hematochezia. Mild lower extremity edema present. No leg pain. No\n confusion. No known weight gain.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Am K+ down to 5.4 after kayexalate, insulin & dextrose\n Action:\n Hemodialysis done today x 3 hrs via L AV fistula\n Response:\n Tolerated HD well\n Plan:\n TX to floor after HD, PM lytes\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abdominal pain this am, no N/V, large loose stool x1, mildly\n elevated lipase & amylase\n Action:\n Po Tylenol for pain x 1, HD done this am x 3 hrs, on renal diet\n Response:\n Abdominal pain improving\n Plan:\n Continue to follow abdominal pain, if abdominal pain worsens may keep\n pt NPO\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ABDOMINAL PAIN;SHORTNESS OF BREATH;HYPERKALEMIA\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 104.6 kg\n Daily weight:\n Allergies/Reactions:\n Nickel\n Rash;\n Precautions:\n PMH: HEMO or PD, Renal Failure\n CV-PMH: Hypertension\n Additional history: hypercholesterolemia, GERD, Migraines, Poly\n substance abuse including cocaine/ETOH/crack/marijuana\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:96\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,340 mL\n 24h total out:\n 200 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:25 AM\n Potassium:\n 5.4 mEq/L\n 04:25 AM\n Chloride:\n 93 mEq/L\n 04:25 AM\n CO2:\n 28 mEq/L\n 04:25 AM\n BUN:\n 110 mg/dL\n 04:25 AM\n Creatinine:\n 21.4 mg/dL\n 04:25 AM\n Glucose:\n 79 mg/dL\n 04:25 AM\n Hematocrit:\n 31.8 %\n 04:25 AM\n Finger Stick Glucose:\n 82\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: cell phone, keys, wallet with $2, no credit cards\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 7\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2158-06-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 380912, "text": "Chief Complaint: fatigue, n/v, sob\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 48 yo M w/ ESRD on HD, substance abuse. Skipped outpt HD x 2wks for no\n clear reason, and developed subsequent fatigue, decreased PO intake,\n nausea, difficulty breathing and diffuse abdominal pain. Noted to be\n hyperkalemic and mildly acidemic. Admitted to the MICU for observation\n and mgmt.\n Allergies:\n Nickel\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Heparin sc, amlodipine, atenolol, Ca acetate, ASA, Protonix, Renagel,\n nictoine patch\n Past medical history:\n Family history:\n Social History:\n -ESRD on HD TTS LUE AVF, due presumably to HTN\n -Hypertension\n -Hypercholesterolemia\n -GERD\n -Migraine Headaches\n -Polysubstance abuse including cocaine, ethanol, marijuana, crack\n Mother has end stage renal disease, diabetes and RA. Cousins also have\n renal disease. Grandparents have hypertension\n Occupation: unemployed\n Drugs: remote cocaine, etOH, marijuana, crack\n Tobacco: 1ppw for a long time\n Alcohol: last one yr ago per pt\n :\n Review of systems:\n Flowsheet Data as of 09:16 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (71 - 89) bpm\n BP: 138/98(107) {132/82(94) - 154/106(116)} mmHg\n RR: 10 (10 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,340 mL\n PO:\n 1,340 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 0 mL\n 1,140 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///28/\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: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: RLQ, no rebound or\n guarding\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 161 K/uL\n 31.8 %\n 10.3 g/dL\n 79 mg/dL\n 21.4 mg/dL\n 110 mg/dL\n 28 mEq/L\n 93 mEq/L\n 5.4 mEq/L\n 145 mEq/L\n 5.4 K/uL\n [image002.jpg]\n 11:25 PM\n 04:25 AM\n WBC\n 5.4\n Hct\n 31.8\n Plt\n 161\n Cr\n 22.1\n 21.4\n TropT\n 0.04\n 0.05\n Glucose\n 124\n 79\n Other labs: CK / CKMB / Troponin-T:68//0.05, Amylase / Lipase:/ 397,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:7.1 mg/dL\n Fluid analysis / Other labs: Serum tox screen- neg\n Imaging: CXR- lowish lung vols but no clear infiltrates\n CT a/p- prelim no acute process, R basilar pleural process and\n atelectasis?\n ECG: Admit ECG- NSR, no clear peaked waves, borderline LAD, TWI I and\n aVL (all unchanged compared to )\n Assessment and Plan\n ESRD/ Uremia- missed HD x 2 wks w/ mild AG met acidosis, hyperkalemia\n -hyperK better w/ kayexalate and Renagel, Ca acetate\n -Renal consult and HD today\n Abdominal pain/ unclear if there might have been a viral\n gastroenteritis precipitating, now with possibly symptoms of uremia, ?\n withdrawal from drug\n -continue PO trial, will make npo if still symptomatic\n -monitor sx after HD\n -exam and hx not consistent with pancreatitis, lipase elevation here\n may be nonspecific\n -may need better contrast (IV and PO) CT a/p if still w/ symptoms\n Rest of plan per housestaff note.\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 20 Gauge - 10:31 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 380831, "text": "48y/o with ESRD with HD 3x's a week who presents with abdominal and\n chest pain, N/V, and general malaise. C/o symptoms for last 2 weeks\n also including SOB, cough, diarrhea. States he has gone to HD because\n he has been ill. Appetite has been poor. K+ 6.9, BUN 111, creat 22.2.\n Elevated lipase and amylase. Peaked T's on EKG. Given calcium\n gluconate, bicarb, D50, Kayxelate, and insulin to treat K+. K+ later\n 6.2 then 5.5. Non IV but PO contrast abdomen/pelvis CT done, nothing\n acute to explain pain. Hypoglycemic to 50, given 1 amp D50 and back to\n 129. Started on D5.45NS @75cc/hr. Hemodynamically stable. AAO x3.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n HR 70-80\ns NSR with peaked T\ns. No ectopy. Has LUE AV fistula with\n +bruit and thrill. Anuric.\n Action:\n Given 30gms kayxelate x1. Monitoring potassium levels closely.\n Response:\n Plan:\n Plan for HD first thing in the AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n Initially c/o lower abdominal pain, tolerable, , has stated this\n has been constant. Bowel sounds positive, abdomen soft and obese,\n tender to palpation.\n Action:\n CT done but showed nothing acute to explain pain. Monitoring pain,\n abdominal exam.\n Response:\n Plan:\n Hypoglycemia\n Assessment:\n Blood sugar 125 upon arrival to MICU. Received on D5.45NS @75cc/hr.\n Action:\n Stopped IVF\ns. Allowed patient to eat and drink. Monitoring blood\n sugars.\n Response:\n Plan:\n v Alert and oriented x3. Able to ambulate to bed, get up to\n commode without difficulty.\n v HR 70-80\ns SR, BP 140-150\ns/90-100\ns. Will start his\n antihypertensives in the morning unless he has a spike in his BP.\n v Lung sounds clear, on 2L nasal prongs, RR 10-18 with sats >95%.\n Occasional strong, nonproductive cough. No SOB at this time.\n v Afebrile, no current ID issues.\n v Will be called out this morning, possibly before HD.\n" }, { "category": "Physician ", "chartdate": "2158-06-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 380837, "text": "Chief Complaint: Hyperkalemia\n HPI:\n Mr. is a 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, decreased PO intake, nausea,\n difficulty breathing and diffuse abdominal pain. He was in his usual\n state of health until two weeks prior to presentation. Last dialysis\n was two weeks ago. He received dialysis at Frecenius dialysis (, , Sa). He does not have a particular reason for skipping\n dialysis. He continued to feel worse and worse. On the day of\n presentation he noted that his breathing was worse and he decided to\n come to the emergency room.\n In the ED, initial vs were: T 97.3 BP 149/103 P 80 R 19 O2 sat 100% on\n RA. Patient was given kayexylate 30 mg, calcium gluconate 10 mg, 1 amp\n sodium bicarbonate, 10 units IV insulin and 1 amp D50 IV x 2. He had a\n CT abdomen without contrast which was negative for acute process. CXR\n did not show significant volume overload.\n On arrival to the emergency room he has no specific complaints. No\n fevers, chills. He has noticed diffuse chest pain which he has had in\n the past. He has mild difficulty breathing improved with supplemental\n oxygen. Diffuse bilateral lower quadrant abdominal pain. Mild\n non-productive cough. Mild diarrhea, no constipation. No melena or\n hematochezia. Mild lower extremity edema present. No leg pain. No\n confusion. No known weight gain.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Nickel\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Home Medications:\n Sevalemer 800 mg TID\n Pantoprazole 40 mg daily\n Aspirin 81 mg daily\n Lisinopril 20 mg daily\n Calcium Acetate 667 mg TID with meals\n Atenolol 100 mg daily\n Norvasc unknown strength\n Past medical history:\n Family history:\n Social History:\n - End stage renal disease secondary to hypertension on dialysis with\n left upper extremity fistula\n - Hypertension\n - Hypercholesterolemia\n - GERD\n - Migraine Headaches\n - Polysubstance abuse including cocaine, ethanol, marijuana, crack\n Mother has end stage renal disease, diabetes and RA. Cousins also have\n renal disease. Grandparents have hypertension.\n Occupation: Unemployed\n Drugs: Remote history of cocaine (last one year ago)\n Tobacco: 1 pack per week\n Alcohol: Last one year ago\n Other: Lives in an apartment \n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Foley, Dialysis\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Anemia\n Neurologic: No(t) Headache\n Allergy / Immunology: No(t) Immunocompromised\n Pain: Minimal\n Pain location: abdomen\n Flowsheet Data as of 02:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 81 (73 - 81) bpm\n BP: 149/102(112) {144/96(106) - 154/102(112)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 740 mL\n PO:\n 740 mL\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 740 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Vitals: T: 97.2 BP: 154/98 P: 22 R:18 O2: 99% on 2L\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, unable to appreciate JVP, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly, mild tenderness in bilateral\n lower quadrants\n GU: no foley\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis. Trace\n edema in the feet bilaterally.\n Neurologic: Faint asterixis\n Labs / Radiology\n 180\n 11.6\n 124 mg/dL\n 22.1 mg/dL\n 113 mg/dL\n 30 mEq/L\n 90 mEq/L\n 5.4 mEq/L\n 143 mEq/L\n 35.6\n 5.7\n [image002.jpg]\n \n 2:33 A7/8/ 11:25 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 22.1\n Glucose\n 124\n Other labs: PT / PTT / INR:12.0/26.0/1.0, CK / CKMB /\n Troponin-T:66//.05, ALT / AST:15/12, Alk Phos / T Bili:/0.2, Amylase /\n Lipase:417/397, Differential-Neuts:46.8, Band:0, Lymph:40.6, Mono:7.9,\n Eos:4.3, Albumin:4.0, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.8 mg/dL\n Imaging: CXR (wet read): No acute cardiopulmonary process\n CT Abdomen without contrast (wet read): Limited scan due to lack of IV\n contrast. No definite abnormality to explain patient's pain.\n Microbiology: None\n ECG: normal sinus rhythm, borderline left axis, normal intervals,\n peaked twaves in lateral leads.\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HYPOGLYCEMIA\n Assessment and Plan: 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, nausea, dyspnea and abdominal pain\n after skipping dialysis for two weeks.\n Uremia/End Stage Renal Disease: Suspect that the patient's symptoms\n are in large part secondary to missing dialysis for two weeks. Of\n primary concern in the emergency room was his hyperkalemia with peaked\n t waves on EKG. His potassium has since returned to 5.5 after medical\n management. Anion gap is elevated at 23 (no ABG from ER to assess acid\n base status). He is breathing comfortably on room air. His mental\n status is not significantly compromised. At present no acute\n indication for emergent dialysis. Will continue medical management for\n tonight with plans for dialysis on the floor in AM.\n - repeat kayexylate dosing tonight\n - repeat potassium check tonight\n - check VBG tonight\n - monitor on telemetry\n - plan for dialysis in AM\n - continue sevalamer, calcium acetate\n Chest Pain: Patient reports vague diffuse chest pain with mild\n dyspnea. Troponin 0.05 on admission without ischemic changes on EKG.\n Of greatest concern would be uremic pericarditis although no signs of\n this on EKG.\n - second set of cardiac enzymes tonight\n - plan for dialysis in AM\n Abdominal Pain/Pancreatitis: Workup in emergency room negative with\n exception of mildly elevated pancreatic enzymes. Patient does report\n mild diffuse bilateral mid-epigastric to lower abdominal pain without\n rebounding or guarding. Reports mild diarrhea and no constipation.\n Similar time course to his missing dialysis.\n - will monitor if pain is worsened by PO intake\n - no IVF for now\n - dialysis tomorrow\n - can consider further imaging if no improvement with conservative\n measures\n Hypertension: Blood pressures currently mildly elevated.\n - continue atenolol\n - continue norvasc (will give 10 mg given patient does not know dose\n and previous notes suggest 20 mg daily)\n - holding lisinopril for hyperkalemia\n FEN: No IVF, replete electrolytes, renal diet\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: Full (discussed with patient)\n Communication: Patient, mother \n Disposition: call out to floor in AM for dialysis\n ICU Care\n Nutrition:\n Comments: Renal diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 10:31 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 380843, "text": "48y/o with ESRD with HD 3x's a week who presents with abdominal and\n chest pain, N/V, and general malaise. C/o symptoms for last 2 weeks\n also including SOB, cough, diarrhea. States he has gone to HD because\n he has been ill. Appetite has been poor. K+ 6.9, BUN 111, creat 22.2.\n Elevated lipase and amylase. Peaked T's on EKG. Given calcium\n gluconate, bicarb, D50, Kayxelate, and insulin to treat K+. K+ later\n 6.2 then 5.5. Non IV but PO contrast abdomen/pelvis CT done, nothing\n acute to explain pain. Hypoglycemic to 50, given 1 amp D50 and back to\n 129. Started on D5.45NS @75cc/hr. Hemodynamically stable. AAO x3.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n HR 70-80\ns NSR with peaked T\ns. No ectopy. Has LUE AV fistula with\n +bruit and thrill. Anuric.\n Action:\n Given 30gms kayxelate x1. Monitoring potassium levels closely.\n Response:\n K+ 5.4 (VBG) 5.7 (corvasc) upon arrival. This morning\n Plan:\n Plan for HD first thing in the AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n Initially c/o lower abdominal pain, tolerable, , has stated this\n has been constant. Bowel sounds positive, abdomen soft and obese,\n tender to palpation.\n Action:\n CT done but showed nothing acute to explain pain. Monitoring pain,\n abdominal exam.\n Response:\n Plan:\n Hypoglycemia\n Assessment:\n Blood sugar 125 upon arrival to MICU. Received on D5.45NS @75cc/hr.\n Action:\n Stopped IVF\ns. Allowed patient to eat and drink. Monitoring blood\n sugars.\n Response:\n Plan:\n v Alert and oriented x3. Able to ambulate to bed, get up to\n commode without difficulty.\n v HR 70-80\ns SR, BP 140-150\ns/90-100\ns. Will start his\n antihypertensives in the morning unless he has a spike in his BP.\n v Lung sounds clear, on 2L nasal prongs, RR 10-18 with sats >95%.\n Occasional strong, nonproductive cough. No SOB at this time.\n v Afebrile, no current ID issues.\n v Will be called out this morning, possibly before HD.\n" }, { "category": "Physician ", "chartdate": "2158-06-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 380892, "text": "Chief Complaint: fatigue, n/v, sob\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 48 yo M w/ ESRD on HD, substance abuse. Skipped outpt HD x 2wks for no\n clear reason, and developed subsequent fatigue, decreased PO intake,\n nausea, difficulty breathing and diffuse abdominal pain. Noted to be\n hyperkalemic and mildly acidemic. Admitted to the MICU for observation\n and mgmt.\n Allergies:\n Nickel\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Heparin sc, amlodipine, atenolol, Ca acetate, ASA, Protonix, Renagel,\n nictoine patch\n Past medical history:\n Family history:\n Social History:\n -ESRD on HD TTS LUE AVF, due presumably to HTN\n -Hypertension\n -Hypercholesterolemia\n -GERD\n -Migraine Headaches\n -Polysubstance abuse including cocaine, ethanol, marijuana, crack\n Mother has end stage renal disease, diabetes and RA. Cousins also have\n renal disease. Grandparents have hypertension\n Occupation: unemployed\n Drugs: remote cocaine, etOH, marijuana, crack\n Tobacco: 1ppw for a long time\n Alcohol: last one yr ago per pt\n :\n Review of systems:\n Flowsheet Data as of 09:16 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (71 - 89) bpm\n BP: 138/98(107) {132/82(94) - 154/106(116)} mmHg\n RR: 10 (10 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 1,340 mL\n PO:\n 1,340 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 0 mL\n 1,140 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///28/\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: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: RLQ, no rebound or\n guarding\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 161 K/uL\n 31.8 %\n 10.3 g/dL\n 79 mg/dL\n 21.4 mg/dL\n 110 mg/dL\n 28 mEq/L\n 93 mEq/L\n 5.4 mEq/L\n 145 mEq/L\n 5.4 K/uL\n [image002.jpg]\n 11:25 PM\n 04:25 AM\n WBC\n 5.4\n Hct\n 31.8\n Plt\n 161\n Cr\n 22.1\n 21.4\n TropT\n 0.04\n 0.05\n Glucose\n 124\n 79\n Other labs: CK / CKMB / Troponin-T:68//0.05, Amylase / Lipase:/ 397,\n Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:7.1 mg/dL\n Fluid analysis / Other labs: Serum tox screen- neg\n Imaging: CXR- lowish lung vols but no clear infiltrates\n CT a/p- prelim no acute process, R basilar pleural process and\n atelectasis?\n ECG: Admit ECG- NSR, no clear peaked waves, borderline LAD, TWI I and\n aVL (all unchanged compared to )\n Assessment and Plan\n ESRD/ Uremia- missed HD x 2 wks w/ mild AG met acidosis, hyperkalemia\n -hyperK better w/ kayexalate and Renagel, Ca acetate\n -Renal consult and HD today\n Abdominal pain/ unclear if there might have been a viral\n gastroenteritis precipitating, now with possibly symptoms of uremia\n -continue PO trial, will make npo if still symptomatic\n -monitor sx after HD\n -exam and hx not consistent with pancreatitis, lipase elevation here\n may be nonspecific\n -may need better contrast (IV and PO) CT a/p if still w/ symptoms\n Rest of plan per housestaff note.\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 20 Gauge - 10:31 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2158-06-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 380893, "text": "Chief Complaint: Hyperkalemia\n HPI:\n Mr. is a 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, decreased PO intake, nausea,\n difficulty breathing and diffuse abdominal pain. He was in his usual\n state of health until two weeks prior to presentation. Last dialysis\n was two weeks ago. He received dialysis at Frecenius dialysis (, , Sa). He does not have a particular reason for skipping\n dialysis. He continued to feel worse and worse. On the day of\n presentation he noted that his breathing was worse and he decided to\n come to the emergency room.\n In the ED, initial vs were: T 97.3 BP 149/103 P 80 R 19 O2 sat 100% on\n RA. Patient was given kayexylate 30 mg, calcium gluconate 10 mg, 1 amp\n sodium bicarbonate, 10 units IV insulin and 1 amp D50 IV x 2. He had a\n CT abdomen without contrast which was negative for acute process. CXR\n did not show significant volume overload.\n On arrival to the emergency room he has no specific complaints. No\n fevers, chills. He has noticed diffuse chest pain which he has had in\n the past. He has mild difficulty breathing improved with supplemental\n oxygen. Diffuse bilateral lower quadrant abdominal pain. Mild\n non-productive cough. Mild diarrhea, no constipation. No melena or\n hematochezia. Mild lower extremity edema present. No leg pain. No\n confusion. No known weight gain.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Nickel\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Home Medications:\n Sevalemer 800 mg TID\n Pantoprazole 40 mg daily\n Aspirin 81 mg daily\n Lisinopril 20 mg daily\n Calcium Acetate 667 mg TID with meals\n Atenolol 100 mg daily\n Norvasc unknown strength\n Past medical history:\n Family history:\n Social History:\n - End stage renal disease secondary to hypertension on dialysis with\n left upper extremity fistula\n - Hypertension\n - Hypercholesterolemia\n - GERD\n - Migraine Headaches\n - Polysubstance abuse including cocaine, ethanol, marijuana, crack\n Mother has end stage renal disease, diabetes and RA. Cousins also have\n renal disease. Grandparents have hypertension.\n Occupation: Unemployed\n Drugs: Remote history of cocaine (last one year ago)\n Tobacco: 1 pack per week\n Alcohol: Last one year ago\n Other: Lives in an apartment \n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Foley, Dialysis\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Anemia\n Neurologic: No(t) Headache\n Allergy / Immunology: No(t) Immunocompromised\n Pain: Minimal\n Pain location: abdomen\n Flowsheet Data as of 02:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 81 (73 - 81) bpm\n BP: 149/102(112) {144/96(106) - 154/102(112)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 740 mL\n PO:\n 740 mL\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 740 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Vitals: T: 97.2 BP: 154/98 P: 22 R:18 O2: 99% on 2L\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, unable to appreciate JVP, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly, mild tenderness in bilateral\n lower quadrants\n GU: no foley\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis. Trace\n edema in the feet bilaterally.\n Neurologic: Faint asterixis\n Labs / Radiology\n 180\n 11.6\n 124 mg/dL\n 22.1 mg/dL\n 113 mg/dL\n 30 mEq/L\n 90 mEq/L\n 5.4 mEq/L\n 143 mEq/L\n 35.6\n 5.7\n [image002.jpg]\n \n 2:33 A7/8/ 11:25 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 22.1\n Glucose\n 124\n Other labs: PT / PTT / INR:12.0/26.0/1.0, CK / CKMB /\n Troponin-T:66//.05, ALT / AST:15/12, Alk Phos / T Bili:/0.2, Amylase /\n Lipase:417/397, Differential-Neuts:46.8, Band:0, Lymph:40.6, Mono:7.9,\n Eos:4.3, Albumin:4.0, Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.8 mg/dL\n Imaging: CXR (wet read): No acute cardiopulmonary process\n CT Abdomen without contrast (wet read): Limited scan due to lack of IV\n contrast. No definite abnormality to explain patient's pain.\n Microbiology: None\n ECG: normal sinus rhythm, borderline left axis, normal intervals,\n peaked twaves in lateral leads.\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HYPOGLYCEMIA\n Assessment and Plan: 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, nausea, dyspnea and abdominal pain\n after skipping dialysis for two weeks.\n Uremia/End Stage Renal Disease: Suspect that the patient's symptoms\n are in large part secondary to missing dialysis for two weeks. Of\n primary concern in the emergency room was his hyperkalemia with peaked\n t waves on EKG. His potassium has since returned to 5.5 after medical\n management. Anion gap is elevated at 23 (no ABG from ER to assess acid\n base status). He is breathing comfortably on room air. His mental\n status is not significantly compromised. At present no acute\n indication for emergent dialysis. Will continue medical management for\n tonight with plans for dialysis on the floor in AM.\n - repeat kayexylate dosing tonight\n - repeat potassium check tonight\n - check VBG tonight\n - monitor on telemetry\n - plan for dialysis in AM\n - continue sevalamer, calcium acetate\n Chest Pain: Patient reports vague diffuse chest pain with mild\n dyspnea. Troponin 0.05 on admission without ischemic changes on EKG.\n Of greatest concern would be uremic pericarditis although no signs of\n this on EKG.\n - second set of cardiac enzymes tonight\n - plan for dialysis in AM\n Abdominal Pain/Pancreatitis: Workup in emergency room negative with\n exception of mildly elevated pancreatic enzymes. Patient does report\n mild diffuse bilateral mid-epigastric to lower abdominal pain without\n rebounding or guarding. Reports mild diarrhea and no constipation.\n Similar time course to his missing dialysis.\n - will monitor if pain is worsened by PO intake\n - no IVF for now\n - dialysis tomorrow\n - can consider further imaging if no improvement with conservative\n measures\n Hypertension: Blood pressures currently mildly elevated.\n - continue atenolol\n - continue norvasc (will give 10 mg given patient does not know dose\n and previous notes suggest 20 mg daily)\n - holding lisinopril for hyperkalemia\n FEN: No IVF, replete electrolytes, renal diet\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: Full (discussed with patient)\n Communication: Patient, mother \n Disposition: call out to floor in AM for dialysis\n ICU Care\n Nutrition:\n Comments: Renal diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 10:31 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n ------ Protected Section ------\n Interim Plan:\n Uremia/End Stage Renal Disease: Suspect that the patient's symptoms\n are in large part secondary to missing dialysis for two weeks.\n Potassium corrected with medical management. His mental status is not\n significantly compromised.\n - Dialysis today\n - monitor on telemetry\n - continue sevalamer, calcium acetate\n Diarrhea: Patient reports having diarrhea for the past 2 weeks and\n vomiting (last vomited 3 days prior). No recent hospitalization or\n antibiotics per his report. Suspect related to uremia.\n - see if his symptoms resolved with dialysis\n - would not send c diff as he is afebrile without WBC\n Abdominal Pain/Pancreatitis: Workup in emergency room negative with\n exception of mildly elevated pancreatic enzymes. Patient does report\n mild diffuse bilateral mid-epigastric to lower abdominal pain without\n rebounding or guarding. Similar time course to his missing dialysis.\n CT without obvious reason for pain.\n - will monitor if pain is worsened by PO intake\n - no IVF for now\n - dialysis today\n - can consider further imaging if no improvement with conservative\n measures\n Hypertension: Blood pressures currently mildly elevated.\n - continue atenolol\n - continue norvasc (will give 10 mg given patient does not know dose\n and previous notes suggest 20 mg daily)\n - holding lisinopril for hyperkalemia\n FEN: No IVF, replete electrolytes, renal diet\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: Full (discussed with patient)\n Communication: Patient, mother \n Disposition: call out to floor after dialysis\n ------ Protected Section Addendum Entered By: , MD\n on: 09:17 ------\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 380879, "text": "48y/o with ESRD with HD 3x's a week who presents with abdominal and\n chest pain, N/V, and general malaise. C/o symptoms for last 2 weeks\n also including SOB, cough, diarrhea. States he has gone to HD because\n he has been ill. Appetite has been poor. K+ 6.9, BUN 111, creat 22.2.\n Elevated lipase and amylase. Peaked T's on EKG. Given calcium\n gluconate, bicarb, D50, Kayxelate, and insulin to treat K+. K+ later\n 6.2 then 5.5. Non IV but PO contrast abdomen/pelvis CT done, nothing\n acute to explain pain. Hypoglycemic to 50, given 1 amp D50 and back to\n 129. Started on D5.45NS @75cc/hr. Hemodynamically stable. AAO x3.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n HR 70-80\ns NSR with peaked T\ns. No ectopy. Has LUE AV fistula with\n +bruit and thrill. Anuric.\n Action:\n Given 30gms kayxelate x1. Monitoring potassium levels closely.\n Response:\n K+ 5.4 (VBG) 5.7 (corvasc) upon arrival. Brown, liquid stool x3 s/p\n kayxelate. This morning K+ 5.4 with BUN/Creat 110/21.4.\n Plan:\n Plan for HD first thing in the AM. Monitor K+.\n Pain control (acute pain, chronic pain)\n Assessment:\n Initially c/o lower abdominal pain, tolerable, , has stated this\n has been constant. Bowel sounds positive, abdomen soft and obese,\n tender to palpation.\n Action:\n CT done but showed nothing acute to explain pain. Monitoring pain,\n abdominal exam.\n Response:\n Slightly elevated amylase may be indicative of a mild pancreatitis.\n Pain remains even after eating. Describes at crampy and gassy (had\n received kayxelate). This morning pain , given 650mg tylenol.\n Plan:\n Monitor for worsening pain. No IVF for now. Consider imaging if\n conservative measures not effective.\n Hypoglycemia\n Assessment:\n Blood sugar 125 upon arrival to MICU. Received on D5.45NS @75cc/hr.\n Action:\n Stopped IVF\ns. Allowed patient to eat and drink. Monitoring blood\n sugars.\n Response:\n AM blood sugar 65.\n Plan:\n MD aware, no intervention at this time. Continue to follow\n fingersticks.\n v Alert and oriented x3. Able to ambulate to bed, get up to\n commode without difficulty.\n v HR 70-80\ns SR, BP 130-150\ns/90-100\ns. Will start his\n antihypertensives in the morning unless he has a spike in his BP.\n v Lung sounds clear, on 2L nasal prongs, RR 10-18 with sats >95%.\n Occasional strong, nonproductive cough. No SOB at this time.\n v Afebrile, no current ID issues.\n v Will be called out this morning, possibly before HD.\n" }, { "category": "Nursing", "chartdate": "2158-06-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 380955, "text": "HPI:\n Mr. is a 48 year old male with a history of end stage renal\n disease, hypertension, hypercholesterolemia and substance abuse who\n presents from home with fatigue, decreased PO intake, nausea,\n difficulty breathing and diffuse abdominal pain. He was in his usual\n state of health until two weeks prior to presentation. Last dialysis\n was two weeks ago. He received dialysis at Frecenius dialysis (, , Sa). He does not have a particular reason for skipping\n dialysis. He continued to feel worse and worse. On the day of\n presentation he noted that his breathing was worse and he decided to\n come to the emergency room.\n In the ED, initial vs were: T 97.3 BP 149/103 P 80 R 19 O2 sat 100% on\n RA. Patient was given kayexylate 30 mg, calcium gluconate 10 mg, 1 amp\n sodium bicarbonate, 10 units IV insulin and 1 amp D50 IV x 2. He had a\n CT abdomen without contrast which was negative for acute process. CXR\n did not show significant volume overload.\n On arrival to the emergency room he has no specific complaints. No\n fevers, chills. He has noticed diffuse chest pain which he has had in\n the past. He has mild difficulty breathing improved with supplemental\n oxygen. Diffuse bilateral lower quadrant abdominal pain. Mild\n non-productive cough. Mild diarrhea, no constipation. No melena or\n hematochezia. Mild lower extremity edema present. No leg pain. No\n confusion. No known weight gain.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Am K+ down to 5.4 after kayexalate, insulin & dextrose\n Action:\n Hemodialysis done today x 3 hrs via L AV fistula\n Response:\n Tolerated HD well\n Plan:\n TX to floor after HD, PM lytes\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abdominal pain this am, no N/V, large loose stool x1, mildly\n elevated lipase & amylase\n Action:\n Po Tylenol for pain x 1, HD done this am x 3 hrs, on renal diet\n Response:\n Abdominal pain improving\n Plan:\n Continue to follow abdominal pain, if abdominal pain worsens may keep\n pt NPO\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ABDOMINAL PAIN;SHORTNESS OF BREATH;HYPERKALEMIA\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 104.6 kg\n Daily weight:\n Allergies/Reactions:\n Nickel\n Rash;\n Precautions:\n PMH: HEMO or PD, Renal Failure\n CV-PMH: Hypertension\n Additional history: hypercholesterolemia, GERD, Migraines, Poly\n substance abuse including cocaine/ETOH/crack/marijuana\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:96\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,340 mL\n 24h total out:\n 200 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:25 AM\n Potassium:\n 5.4 mEq/L\n 04:25 AM\n Chloride:\n 93 mEq/L\n 04:25 AM\n CO2:\n 28 mEq/L\n 04:25 AM\n BUN:\n 110 mg/dL\n 04:25 AM\n Creatinine:\n 21.4 mg/dL\n 04:25 AM\n Glucose:\n 79 mg/dL\n 04:25 AM\n Hematocrit:\n 31.8 %\n 04:25 AM\n Finger Stick Glucose:\n 82\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: cell phone, keys, wallet with $2, no credit cards\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 7\n Transferred to:\n Date & time of Transfer:\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ABDOMINAL PAIN;SHORTNESS OF BREATH;HYPERKALEMIA\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 104.6 kg\n Daily weight:\n Allergies/Reactions:\n Nickel\n Rash;\n Precautions:\n PMH: HEMO or PD, Renal Failure\n CV-PMH: Hypertension\n Additional history: hypercholesterolemia, GERD, Migraines, Poly\n substance abuse including cocaine/ETOH/crack/marijuana\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:155\n D:103\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,340 mL\n 24h total out:\n 200 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:25 AM\n Potassium:\n 5.4 mEq/L\n 04:25 AM\n Chloride:\n 93 mEq/L\n 04:25 AM\n CO2:\n 28 mEq/L\n 04:25 AM\n BUN:\n 110 mg/dL\n 04:25 AM\n Creatinine:\n 21.4 mg/dL\n 04:25 AM\n Glucose:\n 79 mg/dL\n 04:25 AM\n Hematocrit:\n 31.8 %\n 04:25 AM\n Finger Stick Glucose:\n 82\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: micu 7\n Transferred to: 210\n Date & time of Transfer: 2300\n" }, { "category": "ECG", "chartdate": "2158-06-22 00:00:00.000", "description": "Report", "row_id": 212685, "text": "Sinus rhythm. Compared to the previous tracing no diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2158-06-21 00:00:00.000", "description": "Report", "row_id": 212686, "text": "Sinus rhythm. Compared to the previous tracing multiple abnormalities persist\nwithout major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2158-06-21 00:00:00.000", "description": "Report", "row_id": 212687, "text": "Sinus rhythm. Left atrial abnormality. Left axis deviation. Left\nventricular hypertrophy. Diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of multiple abnormalities as noted\npersist without major change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2158-06-21 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1087467, "text": " 3:44 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: NV and abd pain, on Hemodialysis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with abd pain\n REASON FOR THIS EXAMINATION:\n NV and abd pain, on Hemodialysis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf WED 8:17 PM\n Limited scan due to lack of IV contrast. No definite abnormality to explain\n patient's pain.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48-year-old man with abdominal pain, nausea, vomiting, on\n hemodialysis.\n\n TECHNIQUE: CT abdomen and pelvis with oral contrast. No IV contrast was\n administered.\n\n COMPARISON: Compared to CT abdomen and pelvis from .\n\n FINDINGS: There is right basilar dependent atelectasis.\n\n Study is limited for evaluation of solid organs due to lack of IV contrast. In\n the right lobe of the liver, there is a hypodense lesion, 2:8, which appears\n stable in size, though cannot be characterized. Gallbladder, pancreas appear\n normal. Kidneys contain hypoattenuating lesions, which are too small to be\n characterized on the current scan. The bowel appears grossly normal. There\n are no pathologically enlarged lymph nodes within the retroperitoneum or\n mesentery. The adrenal glands appear normal. No free fluid. No free air. There\n is no evidence of bowel obstruction. There are small scattered diverticula in\n the colon; however, there is no evidence of diverticulitis.\n\n CT PELVIS: The sigmoid, urinary bladder and seminal vesicles appear within\n normal limits. There is no free fluid in the pelvis.\n\n OSSEOUS STRUCTURES: There are lucent and sclerotic bony changes likely\n reflective of renal osteodystrophy.\n\n IMPRESSION:\n\n 1. No acute findings in abdomen and pelvis.\n\n 2. Hypodense lesion in the abdominal to liver, incompletely evaluated due to\n lack of IV contrast.\n\n 3. Hypodense renal lesions, not fully characterized.\n\n 4. Bony changes compatible with renal osteodystrophy.\n\n\n (Over)\n\n 3:44 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: NV and abd pain, on Hemodialysis\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2158-06-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1087473, "text": " 4:01 PM\n CHEST (PA & LAT) Clip # \n Reason: chest pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n chest pain\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old male with chest pain.\n\n COMPARISONS: CT and radiograph .\n\n PA AND LATERAL CHEST: Left ventricular configuration of the heart is\n unchanged. The mediastinal and hilar contours are stable. The lung volumes\n are low likely accounting for minimal bibasilar linear atelectasis. There is\n no focal consolidation. No pleural effusion or pneumothorax. Relative\n increased density of the vertebral endplates is consistent with renal\n osteodystrophy.\n\n IMPRESSION: Low lung volumes. No acute cardiopulmonary process.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 102561, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 125\nBSA (m2): 1.62 m2\nBP (mm Hg): 128/74\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 15:25\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\nglobal LV hypokinesis. Moderately depressed LVEF. [Intrinsic LV systolic\nfunction likely depressed given the severity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR].\n\nAORTA: Mildly dilated ascending aorta. Normal aortic arch diameter.\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. Significant\nPR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity is mildly dilated. There is moderate global left\nventricular hypokinesis. Overall left ventricular systolic function is\nmoderately depressed. [Intrinsic left ventricular systolic function is likely\nmore depressed given the severity of valvular regurgitation.] The right\nventricular cavity is dilated. Right ventricular systolic function is\nborderline normal. [Intrinsic right ventricular systolic function is likely\nmore depressed given the severity of tricuspid regurgitation.] The ascending\naorta is mildly dilated. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are mildly thickened. Moderate to severe (3+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar except that the effusion is now smaller (however it was small on the\nprior study).\n\n\n" }, { "category": "ECG", "chartdate": "2111-02-16 00:00:00.000", "description": "Report", "row_id": 295393, "text": "Sinus bradycardia. Left atrial abnormality. Prolonged QTc interval.\nAnteroseptal ST-T wave abnormalities, cannot rule out myocardial ischemia.\nCompared to the previous tracing of the rate has significantly slowed,\nQTc interval prolongation and anteroseptal ST-T wave abnormalities are new.\nClinical correlation is suggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-02-16 00:00:00.000", "description": "Report", "row_id": 1439138, "text": "See data, MD notes/orders. Received alert and oriented 53 year old woman to ICU in no acute distress who presented from Dialysis center to the ER with hypotension. Most recent admission was on . Pt states she has not felt her self for the last several weeks. \"I know my body and it's not right.\" She also states she was not dialized this past Friday because the transporation she arranged did not pick her up. Currently she is alert and oriented and complains of sob and itching.\nNeuro: A&O x 3\nCV: SR/no ectopy, Sbp supported with dopamine gtt currently at 9mcg/kg/min and last cycled blood pressure 122/94.\n\nPulm: 2L nc in place, dry non productive cough noted. Lungs clear, decreased at right base. Pt states her breathing feels \"much better.\"\nShe sleeps with five pillows or sits up at the side of the bed or on the couch.\n\nGU: HD pt, states she voids small quantities several times daily.\n\nGI: Abd soft, bs present, last bm .\n\nSkin: Surfaces grossly intact with palpapble peripheral pulses. Left AV fistula with +thrill and bruit.\n\nSoc: Pt has 4 children, lives with her seventeen year old son and states her hcp is her daughter .\n\nPlan: Being discussed at present by ICU team and the attending physician. Renal MD this pm is to 2-3 liters of fluid off with dialysis. ?Swan Ganz catheter for further cardiac function evaluation. Will notify pts at her request.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-16 00:00:00.000", "description": "Report", "row_id": 1439139, "text": "Adendum: I spoke with pts daughter at to inform her of pts admission to ICU as she was listed at pts HCP.Pts daughter states her mother does not discuss her health care issues with her. At that time she was told the pts condition was stable and that in the event of an emergent change in condition that we would proceed with emergency measures. Pt stated to Dr. that she and her daughter talked several weeks ago about her wishes. Pt also stated to Dr. that she wants to continue treatment but with know heroic measures and status is now DNR/DNI. Message left by Dr. for to set up family meeting tomorrow with pt so that poc and code status can be clarified for all. Message also emailed to social worker for same.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 1439142, "text": "MICU Nursing Progress Note 1500-1900\n\nCode: Full\nAllergies: NKDA\n\nPt admitted to EW from dialysis center because of hypotension and bradycardia. In EW pt found to have K+ 6.8, lactate 5. Pt noted to have missed dialysis appointment on . Given fluid bolus with minimal effect, started on dopa with good effect. Transferred to MICU for further care.\n\nEvents: Pt called out to floor, HD removed 3L, Dopa off since last night.\n\nNeuro: Pt A&O x 3, interacting appropriately with staff, at times can be mildly aggressive. MAE, able to get OOB to commode with no assistance. Pt refusing some meds. Pt denies pain.\n\nCV: HR SR/ST 98-114 with rare PVC, NBP 118-139/68-93. Dopamine drip remains off since last night, pt able to maintain stable BP. HD done today, removed 3L, left arm fistula intact/patent.\n\nResp: Pt on 2L NC, RR 18-30 with sats >94%. Lung sounds clear with intermittent wheezes in bilateral lower lobes. Pt complaining of mild SOB and chest tightness, given albuterol treatment x 2 and spiriva with good effect. Pt also has dry, non-productive cough.\n\nGI: BS x 4, abdomen soft. Soft, golden BM x 1. Tolerating regular, heart healthy diet well.\n\nGU: Pt receiving HD, anuric. Ordered for 2L fluid restriction which pt self monitors.\n\nEndo: Pt being checked q6h, covered on sliding scale. Pt refused daily order for prednisone.\n\nSocial: visiting RN in to visit today, no contact with family this shift.\n\nPlan:\npt called out to floor\nmonitor BS\nmonitor I&O, respiratory status\n" }, { "category": "Nursing/other", "chartdate": "2111-02-18 00:00:00.000", "description": "Report", "row_id": 1439143, "text": "Pt is a 53 y/o female who was brought into ED from Dialysis with hypotension to 60's and k of 6.8. Pt had missed previous HD session and was quite fluid overloaded. Started on Dopamine gtt and brought to MICU6 for monitoring and HD. Currently off Dopamaine and stable for call out.\n\nNeuro: A+O x3, mae, self care, ambulates with steady gait.\n\nResp: Lung sounds clear in apices and diminished in bases. O2 sat mid to high 90's on room air.\n\nCardiac: ST with no ectopy throughout night. HR 100-110's. B/P stable. 110-130's/60's. Echo done yesterday showing MVR, EF 35%, and left ventricly hypokinesis.\n\nGI: Abd soft/nontender with positive bowel sounds. Tolerating renal diet well. One loose bm. Blood sugars unremarkable.\n\nGU: anuric renal failure. AM lytes pending. 3L off from HD yesterday. Will be dialyzed again today.\n\nDerm: Uric acid buildup on skin causing itching at times. Skin otherwise intact. L arm fistula benign. Both piv's out. Currently with out access. IVRN in route.\n\nPlan: Call out to floor. Awaiting bed. HD run today. iv access.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 1439140, "text": "Respiratory Care:\n\nPatient admitted with hypotension. Pmhx: ESRD, Asthma, Copd. Pt. c/o sob. 2.5mg unit dose Albuterol neb given via mouthpiece. Tolerated well. HR 98, RR low 20's. BS few crackles R base, otherwise lungs clear with good aeration. O2 sats 100% on 4lpm nasal prongs. Dry non productive coughs.\nBS unchanged post rx. Pt. states she feel no different after therapy and that rx's don't help. No resp distress noted.\nPlan: Will continue to follow with nebs Q6prn.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 1439141, "text": "Nsg Progress Note 1900-0700\n\nCV - Afebrile. Able to wean dopa off by 2100 and BP stable throughout the night. HR 95-105 with occasional PVC. Labs pending.\n\nResp - BS cl with some crackles to right base. O2 at 2L via NC. Pt states breathing is \"much better\" than when she got to the hospital. She stills becomes SOB upon exertion and has a dry spont cough. Albuterol tx x2 given with min relief. Cepacol lozenges given for the cough with good relief.\n\nGI - Abd soft. Positive BS - pt OOB to bedside commode several times for small BM. Stool is soft, golden and foul smelling. Ravenous appetite. Pt ate all evening and is very anxious to order breakfast - ? increased appetite probably due to the prednisone.\n\nGU - no UO - pt is anuric. Pt tolerated HD well and they were able to take 3L fluid off. Left arm fistula intact and patent. Attempted to get repeat ABG to check pH but difficult stick and patient refused to allow any further attempts.\n\nEndocrine - BS up to 270 - started on RISS - 4am BS down to 191 and will recheck at 0600. Covered x2 with insulin.\n\nNeuro - Pt very awake and alert. Questioning POC and asking appropriate questions and expressing concerns about certain treatments and refusing others. She recieved benadryl x2 for itching with minimal relief. Also recieved seroquel x2 with min results. Pt very antsy and uncomfortable, hungry and itchy - slept very little over the course of the night. Pt is able to get OOB to commode with no assist.\n\nSocial - Daughter expressed concern about long term care of mother. is to organize a meeting between daughter, mother and to discuss wishes and concerns. No calls from family overnight although patient did make several phone calls to family members from the phone in her room.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2136-06-20 00:00:00.000", "description": "R VENOUS DUP EXT UNI (MAP/DVT) RIGHT", "row_id": 761508, "text": " 1:55 PM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: s/p multiple vascular surgeries, s/p left bka. Need vein map\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cad, htn, PVD\n REASON FOR THIS EXAMINATION:\n s/p multiple vascular surgeries, s/p left bka. Need vein map of right leg for\n conduit for BPG on \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preop for vascular bypass.\n\n FINDINGS: Duplex and color Doppler of the right lower extremity demonstrates\n patency of the greater and lesser saphenous veins. The lesser saphenous vein\n only measures approximately .1 cm from the ankle through to the popliteal\n vein. The greater saphenous vein is .15 cm just above the ankle and gradually\n increases to .34 cm at its insertion into the common femoral vein.\n\n IMPRESSION: Patent right greater and lesser saphenous veins, dimensions as\n described. Lesser saphenous vein is diminutive in size overall.\n\n" }, { "category": "Radiology", "chartdate": "2136-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 760936, "text": " 10:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: po check, r/o pneumonia. Pneumonia thorax intraop\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with acutely ischemic R leg. Cannot travel due to acute\n nature of incident. s/p fem-fem excision and aorto-fem biopsy\n REASON FOR THIS EXAMINATION:\n po check, r/o pneumonia. Pneumonia thorax intraop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop, rule out pneumonia.\n\n A single frontal chest radiograph dated is compared with prior\n chest radiograph dated . The cardiomediastinal and hilar contours\n are stable allowing for the patient's rotation. A right IJ catheter\n terminates in the SVC. There is no pneumothorax. The pulmonary vascularity\n is unremarkable. The lungs are clear. There are no pleural effusions.\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2136-06-16 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 761153, "text": " 1:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: s/p aorto-femoral bypass and L ax- bypass, falling hct,\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ax and aorto fem bypass\n REASON FOR THIS EXAMINATION:\n s/p aorto-femoral bypass and L ax- bypass, falling hct, r/o bleeding\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post aorto fem bypass and left axillary bypass.\n Dropping hematocrit. Evaluate for hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis, with the administration of oral\n contrast only.\n\n CT ABDOMEN: There are bilateral pleural effusions, left greater than right\n with consolidation at the left lung base likely representing passive\n atelectasis. The liver, pancreas, spleen, adrenal glands and kidneys are\n unremarkable on this unenhanced study. The patient is status post\n cholecystectomy. Heterogeneous 7 x 4.7 cm soft tissue density is noted in the\n left posterior pararenal space, displacing the left kidney anteriorly. This\n is adjacent to the new aorto fem bypass graft and psoas muscle.\n\n CT PELVIS: The right axillary femoral bypass graft is noted. A large soft\n tissue defect is noted adjacent to the distal end of the prior left axillary\n bypass graft. This graft cannot be visualized below this level, and there is a\n single focus of gas within its lumen. There is a large amount of soft tissue\n stranding and heterogeneous soft tissue density in the region of the left\n iliac vessel. The femoral/femoraly bypass graft also appears to have a focus\n of gas within its lumen. A large surgical defect within the soft tissues is\n noted adjacent to the prior femoral anastomosis site. A large amount of\n subcutaneous edema is noted along the upper thighs and hips. The rectum,\n sigmoid colon are unremarkable. There is no deep pelvic free fluid or\n lymphadenopathy. A Foley catheter is noted decompressing the bladder. Surgical\n clips are seen in the right adnexa.\n\n The osseous structures are unremarkable.\n\n IMPRESSION:\n 1) 7 x 4.7 cm heterogeneous soft tissue mass within the left posterior\n perirenal space extending from the region of the aorto-fem bypass anastomosis\n site. Smaller heterogeneous foci are noted extending into the region of the\n left iliac vessels. No sentinal clot sign, consistent with a more active\n focus of bleeding is noted. These findings are consistent with recent\n hematoma formation.\n 2) Apparently abandoned left axillary fem bypass and fem-fem bypass grafts\n giving the presence of air within its lumen and lack of both proximal and\n distal anastomosis sites. Clinical correlation with the surgical history is\n (Over)\n\n 1:39 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: s/p aorto-femoral bypass and L ax- bypass, falling hct,\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n recommended.\n 3) Bilateral pleural effusions, left greater than right with probable passive\n atelectasis at the left lung base.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2136-06-06 00:00:00.000", "description": "ATHERECTOMY FEM/POP", "row_id": 760375, "text": " 12:56 PM\n UNI-LAT FEMORAL Clip # \n Reason: 57 YO FEmale s/p multiple procedures most recently l ax fem-\n Contrast: OPTIRAY Amt: 75\n ********************************* CPT Codes ********************************\n * ATHERECTOMY FEM/ -51 MULTI-PROCEDURE SAME DAY *\n * ATHERECTOMY FEM/ -59 DISTINCT PROCEDURAL SERVICE *\n * PTA FEMORAL/POPLITEAL -51 MULTI-PROCEDURE SAME DAY *\n * INITAL 3RD ORDER ABD/PEL/LOWER -51 MULTI-PROCEDURE SAME DAY *\n * ADD'L 2ND/3RD ORDER ABD/PEL/LO ATHERECTOMY PERIPHERAL ARTERY *\n * ATHERECTOMY EA ADD'L PERIPHERA PTA PERIPHEREAL ARTERY *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * IV CONSCIOUTIOUS SEDATION PRO NON-IONIC LESS THAN 100CC *\n * NON-IONIC LESS THAN 100CC REMOVL CLOT IN GRAFT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with acutely ischemic leg. Long vascular surgery history.\n (1) Aortobifem ', revised ' (2) fem-fem revision, then removal ' (3) L ax\n\n vein patch '\n REASON FOR THIS EXAMINATION:\n 57 YO FEmale s/p multiple procedures most recently l ax fem-fem requiring\n several revisions now with acutely ischemic right limb--cool right foot with no\n pulses.\n Please assess for thrombosis and possible interventions.\n ______________________________________________________________________________\n FINAL REPORT\n\n EXAMINATION: Right leg runoff on .\n\n HISTORY: 58 year old woman with a long history of extensive peripheral\n vascular disease. She is status post left axillo-bifemoral bypass graft in\n and a femoro-femoral bypass graft. She is status post multiple graft\n revisions and thrombectomies for recurrent graft thromboses. She now presents\n with acute right lower extremity ischemia.\n\n RADIOLOGISTS: Drs. and (the Attending Radiologist) who was\n present and supervised the entire procedure.\n\n TECHNIQUE: The procedure was explained to the patient, and informed consent\n was obtained.\n\n The patient's left flank was prepped and draped in the usual sterile manner\n and ultrasound examination for visualization of the left axillo-femoral graft\n was done. Using ultrasound guidance, the graft was accessed in an antegrade\n fashion using a 19-gauge needle. A 0.035 Glidewire was subsequently advanced\n under fluoroscopic guidance into the femoro-femoral bypass, and the needle was\n exchanged for a 6-French vascular sheath. A 5-French catheter was then\n advanced through the sheath and positioned in the right superficial femoral\n artery. With the catheter in that position, a right leg runoff was performed.\n\n The catheter was then withdrawn into the proximal portion of the femoro-\n (Over)\n\n 12:56 PM\n UNI-LAT FEMORAL Clip # \n Reason: 57 YO FEmale s/p multiple procedures most recently l ax fem-\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n femoral bypass graft, and a contrast injection was performed. The catheter\n was then removed and with the vascular sheath tip within the distal portion of\n the axillo-femoral graft, contrast injection was performed for visualization\n of the distal anastomosis and the proximal left leg runoff.\n\n A 6-French Possis thrombectomy catheter was then advanced through the sheath\n and into the right superficial femoral artery across the femoro-femoral bypass\n graft, and thrombolectomy was performed under fluoroscopic guidance. The\n catheter was withdrawn proximally into the native right common femoral artery,\n then into the native profunda femoral artery. It was subsequently withdrawn\n retrograde into the femoro-femoral bypass graft, then into the distal portion\n of the axillo-femoral graft. This was repeated multiple times until all the\n existing thrombus was cleared. Repeat contrast injection through the\n angiographic sheath positioned in the axillo-femoral graft was performed to\n visualize that distal anastomosis. This was subsequently angioplastied using\n a 4-mm balloon, then a 6-mm balloon, then an 8-mm balloon. The balloon was\n inflated repeatedly under fluoroscopic guidance across the distal axillo-\n femoral graft and into the femoro-femoral graft.\n\n A control angiogram was then performed through the sheath, with the tip\n positioned in the distal axillo-femoral graft.\n\n The sheath was then removed, and manual compression was maintained at the\n graft puncture site until hemostasis was achieved.\n\n The patient tolerated the procedure without immediate complication.\n\n MEDICATIONS/CONTRAST: A total of 75 cc of non-ionic contrast was utilized\n secondary to the patient's severe debilitation. She also received a total of\n 4 mg of Dilaudid and 2.5 mg of Versed, in divided doses under continuous\n hemodynamic monitoring, for conscious sedation.\n\n FINDINGS: Preliminary ultrasound examination of the axillo-femoral graft\n demonstrated markedly decreased blood flow. No Dopplerable signal could be\n obtained over the femoro-femoral bypass graft.\n\n Preliminary arteriogram demonstrated intraluminal filling defects extending\n across the femoro-femoral bypass graft, and into the native common femoral\n artery, and down into the proximal portion of the right superficial femoral\n artery. No contrast was seen flowing into the native profunda femoral artery.\n There was antegrade flow into the native left profunda femoral artery.\n Retrograde flow was also noted into the axillo-femoral graft, proximal to the\n puncture site, demonstrating a markedly narrowed lumen.\n\n Right leg runoff demonstrated a patent distal superficial femoral artery and a\n popliteal artery, without evidence of intraluminal filling defect. Below the\n (Over)\n\n 12:56 PM\n UNI-LAT FEMORAL Clip # \n Reason: 57 YO FEmale s/p multiple procedures most recently l ax fem-\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n knee, a two-vessel runoff was present to the distal leg, with a good-caliber\n posterior tibial artery at the level of the ankle.\n\n Control angiogram following thrombolectomy with the Possis Angiojet\n demonstrated no residual thrombus in the femoro-femoral bypass graft and in\n the proximal right superficial femoral artery. The right profunda femoral\n artery also demonstrated flow without evidence of thrombus. A focal high-\n grade stenosis was revealed at the proximal anastomosis of the femoro-femoral\n bypass graft. This was successfully angioplastied up to 8 mm using an\n angioplasty balloon.\n\n Final arteriogram demonstrated no evidence of residual clot and a patent\n proximal femoro-femoral bypass graft.\n\n Following removal of the access catheter and compression, the right leg\n circulation transiently improved with diminished mottling and increased\n warmth. Following hemostasis, however, no Dopplerable pulses could be\n elicited in the right leg.\n\n IMPRESSION:\n\n 1) Thrombosed femoro-femoral bypass graft and proximal right leg runoff down\n to the distal superficial femoral artery.\n\n 2) Transient restoration of antegrade flow following catheter-directed\n thrombolectomy (Possis Angiojet) and balloon angioplasty of a proximal femoro-\n femoral bypass stricture up to 8 mm.\n\n 3) Diminished flow within the axillo-femoral graft suggesting a proximal\n inflow problem.\n\n These findings were communicated to the Vascular Surgery team upon completion\n of the study.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2136-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 760373, "text": " 12:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for infiltrate/CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with acutely ischemic R leg. Cannot travel due to acute\n nature of incident.\n REASON FOR THIS EXAMINATION:\n Assess for infiltrate/CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acutely ischemic right leg, assess for infiltrate or CHF.\n\n COMPARISON: \n\n CHEST, PORTABLE: The cardiac and mediastinal contours appear normal. The lungs\n are clear. There are no pleural effusions. The pulmonary vasculature appears\n normal. The osseous structures appear normal.\n\n IMPRESSION: No evidence for pneumonia or CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 760424, "text": " 1:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with acutely ischemic R leg. Cannot travel due to acute\n nature of incident.\n REASON FOR THIS EXAMINATION:\n ?CHF- also s/p rt IJ line placement- for position please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right IJ line placement.\n\n COMPARISONS: One day prior.\n\n SINGLE VIEW CHEST: A right IJ catheter terminates in the proximal SVC, in\n appropriate position. There is no pneumothorax. The cardiac and mediastinal\n contours appear normal. The lungs appear clear without evidence for focal\n consolidation. There are no pleural effusions. The pulmonary vasculature\n appears normal.\n\n IMPRESSION:\n\n 1. Appropriate positioning of right IJ line without evidence for pneumothorax.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-06-07 00:00:00.000", "description": "Report", "row_id": 1564374, "text": "S/P AXILLO/POPLIT BPG 11:45 PM-7A\nPT ARRIVED FORM OR @ 11:45PM S/P R AXIL/POPLIT BPG\nS- \"I HURT ALL OVER\"\nO-NEURO-PT A+ O X 3,MAE'S,FOLLOWS COMMANDS.SLEEPING OFF + ON DURING NOC.\nCV-SBP 80'S-130'S SBP,HR 50'S-80 SB->NSR.+DP/PT .NO VEA NOTED.\nRESP-SEE RESP FLOWSHEET FOR VENT/ABG DATA,PT PLACED ON T-PIECE THIS AM,ABG 86/37/7.45/27/1.PT Q2-3HRS FOR SM AMTS THICK YELLOW SECRETIONS.\nGI/GU-PT NPO AFTER 2A / EXTUB TODAY.LOW RESID.U/O ADEQ CLEAR YELLOW URINE VIA FOLEY CATH.\nSKIN-NO NEW ISSUES\nID-T MAX 100\nENDO-FS/SS INSULIN/ORDERS\n NEPHEW VISITED ON EVES.\nA-?EXTUBATE TODAY\nP-NEURO CHECKS,VS,I+O,?EXTUB TODAY,,MONIOTR LAB DATA,,MONITOR SKIN INTEGRITY QS AND PRN,FS/SS/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2136-06-07 00:00:00.000", "description": "Report", "row_id": 1564375, "text": "T-SICU NURSING NOTE\nROS/\n\nNeuro: Pt awake, oriented x 3. Using Dilaudid PCA appropraitely. Pain well managed until approximately early this afternoon when pt experienced LLE pain, ? ischemic pain, LLE slightly cool to touch. ICU team & vascular team aware, in to assess pt. Pt medicated with Fentanyl 100mcg x 2 with gd effect. Pain improved after above.\n\nCV: SR, SBP 90-100's. Rt DP dopplerable, PT palpable. CK,MB, troponin sent 1300. Next check at 2100. EKG improved.\n\nResp: Lungs clear. RR reg nonlabored. O2 2L NC\n\nRenal: U/O qs\n\nGI: NPO. Hypo BS\n\nHeme: Hct 23 post 1 unit PRBCS; Transfused another unit PRBCS\n\nID: Lograde temps\n\nSkin: Incsions with dsgs intact. Rt flank & Lt arm ecchymotic\n\nSocial: husband visiting this afternoon. Info & support provided.\n\nA/P: Pt s/p revasc RLE, continue fluid resuscitation with PRBCS. Continue hemodynamic monitoring, cycle CK, MBs, troponin, monitor pulses, pain management.\n" }, { "category": "Nursing/other", "chartdate": "2136-06-07 00:00:00.000", "description": "Report", "row_id": 1564376, "text": "SICU NURSING NOTE 3P-7P\n PT STATUS UNCHANGED. 1UPRBC GIVEN WITH NO S/S OF REACTION. HEMODYNAMICALLY STABLE. U/O ADEQUATE. PAIN MANAGED WELL WITH DILAUDID PCA. FIRST STEP MATTRESS ORDERED.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-06-07 00:00:00.000", "description": "Report", "row_id": 1564377, "text": "t/sicu transfer note\nThis is a unfortunate female who is s/p axilla/ popliteal bpg sec pta pt presented to osh with cool pulseless rle. Pt arrived to t/sicu and is now to be transferred to vicu\n\npmh/psh: cad/htn/s/p chole appy, tah, 92 aortobifem which became infected and removed, left axibifem in 96, revision of in 97, thrombectomy in 02, r groin debridement sec to infection, s/p left femangio 80 and left bka.\n\nallergies: mso4\n\nr.o.s.: neuro: pt a & o x 3, mae's, f/c's, appropriate. using dilaudid pca with adequate relief.\n\ncv: hr nsr occass ectopy, lytes low repleted, r leg pulses dopp, bp stable. Pt had cp earlier, no cp today yet r/i for mi with cpk 12,000, troponin 12 and next pending. no ekg changes\n\nresp: lungs clear, no sob, gd cough, nonprod. ra sat 98%.\n\ngi: abd soft, hypoactive bs, no bm, npo.\n\ngu: foley draining qs yellow urine\n\nact: pt moves with 1 assist in bed tol well.\n\nskin: bruising noted on r side inc sites with dsd and covered with tegaderm r chest, r abd, r groin r leg.\n\nheme: hct 29.2 after 3 u today. team wants above 30 recieving 1u prbc's now.\n\nid: afebrile, no abx.\n\nsocial: husband in this afternoon, son is care proxy.\n\na/p: cont to monitor, pt r/i for mi with cpk and triponin, no ekg changesmonitor hemodynamics, increase act as tol, pulm toilet, skin care, support, as per plan\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-06-06 00:00:00.000", "description": "Report", "row_id": 1564373, "text": "SICU ADMISSION 430-7P\n PT WAS SENT TO FROM OSH HOSPITIAL AFTER WAKING THIS AM WITH PAINFUL, COLD, AND PULSELESS RLE. SENT TO ANGIO FOR THROMOBOLYSIS WITH NO EFFECT. TO SICU FOR FURTHER EVALUATION.\n\nPMHX: HTN, CAD, HIGH CHOLESTEROL, AND MULTIPLE VASCULAR SURGERIES THAT WERE C/B SEVERAL GRAFT INFECTIONS. L BKA\nALL: MORPHINE\nSOCIAL: LIVES WITH HUSBAND . PT HAS 3 CHILDREN. SON IS HER HEALTH CARE PROXY.\n\nREVIEW OF SYSTEMS\n\nNEURO: PT 3 AND ANXIOUS AT TIMES. MEDICATE WITH DILAUDID PCA FOR PAIN WITH EFFECT. WEEPY AT TIMES D/T IMPENDING SURGERY.\n\nCV: HEMODYNAMICALLY STABLE. NO VEA. SLIGHTLY HTN WITH PAIN AND ANXIETY. RLE COOL AND MOTTLED WITH NO DOPPLERABLE PULSE. ANGIO SITE INTACT WITH NO HEMATOMA NOTED. 2 PIVS. DR INTO EVAL LEG.\n\nRESP: L/S CLEAR. NO SOB OR RESP DISTRESS NOTED. 022L NC WITH GOOD SATS.\n\nGI: NPO. ABD SOFT WITH +BS. NO STOOL OR FLATUS.\n\nGU: U/O ADEQUATE VIA FOLEY. IVF LR AT 100CC/HR.\n\nHEME: STABLE. HEPARIN GTT STARTED AT 1000U/HR WITH NO BOLUS.\n\nENDO: NO ISSUES\n\nID: PT JUST FINISHED 10DAY COARSE OF BACTRIM FOR YEAST INFECTION. AFEBRILE.\n\nSKIN: COCCYX PINK AND UNBROKEN FROM ANGIO TABLE.\n\nSOCIAL: HUSBAND INTO SEE PT.\n\nP: OR TONIGHT FOR VASCULAR SURGERY.\n\n" }, { "category": "Echo", "chartdate": "2136-06-11 00:00:00.000", "description": "Report", "row_id": 68118, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 130\nBSA (m2): 1.56 m2\nBP (mm Hg): 116/50\nStatus: Inpatient\nDate/Time: at 15:20\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. No mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\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 and\ncavity size are normal. Overall left ventricular systolic function appears\ngrossly preserved. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion. Mild (1+) aortic regurgitation is seen.\nThe mitral valve leaflets are structurally normal.\n\n\n" }, { "category": "ECG", "chartdate": "2136-06-20 00:00:00.000", "description": "Report", "row_id": 163223, "text": "Sinus rhythm with slowing of the rate compared to the previous tracing\nof . In addition, there is improvement in the ST-T wave abnormalities\npreviously recorded in leads II, III and aVF. There are now upright T waves in\nlead II and ST-T wave flattening in lead aVF. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2136-06-12 00:00:00.000", "description": "Report", "row_id": 163224, "text": "Sinus rhythm\nInferior nonspecific ST-T abnormalities\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2136-06-08 00:00:00.000", "description": "Report", "row_id": 163225, "text": "Sinus rhythm. Short P-R interval. Non-specific ST-T wave flattening in\nlead aVF. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2136-06-07 00:00:00.000", "description": "Report", "row_id": 163226, "text": "Sinus rhythm,upper normal rate\n ST junctional depression is nonspecific\nlateral T wave flattening\nSince previous tracing, increased heart rate, T wave abnormalities more marked\n\n" }, { "category": "ECG", "chartdate": "2136-06-07 00:00:00.000", "description": "Report", "row_id": 163227, "text": "Sinus rhythm\nSince previous tracing, heart rate decreased\nNormal ECG\n\n" }, { "category": "ECG", "chartdate": "2136-06-06 00:00:00.000", "description": "Report", "row_id": 163228, "text": "Sinus rhythm\nNondiagnostic ST-T abnormalities\nNormal ECG\n\n" } ]

[ { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624357, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624360, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624351, "text": "Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency.\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 624465, "text": "66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. She noted recent dietary changes (started South Beach diet\n with 10lb weight loss) and also recent self DC of statin(2 weeks ago\n abdominal burning). She also reports resuming alcohol use - last\n drink 5 glasses of wine on . Last Hct in system 49 in .\n On admission to EW her hct was 20 and INR 12.7. She was and has been\n hemodynamically stable. Treated with\n 2 bags FFP, 10mg IV Vit K and IV pantoprozole in EW.\n Seen by GI who plan to scope pt today. Given 4 units PRBC\ns overnight\n total with repeat hct 25.3 this AM. Pt called out to the floor as she\n is stable. She has not had elevated CIWA and says she has been dry for\n 11/2 years except for the wine recently.\n Her foley is d/c\nd at 0930 this AM. Has had not stools for guaiac.\n She is anxious for discharge home ASAP.\n Anemia/Elevated INR with hematuria and numerous surface\n bruising(hematoma)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2187-04-04 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 624345, "text": "Chief Complaint: Coagulopathy\n Atrial Fibrillation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient to ED with dyspnea and easy bruising. In addition, patient\n with dark, loose stools and recent evidence of gastroenteritis with\n nausea and diarrhea. Then evolved bruising on chest and legs and arms\n and with hematuria patient to ED for evaluation.\n She has maintained regular dosing of coumadin across time and has\n maintained dosing at 7.5mg/d with 10mg on Thursday. Patient now to\n south beach diet and across first week patient has lost 10 pounds in\n first week but has moved largely to protein only diet.\n In ED-->\n INR=12.7\n HCT=20.1 (baseline at 49 some time ago)\n Given significant coagulopathy and blood loss anemia patient to ICU for\n further care after FFP 2 units given\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n A-Fib--s/p cardioversion (failed), on coumadin chronically\n EtOH abuse--relapse of past week with 5 drinks Friday evening\n --normal colonscopy\n Non-contributory for coagulopathy or atrial fibrillation\n Occupation: Ret'd\n Drugs: None\n Tobacco: None\n Alcohol: H/O abuse, recent use\n Other:\n Review of systems:\n Constitutional: Fatigue\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea\n Genitourinary: No(t) Dysuria, Foley\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:33 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 95 (95 - 96) bpm\n BP: 113/51(65) {113/51(65) - 118/58(70)} mmHg\n RR: 19 (19 - 20) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: L-peri-orbital ecchymosis\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), irregularly irregular\n Peripheral 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: Chest wall ecchymosis\n Abdominal: Soft, Non-tender, Bowel sounds present, OB Positive Stool,\n blood tinged urine\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed, Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 178\n 20.1\n 0.7\n 23\n 13.6\n [image002.jpg]\n Other labs: PT / PTT / INR://12.7\n Fluid analysis / Other labs: U/A >50 RBC's\n ECG: A-Fib--no significant ischemic changes seen\n Assessment and Plan\n 66 yo female with history of atrial fibrillation and with chronic\n anticoagulation with Coumadin now admitted with significant\n coagulopathy with evidence of GI and GU bleeding. This is in the\n setting of coumadin but also with recent change in diet as well as\n gastroenteritis with concern for source of significant blood loss.\n 1) GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)-\n -2 peripheral IV's in place\n -Will correct coagulopathy with Vitamin K (10mg in ED) and FFP (2 units\n in ED), PRBC (2 units in ED)\n -HCT q 8 hours\n -Prep for EGD and colonoscopy in morning\n -PPI \n -ASA and coumadin given\n 2) ATRIAL FIBRILLATION (AFIB)-\n -Follow for rate control and lopressor if needed\n -Hold coumadin while in house\n -Hold on ASA\n -All pending stability of HCT across time\n 3)Hematuria-\n -likely related to coagulopathy\n -WIll re-evaluate for infection\n -Further investigations based upon resolution across time\n 4)Anemia--Secondary to Blood Loss\n -HCT q 8 hours\n -2 IV's in place\n -Transfuse for acute decrease in HCT or trend towards 21\n -Further evaluation if not stabilzied with GI bleed resolved.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2187-04-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 624349, "text": "Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALBUTEROL SULFATE INH Q4-6H PRN\n ATENOLOL 25 mg QD\n DESONIDE 0.05 % Ointment \n ESTRADIOL 25 mcg Tablet IV BID\n SIMVASTATIN 20 mg QHS (not taking)\n WARFARIN 7.5 mg daily\n ASPIRIN 81 mg QD\n CALCIUM 500 + 200 D twice a day\n CHOLECALCIFEROL 1,000 unit daily\n LORATADINE 10 mg daily PRN\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Father died of a MI at the age of 55; Mother had heart trouble and\n emphysema.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol: Had been sober for one year until the last week, her last\n drink was 4 days prior to admission.\n Other: Patient is very active and exercises five days a week, cardio,\n biking, hiking for 60+ minutes.\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea\n Gastrointestinal: Nausea, Emesis, Diarrhea\n Genitourinary: hematuria\n Integumentary (skin): ecchymoses\n Flowsheet Data as of 02:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 96 (96 - 96) bpm\n BP: 118/58(70) {118/58(70) - 118/58(70)} mmHg\n RR: 20 (20 - 20) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\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), Irregularly, irregular\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 lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, numerous ecchymoses over chest, back, hands, buttock, left\n leg, and left periorbital & left oral area\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 178\n 7.0\n 0.7\n 23\n 25\n 100\n 3.7\n 136\n 20.1\n 13.6\n [image002.jpg]\n Other labs: PT / PTT / INR:101.7/40.4/12.7\n ECG: Afib rate of 90, PVC, no ST/Twave chnages as compared with\n .\n Assessment and Plan\n 66F with Afib on coumdain, remote h/o ETOH abuse, CAD risk factors on\n aspirin presents with hematuria and easy bleeding found to have new\n anemia and supratherapeutic INR of 12.\n # GI Bleed - Patient was not levaged in ED concern of inducing more\n trauma and bleeding with elevated INR. Received FFP x2, Vit K 10mg IV\n x1 in ED. Per patient, had normal colonoscopy in (records not in\n our system). Melena has been ongoing for 5 days supporting lower GI\n source(post-pyloris) in the absence of bloody vomiting over the weekend\n when this all started.\n - PIVs large bore x2\n - transfuse 2 units PRBC, then trend HCT, transfuse if continues to\n drop\n - 40mg IV PPI \n - NPO for now\n - monitor on tele\n - trend hct q8H\n - EGD and colonscopy when stable\n - appreciate GI recs\n - hold ASA/coumadin\n # Hematuria - Likely elevated INR.\n - f/u urine cx\n - repeat UA once INR reversed to ensure hematuria resolved\n - Will need outpatient f/u\n # Afib on Coumadin - Prior cardioversion with return to Afib.\n - hold coumadin in setting of GI bleed\n - hold atenolol in setting of GI bleed\n - hold ASA\n - will discuss w/ PCP/Cardiology plan for resuming coumadin once GI\n bleeding resolved\n # Hypercholesterolemia - Hold Simvastatin 20mg qHS, patient\n self-discontinued in the context of abdominal burning\n # History of alcoholism - Patient reports sobriety over past year,\n until last week. No EtOH in last 96 hours.\n - No need for CIWA at this time\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Comments: None\n Lines:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\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 # Leukocytosis\n No bands on diff. Likely stress response from acute\n blood loss anemia\n - continue to trend\n - pan culture if spikes\n # Acute Blood Loss Anemia\n treatment as above for GI bleed\n # Afib on Coumdain\n PCP and cardiology aware of admit, will plan for\n outpatient assessment of need to resume coumadin, will plan on\n continuing to hold on discharge given CHADS of 0\n ------ Protected Section Addendum Entered By: , MD\n on: 14:59 ------\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624443, "text": "Alcohol abuse\n Assessment:\n Patient is not agitated CIWA 2 did complain of difficulty sleeping\n Action:\n Ativan 1mg po given repeated x1. pm care given , room dark door\n closed,\n Response:\n Patient dosed on and off after second dose of ativan\n Plan:\n Maintain quit dark room to promote sleep\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n No BM this shift no N/V HCT 21.6 after @ unit PRBC, INR 1.3 multiple\n bruises unchanged from admission\n Action:\n 2 unit PRBC infused , tolerated clear liquids , NPO after MN for\n endoscopy, OOB to commode flatus no stool\n Response:\n Post infusion HCT pending , Patient states she feels much better\n than she did morning of admission.\n Plan:\n Endoscopy, possible DC to floor.\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624444, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n Alcohol abuse\n Assessment:\n Patient is not agitated CIWA 2 did complain of difficulty sleeping\n Action:\n Ativan 1mg po given repeated x1. pm care given , room dark door\n closed,\n Response:\n Patient dosed on and off after second dose of ativan\n Plan:\n Maintain quit dark room to promote sleep\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n No BM this shift no N/V HCT 21.6 after @ unit PRBC, INR 1.3 multiple\n bruises unchanged from admission\n Action:\n 2 unit PRBC infused , tolerated clear liquids , NPO after MN for\n endoscopy, OOB to commode flatus no stool\n Response:\n Post infusion HCT pending , Patient states she feels much better\n than she did morning of admission.\n Plan:\n Endoscopy, possible DC to floor.\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624352, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency.\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624445, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n Alcohol abuse\n Assessment:\n Patient is not agitated CIWA 2 did complain of difficulty sleeping\n Action:\n Ativan 1mg po given repeated x1. pm care given , room dark door\n closed,\n Response:\n Patient dosed on and off after second dose of ativan\n Plan:\n Maintain quit dark room to promote sleep\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n No BM this shift no N/V HCT 21.6 after @ unit PRBC, INR 1.3 multiple\n bruises unchanged from admission\n Action:\n 2 unit PRBC infused , tolerated clear liquids , NPO after MN for\n endoscopy, OOB to commode flatus no stool\n Response:\n Post infusion HCT 25.3 , Patient states she feels much better than\n she did morning of admission.\n Plan:\n Endoscopy, possible DC to floor.\n" }, { "category": "Physician ", "chartdate": "2187-04-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 624452, "text": "Chief Complaint: CC: WEakness, easy bruising, dark stool\n Admission to : Elevated INR, GI Bleed, Anemia\n 24 Hour Events:\n - seen by GI, plan for EGD AM of \n - Post-transfusion HCT: 21.4, given 2 more units RBCs. and PM coags\n stable at: PT: 14.9 PTT: 23.5 INR: 1.3\n - Urine cltx sent, need to f/u.\n - given 2 mg po ativan for insomnia.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 79 (71 - 96) bpm\n BP: 102/65(70) {98/49(65) - 136/83(87)} mmHg\n RR: 28 (15 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,598 mL\n 708 mL\n PO:\n 1,080 mL\n TF:\n IVF:\n 293 mL\n 143 mL\n Blood products:\n 725 mL\n 565 mL\n Total out:\n 1,000 mL\n 720 mL\n Urine:\n 1,000 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,598 mL\n -12 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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 142 K/uL\n 8.9 g/dL\n 93 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 25.3 %\n 9.5 K/uL\n [image002.jpg]\n 10:14 PM\n 05:42 AM\n WBC\n 9.1\n 9.5\n Hct\n 21.4\n 25.3\n Plt\n 147\n 142\n Cr\n 0.7\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/22.7/1.2, Ca++:8.3 mg/dL, Mg++:1.9\n mg/dL, PO4:3.2 mg/dL\n INR 12 -> 1.3-> 1.2\n Assessment and Plan\n 66F with Afib on coumdain, remote h/o ETOH abuse, CAD risk factors on\n aspirin presents with hematuria and easy bleeding found to have new\n anemia and supratherapeutic INR of 12.\n # GI Bleed - Received FFP x2, Vit K 10mg IV x1 in ED. Anticogulation\n reversed, HCt stable after 2U PRBC yesterday\n - EGD this am\n - PIVs large bore x2\n - 40mg IV PPI \n - NPO for now\n - monitor on tele\n - trend hct q8H, transfuse if continues to drop\n - appreciate GI recs\n - hold ASA/coumadin\n # Hematuria - Likely elevated INR.\n - f/u urine cx\n - repeat UA once INR reversed to ensure hematuria resolved\n - Will need outpatient f/u\n # Afib on Coumadin - Prior cardioversion with return to Afib.\n - hold coumadin in setting of GI bleed\n - hold atenolol in setting of GI bleed\n - hold ASA\n # Hypercholesterolemia - Hold Simvastatin 20mg qHS, patient\n self-discontinued in the context of abdominal burning\n # History of alcoholism - Patient reports sobriety over past year,\n until last week. No EtOH in last 96 hours.\n - No need for CIWA at this time\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-04-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 624342, "text": "Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALBUTEROL SULFATE INH Q4-6H PRN\n ATENOLOL 25 mg QD\n DESONIDE 0.05 % Ointment \n ESTRADIOL 25 mcg Tablet IV BID\n SIMVASTATIN 20 mg QHS (not taking)\n WARFARIN 7.5 mg daily\n ASPIRIN 81 mg QD\n CALCIUM 500 + 200 D twice a day\n CHOLECALCIFEROL 1,000 unit daily\n LORATADINE 10 mg daily PRN\n MULTIVITAMIN daily\n Past medical history:\n Family history:\n Social History:\n Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Father died of a MI at the age of 55; Mother had heart trouble and\n emphysema.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol: Had been sober for one year until the last week, her last\n drink was 4 days prior to admission.\n Other: Patient is very active and exercises five days a week, cardio,\n biking, hiking for 60+ minutes.\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea\n Gastrointestinal: Nausea, Emesis, Diarrhea\n Genitourinary: hematuria\n Integumentary (skin): ecchymoses\n Flowsheet Data as of 02:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 96 (96 - 96) bpm\n BP: 118/58(70) {118/58(70) - 118/58(70)} mmHg\n RR: 20 (20 - 20) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\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), Irregularly, irregular\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 lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, numerous ecchymoses over chest, back, hands, buttock, left\n leg, and left periorbital & left oral area\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 178\n 7.0\n 0.7\n 23\n 25\n 100\n 3.7\n 136\n 20.1\n 13.6\n [image002.jpg]\n Other labs: PT / PTT / INR:101.7/40.4/12.7\n ECG: Afib rate of 90, PVC, no ST/Twave chnages as compared with\n .\n Assessment and Plan\n 66F with Afib on coumdain, remote h/o ETOH abuse, CAD risk factors on\n aspirin presents with hematuria and easy bleeding found to have new\n anemia and supratherapeutic INR of 12.\n # GI Bleed - Patient was not levaged in ED concern of inducing more\n trauma and bleeding with elevated INR. Received FFP x2, Vit K 10mg IV\n x1 in ED. Per patient, had normal colonoscopy in (records not in\n our system). Melena has been ongoing for 5 days supporting lower GI\n source(post-pyloris) in the absence of bloody vomiting over the weekend\n when this all started.\n - PIVs large bore x2\n - transfuse 2 units PRBC, then trend HCT, transfuse if continues to\n drop\n - 40mg IV PPI \n - NPO for now\n - monitor on tele\n - trend hct q8H\n - EGD and colonscopy when stable\n - appreciate GI recs\n - hold ASA/coumadin\n # Hematuria - Likely elevated INR.\n - f/u urine cx\n - repeat UA once INR reversed to ensure hematuria resolved\n - Will need outpatient f/u\n # Afib on Coumadin - Prior cardioversion with return to Afib.\n - hold coumadin in setting of GI bleed\n - hold atenolol in setting of GI bleed\n - hold ASA\n - will discuss w/ PCP/Cardiology plan for resuming coumadin once GI\n bleeding resolved\n # Hypercholesterolemia - Hold Simvastatin 20mg qHS, patient\n self-discontinued in the context of abdominal burning\n # History of alcoholism - Patient reports sobriety over past year,\n until last week. No EtOH in last 96 hours.\n - No need for CIWA at this time\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Comments: None\n Lines:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624421, "text": "Alcohol abuse\n Assessment:\n Patient is not agitated CIWA\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624422, "text": "Alcohol abuse\n Assessment:\n Patient is not agitated CIWA 2 did complain of difficulty sleeping\n Action:\n Ativan 1mg po given repeated x1. pm care given , room dark door\n closed,\n Response:\n Patient dosed on and off after second dose of ativan\n Plan:\n Maintain quit dark room to promote sleep\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n No BM this shift no N/V HCT 21.6 after @ unit PRBC, INR 1.3 multiple\n bruises unchanged from admission\n Action:\n 2 unit PRBC infused , tolerated clear liquids , NPO after MN for\n endoscopy\n Response:\n Post infusion HCT , Patient states she feels much better than she\n did morning of admission.\n Plan:\n Endoscopy, possible DC to floor.\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 624502, "text": "66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. She noted recent dietary changes (started South Beach diet\n with 10lb weight loss) and also recent self DC of statin(2 weeks ago\n abdominal burning). She also reports resuming alcohol use - last\n drink 5 glasses of wine on . Last Hct in system 49 in .\n On admission to EW her hct was 20 and INR 12.7. She was and has been\n hemodynamically stable. Treated with\n 2 bags FFP, 10mg IV Vit K and IV pantoprozole in EW.\n Seen by GI who plan to scope pt today. Given 4 units PRBC\ns overnight\n total with repeat hct 25.3 this AM. Pt called out to the floor as she\n is stable. She has not had elevated CIWA and says she has been dry for\n 11/2 years except for the wine recently.\n Her foley is d/c\nd at 0930 this AM. She has bee voiding well since\n foley is out and initially complained of burning. Now there is no c/o\n burning just urgency. UA sent as ordered. Has had not stools for\n guaiac.\n She is anxious for discharge home ASAP.\n Anemia/Elevated INR with hematuria and numerous surface\n bruising(hematoma)\n Assessment:\n INR was 12.7 on admission with hct 20.\n Action:\n Treated with FFP and 4 units PRBC\ns and INR now 1.2 and hct 27 as od\n noon today. Pt brought to GI suite for EGD at 1400. Called out to the\n floor or may be discharged to home depending on the findings on EGD.\n Response:\n Tolerated EGD. Gastritis. Recommendation for PPI and prescription\n called in for pt.\n Plan:\n Pt to go home at 1800 after she tolerates her dinner.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Sent for EGD at 1400\n Action:\n EGD done. Gastritis seen and pt tolerated procedure well. VSS\n Response:\n Stable post EGD. Given post-procedure instructions. Came back and ate\n meal with plan to D/c home at 1800.\n Plan:\n Her son has been called and pt to go home with him upon discharge. She\n is steady on her feet and vitals are stable.\n Pt discharged home at 1745. Accompanied by her son. ambulation.\n D/C instructions given.\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624362, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624363, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 624490, "text": "66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. She noted recent dietary changes (started South Beach diet\n with 10lb weight loss) and also recent self DC of statin(2 weeks ago\n abdominal burning). She also reports resuming alcohol use - last\n drink 5 glasses of wine on . Last Hct in system 49 in .\n On admission to EW her hct was 20 and INR 12.7. She was and has been\n hemodynamically stable. Treated with\n 2 bags FFP, 10mg IV Vit K and IV pantoprozole in EW.\n Seen by GI who plan to scope pt today. Given 4 units PRBC\ns overnight\n total with repeat hct 25.3 this AM. Pt called out to the floor as she\n is stable. She has not had elevated CIWA and says she has been dry for\n 11/2 years except for the wine recently.\n Her foley is d/c\nd at 0930 this AM. She has bee voiding well since\n foley is out and initially complained of burning. Now there is no c/o\n burning just urgency. UA sent as ordered. Has had not stools for\n guaiac.\n She is anxious for discharge home ASAP.\n Anemia/Elevated INR with hematuria and numerous surface\n bruising(hematoma)\n Assessment:\n INR was 12.7 on admission with hct 20.\n Action:\n Treated with FFP and 4 units PRBC\ns and INR now 1.2 and hct 27 as od\n noon today. Pt brought to GI suite for EGD at 1400. Called out to the\n floor or may be discharged to home depending on the findings on EGD.\n Response:\n Tolerated EGD. Gastritis. Recommendation for PPI and prescription\n called in for pt.\n Plan:\n Pt to go home at 1800 after she tolerates her dinner.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Sent for EGD at 1400\n Action:\n EGD done. Gastritis seen and pt tolerated procedure well. VSS\n Response:\n Stable post EGD. Given post-procedure instructions. Came back and ate\n meal with plan to D/c home at 1800.\n Plan:\n Her son has been called and pt to go home with him upon discharge. She\n is steady on her feet and vitals are stable.\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624365, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n" }, { "category": "Physician ", "chartdate": "2187-04-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 624472, "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 Not tremulous\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, 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, Melena\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy, INR\n improving\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, Anxious\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.3\n HR: 75 (71 - 96) bpm\n BP: 129/70(84) {98/49(65) - 136/83(91)} mmHg\n RR: 28 (15 - 29) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,598 mL\n 1,107 mL\n PO:\n 1,080 mL\n TF:\n IVF:\n 293 mL\n 542 mL\n Blood products:\n 725 mL\n 565 mL\n Total out:\n 1,000 mL\n 965 mL\n Urine:\n 1,000 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,598 mL\n 142 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , Dullness : ), (Breath\n Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :\n , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, Rash: ecchymoses, 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: Normal\n Labs / Radiology\n 8.9 g/dL\n 142 K/uL\n 93 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 25.3 %\n 9.5 K/uL\n [image002.jpg]\n 10:14 PM\n 05:42 AM\n WBC\n 9.1\n 9.5\n Hct\n 21.4\n 25.3\n Plt\n 147\n 142\n Cr\n 0.7\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/22.7/1.2, Ca++:8.3 mg/dL, Mg++:1.9\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n hematuria, hyperlipidemia\n ALCOHOL ABUSE\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n ATRIAL FIBRILLATION (AFIB)\n ANXIETY\n Hct improved to 25 after 4U PRBC. Unclear how much of this is GIB and\n how much has been lost to skin/ muscle. Holding coumadin - would\n question restarting in the future. Will await results of EGD - may be\n able to be discharged if no serious lesion.\n ICU Care\n Nutrition:\n Comments: NPO for EGD\n Glycemic Control:\n Lines:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Prophylaxis:\n DVT: Boots\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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2187-04-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 624475, "text": "Chief Complaint: CC: WEakness, easy bruising, dark stool\n Admission to : Elevated INR, GI Bleed, Anemia\n 24 Hour Events:\n - seen by GI, plan for EGD AM of \n - Post-transfusion HCT: 21.4, given 2 more units RBCs. and PM coags\n stable at: PT: 14.9 PTT: 23.5 INR: 1.3\n - Urine cltx sent, need to f/u.\n - given 2 mg po ativan for insomnia.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 79 (71 - 96) bpm\n BP: 102/65(70) {98/49(65) - 136/83(87)} mmHg\n RR: 28 (15 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,598 mL\n 708 mL\n PO:\n 1,080 mL\n TF:\n IVF:\n 293 mL\n 143 mL\n Blood products:\n 725 mL\n 565 mL\n Total out:\n 1,000 mL\n 720 mL\n Urine:\n 1,000 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,598 mL\n -12 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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 142 K/uL\n 8.9 g/dL\n 93 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 25.3 %\n 9.5 K/uL\n [image002.jpg]\n 10:14 PM\n 05:42 AM\n WBC\n 9.1\n 9.5\n Hct\n 21.4\n 25.3\n Plt\n 147\n 142\n Cr\n 0.7\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/22.7/1.2, Ca++:8.3 mg/dL, Mg++:1.9\n mg/dL, PO4:3.2 mg/dL\n INR 12 -> 1.3-> 1.2\n Assessment and Plan\n 66F with Afib on coumdain, remote h/o ETOH abuse, CAD risk factors on\n aspirin presents with hematuria and easy bruising found to have new\n anemia and supratherapeutic INR of 12.\n .\n # Supratherapeutic INR/Anemia\n anticoagulation reversed last night,\n Received FFP x 2, Vit K 10mg IV x1 in ED. INR 1.2 this am. Hct\n increased to 25.3 after 4U PRBC yesterday. ? GIB with hematuria,\n brusing\n - Hold coumadin/ASA\n - follow INR\n - EGD today\n - PIVs large bore x2\n - 40mg IV PPI \n - NPO\n - monitor on tele\n - recheck Hct this pm\n - appreciate GI recs\n .\n # Hematuria - Likely elevated INR.\n - f/u urine cx\n - repeat U/A once INR reversed to ensure hematuria resolved\n - Will need outpatient f/u\n # Afib on Coumadin - Prior cardioversion with return to Afib.\n - hold coumadin in setting of GI bleed\n - hold atenolol in setting of GI bleed\n - hold ASA\n # Hypercholesterolemia - Hold Simvastatin 20mg qHS, patient\n self-discontinued in the context of abdominal burning\n # History of alcoholism - Patient reports sobriety over past year,\n until last week. No EtOH in last 96 hours.\n - No need for CIWA at this time\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-04-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 624476, "text": "Chief Complaint: CC: WEakness, easy bruising, dark stool\n Admission to : Elevated INR, GI Bleed, Anemia\n 24 Hour Events:\n - seen by GI, plan for EGD AM of \n - Post-transfusion HCT: 21.4, given 2 more units RBCs. and PM coags\n stable at: PT: 14.9 PTT: 23.5 INR: 1.3\n - Urine cltx sent, need to f/u.\n - given 2 mg po ativan for insomnia.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37\nC (98.6\n HR: 79 (71 - 96) bpm\n BP: 102/65(70) {98/49(65) - 136/83(87)} mmHg\n RR: 28 (15 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,598 mL\n 708 mL\n PO:\n 1,080 mL\n TF:\n IVF:\n 293 mL\n 143 mL\n Blood products:\n 725 mL\n 565 mL\n Total out:\n 1,000 mL\n 720 mL\n Urine:\n 1,000 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,598 mL\n -12 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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 142 K/uL\n 8.9 g/dL\n 93 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 104 mEq/L\n 139 mEq/L\n 25.3 %\n 9.5 K/uL\n [image002.jpg]\n 10:14 PM\n 05:42 AM\n WBC\n 9.1\n 9.5\n Hct\n 21.4\n 25.3\n Plt\n 147\n 142\n Cr\n 0.7\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/22.7/1.2, Ca++:8.3 mg/dL, Mg++:1.9\n mg/dL, PO4:3.2 mg/dL\n INR 12 -> 1.3-> 1.2\n Assessment and Plan\n 66F with Afib on coumdain, remote h/o ETOH abuse, CAD risk factors on\n aspirin presents with hematuria and easy bruising found to have new\n anemia and supratherapeutic INR of 12.\n .\n # Supratherapeutic INR/Anemia\n anticoagulation reversed last night,\n Received FFP x 2, Vit K 10mg IV x1 in ED. INR 1.2 this am. Hct\n increased to 25.3 after 4U PRBC yesterday. ? GIB with hematuria,\n brusing\n - Hold coumadin/ASA\n - follow INR\n - EGD today\n - PIVs large bore x2\n - 40mg IV PPI \n - NPO\n - monitor on tele\n - recheck Hct this pm\n - appreciate GI recs\n .\n # Hematuria - Likely elevated INR.\n - f/u urine cx\n - repeat U/A once INR reversed to ensure hematuria resolved\n - Will need outpatient f/u\n # Afib on Coumadin - Prior cardioversion with return to Afib.\n - hold coumadin in setting of GI bleed\n - hold atenolol in setting of GI bleed\n - hold ASA\n # Hypercholesterolemia - Hold Simvastatin 20mg qHS, patient\n self-discontinued in the context of abdominal burning\n # History of alcoholism - Patient reports sobriety over past year,\n until last week. No EtOH in last 96 hours.\n - No need for CIWA at this time\n # Anxiety\n Will give ativan cautiously (0.5mg PO), as she will have\n versed with EGD.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 01:20 PM\n 18 Gauge - 01:20 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2187-04-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 624481, "text": "66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. She noted recent dietary changes (started South Beach diet\n with 10lb weight loss) and also recent self DC of statin(2 weeks ago\n abdominal burning). She also reports resuming alcohol use - last\n drink 5 glasses of wine on . Last Hct in system 49 in .\n On admission to EW her hct was 20 and INR 12.7. She was and has been\n hemodynamically stable. Treated with\n 2 bags FFP, 10mg IV Vit K and IV pantoprozole in EW.\n Seen by GI who plan to scope pt today. Given 4 units PRBC\ns overnight\n total with repeat hct 25.3 this AM. Pt called out to the floor as she\n is stable. She has not had elevated CIWA and says she has been dry for\n 11/2 years except for the wine recently.\n Her foley is d/c\nd at 0930 this AM. She has bee voiding well since\n foley is out and initially complained of burning. Now there is no c/o\n burning just urgency. UA sent as ordered. Has had not stools for\n guaiac.\n She is anxious for discharge home ASAP.\n Anemia/Elevated INR with hematuria and numerous surface\n bruising(hematoma)\n Assessment:\n INR was 12.7 on admission with hct 20.\n Action:\n Treated with FFP and 4 units PRBC\ns and INR now 1.2 and hct 27 as od\n noon today. Pt brought to GI suite for EGD at 1400. Called out to the\n floor or may be discharged to home depending on the findings on EGD.\n Response:\n Plan:\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n EGD performed at 1400\n Action:\n Response:\n Plan:\n" }, { "category": "ECG", "chartdate": "2187-04-05 00:00:00.000", "description": "Report", "row_id": 222365, "text": "Sinus rhythm. Compared to previous tracing cardiac rhythm is now sinus\nmechanism.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2187-04-04 00:00:00.000", "description": "Report", "row_id": 222366, "text": "Atrial fibrillation with a mean ventricular rate of 93 and ventricular\npremature depolarization and diffuse non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of the cardiac\nrhythm is now atrial fibrillation.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624382, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624383, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624386, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 17:42 ------\n" }, { "category": "Nursing", "chartdate": "2187-04-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 624387, "text": "Atrial Fibrillation, paroxysmal with DCCV , since returned to\n Afib.\n Hypercholesterolemia\n Mitral regurgitation\n History of sexual abuse\n History of alcoholism\n Basal cell Carcinoma s/p Mohs surgery\n s/p Tonsillectomy\n s/p Cataract surgery\n Self reported normal colonoscopy in at \n Chief Complaint: GI bleed\n HPI:\n 66F with Afib on coumadin, EtOH abuse, presenting with bruising and\n hematuria, found to have supratherapeutic INR and new anemia. She had\n noted bruising over arms, legs, and chest over the past several days.\n Also has been dizzy and short of breath with exertion and gross\n hematuria on the morning of admission. ROS also positive for GI\n illness over the weekend with loose dark stools, nausea and non-bloody\n vomitus. Most recent INR had been 3 on ; had been advised to\n continue 7.5 mg daily, but she reported taking 7.5 mg daily except 10\n mg on Thursdays. She noted recent dietary changes (started South Beach\n diet with 10lb weight loss) and also recent self DC of statin(2 weeks\n ago abdominal burning). She also reports resuming alcohol use -\n last drink 5 glasses of wine on . Last Hct in system 49 in \n .\n In ED, patients initial vitals: temp 97.8 HR 88 ireg BP 127/56 RR16\n 100% RA. Remained hemodynamically stable. Guaiac positive. INR of\n 12.7. with Hct 20.1. Given Pantoprazole 40 mg x2, FFP x2, IV vitK 10mg\n x1, ativan 0.5mg IV x1. GI was consulted.\n On the floor, she denied any pain or shortness of breath and was lying\n comfortably in bed. Her last BM was this am and she confirmed dark,\n loose stool at the time. She denies visual changes, HA, numbness or\n weakness. She denies dysuria, frequency or urgency. Prior to transfer\n to pt was given 80 mg iv protonix, 10 mg iv vit k and was\n transfused with 2 units prbc\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Arrived to with stable vs. on room air o2 sats> 995. lungs cta. Pt\n npo. Denies n/v or sob. Pt was not lavaged in the ed because of the\n concern of inducing more trauma and bleeding with elevated inr. Per pt\n she had normal colonoscopy in . according to pt melena has been\n ongoing for 5 days supoorting lower gi source. Pt with multiple areas\n of bruising- l eye, r chest wall,r upper lip,r side of neck,\n Action:\n Pt now transfused with 2 u prbc\ns. npo status maintained. Hemodynamics\n monitored closely.\n Response:\n Stable hemodynamics since admit. No stool output since admit.\n Plan:\n Maintain npo status. Once blood transfusion are completed will recheck\n labs. Maintain 2 large bore iv\ns. will give maintenance ivf when\n transfusions finish. Ppi iv bid. Egd and colonoscopy when stable.\n Transfuse prbc\ns if hct drops. Hold asa and coumadin. Follow gi recs.\n Continue to follow hemodynamics closely.\n" } ]

[ { "category": "Radiology", "chartdate": "2160-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 861001, "text": " 10:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change, r/o effusion, CHF\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p ureterostomy and swan placmeent and removal\n REASON FOR THIS EXAMINATION:\n assess interval change, r/o effusion, CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Status post ureterostomy and Swan-Ganz placement and removal.\n Assess for interval change.\n\n FINDINGS: AP single view of the chest with patient in semi-upright position\n is compared with a previous similar study dated . A previously\n present NG tube has been removed. A right sided internal jugular vein\n approach sheath remains and terminates in the upper lower portion of the SVC.\n The patient is status post sternotomy. Moderate cardiac enlargement is\n present. Left sided basal density persists and obliterates the diaphragmatic\n contour. This coincides with a blunted pleural sinus and pleural thickening\n along the lower lateral chest wall. The right diaphragmatic contour is\n preserved but the right lateral pleural sinus is not included in the image\n field.\n\n In comparison with the next preceding study of , no significant\n interval change can be identified. Thus, there is no pneumothorax and no\n conclusive evidence for acute pulmonary congestion or infiltrates. Pleural\n density on left side similar as it existed before.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2160-05-05 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 861517, "text": " 8:50 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Eval for ileus/obstruction\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with bladder cancer, now question ileus/obstruciton\n REASON FOR THIS EXAMINATION:\n Eval for ileus/obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with bladder cancer and question of ileus or\n obstruction.\n\n 3 views of the abdomen including upright and supine show multiple air fluid\n levels within the small bowel and a moderate degree of small bowel dilatation\n up to 5.6 cm. There is no sign of free air or free fluid. There is no sign of\n bowel wall edema or ischemia. Small amount of gas is seen distally in the\n rectum. The patient has a left nephrostomy tube in place. The patient is\n status post median sternotomy. Clips are present in the pelvis extending into\n the right groin.\n\n IMPRESSION: Partial or developing small bowel obstruction, likely in the mid\n to distal small bowel. No free air.\n\n" }, { "category": "Radiology", "chartdate": "2160-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 860929, "text": " 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumothorax, pulmonary edema\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p ureterostomy and swan placmeent and removal\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post ureterostomy and Swan placement and removal, assess\n for pneumothorax or pulmonary edema.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: There has been interval placement of a right internal jugular\n venous access catheter with tip terminating in the upper SVC. No pulmonary\n artery catheter is visualized. A nasogastric tube is seen with tip\n terminating in the gastric body. The heart size and mediastinal contours are\n unchanged. The examination is limited by technique and motion. Allowing for\n this, the costophrenic angles are poorly visualized bilaterally. There is no\n pneumothorax and no evidence of frank consolidation or congestive heart\n failure. The osseous structures appear unchanged.\n\n IMPRESSION: 1. Right internal jugular sheath tip in upper SVC. No\n pneumothorax.\n 2. Nasogastric tube in satisfactory position.\n 3. Limited examination due to technique and motion. Improved visualization of\n the bases could be achieved by repeat PA and lateral chest x-ray. No definite\n evidence of congestive heart failure or pneumonia.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2160-05-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 861139, "text": " 10:13 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u left pleural effusion. r/o edema/consolidation.\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man , 30%, 92% ra, CHF\n REASON FOR THIS EXAMINATION:\n f/u left pleural effusion. r/o edema/consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 72-year-old male with CHF.\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n COMPARISON: Chest x-ray taken .\n\n FINDINGS: Right IJ line remains in place. The patient is status post median\n sternotomy. Again, note is made of cardiomegaly with CHF. Tortuous aorta is\n noted.\n\n IMPRESSION:\n\n Cardiomegaly with improving CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 861018, "text": " 1:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check position\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p Right IJ CVL placement\n REASON FOR THIS EXAMINATION:\n check position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ central venous line placement.\n\n COMPARISON: Radiograph dated and at 10:25 a.m.\n\n AP PORTABLE SEMIUPRIGHT VIEW OF THE CHEST: There is interval placement of a\n right IJ central line with interval removal of the vascular sheath in the\n right IJ. There is stable cardiomegaly with pulmonary vascular engorgement\n and bilateral pleural effusions consistent with CHF.\n\n IMPRESSION: Right IJ line in satisfactory position. No evidence of\n pneumothorax.\n CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-04-28 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 860773, "text": " 5:12 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BLADDER CA\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CHF and bladder CA pre op for pallative urological\n procedure\n REASON FOR THIS EXAMINATION:\n evidence of CHF, acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bladder CA, 72-year-old with CHF, preop chest for palliative\n urological procedure.\n\n Comparison is made to prior study of . Postoperative changes\n from median sternotomy are again noted.\n\n FINDINGS: There is cardiomegaly and arteriosclerotic changes involving\n thoracic aorta. There is no evidence of pleural effusion or pneumothoraces.\n Low lung volumes involving the lower lobes due to poor inspiratory effort are\n noted. Findings have not significantly changed since the prior study.\n\n IMPRESSION: Cardiomegaly, but no evidence of congestive heart failure.\n\n Postoperative changes.\n\n" }, { "category": "ECG", "chartdate": "2160-04-29 00:00:00.000", "description": "Report", "row_id": 271850, "text": "Probable sinus rhythm\nRight bundle branch block\nLeft anterior fascicular block\nOld Inferolateral myocardial infarct\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2160-04-28 00:00:00.000", "description": "Report", "row_id": 271851, "text": "Sinus rhythm\nMarked left axis deviation\nRight bundle branch block and left anterior fascicular block\nOld inferior myocardial infarction\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2160-04-29 00:00:00.000", "description": "Report", "row_id": 1416073, "text": "NSG ADMISSION NOTE\nMr. is a 72yo male admitted to MICU/SICU directly from the OR S/P cystectomy and removal of pelvic mass. PMH/PSH significant for CAD, CABG , MI . IDDM, EF 25-30% by ETT, old burns covering 70% of his body in the 's (steel worker, burned at work), bladder ca. Per intern surgery today was pallitive, R kidney connected to L kidney/nephrostomy tube. Pt is speaking, ? understands any English. He is married, lives with wife who is also speaking, has two sons who speak English. No health care proxy. Full code. Intra op pt rec'd neo for hypotension, ca repleted, 2units PRBC given for Hct 31, INR 1.2 pre-op, treated with 2units FFP. Total 4100 LR given in OR, 565u/o, 1600ml EBL. Lasix, Vanco and insulin given intra-op. Please refer to FHA for further details.\n\nCURRENT STATUS\nNeuro: Pt sedated with Propofol currently at 30mcg/kg/min. Prior to initiation of Propofol pt noted to be moving arms, head. No attempts to speak or communicate noted. Epidural T10 with Dilaudid 10mcg/ml and Bupivicaine 0.1% infusing at 6ml/hr per pain team. Epidural site with scant amt old blood noted.\n\nCV/Pulm: MP=SB-NSR, 50's-60's with occ PVC's noted. R Swan DC'd by intern, cordis in place. R rad A-line zero'd and cal to monitor, good waveform. NBP correlating within 10points of A-line. Dsg D+I. Remains vented at this time AC14x700x50x5. BS clear bil. Sats high 90's-100%.\n\nGI/GU: Abd dsg D+I. JP intact, emptied for 30ml ser-sang fluid. Hypoactive bowel sounds noted RLQ. NGT-->LIS draining scant amt dark brown material. Nephrostomy tube draining light yel urine, qs q1h.\n\nID/Endo/Integ: Afebrile. On Vanco. Sliding scale insulin coverage ordered for q6h fingersticks. Old scarring noted to L arm, both legs, L side body. L groin area excorriated, nystatin powder ordered. No open areas noted.\n\nPsychosocial/Plan: Wife and children in to visit. Emotional support given to pt and fam. Plan is for pt to wean and extubate as tolerated this afternoon, cont'd epidural. Monitor VS, I+O, breath sounds, cont with current nursing/medical regime.\n" }, { "category": "Nursing/other", "chartdate": "2160-04-29 00:00:00.000", "description": "Report", "row_id": 1416074, "text": "ADDENDUM TO ABOVE NOTE\nPt extubated at 1700, placed on np at 6l with sats 97-99%. Lopressor 5mg IV x1 and 25mg per NGT given for BP 180's with BP decreased to 140's. Next labs due at 2200.\n" }, { "category": "Nursing/other", "chartdate": "2160-04-30 00:00:00.000", "description": "Report", "row_id": 1416075, "text": "Neuro: Pt alert. speaking but knows a little English. Appears to be A&O. Slept well.\n\nResp: Lungs CTA. O2 vial NC at 5L/min w/ sats upper 90's. Beginning to cough this AM as more awake but so far has been non productive. Send sputum if able.\n\nC/V: HR 60's to 70's and sinus. Began having frequent PVC's. Labs sent early. Mag repleated w/3amps in 250 NSS over 2 hours. Infrequent PVC's at this time. Lytes redrawn at 0500 with results pending. Given Lopressor IV and PO yesterday. BP and HR stable since.\n\nGU/GI: Abd obese. Dsg to abd dry and intact. Not changed this shift. JP drain with sero sang drainage. L nephrostomy draining clear yellow urine. Given 250 ml NSS over 1 hour for low output. Pt now taking H2O PO without N/V. Has NGT but this is clamped. Will most likely be d/c'd this AM. Blood washed from penis. Urology intern says that some bleeding/clots from penis is normal.\n\nPain: Pt denies pain/discomfort except with turning. Continues to receive Dilaudid epidural at 6ml/12mg/hr with good effect. Pt able to assist with turns.\n\nEndo: blood sugar at MN 120. Pt spiked temp last evening. Blood cx drawn from cordis and A line, urine spec sent, send sputum if able to obtain.\n\nAccess: Pt has cordis RIJ, A Line R radial, #20 R hand and #22 left wrist. Pt is a very difficult stick. If pt to receive chemo may require PICC placement.\n\nSocial: Sons called last evening x3 for updates on pt's care.\n\nPlan: ? D/C NGT. Begin clear liq diet and advance as tolerated. ?Begin PO pain meds and d/c epidural. Monitor abd dsg and drain. ? dsg change. Monitor temp and cx's.\n" } ]

[ { "category": "ECG", "chartdate": "2113-10-15 00:00:00.000", "description": "Report", "row_id": 195513, "text": "Sinus tachycardia. Non-specific inferior ST-T wave abnormalities. No previous\ntracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2113-10-17 00:00:00.000", "description": "Report", "row_id": 1392118, "text": "cv: bp stable. hr 60's to 80''s nsr no ectopy. pt hr up to 138 when pt stood to void at 0200 but decreased to 64 nsr when pt returned to bed. dr .. labs returned at this time k= 3.2 tx with 40 kcl/500 ns and 60 meq kcl tabs po. mag = 1.7 mag 2 grams iv given.\n\ngi: abd soft bowel sounds present. denies nausea and no vomiting.\n\ngu: voiding in large amounts clear yellow urine.\n\nendo: pt received nph 17 units at . insulin drip off at 2300. iv d5 1/2 ns off at 2400. initially pt getting chensticks q 1/2 hour...doing well so frequency decreaseed to q 2 hours and covering blood sugars with humalog q 2 hours. see careview for all blood sugars\n\nmental status; pt alert and oriented. anxious to get his blood sugars under good control and to get d.c'd as quickly as possible so that he can resume his classes at school.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-10-16 00:00:00.000", "description": "Report", "row_id": 1392116, "text": "7pm to 7am:\n\nPt in now off insulin gtt and AnGap closed. Pt has been started on NPH and is currently on humalog SS.\n\nROS:\n\n(NEURO)\nPt is alert and oriented x 3. Pt felt sl restless last night, and reported he was unable to fall asleep. Pt given ativan 0.5mg x 2 with no effect. Pt was able to sleep after trazadone 25mg po given. Pt reported that he felt much better this am at compare to last night.\n\n(ENDO)\nPt was started on NPH last night and was taken off insulin gtt at 2 am. Pt is now on humalog SS as noted. Since pt has not needed any coverage of humalog at this time...? start pt on RISS instead since pt uses Reg insulin at home. LABS: AnGAP closed at 14-19. K level this am 3.9 . Phos low at 1.4 last night and Kphos given IV. Level this am 1.6-> pt will need another level drawn.\n\n(CV)\nPt is NSR with no ectopy noted upon rest. Pt becomes tachycardic with minor activity (110-130's). Pt felt sl SOB with activity last night (No change in o2sat), but not this am. No edema noted. F/U on EL.\n\n(GI)\nNo N/V/D at this time. IVF as noted at 150 cc/hr. Pt has been able to tol clear liq...may advance diet this am to reg diabetic diet (has order).\n\n(GU)\nPt urinating lg amounts via urinal as noted.\n\nPLAN:\n * ? dischage home or transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2113-10-16 00:00:00.000", "description": "Report", "row_id": 1392117, "text": "NURSING NOTE 7A-7P REIVEW OF SYSTEMS:\nNEURO: ALERT AND ORIENTED X3. OOB TO CHAIR FOR MOST OF AFTERNOON. PATIENT CURRENTLY PHARMACOLOGY STUDENT AND AWARE OF PLAN AND TREATMENTS.\nC/V: SR TO ST RATE 80-120, BP 101-129/55-75, PATIENT BECOMES TACHYCARDIC TO 110 WITH ACTIVITY. PHOSPHOROUS LEVEL 1.0 AND REPLETED WITH POTASSIUM PHOSPHATE IV AND NEUTRA-PHOS2 PO.\nENDO: INSULIN DRIP RESTARTED AND TITRATED FROM 4 UNITS TO 10 UNITS PER HOUR AS ANION GAP REOPENED. FS DONE Q1HOUR RANGING FROM 98-344. CURRENTLY INSULIN DRIP INFUSING AT 4 UNITS/HR. PATIENT ATE DINNER AND NPH INSULIN HELD PER DR PENDING CONSULT FROM CLINIC.\nD5 INFUSING AT 250CC/HR AS ORDERED.\nRESP: O2 SAT 97-99% ON ROOMAIR. LUNG SOUNDS CLEAR.\nGI: ABD SOFT POSITIVE BOWEL SOUNDS. TAKING PO DIABETIC DIET WELL. NO BM.\nGU: VOIDING IN LARGE AMOUNTS CLEAR YELLOW URINE.\nSOCIAL: PATIENTS BROTHER AND FRIENDS INTO VISIT.\nACCESS: TWO PIV LINES INTACT, #20 RIGHT HAND, #20 LEFT WRIST.\nPLAN: CONTINUE ON INSULIN DRIP, CONTINUE D51/2 AT 250CC/HR. CONSULT MD DOSE OF NPH INSULIN.\n" }, { "category": "Nursing/other", "chartdate": "2113-10-15 00:00:00.000", "description": "Report", "row_id": 1392115, "text": "MICU NPN Admit note\n\nPt admitted from EW with c/o 2 days n/v. He was found to have a BS 607, anion gap 43, metabolic acidosis, ABG: 7/14/23/118/8. Urine was positive for glucose and ketones. He was given 1amp calcium gluconate, 2 amps Na bicarb, insulin load of 10u/hr, and insulin gtt starting at 7u/hr. Pt transferred to MICU for futher management.\nPMH: IDDM x19 years, neuropathy, h/o sz (last one 1.5 years ago), scoliosis, difficulty focusing-on ritalin.\nNKDA\nPlease see carevue for all objective data.\nNeuro: AA&Ox3. Pleasant and cooperative.\nREsp: LS CTA. 96-100% on RA. Denies SOB.\nCV: hemodynamically stable. HR, ST. No ectopy noted. Pt has 2 peripheral IVs.\nGI: Abdominal soft/ non tender. Pt vomited x 1 since arrival. c/o nausea and receieved compazine. Clear liquid diet and to advance as tolerated. protonix ordered\nGU: voids\nEndo: Insulin gtt @ 2u/hr. FS q 1 hour. Goal BS 200-250 until gap closes. Plan will be to transition pt to Standing doses and RISS at that time. afternoon labs Gap closing and bicarb rising. D5.45%NS with20meq KCL infusing @ 250cc/hr x 2 L. Will need to check with Dr. regarding future fluid orders.\nSocial: pt is pharmacy student at .\nDispo: REmain in MICU. Full Code\n" }, { "category": "Radiology", "chartdate": "2113-10-15 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 928200, "text": " 5:22 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with severe nausea/vomiting\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe nausea, vomiting, rule out obstruction.\n\n Single supine view of the abdomen. The lower pelvis and obdurator foramina\n are not included. There is also blurring due to motion.\n\n Gas is seen in nondilated loops of small and large bowel. Gas and stool are\n noted in the rectum. No dilated gas filled loops of bowel to suggest the\n presence of obstruction are identified. There is suggestion of rotary\n scoliosis of the thoracolumbar spine, not fully evaluated here.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928180, "text": " 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with nausea, vomiting\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nausea, vomiting, assess for infiltrate.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Heart size is borderline. There is moderate to moderately severe left convex\n scoliosis centered in the mid/lower thoracic spine. There is no CHF, focal\n infiltrate, or effusion. Compared with , no significant change is\n identified.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-06-14 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1189776, "text": " 3:29 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: COLD FOOT\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p thrombectomy L leg\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line needed for antibiotics.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling right arm PICC line into the SVC under\n fluoroscopic guidance. The old PICC line was then removed and a peel-away\n sheath was then placed over the guidewire. A new double-lumen PICC line\n measuring 52 cm in length was then placed through the peel-away sheath. The\n tip of the catheter; however, could not be advanced beyond the right\n subclavian vein. Contrast was injected revealing obstruction of the right\n subclavian vein with multiple collaterals. The PICC line and the guidewire\n were removed. Inner dilator of the peel-away sheath was removed and a 0.035\n guidewire was advanced through the peelaway sheath and used to successfully\n navigate past the subclavian obstruction into the SVC. Using a Kumpe\n catheter, the Glidewire was exchanged for an Amplatz wire. An 8 French x 30\n cm peel-away sheath was then advanced over the Amplatz wire with its tip\n positioned in the brachiocephalic vein. The inner dilator was removed and the\n PICC line was introduced through the sheath and its tip positioned in the\n distal SVC. The sheath was removed. Both ports aspirated and flushed easily\n and were capped. Sterile dressings were applied.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful fluoroscopically guided midline exchanged for a new\n double-lumen PICC line. Final internal length is 52 cm and the tip was\n positioned in the distal SVC. Line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1189361, "text": " 10:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: DHT placement***LOW film please\n Admitting Diagnosis: COLD FOOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman vent dep/s/p LLE thrombectomy\n REASON FOR THIS EXAMINATION:\n DHT placement***LOW film please\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff tube placement.\n\n SINGLE AP PORTABLE VIEW CENTERED LOW. The radiopaque portion of the Dobbhoff\n tube overlies the lower chest in the midline and does not extend beyond the\n esophagogastric junction. There is increased opacity at left greater than\n right bases, not well evaluated on this film.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1189934, "text": " 12:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: COLD FOOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p LLE thrombectomy/stent\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after left lower extremity\n thrombectomy and stenting.\n\n Portable AP chest radiograph was compared to .\n\n Tracheostomy is in unchanged location. The feeding tube tip passes below the\n diaphragm, terminating along the inferior margin. The patient is in\n interstitial pulmonary edema. There is also worsening of the left pleural\n consolidation worrisome for interval development of an infectious process.\n Bilateral pleural effusion are moderate, associated with the bibasal\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-11 00:00:00.000", "description": "CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS", "row_id": 1189314, "text": " 12:26 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: please eval for arterial thrombus L lower extremity\n Field of view: 50 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with pulseless cold L foot\n REASON FOR THIS EXAMINATION:\n please eval for arterial thrombus L lower extremity\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw SAT 1:34 AM\n 4.1 x 3.8cm infrarenal AAA. left femoral artery occlusion below the level of\n the profunda takeoff (3a:138). the left profunda appears to remain patent,\n which is able to supply a short segment of distal femoral (3a:203), but the\n popliteal is occluded. profunda branches continue distially supplying the\n peroneal art that continues into the foot; however the PT and AT are occluded.\n right runoff supplies 3 vessels. severe atherosclerotic disease. massive\n ventral hernia resulting in herniation of nearly all intraabdominal contents.\n no bowel obstruction. left renal cyst. ? bilateral femoral head AVN. final\n read pending recons.\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY OF THE PELVIS AND LOWER EXTREMITIES\n\n HISTORY: Pulseless cold left foot. Question arterial thrombosis in the left\n lower extremity.\n\n COMPARISONS: The pelvis can be compared to . No earlier\n comparison available for the lower extremities.\n\n Shortly after the study, a preliminary interpretation was provided by Dr.\n that stated \"4.1 x 3.8 cm infrarenal abdominal aortic aneurysm. Left\n femoral artery occlusion below the level of the profunda takeoff (3A:138).\n The left profunda appears to remain patent, which is able to supply a short\n segment of distal femoral (3A:203), but the popliteal is occluded. The\n profunda branches continue distally supplying the peroneal artery that\n continues into the foot; however, the PT and AT are occluded. Right runoff\n supplies three vessels. Severe atherosclerotic disease. Massive ventral\n hernia resulting in herniation of nearly all intra-abdominal contents. No\n bowel obstruction. Left renal cyst. Question bilateral femoral AVN. Final\n read pending reconstructions.\"\n\n TECHNIQUE: Multidetector CT images of the pelvis and lower extremities were\n obtained with and without intravenous contrast including CT angiography.\n Sagittal, coronal as well as MIP and volume-rendered reformations of the\n vasculature were also constructed.\n\n CT OF THE PELVIS: There is a large incompletely characterized ventral hernia\n containing the liver, spleen, gallbladder, pancreas, and most of the bowel.\n An aneurysm of the abdominal aorta is similar in size, measuring 41 x 38 mm in\n axial dimensions. Vascular calcifications are widespread. The inferior\n mesenteric artery appears patent.\n (Over)\n\n 12:26 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: please eval for arterial thrombus L lower extremity\n Field of view: 50 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CTA OF THE LOWER EXTREMITIES: There is stenosis along the origin of the left\n common internal iliac artery and distal branches of the internal iliac\n arteries are poorly opacified bilaterally. The left common femoral artery\n shows moderate stenosis and shortly beyond its origin, the superficial femoral\n artery is occluded throughout most of its course. There is slight\n reconstitution of the distal portion via deep profunda branch related\n collaterals, noting that the deep branch of the femoral artery is patent.\n Distal branches of that same artery supply thready flow to the peroneal\n artery, apparently via geniculate arteries in part, while the anterior and\n posterior tibial arteries as well as the popliteal artery are occluded. The\n dorsalis pedis is also not opacified.\n\n CTA OF THE LOWER EXTREMITIES: On the right, there is mild stenosis of the\n right common femoral artery. The right superficial femoral artery is\n irregularly narrowed, at times to a fairly severe degree throughout its course\n and markedly attenuated, particularly along its distal portion, although it\n does not appear occluded. Likewise there is narrowing of the popliteal but\n again patent. There is apparently collateral flow to the distal part of the\n anterior tibial, although its proximal portion is occluded. The posterior\n tibial is also absent on the right. The dorsalis pedis is patent.\n Bilaterally there is fairly widespread edema, particularly in the feet.\n\n BONE WINDOWS: Moderate degenerative changes are present along the lower\n lumbar facets with prior lower lumbar laminectomies. Mixed sclerotic\n appearance of the bony structures may suggest an underlying metabolic bone\n abnormality. There is widespread muscular atrophy bilaterally. The right\n profunda femoral artery is patent. Patchy mixed sclerosis and lucency in each\n femoral head may be due to avascular necrosis, although neither head shows\n collapse.\n\n IMPRESSION:\n\n 1. Widespread severe atherosclerotic disease as outlined above including\n occlusion of most of the left superficial artery.\n\n 2. Abdominal aortic aneurysm, stable in size and measuring up to 41 mm.\n\n 3. Mixed sclerotic and lytic appearance of bones without discrete lesions,\n possibly reflecting a metabolic abnormality; correlation with laboratory\n testing and consideration of bone mineral density screening are suggested when\n clinically appropriate.\n\n 4. Irregular appearance of each femoral head, potentially related to\n avascular necrosis.\n\n (Over)\n\n 12:26 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: please eval for arterial thrombus L lower extremity\n Field of view: 50 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Large ventral hernia containing most of the solid organs and bowel.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1189367, "text": " 11:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: DHT placement***low film please->DHT advanced\n Admitting Diagnosis: COLD FOOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with s/p LLE thrombectomy/DHT advanced\n REASON FOR THIS EXAMINATION:\n DHT placement***low film please->DHT advanced\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left lower extremity thrombectomy, Dobbhoff tube\n advanced.\n\n Single AP view centered in the lower chest/abdomen.\n\n The Dobbhoff tube follows an atypical course extending to the left lateral\n side of the abdomen. Review of a torso CT indicates the presence of a\n large ventral hernia. The Dobbhoff tube on today's exam follows the expected\n course of the NG tube seen in the herniated stomach, on that torso CT.\n Therefore, notwithstanding its unusual appearance on today's CXR, the Dobhoff\n tube likely lies in the stomach, within the ventral hernia. However, it cannot\n be confirmed to pass beyond the pylorus.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1189456, "text": " 6:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 74 year old woman with picc placement\n Admitting Diagnosis: COLD FOOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with picc placement\n REASON FOR THIS EXAMINATION:\n 74 year old woman with picc placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n No PICC line is identified at this time. A tracheostomy tube is present, tip\n approximately 3 cm above the carina. An NG type tube is present, tip\n extending beneath the diaphragm off film.\n\n The lungs are hyperinflated suggesting COPD. There are bilateral effusions,\n increased retrocardiac density consistent with left lower lobe collapse and/or\n consolidation.\n Incidental note is made of marked narrowing of the right shoulder\n acromiohumeral distance consistent with a chronic rotator cuff tear together\n with severe right AC joint osteoarthritis.\n\n IMPRESSION: No PICC line identified. Clinical correlation requested.\n\n" }, { "category": "ECG", "chartdate": "2163-06-11 00:00:00.000", "description": "Report", "row_id": 241705, "text": "Artifact is present. Sinus rhythm. Atrial ectopy. Non-specific ST-T wave\nchanges. Compared to the previous tracing of atrial ectopy and\nST-T wave changes are new.\n\n" } ]

[ { "category": "ECG", "chartdate": "2157-09-02 00:00:00.000", "description": "Report", "row_id": 146950, "text": "Normal sinus rhythm. Compared to the previous tracing of the right\nprecordial anterior T wave changes have resolved.\n\n" }, { "category": "Radiology", "chartdate": "2157-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099846, "text": " 7:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with DKA, want to rule out infection.\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: DKA. Concern for infection.\n\n FINDINGS:\n\n AP radiograph of the chest is reviewed without previous studies for\n comparison. There is no consolidation, pulmonary edema, or pleural fluid.\n The cardiomediastinal silhouette is normal.\n\n\n" }, { "category": "Physician ", "chartdate": "2157-09-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 486733, "text": "Chief Complaint: DKA\n HPI:\n This is a 31 year old female with history of diabetes mellitus type 1\n who presents today with DKA thought secondary to mechanical failure of\n her insulin pump. She awoke around 3:00 this morning with kinking of\n the tubing of her insulin pump and similar problems. This has been\n something of a chronic problem with her pump and she thought she had\n resolved it. Nevertheless, she did not feel well afterward and at work\n this morning had a blood sugar>600 (the limits of her monitor). She\n also noted some confusion at work and was persistently thirsty despite\n drinking large amounts of water. Mild nausea without vomiting or\n abdominal pain. She called her former endocrinologist from during her\n pregnancy, who told her to come into the ED.\n In the ED, initial vs were: T98.6, P108, BP 119/86, RR 18, O2 Sat 100%\n on RA. She had a 28 point gap. She was started on an insulin drip\n improvement in her sugars, started on fluids, and transferred to the\n floor.\n Currently, she reports feeling better and nearly back to baseline\n except for mild headache.\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n ------------------------\n -ALBUTEROL Inhaler PRN\n -CITALOPRAM 60 mg daily\n -Insulin Lispro by pump\n -NORGESTREL-ETHINYL ESTRADIOL daily\n -OMEPRAZOLE - 40 mg daily\n Past medical history:\n Family history:\n Social History:\n -Diabetes Mellitus Type 1\n -Allergic Rhinitis/Asthma\n -Depression/Anxiety\n Notable for DM, Major depressive disorder, Alzheimer's Disease\n Occupation: Works at \n Drugs: Denies\n Tobacco: No smoking in five years\n Alcohol: Social\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Gastrointestinal: Abdominal pain\n Genitourinary: No(t) Dysuria\n Endocrine: Hyperglycemia\n Neurologic: Headache\n Flowsheet Data as of 07:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 76 (76 - 95) bpm\n BP: 107/65(75) {105/61(73) - 111/69(75)} mmHg\n RR: 17 (17 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 715 mL\n PO:\n TF:\n IVF:\n 715 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 215 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: 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 lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): Person, Place, Time, and Situation, Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 234 mg/dL\n 1.0 mg/dL\n 19 mg/dL\n 22 mEq/L\n 104 mEq/L\n 4.5 mEq/L\n 136 mEq/L\n [image002.jpg]\n \n 2:33 A9/25/ 03:40 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.0\n Glucose\n 234\n Other labs: Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n ECG: Sinus arrythmia at rate of 81. No concerning ST or T wave\n changes.\n Assessment and Plan\n This is a 31 y.o. female with DM presenting in DKA. Now with gap\n closed and blood glucose <200.\n 1) Diabetic Ketoacidosis: Relatively clear precipitant in kinked tube\n from insulin pump. Patient is eating and off insulin drip more than\n one hour. Fluids stopped and patient was given a dose of insulin\n glargine reccs. We will finish work up for infectious\n causes with CXR. Then patient will be restarted on lantus and continue\n humalog carb counting regimen per previous. Will need follow\n up.\n -Chest radiograph to evaluate for pneumonia\n -Insulin glargine 15 units QPM\n -Insulin lispro per previously established carbohydrate counting\n regimen\n -Recheck lytes this PM and call out if gap remains closed\n 2) Diabetes Mellitus Type 1: Patient is to stop using pump and will\n start glargine 15 units QPM with dosing before meals with carb\n correction per her previous regimen.\n -F/ reccs\n -Q4 finger sticks\n - F/U\n 3) Headache: Mild, likely due to dehydration.\n -Acetaminophen\n -Encourage PO\n 4) Depression: Continue home citalopram\n 5) GERD: Continue home omeprazole\n 6) FEN: Full diet\n 7) PPx: Ambulate for DVT, continue home PPI\n 8) Dispo: Call out to floor once another set of labs w/o anion gap\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:50 PM\n Prophylaxis:\n DVT: (ambulate)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2157-09-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 486734, "text": "Chief Complaint: DKA\n HPI:\n This is a 31 year old female with history of diabetes mellitus type 1\n who presents today with DKA thought secondary to mechanical failure of\n her insulin pump. She awoke around 3:00 this morning with kinking of\n the tubing of her insulin pump and similar problems. This has been\n something of a chronic problem with her pump and she thought she had\n resolved it. Nevertheless, she did not feel well afterward and at work\n this morning had a blood sugar>600 (the limits of her monitor). She\n also noted some confusion at work and was persistently thirsty despite\n drinking large amounts of water. Mild nausea without vomiting or\n abdominal pain. She called her former endocrinologist from during her\n pregnancy, who told her to come into the ED.\n In the ED, initial vs were: T98.6, P108, BP 119/86, RR 18, O2 Sat 100%\n on RA. She had a 28 point gap. She was started on an insulin drip\n improvement in her sugars, started on fluids, and transferred to the\n floor.\n Currently, she reports feeling better and nearly back to baseline\n except for mild headache.\n Allergies:\n Penicillins\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n ------------------------\n -ALBUTEROL Inhaler PRN\n -CITALOPRAM 60 mg daily\n -Insulin Lispro by pump\n -NORGESTREL-ETHINYL ESTRADIOL daily\n -OMEPRAZOLE - 40 mg daily\n Past medical history:\n Family history:\n Social History:\n -Diabetes Mellitus Type 1\n -Allergic Rhinitis/Asthma\n -Depression/Anxiety\n Notable for DM, Major depressive disorder, Alzheimer's Disease\n Occupation: Works at \n Drugs: Denies\n Tobacco: No smoking in five years\n Alcohol: Social\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Gastrointestinal: Abdominal pain\n Genitourinary: No(t) Dysuria\n Endocrine: Hyperglycemia\n Neurologic: Headache\n Flowsheet Data as of 07:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 76 (76 - 95) bpm\n BP: 107/65(75) {105/61(73) - 111/69(75)} mmHg\n RR: 17 (17 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 715 mL\n PO:\n TF:\n IVF:\n 715 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 215 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: 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 lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): Person, Place, Time, and Situation, Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 234 mg/dL\n 1.0 mg/dL\n 19 mg/dL\n 22 mEq/L\n 104 mEq/L\n 4.5 mEq/L\n 136 mEq/L\n [image002.jpg]\n \n 2:33 A9/25/ 03:40 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.0\n Glucose\n 234\n Other labs: Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n ECG: Sinus arrythmia at rate of 81. No concerning ST or T wave\n changes.\n Assessment and Plan\n This is a 31 y.o. female with DM presenting in DKA. Now with gap\n closed and blood glucose <200.\n 1) Diabetic Ketoacidosis: Relatively clear precipitant in kinked tube\n from insulin pump. Patient is eating and off insulin drip more than\n one hour. Fluids stopped and patient was given a dose of insulin\n glargine reccs. We will finish work up for infectious\n causes with CXR. Then patient will be restarted on lantus and continue\n humalog carb counting regimen per previous. Will need follow\n up.\n -Chest radiograph to evaluate for pneumonia\n -Insulin glargine 15 units QPM\n -Insulin lispro per previously established carbohydrate counting\n regimen\n -Recheck lytes this PM and call out if gap remains closed\n 2) Diabetes Mellitus Type 1: Patient is to stop using pump and will\n start glargine 15 units QPM with dosing before meals with carb\n correction per her previous regimen.\n -F/ reccs\n -Q4 finger sticks\n - F/U\n 3) Headache: Mild, likely due to dehydration.\n -Acetaminophen\n -Encourage PO\n 4) Depression: Continue home citalopram\n 5) GERD: Continue home omeprazole\n 6) FEN: Full diet\n 7) PPx: Ambulate for DVT, continue home PPI\n 8) Dispo: Call out to floor once another set of labs w/o anion gap\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:50 PM\n Prophylaxis:\n DVT: (ambulate)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n ------ Protected Section ------\n Patient seen and examined with housestaff. 31 year-old woman admitted\n with DKA secondary to pump catheter dysfunction; no obvious focus of\n infection as source, but will obtain chest radiograph. Initiated on\n intravenous insulin infusion with successful closure of anion gap.\n Insulin glargine administered and she will also receive sliding scale\n coverage. She is now tolerating oral intake. She remains\n hemodynamically stable. Will transfer to floor bed.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:07 ------\n" }, { "category": "Nursing", "chartdate": "2157-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 486672, "text": "31F with DM1 wears insulin pump, tubing keeps kinking. Had sugars of\n >600 today. Unable to get follow up in diabetes clinic until\n . In ED first chem set revealing glu 684, K 5.7 (hemolyzed),\n Na 126, received 1L NS, second chem set glu 662, K 5, Na 128, pt\n insulin pump d/c\nd received 10 units regular insulin IV then\n started on insulin drip at 7units/hr. Glu post insulin 393. Pt given\n additional liter of NS with 20mEq K. Otherwise HD stable. Sent to\n MICU for management of DKA.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-09-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 486794, "text": "31F with DM1 wears insulin pump, tubing keeps kinking. Had sugars of\n >600 today. Unable to get follow up in diabetes clinic until\n . In ED first chem set revealing glu 684, K 5.7 (hemolyzed),\n Na 126, received 1L NS, second chem set glu 662, K 5, Na 128, pt\n insulin pump d/c\nd received 10 units regular insulin IV then\n started on insulin drip at 7units/hr. Glu post insulin 393. Pt given\n additional liter of NS with 20mEq K. Otherwise HD stable. Sent to\n MICU for management of DKA.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Insulin gtt weaned off and lantus started 3 pm (15 units given).\n Action:\n FSBS at 8 pm 75 and pt given some juice. FSBS increased to 359. Pt\n given 10 units of humalog and follow up FSBS was 400. Pt given an\n additional 8 units of humalog and follow up FSBS 101.\n Response:\n FSBS at 4 am down to 69 (asymptomatic) and pt given juice and gram\n cracker. HD stable. All serum labs stable and WNLs.\n Plan:\n Follow up labs and follow FSBS very closely (q4hrs to q2hrs prn). Plan\n to DC home today. ? need to increase lantus dosage today.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n DIABETIC KETOACIDOSIS\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 81.8 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Precautions: No Additional Precautions\n PMH: Asthma, Diabetes - Insulin\n CV-PMH:\n Additional history: depression\n Surgery / Procedure and date: none\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:87\n D:53\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 56 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 480 mL\n 24h total out:\n 1,150 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 03:29 AM\n Potassium:\n 4.1 mEq/L\n 03:29 AM\n Chloride:\n 106 mEq/L\n 03:29 AM\n CO2:\n 24 mEq/L\n 03:29 AM\n BUN:\n 17 mg/dL\n 03:29 AM\n Creatinine:\n 0.8 mg/dL\n 03:29 AM\n Glucose:\n 67 mg/dL\n 03:29 AM\n Hematocrit:\n 37.4 %\n 03:29 AM\n Finger Stick Glucose:\n 69\n 04:00 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": "2157-09-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 486792, "text": "Demographics\n Attending MD:\n F.\n Admit diagnosis:\n DIABETIC KETOACIDOSIS\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 81.8 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Precautions: No Additional Precautions\n PMH: Asthma, Diabetes - Insulin\n CV-PMH:\n Additional history: depression\n Surgery / Procedure and date: none\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:87\n D:53\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 56 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 480 mL\n 24h total out:\n 1,150 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 03:29 AM\n Potassium:\n 4.1 mEq/L\n 03:29 AM\n Chloride:\n 106 mEq/L\n 03:29 AM\n CO2:\n 24 mEq/L\n 03:29 AM\n BUN:\n 17 mg/dL\n 03:29 AM\n Creatinine:\n 0.8 mg/dL\n 03:29 AM\n Glucose:\n 67 mg/dL\n 03:29 AM\n Hematocrit:\n 37.4 %\n 03:29 AM\n Finger Stick Glucose:\n 69\n 04:00 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": "2157-09-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 486790, "text": "31F with DM1 wears insulin pump, tubing keeps kinking. Had sugars of\n >600 today. Unable to get follow up in diabetes clinic until\n . In ED first chem set revealing glu 684, K 5.7 (hemolyzed),\n Na 126, received 1L NS, second chem set glu 662, K 5, Na 128, pt\n insulin pump d/c\nd received 10 units regular insulin IV then\n started on insulin drip at 7units/hr. Glu post insulin 393. Pt given\n additional liter of NS with 20mEq K. Otherwise HD stable. Sent to\n MICU for management of DKA.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Insulin gtt weaned off and lantus started 3 pm (15 units given).\n Action:\n FSBS at 8 pm 75 and pt given some juice. FSBS increased to 359. Pt\n given 10 units of humalog and follow up FSBS was 400. Pt given an\n additional 8 units of humalog and follow up FSBS 101.\n Response:\n FSBS at 4 am down to 69 (asymptomatic) and pt given juice and gram\n cracker. HD stable. All serum labs stable and WNLs.\n Plan:\n Follow up labs and follow FSBS very closely (q4hrs to q2hrs prn). Plan\n to DC home today. ? need to increase lantus dosage today.\n" }, { "category": "Nursing", "chartdate": "2157-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 486690, "text": "31F with DM1 wears insulin pump, tubing keeps kinking. Had sugars of\n >600 today. Unable to get follow up in diabetes clinic until\n . In ED first chem set revealing glu 684, K 5.7 (hemolyzed),\n Na 126, received 1L NS, second chem set glu 662, K 5, Na 128, pt\n insulin pump d/c\nd received 10 units regular insulin IV then\n started on insulin drip at 7units/hr. Glu post insulin 393. Pt given\n additional liter of NS with 20mEq K. Otherwise HD stable. Sent to\n MICU for management of DKA.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Received pt from ED on insulin drip at 7units/hr, q1h fingersticks\n done, labs sent on arrival.\n Action:\n Blood sugars trending downward, most recent at 1700 186, insulin drip\n titrated MD order, received evening dose lantus (pt not normally on\n lantus, just used to transition off insulin drip), ordered for\n continuous IV fluids. K also trending down, last K 4.5.\n Response:\n AG closed, pt reports feeling better, ordering dinner for tonight.\n Plan:\n Continue to wean off insulin drip recommendations, may be\n discharged home this evening.\n" }, { "category": "Nursing", "chartdate": "2157-09-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 486628, "text": "31F with DM1 wears insulin pump, tubing keeps kinking. Had sugars of\n >600 today. Unable to get follow up in diabetes clinic until\n . In ED first chem set revealing glu 684, K 5.7 (hemolyzed),\n Na 126, received 1L NS, second chem set glu 662, K 5, Na 128, pt\n insulin pump d/c\nd received 10 units regular insulin IV then\n started on insulin drip at 7units/hr. Glu post insulin 393. Pt given\n additional liter of NS with 20mEq K. Otherwise HD stable. Sent to\n MICU for management of DKA.\n" } ]

[ { "category": "Radiology", "chartdate": "2101-12-20 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 1220588, "text": " 11:28 AM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: s/p fall, trauma protocol\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/ down flight of stairs, right radial wrist\n tenderness\n REASON FOR THIS EXAMINATION:\n s/p fall, trauma protocol\n ______________________________________________________________________________\n WET READ: MMDI TUE 2:47 PM\n Subtle nondisplaced radial styloid fracture.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Three views of the right wrist .\n\n COMPARISON: None.\n\n INDICATION: Status post fall downstairs. Right radial wrist tenderness.\n\n FINDINGS: Subcutaneous edema. There is a subtle linear lucency through the\n radial styloid of the distal radius, consistent with a nondisplaced fracture.\n No other fracture. No dislocation.\n\n IMPRESSION: Subtle nondisplaced radial styloid fracture.\n\n This was also reported to Dr. by Dr. via telephone at 2:45pm.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1220575, "text": " 10:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall down ten steps, no focal neuro deficits\n REASON FOR THIS EXAMINATION:\n trauma protocol\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf TUE 11:34 AM\n New small right extra-axial hemorrhage (2:19).\n New small subfalcine subdural hemorrhage (2:22).\n Large subcutaneous fronto-parietal hematoma (601b:36).\n ? small nasal bone fracture (3:24).\n WET READ VERSION #1 IPf TUE 11:32 AM\n New small right extra-axial hemorrhage (2:19).\n New small subfalcine subdural hemorrhage (2:22).\n WET READ VERSION #2 IPf TUE 11:33 AM\n New small right extra-axial hemorrhage (2:19).\n New small subfalcine subdural hemorrhage (2:22).\n Large subcutaneous fronto-parietal hematoma (601b:36).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post-fall down 10 steps. No focal neuro deficit.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast administered.\n\n COMPARISON: MRI brain .\n\n FINDINGS: There is small right frontal parietotemporal extra-axial hemorrhage\n (601b:51). There is a small posterior subfalcine subdural hematoma (601b:81)\n tracking along the right tentorial leaflet. There is no evidence of large\n acute territorial infarction or large masses. The ventricles and sulci are\n slightly prominent, likely age related. There is no shift of midline\n structures.\n\n There is possible nasal bone fracture (3:24). Mucosal thickening is seen in\n the maxillary sinuses and ethmoid air cells. There is large soft tissue\n hematoma-laceration in the subcutaneous tissue of the left frontoparietal\n region. A left parotid lesion measuring approximately 2.5 cm is seen and\n better assessed on prior studies.\n\n IMPRESSION:\n 1. Small right frontal acute temporoparietal extra-axial, likely subdural\n hemorrhage.\n 2. Small acute posterior subfalcine subdural hemorrhage layering along the\n right tentorial leafleft. Follow up as clinically indicated.\n 3. Large frontoparietal subcutaneous hematoma-laceration.\n 4. Stable lesions within the left parotid gland characterized as likely a\n venolymphatic malformation on last MRI brain from .\n 5. Possible nasal bone fracture.\n (Over)\n\n 10:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2101-12-20 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1220576, "text": " 10:42 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n FINAL ADDENDUM\n Minimal anterolsithesis of left lateral mass of C1 wrf C2 is noted-of\n uncertain significance.\n\n\n\n 10:42 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall down ten steps, no focal neuro deficits\n REASON FOR THIS EXAMINATION:\n trauma protocol\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf TUE 11:36 AM\n Osteopenia. No acute fracture seen.\n C5-C6 level large posterior osteophyte impinging the thecal sac placing cord\n for risk of injury in appropriate clinical setting.\n Correlate with symptoms.\n If concern consider MRI.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall down 10 steps. No focal neurologic deficits.\n\n TECHNIQUE: CT C-spine without IV contrast. Coronal and sagittal reformatted\n images provided.\n\n COMPARISON: MR .\n\n FINDINGS: The alignement of the cervical spine is preserved. There is no\n prevertebral soft tissue edema. There is diffuse osteopenia. No discrete\n acute fracture is seen. There are multilevel degenerative changes in the\n cervical spine. Posterior to vertebral bodies of\n C5-C6, there is a large osteophyte impinging on the thecal sac anteriorly.\n Thin lucent line between the osteophyte and vertebral body may relate to the\n orientation; however, trauma related changes cannot be excluded as no recent\n priors are available. Imaged portion of the lung apices show scarring in the\n left lung apex. Similar lesion within the left parotid gland seen on multiple\n prior studies.\n\n IMPRESSION:\n 1. Osteopenia. No discrete acute fracture is seen. Thin lucent line at C2\n base can relate to artifact/osteopenia or very minimal fracture without\n displacement of the fragments.\n 2. C5-C6 level large posterior osteophyte impinging on the thecal sac and\n deforming the cord. Thin lucent line between the osteophyte and vertebral body\n may relate to the orientation; however, trauma related changes cannot be\n excluded as no recent priors are available.correlate clinically to decide on\n the need for further workup.\n 3. Stable lesion within the left parotid gland seen on multiple prior\n studies, characterized as likely a venolymphatic malformation.\n 4. Scarring in the left lung apex.\n (Over)\n\n 10:42 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2101-12-20 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1220577, "text": " 10:42 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall down ten steps, no focal neuro deficits, has pain\n over midthoracic spine but not step off lesion, diffuse abdominal pain\n REASON FOR THIS EXAMINATION:\n trauma protocol\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf TUE 12:15 PM\n No evidence of acute trauma on CT torso.\n No acute change from non-contrast CT torso from .\n Mild interval decrease in size of multiple LN.\n WET READ VERSION #1 IPf TUE 11:47 AM\n No evidence of acute trauma on CT torso.\n No change from non-contrast CT torso from .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall down 10 steps. Pain over mid thoracic spine.\n Newly diagnosed lymphoma of the stomach. History of cervical cancer and\n radiation in the past (per prior reports).\n\n TECHNIQUE: Noncontrast CT torso. IV contrast was not administrated due to\n concern by family members (daughter and grandson are physicians) due to\n baseline renal function. Dr. (ED attending) discussed with the\n family and decision was made to proceed without IV contrast due to family\n concern.\n\n COMPARISON: CT torso of , PET-CT of , and MR pelvis of\n .\n\n FINDINGS:\n\n The study is suboptimal due to lack of IV contrast; limitations were discussed\n prior scanning.\n\n CT CHEST: There is interval decrease in size of mediastinal, hilar and\n axillary lymph nodes. Scattered small lymph nodes are seen in the bilateral\n axilla, mediastinum, and hila, however, with interval decrease in size\n compared to last CT from . There are mild coronary artery\n calcifications. There is no pericardial effusion.\n\n There is a stable small right pleural effusion and adjacent opacity, likely\n small atelectasis. There is interval decrease in size of bilateral pulmonary\n nodules, largest in the right middle lobe measuring 5 mm (2:27). There is no\n pneumothorax. There is a stable linear scarring in the left lung apex.\n Scattered calcifications are seen in the thoracoabdominal aorta.\n\n CT ABDOMEN: Evaluation of solid organs is suboptimal due to lack of IV\n contrast. With this limitation in mind, the appearance of the liver and\n spleen appears grossly within normal limits. There is cholelithiasis. The\n (Over)\n\n 10:42 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: trauma protocol\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pancreas appears grossly unremarkable. Bilateral adrenal glands are normal.\n\n Diffuse wall thickening is seen in the stomach from known lymphoma. There is\n interval decrease in stranding about the duodenum. There is interval decrease\n in size of ill-defined retroperitoneal mass, difficult to measure. There is a\n persistent bilateral moderate hydronephrosis and hydroureter to the level of\n the retroperitoneal mass with associated stranding. There is interval\n decrease in size of retroperitoneal and mesenteric lymph nodes. No free air\n is seen. There are no acute findings on a noncontrast CT thought to be\n related to the acute trauma.\n\n CT PELVIS: There are bilateral total hip prosthesis, which gives significant\n amount of artifact in the pelvis. Ill-defined soft tissue surrounding the\n cervix is better evaluated on the last MR pelvis. There is interval decrease\n in size of bilateral inguinal lymph nodes. The urinary bladder appears\n grossly unremarkable. Similar very large ventral abdominal wall hernia is\n seen containing loops of large and small bowel. There is trace fluid within\n the pelvis, similar to prior. There is a similar large parastomal hernia in\n the left lower abdominal quadrant.\n\n OSSEOUS STRUCTURES: Multilevel degenerative changes are seen.\n No acute fracture is seen.\n\n IMPRESSION:\n 1. No evidence of acute injury on a noncontrast CT torso.\n 2. Interval decrease in size of mediastinal, hilar, retroperitoneal and\n inguinal lymph nodes.\n 3. Interval decrease in size of the retroperitoneal mass.\n 4. Diffuse gastric wall thickening consistent with known gastric lymphoma.\n 5. Interval decrease in size in bilateral pulmonary nodules.\n 6. Persistent small right pleural effusion.\n 7. Stable large ventral wall hernia containing loops of large and small\n bowel. No evidence of bowel obstruction.\n 8. Persistent bilateral moderate hydronephrosis and hydroureter extending to\n the level of the retroperitoneal mass.\n 9. Ill-defined soft tissue surrounding the cervix, better evaluated on most\n recent pelvic MR from .\n\n" }, { "category": "Radiology", "chartdate": "2101-12-23 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1221072, "text": " 1:56 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: interval change SDH, other acute process to explain worsenin\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with ALL admitted s/p mechanical fall down 10 steps\n found to have subdural hematoma stable on repeat CT, now w/worsening L-sided\n headache and dizziness with neck flexion. NON CONTRAST ONLY.\n REASON FOR THIS EXAMINATION:\n interval change SDH, other acute process to explain worsening symptoms\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for interval change to explain patient's worsening\n left-sided headache and dizziness with neck flexion.\n\n COMPARISON: CT C-spine from and MRI of the brain from\n .\n\n TECHNIQUE: Helical 2.5-mm axial MDCT sections were obtained from the skull\n base through the T3 level. Sagittal and coronal reformations were obtained.\n\n FINDINGS: There has been no interval acute change since the prior study three\n days ago. Once again noted is a prominent disc osteophyte causing moderate\n but non-critical stenosis of the vertebral canal, abutting the spinal cord at\n the C5-C6 level. There are several vertebral body lucencies at the C2, C3,\n and C4 levels, which are unchanged from the prior study but were not present\n on the MRI of the brain performed in . There is no marked change in the\n prevertebral soft tissues.\n\n IMPRESSION:\n 1. No acute interval change to explain patient's symptoms. If there is\n continued clinical concern, MRI of the neck is recommended for evaluation of\n the neural structures or ligamentous injury to the spine.\n 2. Several vertebral body lucencies in the cervical spine, new from ,\n which may be related to the patient's osteopenia; however, evaluation with MRI\n is recommended due to the patient's history of leukemia.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-26 00:00:00.000", "description": "R US MSK ELBOW RIGHT", "row_id": 1221323, "text": " 5:37 PM\n US MSK ELBOW RIGHT Clip # \n Reason: eval for abscess/fluid collection at old PICC site\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with lymphoma s/p fall w wrist fracture, here with infection\n at prior (R arm) PICC site.\n REASON FOR THIS EXAMINATION:\n eval for abscess/fluid collection at old PICC site\n ______________________________________________________________________________\n WET READ: GMSj MON 6:53 PM\n Targeted ultrasound at skin insertion site of prior PICC in the medial right\n arm:\n\n -Small 0.4 x 0.4 x 0.4 cm fluid collection in the superficial skin just below\n the puncture site - probable small developing abscess.\n\n -Overlying skin is markedly thickened - which corresponds with erythema and\n induration seen on physical exam (covering a larger area)\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with lymphoma, now presenting with induration and\n erythema overlying an old right arm PICC site. Evaluation for abscess or\n fluid collection.\n\n COMPARISON: None available in the system\n\n TARGETED MEDIAL RIGHT ARM ULTRASOUND: Targeted ultrasound at the skin\n insertion site of a prior right PICC line just proximal to the medial\n antecubital fossa was completed. At the site of prior line insertion, there\n is overlying skin erythema and induration. Ultrasound images of this region\n demonstrate diffuse skin thickening. Within the superficial subcutaneous\n tissues just beneath the skin puncture site, there is a small fluid collection\n measuring 0.4 (TV) x 0.4 (AP) x 0.4 (CC) cm, demonstrating irregular posterior\n acoustic shadowing. Findings are suggestive of a small superficial abscess at\n the skin insertion site of the prior line. No large or deep fluid collection\n is identified.\n\n IMPRESSION: Sub 5-mm fluid collection in the superficial subcutaneous tissues\n of the prior right PICC insertion site, findings which could reflect a small\n developing abscess.\n\n ADDENDUM: This small hypoechoic area is actually caused by acoustic shadowing\n from the indurated skin. While the subcutaneous fat is inflamed, there is no\n drainable fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-22 00:00:00.000", "description": "VENOUS DUP UPPER EXT UNILATERAL", "row_id": 1220947, "text": " 3:21 PM\n VENOUS DUP UPPER EXT UNILATERAL Clip # \n Reason: please evaluate for R arm or DVT or drainable fluid collecti\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81F w/recent chemo for B cell lymphoma admitted after mechanical fall at home\n with R radial fracture, also found to have R upper arm worsening erythema and\n induration surrounding site of recent PICC line, concern for abscess, DVT\n REASON FOR THIS EXAMINATION:\n please evaluate for R arm or DVT or drainable fluid collection at site of\n recent RUE PICC\n ______________________________________________________________________________\n WET READ: 5:11 PM\n No fluid collection. Thrombus in right basilic vein which is a superficial\n vein. No DVT in the right upper extremity.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with recent chemo for B-cell lymphoma,\n admitted after mechanical fall at home with right radial fracture, also found\n to have right upper arm worsening erythema and induration surrounding site of\n recent PICC. Evaluate for abscess DVT.\n\n COMPARISON: None.\n\n FINDINGS: -scale and color Doppler imaging was obtained of the right\n subclavian, internal jugular, axillary, basilic, brachial and cephalic veins.\n There is nonocclusive thrombus seen in the right basilic vein which is a\n superficial vein. There is no thrombus seen in the deep veins which\n demonstrate normal flow, compressibility and augmentation. There is no\n abscess or fluid collection seen.\n\n IMPRESSION: Thrombus in the right basilic vein, a superficial vein. No\n evidence of DVT in the right upper extremity. No drainable fluid collection\n or abscess.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1221071, "text": " 1:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change SDH, other acute process to explain worsenin\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with ALL admitted s/p mechanical fall down 10 steps\n found to have subdural hematoma stable on repeat CT, now w/worsening L-sided\n headache and dizziness with neck flexion\n REASON FOR THIS EXAMINATION:\n interval change SDH, other acute process to explain worsening symptoms\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for interval change and subdural hematoma in patient\n with ALL status post mechanical fall three days ago, now with worsening left\n side headache and dizziness with neck flexion.\n\n COMPARISONS: NECT of the head from through .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: Again, there has been no interval change in the thickness or extent\n of the small right frontotemporal subdural hematoma. A small amount of\n subdural hematoma tracking along the falx is also unchanged. There is no\n evidence of new hemorrhage, edema, mass, mass effect, or infarction. White\n matter changes consistent with chronic small vessel ischemic disease again\n noted. The left frontoparietal subgaleal hematoma is markedly smaller. The\n remainder of the osseous structures and extracranial soft tissues show no\n interval change.\n\n IMPRESSION: No marked change from previous study to explain patient's\n worsening symptoms.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1220683, "text": " 5:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Perform at 0600 am am. Interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Perform at 0600 am am. 81 year old woman s/p fall down ten steps, with R\n subdural hematoma\n REASON FOR THIS EXAMINATION:\n Perform at 0600 am am. Interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 7:01 AM\n No signficant interval change in degree of SDH overlying the right cerebral\n hemisphere. Right posterior parafalcine SDH is slightly decreased. New right\n frontoparietal subgaleal hematoma and slightly increased left frontoparietal\n subgaleal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with right subdural hematoma. Evaluate for\n interval change.\n\n TECHNIQUE: Sequential axial images were acquired through the head without\n administration of intravenous contrast material. Multiplanar reformations\n were performed.\n\n COMPARISON: CT head from .\n\n FINDINGS: There is no significant change in thickness or extent of the\n relatively thin right frontotemporoparietal region subdural hematoma, with\n little mass effect (2:12). Additional subdural hematoma along the right\n portion of the posterior falx is slightly decreased in size, possibly related\n to redistribution over the right leaflet of the tentorium cerebelli.\n\n There is no new intracranial hemorrhage, edema, shift of normally midline\n structures, hydrocephalus, or acute large vascular territorial infarction.\n Periventricular and subcortical white matter hypodensities are consistent with\n sequelae of chronic small vessel ischemic disease. Prominence of the\n ventricles and sulci represents age-related involutional change.\n\n Mucosal thickening is seen within the right maxillary sinus. The remainder of\n the visualized portions of the paranasal sinuses and mastoid air cells are\n well- aerated. The orbits are grossly unremarkable aside from evidence of\n bilateral ocular lens surgery. As before, there is a left frontoparietal\n subgaleal hematoma, unchanged in overall extent. Additionally, more edema is\n evident in the right frontoparietovertex subgaleal scalp (2:16).\n\n IMPRESSION:\n\n 1. No significant interval change in the extent of subdural hematoma\n overlying the right cerebral convexity. Decreased right parafalcine\n component, posteriorly, could relate to redistribution.\n\n (Over)\n\n 5:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Perform at 0600 am am. Interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. No new intracranial hemorrhage or evidence of acute large vascular\n territorial infarction.\n\n 3. No shift of midline structures or central herniation.\n\n 4. Stable left frontoparietal scalp subgaleal hematoma, without underlying\n fracture (better-assessed on yesterday's dedicated bone imaging).\n\n" }, { "category": "ECG", "chartdate": "2101-12-20 00:00:00.000", "description": "Report", "row_id": 114651, "text": "Sinus rhythm with atrial premature beats. Left axis deviation. Early\ntransition. Voltage criteria for left ventricular hypertrophy (lead aVL).\nCompared to the previous tracing of the R wave progression is now\nnormal in leads V3-V6.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2140-04-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 953188, "text": " 9:23 PM\n CHEST (PA & LAT) Clip # \n Reason: eval: PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with fever\n REASON FOR THIS EXAMINATION:\n eval: PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old male with fever.\n\n PA AND LATERAL CHEST RADIOGRAPH: Comparison was made with the prior chest\n radiograph dated . The PA radiograph is technically limited, with\n vague increased density overlying the entire film. The heart is normal in\n size, and mediastinal contour is within normal limits. On lateral view, there\n is no definitive consolidation or effusion, however, there is confluent\n opacity overlying the hilum.\n\n IMPRESSION: 1. Limited PA view probably due to technical reason. No acute\n cardiopulmonary process identified on this study. If clinical concern\n persists, please repeat the frontal view.\n 2. Opacity overlying the hilum, which can represent hilar adenopathy. Further\n evaluation is recommended. Dr. was informed in the monrning of\n .\n\n" }, { "category": "Radiology", "chartdate": "2140-04-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 953252, "text": " 10:32 AM\n CHEST (PA & LAT) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: FEVER,HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with HIV, fevers, crackles in right lung base.\n\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Fever, crackles in right lung base, HIV.\n\n Comparison is made with prior studies from and .\n\n PA AND LATERAL VIEWS OF THE CHEST: Cardiac size is normal. Engorgement of\n the vasculature, haziness of the hila bilaterally, and diffuse septal\n thickening are new. Calcified granuloma in the right lung is unchanged. There\n are no pleural effusions or pneumothorax.\n\n IMPRESSION: Rapid onset interstitial pattern, most likely due to fluid\n overload, but viral pneumonia cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 953180, "text": " 7:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval: bleed, mass effect\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with Fever, HA, HIV\n REASON FOR THIS EXAMINATION:\n eval: bleed, mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: Fever, headache, HIV positive, rule out mass or bleed.\n\n COMPARISON: CT head without contrast, .\n\n TECHNIQUE: CT head without contrast.\n\n FINDINGS: There is no intracranial hemorrhage. There is no shift of normally\n midline structures, mass effect or hydrocephalus. The -white matter\n differentiation is preserved. There are no fractures identified.\n\n IMPRESSION: Unchanged exam from previous . No acute\n abnormality identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 953504, "text": " 8:51 AM\n CHEST (PA & LAT) Clip # \n Reason: reevaluate infiltrate\n Admitting Diagnosis: FEVER,HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with HIV, fevers, crackles in right lung base.\n\n REASON FOR THIS EXAMINATION:\n reevaluate infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV, fevers and crackles at right lung base. Evaluate for\n infiltrate.\n\n Comparison: and .\n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: Reduction in perihilar haze and\n interstitial edema suggests improved volume status. Tiny bilateral pleural\n effusions persist. A tiny granuloma is noted in the right lung, the lungs are\n otherwise clear. Cardiac and hilar contours are normal. Prominence of the\n right paratracheal stripe persists and may reflect azygous prominence as well\n as possible mediastinal lymphadenopathy.\n\n IMPRESSION: Resolution of interstitial edema with persistent small bilateral\n pleural effusions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1293497, "text": " nursing note 00-00 - .\nPt presented to the ed with a temp of 102.5 ,hypotension and generalised body rash .Pt is just recently diagnoised with hiv positive and was d/c from hospital ago with ? episode of acute renal failure as per pt .Pt was on augmentin since d/c and was due to start bactrin,pt may have had allergic reaction after taking bactin .Pt is alert and orientated x 3 .Pt received 7lt of fluid in the ed dept .Lp taken which was neg,pt did have high opening pressure due to position (24 ) .Head ct,nad .No c/o of headache .Pt c/o of generalised muscle pain in limbs,oxycodone given with good relief .\nGI/GU:\nPt has positive bowel sounds, no loose stool ,and is passing large volumes of clear yellow urine .Urine sent to lab for analysis .\nCV:\nTmax 101.4,tylenol given .Bl cultures sent from the ed dept .Bp stable at present,see carevue for obj data .Pt has s/t to nsr with occ pvc's .Continues on maint fluids 100cc per hour .\nResp:\nPt in no acute resp distress,02 sats 98-100 % r/a .\nSocial :\nPt called partner during the night.\nSkin:\nPt has iv access x 2 ,wnl .Generalised body rash acc with high temp,same reduced since admission.Eye drops administered q 4hr ,eyes are red and bloodshot .Throat swab taken.\nPlan :\nAwaiting blood culture results.Find and treat cause of infection .Reassure pt .Monitor bp and treat accordingly.\n\n" } ]

[ { "category": "ECG", "chartdate": "2102-03-23 00:00:00.000", "description": "Report", "row_id": 202201, "text": "Sinus tachycardia\nPoor R wave progression\nNonspecific inferolateral ST-T wave changes\nSince previous tracing, the rate in slower\n\n" }, { "category": "ECG", "chartdate": "2102-03-22 00:00:00.000", "description": "Report", "row_id": 202202, "text": "Sinus tachycardia. Non-specific inferolateral ST-T wave abnormalities. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-22 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 904653, "text": " 9:31 PM\n TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: asseess for nec fasc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with leg infection. please do soft tissue film to look for\n air in sq tissue\n REASON FOR THIS EXAMINATION:\n asseess for nec fasc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old woman with leg infection.\n\n RIGHT TIBIA/FIBULA, TWO VIEWS: There is marked soft tissue swelling over the\n anterior portion of the leg and ankle, however, no subcutaneous air is seen.\n No fractures are identified. Cortices are intact. Bony alignment is\n satisfactory.\n\n IMPRESSION: No fractures. Soft tissue prominence.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-03-24 00:00:00.000", "description": "Report", "row_id": 1409480, "text": "pmicu npn 7p-7a\n\n\n 36yo woman presented to an osh with right lower leg cellulitis possibly secondary to a spider bite. overnoc, the pt continued to spike fevers despite tylenol dosing and abx coverage. her most pressing complaint has been a persistent, moderate to severe ha that has been refractory to morphine dosing ~q2hrs. the pt states that she does develop ha's at home which she attributes to stress but are never this severe and generally respond to motrin. of note, however, is the fact that she continued to maintain an even to negative fluid balance overnoc despite maintainence fluids and an increase in po fluid intake. she c/o feeling thirsty as well. ?whether the pt is still moderately volume depleted and this may be contributing to her ha's.\n she is hemodynamically stable. anticipate transfer to medicine later today.\n\nreview of systems\n\nrespiratory-> lung sounds cta while maintaining sats >96% on ra. denies subjective c/o sob.\n\ncardiac-> persistently tachycardic d/t fevers. hr 100-110's, st with no noted ectopy. received potassium and phosphorous repletion last evening. am chemistries still pnding. sbp 110-150's.\n\nneuro-> a&o x3, pleasant and cooperative w/care. fully independent w/adl's at baseline. recurrent ha's as noted above. pt states she is having less pain from right leg.\n\ngi-> abd is obese w/+bs. tolerating a house diet. denies c/o nausea. no bm since admission.\n\ngu-> uop >100cc/hr with an even to negative fluid balance. ?whether pt would benefit from more aggressive fluid repletion. would continue to encourage po intake of fluids.\n\nid-> tmax 102.7 orally. last dose of tylenol given @mn with a steady decrease in her temperature curve since that time. she is receiving abx for the cellulitis. urine and blood cxs are still pnding. of note, her wbc has been wnl.\n\naccess-> 2 peripheral angiocaths located in either antecub.\n\nsocial-> pt's family was in last noc to visit.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-23 00:00:00.000", "description": "Report", "row_id": 1409479, "text": "Nursing Progress Note:\n\nEvents: Pt. was to be called out to floor but spiked a temp of 104.6, cultures sent, fluids continued, pt. to remain on floor overnight for observation and management.\n\nNeuro: Pt. is alert, oriented, pleasant and cooperative,MAE although moving R leg causes pain due to cellulitis.. Pt. c/o severe HA several times today for which 2mg Morphine was given with good effect.\n\nCV: HR 110s-120s ST with no ectopy, NBP 110s-140s/30s-50s. Pt. received with Presept catheter in R SC but this was d/c's in anticipation of calling pt. out. Pt. initially had 2 PIVs but one was d/c'd due to pain and redness and new 18g was placed in R AC. Pt. also has a 20g in L AC which is patent although positional. Pt. currently has NS running @ 150cc/hour for one liter and NS with Phos and K running.\n\nResp: RR 10s-20s, 02 sats>96% on room air, LS clear to all lobes.\n\nGI: BSX4, abdomen obese, no BM on shift. Appetite has increased during day, pt. orders own food from room service menu.\n\nGU: UO 100-200cc/hour.\n\nSkin: Red patchy areas to RLE below knee and one small area on L thigh with perimeters marked. No increase in size of ares and per pt. areas are much less red than they were yesterday. No open areas noted.\n\nID: Initial infection thought to be due to spider bite being treated with abx. Today pt. spiked temp of 104.6, blood cultures were drawn from new peripheral IV site, urine culture sent and 1g Tylenol given. Presept catheter tip was also sent for culture. Lactate drawn now 1.4 up from 0.8. Temp now decreased to 101.\n\nPlan: Monitor Temp, follow cultures, possible call out to floor tomorrow.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-24 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 904843, "text": " 8:38 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: please evaluate for DVT, lymphangitis\n Admitting Diagnosis: CELLULITIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with cellulitis of RLE\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT, lymphangitis\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT VENOUS ULTRASOUND, LOWER EXTREMITY\n\n INDICATION: 36-year-old woman with cellulitis of right lower extremity,\n please evaluate for DVT.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler son of the right lower extremity\n including the right common femoral, superficial femoral, and popliteal veins\n were performed. Normal flow, augmentation, compressibility, and waveforms\n were demonstrated. Intramural thrombus was not identified.\n\n IMPRESSION: No evidence for DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 904662, "text": " 11:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: placement, ptx\n Admitting Diagnosis: CELLULITIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman s/p L SCL placement\n REASON FOR THIS EXAMINATION:\n placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left subclavian line placement.\n\n COMPARISON: None.\n\n FINDINGS: The left subclavian central venous line tip overlies the mid SVC.\n The heart size and mediastinal contours are normal. Volumes are low. There\n is no evidence of pneumothorax. There is no lobar consolidation or CHF.\n\n IMPRESSION: No pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-03-23 00:00:00.000", "description": "Report", "row_id": 1409478, "text": "1900-0700 rn notes micu\n\n36 y.o female with h/o of HTN, high cholesterlevel,admitted to ED from OSH d/t cellulites of RLE, lilkely from spider bite, fever 104, rigors, WBC 20, tachy 130. in ED lactate 1.9, after 5L fluid pt dropped BP to low 90's, pt start on MUST protocol, received tylenol, motrine. in ED xray of RLE done to r/o SQ air, Xray normal. in pt received Ativan for central line placement. admitted ti the unit for further monitoring.\n\nneuro: lethargic after Ativan, easily arousable, Ox3. follows commnds. MAE. pt c/o headache, received Tylenol po 650mg.\n\nresp: RA sat 96-97%, LS clear.\n\ncv: HR 112-115, ST, no ectopy. BP 115-118/46/58. cont NS 150cc/hr for 2L., cont MUST protocol, last lactate 0.8, WBC 8.9. CVP 10-14. SVO2 78-86 slightly unaccurate-> no waves form, no wedge, SQ1 4.\n\ngi/gu: foley in place, drainge yellow/clear urine >30cc/hr. abd obese, BS +. pt on house diet.\n\nskin: redness that marked on RLE gouing up to tigh, appear red spot on LUE.\n\nplan: cont monitoring skin condition, lactate by sepsis protocol\n cont monotoring cardio status\n ? transfer to the floor.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2149-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 996799, "text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman s/p MI with mild pulmonary edema\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of patient with pulmonary edema.\n\n Portable AP chest radiograph compared to .\n\n Moderate-to-severe cardiomegaly is unchanged. Mediastinal silhouette is\n stable in a patient after median sternotomy and most likely CABG. Mild\n pulmonary edema has improved and is accompanied by bilateral pleural effusion.\n\n The dual-lead right pacemaker is in unchanged position with leads terminating\n in right atrium and right ventricle.\n\n IMPRESSION: Improvement in still present mild pulmonary edema. Moderate-to-\n severe cardiomegaly.\n\n DL\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2149-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 996438, "text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pulmonary edema\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman on HD for ESRD, s/p cath and stent with crackles at her bases\n REASON FOR THIS EXAMINATION:\n Assess for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Woman on hemodialysis with ESRD with crackles at her bases,\n assess for pulmonary edema.\n\n No prior studies are available for comparison.\n\n There is mild cardiomegaly. Right pleural effusion is small. There is\n evidence of fluid overload with prominence of the pulmonary vasculature with\n no overt interstitial pulmonary edema. Right transvenous pacemaker leads\n terminating from the position in the right atrium and right ventricle. The\n patient is post median sternotomy.\n\n\n DR. \n" }, { "category": "Echo", "chartdate": "2149-02-05 00:00:00.000", "description": "Report", "row_id": 85507, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Assess wall motion, nstemi.\nHeight: (in) 61\nWeight (lb): 160\nBSA (m2): 1.72 m2\nBP (mm Hg): 97/38\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 09:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate-severe AS\n(area 0.8-1.0cm2). Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Mild to\nmoderate (+) MR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction with hypokinesis of the basal\nto mid inferior segments. Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets are moderately\nthickened. There is moderate to severe aortic valve stenosis (area\n0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. There is no mitral valve prolapse. Mild to moderate\n(+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild focal left ventricular systolic dysfunction. Moderate to\nsevere aortic stenosis. Mild to moderate mitral regurgitation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-02-08 00:00:00.000", "description": "Report", "row_id": 1668414, "text": "CCU NPN\n\n0700-1500\n\nPt has been pain free all day, hr 61-68 sr no vea, occasionally a paced. bp 101-110/43-64. Lopressor has been changed to metoprolol XL 50 mg qd, to be given at night. Continues on Isosorbide 20 mg tid, ASA, plavix. Ankle w/ +1 edema.\nLungs w/ crackles at base, SATs 94-95 on RA. No c/o sob\nNo GI issues\nAwaiting hemodyalysis this afternoon.\nBS wnl\nA: PF awaiting hemodialysis\nP: Gently ultrafiltration during dialysis, monitor for pain.\nContinue CV meds. ? c/o if PF during dialysis\n" }, { "category": "Nursing/other", "chartdate": "2149-02-08 00:00:00.000", "description": "Report", "row_id": 1668415, "text": "CCU NURSING 1500-1900\nS/O.\nCV: DENIES CHEST PAIN, C/O SOB UPON TRANSFER FROM CHAIR TO BED, RELIEVED QUICKLY WITH REST AND RESTARTING O2 2L NC, VSS\n\nRESP: LUNGS BASILAR CRACKLES, SATS 94% ON ROOM AIR 96-99% ON 2L NC\n\nGI: TOLERATING CARDIAC/DIABETIC DIET, RECEIVED 2 UNITS REGULAR W/DINNER FOR FS 163\nHEME: HCT IN AM 26 - T+C FOR 1 UNIT, CONSENT OBTAINED, NEEDED 2ND SAMPLE FOR BB, AWAITING BLOOD TO BE READY\n\nRENAL: DIALYSIS STARTED ~ 1700, TOLERATING WELL THUS FAR\n\nA/P: TX 1 UNIT PRBC'S AS ORDERED, CONT DIALYSIS, FOLLOW FS AND TREAT PER SS PROTOCOL, START LONG-ACTING BETA BLOCKER , KEEP PT/FAMILY INFORMED OF CONDITION, POC, EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2149-02-06 00:00:00.000", "description": "Report", "row_id": 1668408, "text": "S:\"I have chest pain 8 out of 10\". \"I think it might be heartburn\".\n\nCV:NSR/ST hr 60-70's. Pt c/o chest pain changes, ST segment monitor showed st depression in lead two -3 now -1.5. pt received 3 sl nitroglycerine with little effect and 2mg ivp morphine.pt was then started on nitro gtt also lopressor 5 mg po x2 and 25mg lopressor po hr decreased to 79 nsr and bp now 91/51. Pt had 800cc uf today with hemodialysis, bp did drop to 80's during treatment goal of 3liters was decreased to 800cc. Nitro being titrated off. + LE pulses femoral site intact.\n\nGU:pt received hemodialysis today for 4hrs gentle fluid removal. pts bp after hd tx was complete was 100's no urin output today. rn spoke to pt about fluid restrictions while on hemodialysis at home.\n\nGI:Pt had loose bm x3 this a.m. no diarrhea this afternoon. pt tolerated her meals well. BS +.\n\nresp: LSC pt on 2liters nc with o2 sats in the 90's. pt o2 sats decreased while pt was having chest pain.\n\nneuro:alert and oriented x3. children into visit.\n\nID:afebrile.\n\nAccess:2 PIV.\n\nskin:intact.\n\nA:ekg changes with chest pain.\n\nP:pt may have hemodialyis again in a.m. monitor hr and assess for chest pain. Pt may go back to cath lab to take another look.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-02-06 00:00:00.000", "description": "Report", "row_id": 1668409, "text": "CV:HR 100's 130's, dobutamine 7mcg/kg/min with a urin output of 70-80cc/hr urin output decreased to 50cc/hr dobutamine increased to 8mcg/kg/min urin output increased to 80cc/hr. hr increased to 140's dobutamine decreased to 7mcg/kg/min. pts dobutamine may be titrated down if hr reaches 130's. pt will go for pa line placement in a.m npo after midnight. dobutamine needs to off 1hr before cath lab. pt will then be started on milrinone in cath lab. BILAT LOWER EXTREMITY EDEMA\n\nResp:high rr when he sleeps 40's o2 sats decrease when pt sleeps o2 2l nc to help maintain o2 sats. LSC\n\nGU:maintaining 70-80cc/hr urin output pt using urinal.\n\nGI:pt ate well used commode x2 today bs+. pt hr increased to 170's with exertion to commode may want to just use bedpan if needing to have a bm.\n\nneuro:social services are involved. pt's wife support family she works over 40 hrs a week and pt is stay at home dad. pt needs help with meds at home. pt may go home with home milrinone and md are worried if pt will be able to care for himself. wife is very busy and is already stretched to th limit. children are 10 and 4yrs old.\n\naccess:2 PIV.\n\nA:32yo male c dilated cm + fluid overload decompensated heart failure.\n\nP: URIN OUTPUT GOAL 70-80CC/HR, TITRATE DOBUTAMINE IF HR >130'S OR SYMTOMATIC, EMOTIONAL SUPPORT, HOLD LISINOPRIL AND BB.\n" }, { "category": "Nursing/other", "chartdate": "2149-02-05 00:00:00.000", "description": "Report", "row_id": 1668404, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P MI; STENT LAD\n\nS- \" I HAVE THAT PAIN IN MY CHEST- NOW IT'S UP TO MY NECK..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT ARRIVED FROM CATH LAB S/P STENT TO LAD AT 7P, VSS CP FREE.\nSHEATH D/C 9P FOR ACT 169 WITHOUT ISSUE- POPLITEAL PULSES/ (+), NO OOZE OR HEMATOMA THIS SHIFT.\n PT STARTED ON HEMODIALYSIS 9:30P AND BY 10:40P C/O CP- 7/10 UP TO . STATES SHE \" HAD HAD THE PAIN FOR 1/2 HOUR ALREADY\" BEFORE SHE TOLD THE DIALYSIS RN. WITH PAIN- HR- 90-100 ST, UP FROM 60-70'S AND BP- 120/70. PT WITH SIGNIFICANT EKG CHANGES- ST SEGMENT DEPRESSED\nANT/LAT- CALLED CV FELLOW- TREATED WITH 2 MS, 3 SL TNG, 5 MG IV LOPRESSOR FROM 10:45-11:10P. SERIAL EKGS' OBTAINED, CYCLING CPK'S. ABOUT TO ADD TNG GTT BUT BP DOWN TO 80'S SYSTOLICALLY FOR THE REST OF THE SHIFT S/P MEDS FOR THE PAIN. PT CP FREE BY 11:15 PM- EKG WITH RESOLVING ST SEGMENTS. CV FELLOW CONSULTED INTERVENTIONAL ATTENDING RE: ? PLAN FOR RELOOK BUT DECLINED CURRENTLY D/T PT'S ANATOMY AND RESOLVING ISCHEMIA WITH MEDICAL TX.\n\nOVERALL- HR- 60-90'S SR, AFIB, AV PACED. CURRENTLY BACK IN SR -72, NO CP. BP- 86/50'S BY CUFF- OF NOTE, ALINE WAS 20 PT HIGHER REMOVAL FROM RT FEMORAL SITE.\nPULSE REMAINS PRESENT, FEMORAL SITE, CLEAN WITH TRANSPARENT DSG IN PLACE. 1ST SET CPK (-). PT STARTED ON HEPARIN GTT 900U AT 1AM- TO RECHECK LABS/PTT 7AM.\n\n PT WITH SOME FAINT CX WITH CP ISSUE- CURRENTLY CLEAR WITH O2 SAT 99% ON 2LNP. DENIES SOB BUT WITH CP WANTING TO SIT BOLT UPRIGHT AT 90 DEGREES ( ? MORE ANXIETY). PT COMFORTABLE ON NC CURRENTLY.\nNO FLUID TAKEN OFF WITH HEMODIALYSIS RUN THIS EVENING. STOPPED 1/2 HOUR SHORT OF GOAL 2 HOUR RUN.\n\nRENAL- SEE ABOVE- ISSUE WITH CP 1 HOUR INTO HD, NOT REPORTED TO RN UNTIL 1.5 HOUR INTO SESSION. TO RECHECK LYTES THIS AM. HD STOPPED 1/2 HOUR EARLY D/T SYMPTOMS.\n\nID- AFEBRILE\n\n PT NPO - SHEATHS REMOVED, THEN HD, THEN CP, THEN ASLEEP.\nGIVEN 1/2 DOSE GLARGINE THIS SHIFT , 2 U REG - ON INSULIN SCALE TO COVER BLOOD SUGARS. (+) BOWEL SOUNDS, NO STOOL THIS SHIFT.\nIVF AT KVO S/P CATH.\n\n PT GIVEN 2 AMPS HCO3 AND 2 AMPS CAGLUC ON ADMISSION. SERUM HCO3- 18, CA+ 9.5. REPEAT K IMMEDIATELY AT CESSATION OF HD- 4.1( NOT EQUILABRATED.)\n\nLINES- 2 #22- PATENT, FLUSHED.\nKVO THROUGH ONE, HEPARIN GTT THROUGH THE OTHER.\n\nSKIN- NO ISSUES- TURNING WITH ASSIST, BACK CARE.\n\nSOCIAL/ PT VERY 2 DAUGHTERS HERE WHEN PT PHONE NUMBERS GIVEN AND RECIEVED FOR CONTACT INFO. ALL AWARE OF CURRENTLY PLAN OF CARE. PT FULL CODE.\n\nA/ PT ADMITTED TO CCU FOR (+) MI IN NEED OF URGENT HD S/P SHEATH REMOVAL FOR PEAKED T W /HYPERKALEMIA\n - PT DEVELOPING ISCHEMIA IN REGION OF CV INTERVENTION DURING HD- RESOLVING WITH MED MANAGEMENT CURRENTLY.\n\n\nCONTINUE TO CLOSELY FOLLOW PT HEMODYNAMICS/S/SX ISCHEMIA OR STENT PROBLEMS/ACUTE REOCCLUSION. EKG WITH ANY FURTHER CP. CHECK PTT 7A WITH CYCLING OF CPK - MAINTAIN THERAPEUTIC LEVEL PTT. RECHECK LYTES AFTER 90% COMPLETED HD LAST EVENING.\nRESTART PT'S ISORDIL SR IF BP ALLOWS- IV TNG FOR ANY FURTHER CP, IF BP ALLOWS. START LOPRESSOR DOSE AS WELL WITHIN B\n" }, { "category": "Nursing/other", "chartdate": "2149-02-05 00:00:00.000", "description": "Report", "row_id": 1668405, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P MI; STENT LAD\n(Continued)\nP PARAMETERS.\nCOMFORT/DECREASE ANXIETY.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE- CALL DAUGHTER RE: EVENT LAST NITE OF CP/KEEP INFORMED OF PROGRESS.\nCONTINUE TO OBSERVE IN MEDICAL REGIMEN.\n" }, { "category": "Nursing/other", "chartdate": "2149-02-05 00:00:00.000", "description": "Report", "row_id": 1668406, "text": "CCU NPN\n\n0700-1900\n\nS: \"I feel so much better today\"\nO: please see carevue for all objective data\nneuro: alert, oriented x3 cooperative w/ care\ncv: hr 60-71 sr no vea, bp 81-98/36-51.lopressor and isordil doses held this am d/t hypotension. Pain free. CK 118/ MB 14, K 5.1 this am. Heparin d/c ECHO-> mild LV dysfunctin, mod aortic stenosis.\nresp: SATs 99% on RA, lungs cta.\ngi: good appitite, lg soft bm\ngu: anuric. Decision made to delay dialysis until tomorrow d/t hypotension.\nid: afebrile\nskin: intact\nactivity: OOB to chair w/ one assist, able to pivot.\nA: relative hypotension, \nP: monitor for pain, follow bp. awaiting phlebotomy to draw ck and k.\ndialysis in am. Maximize cv meds as bp allows.\nP:\n" }, { "category": "Nursing/other", "chartdate": "2149-02-06 00:00:00.000", "description": "Report", "row_id": 1668407, "text": "CCU Nursing Progress Note 1900-0700\nS: no cp nor SOB\n\nO: see CCU flow sheet for complete objective data\n\nCV: HR 60-74 NSR, occ A-paced, rare AV paced. BP 86-116/40-55. Given pm dose of isordil. Pm dose of lopressor held d/t SBP <100. Held this am as pt states she does not take lopressor or isordil on dialysis days and pt is scheduled for dialysis today. K 5.6--given dose of kayexalate. EKG without ^^T waves. Repeat K PND. Pivots from bed to commode with asst of 1.\n\nResp: lungs clear, sats >93% on RA\n\nGI: up most of night with diarrhea. Had loose stool early in the evening prior to kayexalate. Freq liq stool after kayexalate. Pt states that she usually takes immodium prior to meals at home d/t diarrhea. Pt refusing 10 Units of glargine--\"too much insulin.\" BS trends and pt's statement reviewed with HO. Pt. given 5 Units of glargine adn 2 units of regular @ 2200 for BS 157. Snack given before bed.\n\nGU: voided ~ 20 cc\n\nID: afebrile.\n\nSkin : intact\n\nAccess: 1 PIV\n\nSocial: daughter called to inquire re: pt's status.\n\nA: ^^ K again this evening, no ECG changes.Diarrhea following Kayexalate, but pt's baseline is loose stools\n\nP: continue to monitor BP closely with dialysis. Check with HO re: hold meds prior to dialysis. Follow elecrolytes. Monitor BS.\n" }, { "category": "Nursing/other", "chartdate": "2149-02-09 00:00:00.000", "description": "Report", "row_id": 1668416, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"IS MY BLOOD PRESSURE ALRIGHT? I HAVE NO CHEST PAIN\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE WITH CARE. TURNS SELF IN BED WITH MINIMAL ASSISTANCE. SLEPT IN LONG NAPS OVERNIGHT. DENIES C/O PAIN.\n\nCV: BP 107/41-88/31. HR 64-68 SR NO VEA NOTED. NO CP. RECEIVED 1 UNIT PRBC WITHOUT INCIDENT FOR HCT 26. AM HCT PENDING.\n\nRESP: DIMINISHED BREATH SOUNDS. O2 SAT ON 2L 98%. C/O 1 EPISODE OF FEELING \"SHORT OF BREATH\". O2 PLACED BACK ON, (PT. WAS ON ROOM AIR AT THE TIME OF INCIDENT) AND REPOSITIONED WITH PILLOWS UNDER BOTH ARMS. PT.STATES RELIEF WITH O2 AND REPOSITIONING.\n\nGU: HEMODIALYSIS COMPLETED AT 1900, DIALYSED OFF 2L. TOL RUN WELL. LEFT ARM FISTULA SITE INTACT. NO BLEEDING NOTED.\n\nGI: APPETITE GOOD. + BOWEL SOUNDS. PASSING GAS. WILL NEED COLACE AND SENNA TODAY.\n\nENDO: RECEIVED GLARGINE 10 UNITS AS ORDERED. BLOOD SUGARS WNL. NOO SSRI NEEDED.\n\nA: S/P NSTEMI, HYPOTENSIVE FOLLOWING HEMODIALYSIS, NATIVE 3VD, S/P STENT PLACEMENT TO LIMA.\n\nP: CONT TO FOLLOW LABS, HCT, LYTES. MONITOR I/O. ENCOURAGE INCREASED ACTIVITY AS TOL. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2149-02-06 00:00:00.000", "description": "Report", "row_id": 1668410, "text": "please disregard last note posted this note was wriiten in error. This note was for another pt. thank you\n" }, { "category": "Nursing/other", "chartdate": "2149-02-07 00:00:00.000", "description": "Report", "row_id": 1668411, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P MI/ICHEMIA W HD\n\nS- DENIES PAIN, SLEEPING MOST OF NITE.\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS WITH UNCHANGED HEMODYNAMICS- HR- 65-76 SR, MINIMAL VEA. SOME AV PACING. DENIES CP THIS SHIFT OR SOB. BP- 81/45-95/55 VIA CUFF, OF NOTE ALINE 20 PTS HIGHER WHEN IN PLACE EARLIER IN WEEK.\nPT GIVEN LOPRESSOR 12.5 10P AND 6A DOSE( 1/2 DOSE) D/T MARGINALLY LOW BP - TO KEEP HR WITHIN CONTROL.\nREMAINS ON ASA/PLAVIX.\n\n PT 2 L NP- 02 SATS 98-97%. CLEAR LUNGS, NO ISSUES CURRENTLY.\n\n PT S/P HD - 800 CC OFF- STOPPED EARLY D/T REPEAT OF ISCHEMIA/CP. AM LYTES/POST HD LYTES WNL. PLAN TO MAXIMIZE B BLOCKER IN HOPES TO AVOID DEMAND ISCHEMIA WITH NEXT ROUND OF HD.\n\nID- LOW GRADE TEMPS- 99- NO TEMP SPIKE.\n\nGI/ PT ON SS REG COVERAGE, GLARGINE AT BEDTIME.\nCURRENTLY SUGARS- 135-77 THIS SHIFT.\nNO REGULAR COVERAGE THIS SHIFT. NO KEXILATE NOR DIARRHEA THIS SHIFT.\n\nLINES- 2 #22- PT DIFFICULT STICK. CALLING PHLEBOTOMY FOR LAB CHECKS- ABLE TO DRAW OFF LOWER #22 FOR LABS BUT THAT IV WILL BE OUTDATED TODAY.\n\n PT , COMFORTABLE, ALERT AND ORIENTED. DAUGHTER NEXT OF PRESENT ON EVENINGS- WOULD LIKE TO BE CALLED FOR ANY FURTHER ISCHEMIC EVENTS/PROBLEMS NO MATTER WHAT TIME.- PHONE # ON BOARD IN ROOM.\nPT SLEPT ALL NITE, NO ISSUES.\n\nA/ PT S/P R/I MI CONTINUES WITH ISCHEMIA/CP WITH HEMODIALYSIS.\n\nPLAN- MAXIMIZE B BLOCKER /RATE CONTROL AS BP ALLOWS.\nCONTINUE TO MAXIMIZE ANTIICHEMIC REGIMEN. INCREASE ACTIVITY AS PT TOLERATES. ? PT CONSULT TO ASSIST.\nNUTRITION/SS REG INSULIN COVERAGE/GLARGINE.\nKEEP PT AWARE OF PLAN OF CARE AS WELL AS DAUGHTER(S).\n? C/O TO FLOOR TODAY, ONCE MEDICALLY APPROPRIATE.\nOBTAIN NEW ACCESS TODAY, MINIMIZE/CONSOLIDATE BLOOD STICKS D/T DIFFICULTY WITH PHLEBOTOMY.\n" }, { "category": "Nursing/other", "chartdate": "2149-02-07 00:00:00.000", "description": "Report", "row_id": 1668412, "text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\nCV- Tele: SR w/ occ PVC & some AV pacing- HR 61-71- no c/o chest pain-\nNIBP 90-109/41-54 MAPs 54-66 on low dose lopressor 12.5mg X2 early am-\nunable to give afternoon dose due to low B/P while being ultrafiltrated- Hct 25.1- K 4.9- Mg 1.8- CPK 154 MB 20\n\nResp- lung sounds diminished @ bases, otherwise clear- resp even, non-labored- SpO2 93-98% on room air.\n\nNeuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\n\nGI- abd obese soft (+) bowel sounds- taking Po well- no c/o N/V- had 1 large soft formed stool this am quiac (-)- glucose range 72-107 today-\nno insulin needed.\n\nGU- voided scant amt- ultrafiltrated 1900cc today- run uneventful-\nBUN/Crea this am 20/3.4- dialysis scheduled tomorrow (Tues, Thurs, Sat).\n\nAccess- saline lock X2 patent.\n\nID- afebrile- WBC 7.5\n\nA- no c/o chest pain w/ ultrafiltration today- hemodynamically stable.\n\nP- dialysis tomorrow- give PM lopressor @ if SBP >100- con't present medical management- offer emotional support.\n\n\u0013\n" }, { "category": "Nursing/other", "chartdate": "2149-02-08 00:00:00.000", "description": "Report", "row_id": 1668413, "text": "2300-0700\nNursing Progress Note\n Awoke at 0400..with substernal chest pain. Room air sat 90%. Placed on 4l nasal prongs, with 02 sat up to 98%.Resp rate 22.\n\n EKG done. Repositioned in bed..Lungs with cxs 3/4 up bliat ... pain resolving on own after ~~10 minutes. Dr in to evaluate.\n\nMidnight finger stick 114..Checked again at 0400..found to be 85..patient given apple juice per her request.\n\nAM labs obtained.\n0600 25mg of lopressor held pre-dialysis this morning.\nAM Lytes pending\nAnticipate HD/UF today\n" }, { "category": "ECG", "chartdate": "2149-02-04 00:00:00.000", "description": "Report", "row_id": 214964, "text": "Demand ventricular pacing and irregular narrow complex rhythm, probably atrial\nfibrillation. Compared to the previous tracing the rate is slower, the rhythm\nmore irregular and the ventricular pacing is new. ST segment elevation in\nlead aVR persists. Clinical correlation is suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2149-02-04 00:00:00.000", "description": "Report", "row_id": 214965, "text": "Probable sinus tachycardia with sinus arrhythmia. Compared to the previous\ntracing the rate has increased. P wave amplitude has increased.\nThe P-R interval is shorter. QRS interval is narrower. The Q-T interval is\nshorter. ST-T wave abnormalities are less. There are now R waves across\nthe precordium raising the possibility of the prior tracings being related\nto hyperkalemia or other metabolic derangements. Clinical correlation is\nsuggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2149-02-09 00:00:00.000", "description": "Report", "row_id": 214959, "text": "Sinus rhythm. Borderline first degree A-V block. Borderline left axis\ndeviation. Intraventricular conduction defect. Inferolateral ST-T wave\nchanges which are non-specific but cannot rule out myocardial ischemia.\nLow QRS voltages in the limb leads. Compared to the previous tracing\nof intraventricular conduction defect is new. Inferolateral\nST-T wave changes persist. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2149-02-07 00:00:00.000", "description": "Report", "row_id": 214960, "text": "Sinus rhythm. Inferolateral ST segment depression. Compared to the previous\ntracing the heart rate has decreased and ischemic repolarization abnormalities\nare significantly less prominent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2149-02-06 00:00:00.000", "description": "Report", "row_id": 214961, "text": "Sinus rhythm with intermittent demand electronic atrial pacing. Diffuse\nmarked ST segment depressions with T wave inversions suggestive of an acute\nintercurrent ischemic process. Compared to the previous tracing of \nheart rate has increased, now with ischemic electrocardiographic abnormalities.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2149-02-05 00:00:00.000", "description": "Report", "row_id": 214962, "text": "Atrial paced rhythm. Compared to the previous tracing of cardiac\nrhythm is now atrial paced.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2149-02-05 00:00:00.000", "description": "Report", "row_id": 214963, "text": "Sinus rhythm. Late R wave progression. ST-T wave abnormalities. Compared to\nthe previous tracing sinus rhythm is now present.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2149-02-04 00:00:00.000", "description": "Report", "row_id": 215172, "text": "Probable sinus rhythm with P-R interval prolongation. Marked left axis\ndeviation. Intraventricular conduction delay. Q-T interval prolongation.\nQ waves in leads V1-V3. Probable old anteroseptal myocardial infarction.\nCompared to the previous tracing earlier on the axis is more apparent.\nThe QRS interval is wider. The ST segment elevation in lead aVR is less\nprominent. Otherwise, probably no change. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2149-02-04 00:00:00.000", "description": "Report", "row_id": 215173, "text": "Baseline artifact. Probable sinus rhythm. Borderline P-R interval\nprolongation. Low limb lead voltage. Intraventricular conduction delay.\nIndeterminate axis. Q waves in leads V1-V4. Consider anteroseptal myocardial\ninfarction of indeterminate age. Q-T interval prolongation. ST-T wave\nabnormalities. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2115-03-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1178968, "text": ", NSURG SICU-A 3:09 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o new or growing intracranial bleed\n Admitting Diagnosis: CEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with new dizziness and worsening nausea/heachaches\n REASON FOR THIS EXAMINATION:\n r/o new or growing intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n Stable intraparenchymal hemorrhage in the right cerebellar hemisphere. No\n acute changes.\n\n" }, { "category": "Radiology", "chartdate": "2115-03-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1178967, "text": " 3:09 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o new or growing intracranial bleed\n Admitting Diagnosis: CEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with new dizziness and worsening nausea/heachaches\n REASON FOR THIS EXAMINATION:\n r/o new or growing intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw SUN 4:04 PM\n PFI:\n\n Stable intraparenchymal hemorrhage in the right cerebellar hemisphere. No\n acute changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New dizziness and worsening headache. Evaluate for change in\n intracranial bleed.\n\n CT HEAD: Imaging was performed through the brain without IV contrast.\n\n COMPARISON: CT head, .\n\n FINDINGS: In the right cerebellar hemisphere is a 13 x 18 mm hyperdense focus\n with surrounding edema, unchanged since the previous examination. No new\n areas of hemorrhage are present. The size and configuration of ventricles\n appears unchanged. No new areas of edema are present. No mass effect or\n midline shift is present. No evidence for acute vascular infarct is present.\n -white matter differentiation is well preserved. Osseous structures are\n intact. The visualized sinuses are clear.\n\n IMPRESSION:\n\n Stable intraparenchymal hemorrhage in the right cerebellar hemisphere. No\n acute changes.\n\n" }, { "category": "Radiology", "chartdate": "2115-03-15 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1178726, "text": " 10:06 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 34 year old man with R cerebellar hemorrhage, r/o underlying\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with R cerebellar hemorrhage, r/o underlying lesion\n REASON FOR THIS EXAMINATION:\n 34 year old man with R cerebellar hemorrhage, r/o underlying lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SAT 12:31 AM\n A 12 x 14 x 18 mm area in the right cerebellar hemisphere, corresponding to\n the CT findings of focal intraparenchymal hemrrhage, with mass effect and an\n apparent feeding vessel. This mass-like lesion demonstrates rim enhancement\n and hterogeneous internal enhancement. DDx favors neoplastic process.\n However, AVM remains in the differential diagnosis.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with right cerebellar hemorrhage.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following gadolinium. Correlation was made with the head CT\n examination of .\n\n FINDINGS: As seen on the head CT, there is an acute hemorrhage seen in the\n right cerebellar hemisphere at the junction of the hemisphere and the middle\n cerebellar peduncle measuring approximately 16 x 14 mm. Mild surrounding\n edema is seen. Minimal indentation on the right side of the fourth ventricle\n is seen. There is subtle increased signal in the periphery noted on\n pre-gadolinium T1-weighted images. Following gadolinium, most of the areas at\n the periphery of the lesion are accounted for by pre-gadolinium\n hyperintensities except for subtle enhancement at the inferior aspect. There\n is a venous structure extending to the superior aspect of the lesion\n identified from the cerebellar fissure indicating a developmental venous\n anomaly best visualized on series 101 images 77, 282. A small additional area\n of susceptibility abnormality is seen in right centrum semiovale, series 6,\n image 17. Subtle enhancement is also seen in this region. No other areas of\n susceptibility abnormalities or focal signal abnormalities noted or abnormal\n enhancement seen.\n\n The ventricles and extra-axial spaces are normal in size.\n\n IMPRESSION:\n 1. Right cerebellar acute hemorrhage measuring 16 x 14 mm with mild\n surrounding edema and mass effect on the fourth ventricle.\n 2. In association with the adjacent developmental venous anomaly and\n additional area of susceptibility in the right centrum semiovale, the\n hemorrhage likely is related to a cavernous malformation. No definitely\n enlarged arterial or venous structures are seen to indicate underlying\n (Over)\n\n 10:06 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 34 year old man with R cerebellar hemorrhage, r/o underlying\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n arteriovenous malformation. Followup study can help for further assessment if\n clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-18 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 1179063, "text": " 11:30 AM\n CAROT/CEREB Clip # \n Reason: ? caverness angioma\n Admitting Diagnosis: CEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100ML OPTI240; 64ML OPTI320\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 CAROTID/CERVICAL BILAT *\n * CAROTID/CEREBRAL BILAT EXT CAROTID BILAT *\n * VERT/CAROTID A-GRAM MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with right cerebellar hemorhage\n REASON FOR THIS EXAMINATION:\n ? caverness angioma\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Right cerebellar hemorrhage, rule out arteriovenous\n malformation.\n\n ATTENDING PHYSICIAN: , MD\n\n ASSISTANT: , NP\n\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, right internal\n carotid artery arteriogram, right external carotid artery arteriogram, left\n common carotid artery arteriogram, left internal carotid artery arteriogram,\n left external carotid artery arteriogram, left vertebral artery arteriogram,\n right common femoral artery arteriogram and Angio-Seal closure of right common\n femoral artery puncture site.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n fentanyl and Versed throughout the total intraservice time of 45 minutes,\n during which the patient's hemodynamic parameters were continuously monitored.\n\n DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV\n sedation was given. Following this, both groins were prepped and draped in a\n sterile fashion. Access was gained to the right common femoral artery using a\n Seldinger technique. The common femoral artery was seen to be significantly\n above the femoral head. Following this, 5 French vascular sheath was placed\n in the right common femoral artery. We now catheterized the above-mentioned\n vessels and AP, lateral filming was done. This revealed no evidence of\n aneurysm, arteriovenous malformation or dural AV fistula. Therefore, we did a\n right common femoral artery arteriogram and a 6 French Angio-Seal was used for\n closure of the right common femoral artery. The patient tolerated the\n procedure well. There were no complications.\n\n FINDINGS: Right common carotid artery arteriogram shows no evidence of\n stenosis at the right common carotid artery bifurcation.\n (Over)\n\n 11:30 AM\n CAROT/CEREB Clip # \n Reason: ? caverness angioma\n Admitting Diagnosis: CEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100ML OPTI240; 64ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Right external carotid artery arteriogram shows no evidence of dural AV\n fistula. The right occipital artery is seen to be fairly large and has\n extensive arborization. There is a large suboccipital cavernous plexus of\n veins.\n\n Right internal carotid artery arteriogram shows that the right internal\n carotid artery fills well along the cervical, petrous, cavernous and\n supraclinoid portion. The anterior and middle cerebral arteries are seen well\n with no evidence of aneurysms or arteriovenous malformations.\n\n Left vertebral artery arteriogram shows filling of the left vertebral artery\n and the basilar artery with reflux into the right vertebral artery. Both\n posterior cerebral arteries are seen well. Both superior cerebellar arteries\n are seen well. No aneurysms are seen. There is no evidence of dural AV\n fistula.\n\n Left common carotid artery bifurcation shows no evidence of stenosis.\n\n Left internal carotid artery arteriogram shows that the left internal carotid\n artery fills well along the cervical, petrous, cavernous and supraclinoid\n portion. The anterior and middle cerebral arteries are seen well with no\n evidence of aneurysms or arteriovenous malformation. The posterior\n communicating artery is seen with flash filling of the right posterior\n cerebral artery. Left external carotid artery arteriogram shows no evidence\n of dural AV fistula.\n\n Right common femoral artery arteriogram shows widely patent right common\n femoral artery.\n\n IMPRESSION: underwent cerebral angiography which failed to reveal\n an AVM or AV fistula that could account for his right cerebellar hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2115-03-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1178860, "text": " 5:51 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change acute worseing dizziness\n Admitting Diagnosis: CEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with right cerebellar mass\n REASON FOR THIS EXAMINATION:\n interval change acute worseing dizziness\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh SAT 7:28 PM\n PFI: Unchanged appearance of right cerebellar intraparenchymal hemorrhage\n with surrounding edema; prior MR suggested the underlying lesion may be a\n cavernous malformation and is better characterized on that study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 34-year-old male with right cerebellar mass, now with worsening\n dizziness.\n\n STUDY: CT of the head without contrast.\n\n COMPARISON: Reference head CT from from an outside hospital\n and MR of the head with and without contrast from .\n\n FINDINGS: Again is seen an area of dense material in the right cerebellar\n hemisphere that measures 12 x 17 mm in the axial plane (2; 9). It appears\n similar in size compared to prior study. There is a small amount of\n surrounding vasogenic edema. Additionally, there is mild mass effect on the\n neighboring fourth ventricle.\n\n Otherwise, the -white matter differentiation is preserved. The ventricles\n and sulci appear normal in size and configuration, and stable compared to\n prior studies. The paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION: Unchanged appearance of right cerebellar intraparenchymal\n hemorrhage with surrounding edema; prior MR suggested the underlying lesion\n may be a cavernous malformation and is better characterized on that study.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-03-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1178861, "text": ", NSURG SICU-A 5:51 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change acute worseing dizziness\n Admitting Diagnosis: CEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with right cerebellar mass\n REASON FOR THIS EXAMINATION:\n interval change acute worseing dizziness\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unchanged appearance of right cerebellar intraparenchymal hemorrhage\n with surrounding edema; prior MR suggested the underlying lesion may be a\n cavernous malformation and is better characterized on that study.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2197-05-27 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1132846, "text": " 1:02 PM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: ELAVATED AFP,VARICES EVAL FOR PV PATENCY\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and new esophageal varices. elevated AFP\n REASON FOR THIS EXAMINATION:\n ?portal venous flow and cirrhosis. ?hepatoma\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc SAT 2:57 PM\n 1. Appearance of liver is consistent with provided history of cirrhosis. No\n focal liver mass seen although echogenicity and heterogeneity of the liver\n parenchyma somewhat limits assessment for such.\n 2. Patent hepatic vasculature, with normal hepatopetal direction of flow in\n the portal veins. Patent umbilical vein and splenomegaly consistent with\n portal hypertension. There is also mild ascites.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with cirrhosis, new esophageal varices and elevated\n AFP. Here to assess cirrhosis, portal venous flow, and for hepatoma.\n\n COMPARISON: None available on PACS.\n\n ABDOMINAL ULTRASOUND WITH DOPPLER: The liver has heterogeneous and echogenic\n appearance, compatible with the provided history of cirrhosis. No focal liver\n lesion is seen. There is no intra- or extra-hepatic biliary ductal\n dilatation, with the common duct measuring 3 mm. The gallbladder appears\n normal, without stones. Pancreas is not well visualized due to overlying\n bowel gas but where visualized along the midline, no focal abnormality is\n seen. The spleen is enlarged, measuring 16 cm. Trace perihepatic and\n perisplenic ascites is noted as well as small ascites in the lower quadrants.\n\n The kidneys measure 13.3 cm on the right and 13.8 cm on the left. The kidneys\n appear normal, without evidence of stone, hydronephrosis or mass. The urinary\n bladder is not well distended but appears unremarkable.\n\n Color and pulse Doppler evaluation was performed over the liver, demonstrating\n normal hepatopetal flow within the portal veins, as well as normal waveforms\n in the hepatic veins and IVC, as well as the hepatic artery. The splenic vein\n is patent. No definite varices are noted however there is widely patent\n umbilical vein.\n\n IMPRESSIONS:\n\n 1. Appearance of liver is consistent with provided history of cirrhosis. No\n focal liver mass seen.\n\n 2. Patent hepatic vasculature, with normal hepatopetal direction of flow in\n the portal veins. Patent umbilical vein and splenomegaly consistent with\n portal hypertension. Small ascites.\n\n (Over)\n\n 1:02 PM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: ELAVATED AFP,VARICES EVAL FOR PV PATENCY\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2197-05-27 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1132847, "text": ", C. MED MICU 1:02 PM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: ELAVATED AFP,VARICES EVAL FOR PV PATENCY\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and new esophageal varices. elevated AFP\n REASON FOR THIS EXAMINATION:\n ?portal venous flow and cirrhosis. ?hepatoma\n ______________________________________________________________________________\n PFI REPORT\n 1. Appearance of liver is consistent with provided history of cirrhosis. No\n focal liver mass seen although echogenicity and heterogeneity of the liver\n parenchyma somewhat limits assessment for such.\n 2. Patent hepatic vasculature, with normal hepatopetal direction of flow in\n the portal veins. Patent umbilical vein and splenomegaly consistent with\n portal hypertension. There is also mild ascites.\n\n" }, { "category": "ECG", "chartdate": "2197-05-27 00:00:00.000", "description": "Report", "row_id": 280511, "text": "Normal sinus rhythm, rate 71. Borderline Q-T interval prolongation. Compared to\nthe previous tracing of sinus tachycardia has given way to normal sinus\nrhythm and anterolateral repolarization changes have resolved.\n\n" }, { "category": "ECG", "chartdate": "2197-05-26 00:00:00.000", "description": "Report", "row_id": 280512, "text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2168-12-27 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1165654, "text": " 8:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for R IJ placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with RIJ placement\n REASON FOR THIS EXAMINATION:\n assess for R IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ placement.\n\n FINDINGS: In comparison with the study of earlier in this date, there has\n been placement of a right IJ catheter that extends to the mid portion of the\n SVC. Continued enlargement of the cardiac silhouette with elevated pulmonary\n venous pressure and bilateral effusions with compressive atelectasis at the\n bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-12-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1166188, "text": " 10:12 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for pneumonia and other intrapulmonary process\n Admitting Diagnosis: PNEUMONIA\n Field of view: 32 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with MRSA bacteremia with unknown source, Lupus, ESRD on\n dialysis also with left hip pain\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia and other intrapulmonary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd SAT 2:49 AM\n Large bilateral effusions with compressive atelectasis. No pna in aerated\n lungs.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with MRSA bacteremia of unknown source, lupus,\n end-stage renal disease on dialysis with left hip pain. Question pneumonia or\n other acute process.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired from the thoracic inlet through the\n pubic symphysis following administration of intravenous contrast. Multiplanar\n reformations were generated.\n\n CT CHEST: A 1.2 cm hypodense nodule is present in the right lobe of thyroid.\n There are prominent anterior chest wall and anterior abdominal wall varices,\n best appreciated on coronal view (300B, 11), suggestive of -occlusive\n disease, which could be a complication of long-term hemodialysis. Note is\n made of a right internal jugular central venous catheter which enters the SVC,\n but takes an abnormal distal course anteriorly into what is likely a\n collateral vein in the anterior chest wall (301B, 30). The SVC is not\n opacified with contrast, likely occluded, and may contain thrombus. There are\n moderate atherosclerotic calcifications in the proximal arch vessels and\n aortic arch. Extensive paratracheal varices are also seen (2, 20).\n\n The heart is normal in size without pericardial effusion. There are\n multivessel coronary arterial and mitral annular calcifications. Borderline\n sized mediastinal and axillary lymph nodes are present.\n\n There are large bilateral nonhemorrhagic pleural effusions, which in dependent\n portions measure up to 20 Hounsfield units, suggestive of complex component.\n In the aerated lungs, there is no definite consolidation to suggest infection.\n Central upper airways are patent.\n\n CT ABDOMEN: There is relative hepatic hypoattenuation at the junction of left\n and right lobes (2, 61), suggestive of focal fatty infiltration. Hepatic and\n portal veins are patent. There is no biliary dilation. The gallbladder is\n decompressed with circumfirential wall thickening, likely from\n (Over)\n\n 10:12 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for pneumonia and other intrapulmonary process\n Admitting Diagnosis: PNEUMONIA\n Field of view: 32 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n underdistention. The spleen, pancreas, and adrenal glands are unremarkable.\n Bilateral kidneys are atrophic, consistent with known end-stage renal disease.\n Several renal cysts are seen bilaterally, some of which too small to fully\n characterize.\n\n The stomach, small and large bowel loops are normal in caliber. It is\n difficult to evaluate bowel walls, due to lack of intra-abdominal fat. Fecal\n material is present within the colon. There is no free air.\n\n Atherosclerotic calcification is seen in the descending aorta extending into\n proximal branching vessels. Although the atrophic kidneys enhance, there is\n no definite renal artery opacification. An IVC filter is in place, with a\n focal filling defect just inferior to it, which likely represent thrombus (2,\n 69). Multiple abdominal wall collateral vessels are noted.\n\n CT PELVIS: A large caliber tunneled catheter is present in the left common\n iliac vein. This catheter terminates just inferior to the IVC filter. There\n is massive distention of the bladder, the inferior aspect of which is poorly\n evaluated due to metal streak artifact from a left hip hemiarthroplasty.\n There is a multiseptated cystic structure abutting the left posterolateral\n aspect of the bladder, unclear whether contiguous or separate from the\n bladder. This could represent a large ureterocele, or alternatively a left\n adnexal lesion. Much of the remainder of the pelvic structures are also\n obscured by streak artifacts. The rectum appears within normal limits. There\n is anasarca.\n\n BONE WINDOW: There is suggestion of very mild diffuse sclerotic appearance to\n the osseous structures, which could be seen in the setting of end-stage renal\n disease and renal osteodystrophy. No focal concerning lesion.\n\n IMPRESSION:\n 1. Large bilateral pleural effusions with attenuation suggestive of complex\n or exudative component, associated with compressive atelectasis. No evidence\n of pneumonia in the aerated lungs.\n 2. Extensive anterior chest wall and abdominal wall varices, with occluded\n SVC and thrombus in the IVC just distal to the IVC filter.\n 3. Indwelling right internal jugular tunneled catheter tip taking abnormal\n course anteriorly into one of collateral vessels in the anterior chest wall.\n This catheter should not be used.\n 4. 1.2 cm right lobe thyroid nodule. Nonemergent ultrasound is recommended\n if not already performed.\n 5. Massively distended bladder. Recommend clinical correlation.\n 6. Borderline mediastinal and axillary lymph nodes, likely reactive.\n 7. Multiseptated cystic structure abutting the left posterolateral aspect of\n (Over)\n\n 10:12 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for pneumonia and other intrapulmonary process\n Admitting Diagnosis: PNEUMONIA\n Field of view: 32 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the bladder, unclear whether contiguous or separate from the bladder. This\n could represent a large ureterocele, or alternatively a left adnexal lesion.\n Ultrasound may be considered to exclude adnexal origin, since uterus and\n ovaries are poorly evaluated on current exam.\n\n Findings reported to Dr. at approximately 11:55 pm on , .\n\n" }, { "category": "Echo", "chartdate": "2168-12-28 00:00:00.000", "description": "Report", "row_id": 83715, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Pericardial effusion.\nHeight: (in) 65\nWeight (lb): 100\nBSA (m2): 1.47 m2\nBP (mm Hg): 109/58\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 15:43\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: 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: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Eccentric MR\njet. Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR may be\nsignificantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\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 >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve leaflets are moderately thickened. No mass or\nvegetation is seen on the mitral valve. An eccentric, posteriorly directed jet\nof moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.] The\ntricuspid valve leaflets are mildly thickened. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Moderately thickened and calcified mitral valve with at least\nmoderate, posteriorly directed mitral regurgitation. No obvious vegetation\nseen. Normal biventricular systolic function. Large left pleural effusion.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\nCompared with the prior study (images reviewed) of \n\n\n" }, { "category": "ECG", "chartdate": "2168-12-28 00:00:00.000", "description": "Report", "row_id": 228329, "text": "Sinus tachycardia. Consider prior anterior wall myocardial infarction. Since\nthe previous tracing of same date the rate is faster and delayed R wave\nprogression is more prominent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2168-12-28 00:00:00.000", "description": "Report", "row_id": 228330, "text": "Sinus rhythm. Delayed R wave progression is non-diagnostic but cannot exclude\nprior anterior wall myocardial infarction. Clinical correlation is suggested.\nSince the previous tracing of there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2168-12-27 00:00:00.000", "description": "Report", "row_id": 228331, "text": "Sinus rhythm. Delayed R wave progression is non-diagnostic but cannot exclude\nprior anterior wall myocardial infarction. Clinical correlation is suggested.\nSince the previous tracing of QRS voltage is less prominent.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2130-08-10 00:00:00.000", "description": "Report", "row_id": 1606498, "text": "7am-7pm update\nNeuro: pt initally on propofol gtt. propofol gtt weaned to off and pt extubated ~ 11 am. PERRL. pt alert. orientated x2 (disorientaetd to place). MAE and able to follow commands.\n\nCV: pt tachycardic. HR 120-140's. pt ST with PAC's and in and out of afib. fluid bolus given for tachycardia -> HR remains in the 120's after the fluid boluses. lopressor increased to TID this afternoon. SBP 90-140's. neo gtt weaned to off this am. cardiology into evaluate PPM -> mode DDD. rate on PPM 70-110. pp by doppler.\n\nresp: pt extuabted ~ 11 am and placed on 40% face tent. see flowsheets for abg's. 02 sats 93-100% LS clear with dim bases bil. inspir wheezing noted this afternoon. alb nebs given. CPT done. pt using IS to 500\n\ngi/gu: pt with + bs. tolerating clears. foley draining clear yellow urine. UO adequate\n\nID: t max 99.6 AX. continues on unaysn q8H\n\ncomfort: morpine ~q2-3H for pain cotrol\n\nplan: pulm toliet, pain control, start anticougulation in am, advance diet and activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2130-08-10 00:00:00.000", "description": "Report", "row_id": 1606497, "text": "NEURO: ORALLY INTUBATED TO VENT. SEDATED ON PROPOFOL GTT. NOT LIGHTENED D/T PULM/02 ISSUES S/P R THORACOTOMY FOR LOCULATED EMPYEMA. PEARL AT 2MM. HX OF DEMENTIA.\n\nPULM: LUNGS CLEAR. SX'D FOR VERY TENACIOUS YELLOW/BLD TINGED SPUTUM. HARD TO OBTAIN, REQUIRES LAVAGING TO OBTAIN. SX'D ORALLY FOR COPIOUS AMTS THICK CLEAR-WHITE SECRETIONS. 3 R ANT CHEST TUBES TO 20CM WATER SX, DRAINING SCANT AMOUNTS SEROSANGUINOUS FLUID. NO CREPITUS, NO AIR LEAK. ON SIMV MODE WITH 5 PS, 8 PEEP, TV 700. RATE INITIALLY 8 INCREASED TO 12 WITH GOOD ABG'S. FI02 DECREASED FROM 0.5 TO 0.4 WITH GOOD SAT AND P02. PROPOFOL WEANED TO 15 MCG/KG/MIN.\n\nCV: ERRATIC RHYTHM WITH HYPOTENSION. RAF TO SINUS TACHYCARDIA TO MAT. VR 112-130'S. MD'S AWARE OF RATE/RHYTHM. NEO GTT STARTED TO KEEP MAP > 60. LOPRESSOR 25 VIA OGT AT 2200 TO ATTEMPT TO SLOW HR WITHOUT EFFECT. 1.5 LITERS LR, 500CC HESPAN GIVEN FOR HR/BP WITH BRIEF EFFECT. BUN 47/CRAT 0.8. CVP 8-16. CA/K REPLETED. PALPABLE PEDAL PULSES. T MAX 101.8. BLD CX X 2 OBTAINED FROM R RADIAL A-LINE MD, MD DID NOT WANT PAN CX. RIJ DOUBLE LUMEN OOZY, SITE WITHOUT REDNESS. WBC 16.5. CARDIAC ENZYMES NEGATIVE X 2. THIRD ISO ENZYME DUE AT 1030.\n\nENDO: FSBS 153-120. RX'D PER CSRU PROTOCOL.\n\nGI: ABD SOFT, HYPOACTIVE BS. OGT TO LCS WITH 150 CC BILIOUS DRAINAGE.\n\nGU: FOLEY TO CD DRAINING QS AMTS CLEAR YELLOW URINE.\n\nSOCIAL: WIFE VISITED LAST EVE AT AND CALLED IN FOR UPDATE THIS AM AT 0600.\n\nPLAN: CONTINUE PROPOFOL GTT/VENTILATION ON ABOVE SETTINGS UNTIL DR TALKS WITH DR ABOUT PLACEMENT OF EPIDURAL CATH FOR PAIN MANAGEMENT FOR OPTIMAL PULM HYGIENE. TIRTRATE NEO TO KEEP MAP > 60 AND ADEQUATE UO. ? MORE IVF TO KEEP HYDRATED. REPEAT CHEST XRAY THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2130-08-13 00:00:00.000", "description": "Report", "row_id": 1606503, "text": "Neuro: pt alert oriented, very frustrated with tubes can't move in bed Feels he is starting to hear things. Intermittently dozing despite given sleeping pill last night.\nResp: o2 sats 94-95% coughing and raising moderate amounts of thick white secretions. Robitussin dm given for persistent cough with good effect. Md removed 1 chest tube last evening. THe other two remain to H20 seal with no drainage noted.\nC/V: hemodynnmically stable. Hct 24.7\nGI: swollowing pills without difficulty.\nEndo: Blood sugar elevated last evening 152 ho aware no treatment ordered rechecked this am down to 112.\nGu: adequate urine output.\nSkin: incisions clean and dry.\nPlan: transfer to floor today.\n\n" }, { "category": "Nursing/other", "chartdate": "2130-08-13 00:00:00.000", "description": "Report", "row_id": 1606504, "text": "Addendum\npt went into afib last evening rate 110-130. treated with toatal of 20mg iv lopressor over several hours and finally going back into paced rhythm. Po lopressor increased to 50mg po bid starting in am.\n" }, { "category": "Nursing/other", "chartdate": "2130-08-13 00:00:00.000", "description": "Report", "row_id": 1606505, "text": "7a-7p\nvss, oob to chair most of day & ambulating in hallway with PT x 1 today, tol well, foley cath leaking & dc'd, penile pouch applied, family in with pt most of day, diet taken well, bm x 1, good uo, coughing productively, lg amt thick tan sputum, to tx to floor @ 1730\n" }, { "category": "Radiology", "chartdate": "2130-08-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832694, "text": " 8:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumothorax\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year male with pleural effusion, s/p decortication\n\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 79 y/o man with pleural effusion s/p decortication. Please assess for\n pneumothorax.\n\n COMPARISON: .\n\n CHEST AP: There is stable cardiomegaly. Mediastinal and hilar contours are\n unremarkable. There is interval decrease in the right pleural effusion\n compared to previous study. There are now 3 right sided chest tubes. There is\n a small left pleural effusion. Right IJ tip is in the SVC. ETT is\n appropriately positioned at the thoracic inlet. NG tube tip is within the\n stomach. Pacemaker leads are in unchanged position. There is small amounts of\n ____ subcutaneous emphysema.\n\n IMPRESSION: Interval placement of right chest tubes x 3. Improvement of right\n pleural effusion. Stable appearance of small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-08-07 00:00:00.000", "description": "CHEST (LAT DECUB ONLY)", "row_id": 832322, "text": " 4:42 AM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: SOB - R sided infiltrate/effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n SOB - R sided infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n RIGHT LATERAL DECUBITUS VIEW: There is collapse/consolidation of the right\n middle and lower zones. Opacities are also visualized in the right upper\n zone. The left lung is clear. Dual chamber pacer is visualized. There is\n blunting of the left costophrenic angle.\n\n IMPRESSION: Right middle and lower zone collapse/consolidation, some element\n of pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832470, "text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusion/compare for interval change/r/o pneumothorax\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year male with pleural effusion, s/p tap on \n\n REASON FOR THIS EXAMINATION:\n eval effusion/compare for interval change/r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thoracentesis for pleural effusion, evaluate for\n interval change in pneumothorax.\n\n COMPARISON: .\n\n CHEST AP PORTABLE RADIOGRAPH: There is stable cardiomegaly. There is an\n unchanged large partially loculated right pleural effusion with new chest tube\n positioned with tip overlying its lateral component. There is a slight\n decreased left pleural effusion. No pneumothorax identified. The soft\n tissues are remarkable only for dual pace maker with tips overlying right\n atrium and ventricle. The osseous structures are unremarkable.\n\n IMPRESSION:\n 1) Unchanged large and partially loculated right pleural effusion, with\n overlying chest tube.\n 2) Probable slight decrease in the small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-08-07 00:00:00.000", "description": "RENAL U.S.", "row_id": 832323, "text": " 5:23 AM\n RENAL U.S. Clip # \n Reason: INC CREAT. R/O OBSTRUCTION/PYELO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with bad pna, w/ wbc 25, and cr 2.5. BUN/Cr ration suggests\n perhaps pre-renal, but h/o prostate ca s/p xrt and on flomax.\n REASON FOR THIS EXAMINATION:\n r/o obstruction/pyelo\n ______________________________________________________________________________\n WET READ: AZm MON 5:48 AM\n No hydronephrosis. Simple cysts in both kidneys\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: High creatinine. Evaluate for obstruction.\n\n RENAL ULTRASOUND: The right kidney measures 11.3 cm. The left kidney\n measures 11.1 cm. There is a 2 x 1.8 x 1.9 cm simple cyst in the upper pole\n of the right kidney. A 3.3 x 4.4 x 3.7 cm simple cyst is visualized in the\n interpolar region of the left kidney. There are no stones or hydronephrosis.\n No renal masses are identified.\n\n IMPRESSION: No evidence of hydronephrosis. Simple cysts.\n\n" }, { "category": "Radiology", "chartdate": "2130-08-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832929, "text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumothorax\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year male with pleural effusion, s/p decortication\n\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post decortication, assess for pneumothorax.\n\n COMPARISON: .\n\n CHEST, AP PORTABLE RADIOGRAPH: The cardiac, mediastinal and hilar contours\n are stable in appearance. The two chest tubes are noted overlying the right\n upper lobe, without evidence of pneumothorax. The atelectasis at the right\n lung base and small right pleural effusion are unchanged; however, there is\n increasing consolidation at the left lung base and increasing pleural\n effusion. Dual-lead pacemaker tips are in unchanged position.\n\n IMPRESSION:\n\n 1) No evidence of residual pneumothorax.\n 2) Increasing consolidation in the left lower lobe with adjacent left pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832321, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB - eval for infil or CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n SOB - eval for infil or CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: SOB.\n\n PORTABLE AP CHEST: There is collapse/consolidation at the right mid and lower\n zones. Dual chamber pacer is visualized with its leads overlying the right\n atrium and ventricle. The left lung is clear. There is blunting of the left CP\n angle.\n IMPRESSION: Right middle and lower zone collapse/consolidation. Mass in that\n region cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2130-08-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 833036, "text": " 10:28 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumothorax\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79M s/p thoractomy and decortication\n\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post thoracotomy and decortication. Assess pneumothorax.\n\n Comparison is made to the prior study from .\n\n This report was dictated on because the initial report from \n was lost during the transcription process.\n\n PA AND LATERAL CHEST: Allowing for differences in technique, there is stable\n cardiomegaly and bibasilar consolidations associated with unchanged pleural\n effusions.\n\n" }, { "category": "Nursing/other", "chartdate": "2130-08-07 00:00:00.000", "description": "Report", "row_id": 1606493, "text": "MICU NPN\nPlease see FHPA for PMH and events leading to MICU admit.\n\nPt arrived to CCU ~0700 from EW after experiencing ^ SOB at home. CXR-> rll pna, and pleural effusion. INR 6.0, pt received total 5 units FFP and 10mg Vit K. Thoracentesis done for ~ 500cc straw colored fluid. CXR after showed lg fluid collection. Chest tube placed and drained initially bloody drainage, now serosanguinous. Has drained 525cc since insertion. CT done post CT placement to evaluate for loculated fluid collection. SATS 88-95 on 6lnp. pt c/o sob w/ rr ^ 30-40.\n\nhemodynamically stable w/ hr 70-80 AVP, bp 110-130/50-60.\ngi: poor appitite, NPO for ? OR .\ngu: foley placed, uo 200cc since mn. Cr 2.5 up from base of 1.1.\nid: wbc 25, afebrile, on ceftriaxone and zithromax.\nskin: intact\nneuro: pt w/ slight dementia at baseline, becoming confused as to time and place occasionally, easily reoriented.\nA: lg pleural effusion requiring CT, ? infectious process\nP: Monitor CT drainage, cont abx, ? OR in am\n\n" }, { "category": "Nursing/other", "chartdate": "2130-08-08 00:00:00.000", "description": "Report", "row_id": 1606494, "text": "CCU Nursing Progress Note 7p-7a\nS: \" I know I have that in but I just don't feel like I am emptying my bladder. If I have to I will stand\".\n\nMS: Baseline slight dementia. Confused at times needing frequent reexplanation of need for f/c, meds etc. Pt ^ aggitated at 2300 and 0300 regarding discomfort associated w/ f/c. Pt given 2-4 mg IV Morphine w/ good effect. Pt has baseline back pain secondary to arthritis but no c/o back pain overnoc. Pt slept well w/ minimal interruption otherwise. Zyprexa and Aricept doses administered per order.\n\nCV: VSS. AV paced 70-79. No ectopy noted. NBP 70-153/25-49. (Pt lying on right side much of shift with BP cuff on BENT left arm resulting in lower BP). When aroused BP ^ 90s-100s. SBP ^ 153 during episodes of aggitation. No c/o CP. HCT this am 30.7. Electrolytes wnl. INR remains elevated at 2.8. ( Prior to thoracentesis yesterday INR ^ 6.0 requiring 5 U FFP and Vit K dose).\n\nResp: LS clr in upper lung fields diminished in bases. Pt tolerating r basilar CT well. DSG site CDI. No leak or crepitus noted. CT remains to suction. Received pt w/ s/s drainage noted. This am straw like in color. Total of 130cc drainage noted ovenroc in total. CXR following thoracentesis/ CT cont reveal moderately sized right pleural effusion and sm left pleural effusion, Sm amt SC emphysema noted on R lateral chest wall and both atelectesis/ consolidation noted in R base. Pt denies SOB overnoc. RR 25-31 on 6L NC. O2 sats 95-95%.\n\nGI/GU: NPO for OR this am. +BS. No stool. Pt tolerating po meds w/o difficulty. F/C to gravity. UO 60-140cc cyu q 1-2 hrs. Bilateral simple cysts noted on kidneys. Cont to follow. BUN/Cr this am improved to 66/1.6.\n\nID: Pt remains afebrile. WBC this am 19.6( 25). Thoracentis fluid culture indicative of infectious process vs malignancy. Pt remains on Ceftriaxone and Azithromycin.\n\nSkin: Intact. R basilar ct dsg CDI.\n\nA/p: VSS overnoc. S/P thoracentesis and CT placement. No pain associated w/ CT. Pt c/o penile discomfort secondary to f/c. Managed pain w/ lidocaine urojet injection and IV Morphine doses. Cont to manage pain as indicated. Surgery today for cont loculated moderately sized pleural effusion. Cont to support pt and family as indicated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-08-11 00:00:00.000", "description": "Report", "row_id": 1606499, "text": "NEURO: ALERT. DISORIENTED TO PLACE AND EVENTS (hx dementia) BUT PLEASANT AND COOPERATIVE. HOLLERS OUT WHEN WAKENS, ORIENTS EASILY. PEARL, MAE, FOLLOWS COMMANDS. C/O A LOT OF PAIN IN R SIDE. MORPHINE IV Q2H FOR PAIN CONTROL.\n\nPULM: 40% HUMIDIFIED FM INCREASED TO 50% FOR SATS 92%. RESPIRATIONS SHALLOW, REQUIRES FREQUENT REMINDERS TO DEEP BREATHE, NOT TO HOLD HIS BREATH WHEN MOVING. STRONG COUGH EFFORT BUT SECRETIONS VERY THICK, UNABLE TO EXPECTORATE, SWALLOWS. LUNGS DIMINISHED R BASE, OCCASIONAL WHEEZING RESPONSIVE TO NEB RX. UNASYN IV. AFEBRILE. SCANT SEROSANGUINOUS DRAINAGE FROM 3 R PLEURAL CHEST TUBES. EPISODE OF SM-MOD AMT SANGUINOUS DRAINAGE FROM AROUND CHEST TUBE INSERTION SITES WHEN OOB. NO AIR LEAK, NO CREPITUS. VASELINE GAUZE AROUND INSERTION SITE, OCCLUSIVE DSG APPLIED.\n\ncv: SINUS TACH UNTIL 2130 WHEN CONVERTED TO PACED RHYTHM 70'S. REMAINS IN PACED RHYTHM REST OF SHIFT. R RADIAL A-LINE DAMPENED, UNABLE TO USE FOR RELIABLE BP MONITORING BUT ABLE TO DRAW LABS. PALPABLE PEDAL PULSES. CVP 4-8. NBP STABLE OFF ALL GTTS AND WITHOUT FLUID BOLUS'S.\n\nENDO: FSBS 113. NO SSRI COVERAGE ORDERED.\n\nGI: + BOWEL SOUNDS. TAKING H20 WELL. NO FLATUS OR BM.\n\nGU: FOLEY TO CD WITH QS AMTS CLEAR URINE.\n\nPLAN: CONTINUE AGGRESSIVE PULM HYGIENE. OOB AS MUCH AS POSSIBLE. REPEAT CHEST XRAY TO EVALUATE R LUNG EFFUSION. ? DC CHEST TUBES TODAY. ASK MD EPIDURAL PAIN MANAGEMENT AS NARCOTICS LIKELY TO CAUSE INCREASED CONFUSION AND RESPIRATORY DEPRESSION.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-08-11 00:00:00.000", "description": "Report", "row_id": 1606500, "text": "7am-7pm update\nneuro: pt alert and orieanted x 2 (disorienated to place/ current events). dozzing this afternoon. Pt able to MAE and follow commands.\n\ncv: pt 100% AV paced (pt with PPM, DDD mode, rate 70-110). BP stable. started on coumadin this evening (for afib). continues on lopressor and amio PO. pp by doppler.\n\nresp: ls clear with dim bases bil. pt initally on 50% face tent -> placed on 4 L nc this afternoon. O2 sats 94-98%. pt becomes slighly wheezy with activty -> pt reciveing alb nebs. using IS to 500. CT to water seal. no airleak. no crepitis\n\ngi/gu: pt with + bs. abd soft. pt coughing when drinking water this am (team aware and into evalute) ?? aspiration. pt sleepy at the time -> ?? if coughing d/t lethargy. pills crushed and given in custard. foley draining clear yellow urine. UO adequate\n\ncomfort: motrin q6H. morphine PRN\n\nplan: pulm toliet, pain control, ? 2 in am, monitor swallowing\n" }, { "category": "Nursing/other", "chartdate": "2130-08-12 00:00:00.000", "description": "Report", "row_id": 1606501, "text": "NEURO- ALERT/ORIENTED TO SELF, DIORIENETATED TO TIME.PLEASANT.COOPERATIVE WITH CARE. MAE.FOLLOWSCOMMANDS.\n\nCV- NSR. NO ECTOPY. BP STABLE.\n\nRESP- 3LNC=98%. LSC UPPERS. DIM LT BASE. FINE CRACKLES RT BASE. CT TO H20 SEAL. MIN. DRG. DSG INTACT.\n\nGI/GU- ABD SOFT. + BS. SWALLOWING MEDICATION WITHOUT DIFFICULTY. SLIGHT COUGH. ADEQ. AMT. CLEAR YELLOW URINE.\n\nLABS- PENDING.\n\nPAIN- 600MG MOTRIN A/O.\n\nPLAN- OOB TO CHAIR. ??? DC CT??? TRANSFER TO 2 WHEN BED AVAIL.\n" }, { "category": "Nursing/other", "chartdate": "2130-08-12 00:00:00.000", "description": "Report", "row_id": 1606502, "text": "7a-7p\nsee transfer note\n" }, { "category": "Nursing/other", "chartdate": "2130-08-09 00:00:00.000", "description": "Report", "row_id": 1606495, "text": "admission note\npt recived from OR ~ 1830.\n\npt admmited to hospital with c/o productive cough x 3 weeks. increasing SOB x past 3 days (proir to admission)\n\nPt to MICU R thorecentesis done and then R CT placed.\nchest CT done showing R locuated area. ?? empyemea\n\n: pt recived from OR S/P R VATS (unable to completely drain empyemea so open throcotomy done) pt recived with 3 pleural CT draining serousaiginous fluid. propfol gtt started. PERRL. HR 110-130's. afib. BP labile. LS clear with dim RLL. pt difficult intubation. Pt placed on 50% IMV, PEEP at 8 (per thorasic team). OGT placed -> draining billious fluid. foley draining clear yellow urine\n\nplan: keep sedated overnight, monitor hemodynamicas, montior CT output, keep PEEP at 8, antibiotics\n" }, { "category": "Nursing/other", "chartdate": "2130-08-10 00:00:00.000", "description": "Report", "row_id": 1606496, "text": "pt.presently on simv+ps ventilation, abg alkalotic, bs coarse, will wean as tol when more awake.\n" }, { "category": "Radiology", "chartdate": "2130-08-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 833445, "text": " 10:11 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79M s/p thoractomy and decortication\n\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thoracotomy and decortication, evaluate for\n pneumothorax.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL RADIOGRAPH: There is stable mild enlargement of the\n cardiac silhouette. The aorta is unfolded. Again seen in the mild pulmonary\n vascular redistribution and bilateral pleural effusions, right greater than\n left. These are not significantly changed. The dual-lead pacemaker tips are\n unchanged position. There has been interval removal of the one chest tube\n overlying the right upper lobe, without evidence of pneumothorax. The right\n lower lobe chest tube is in unchanged position. The osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. No evidence of pneumothorax status post chest tube removal.\n 2. Unchanged bilateral pleural effusions, right greater than left with\n residual chest tube overlying the effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-08-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 832435, "text": " 5:56 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: infectious process or malignancy?\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with few days of progressive shortness of breath and tachypnea\n with large right sided pleural effusion s/p chest tube.\n REASON FOR THIS EXAMINATION:\n infectious process or malignancy?\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Progressive shortness of breath, tachypnea and a large right-sided\n pleural effusion status post chest tube placement.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast chest CT (elevated creatinine precluded the\n administration of IV contrast).\n\n FINDINGS: Central venous line is in place. There are calcifications within the\n aortic arch. There is no axillary or definite hilar lymphadenopathy. Small\n lymph nodes are noted in the pretracheal region which do not meet criteria for\n pathologic enlargement. A right-sided basilar chest tube is present. There is\n an loculated moderate-sized right pleural effusion. Subcutaneous emphysema is\n noted along the right laterl chest wall. There is compressive atelectasis as\n well as consolidation with air bronchograms at the right lung base. There is a\n small left pleural effusion. Motion artifact slightly limits assessment of the\n lung parenchyma. No definite nodules or masses are appreciated.\n\n There are bilateral simple cysts within the kidneys, the larges measuring 4 cm\n at the left midpole. Assessment of the abdominal organs is limited by motion\n and lack of intravenous contrast.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions.\n Degenerative changes are seen throughout the spine.\n\n IMPRESSION:\n 1. Limited exam due to breathing artifact and lack of intravenous contrast.\n Loculated moderate-sized right pleural effusion with right lung base\n consolidation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2130-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832722, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year male with pleural effusion, s/p decortication\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post decortication, evaluate for pleural effusion.\n\n COMPARISON: .\n\n CHEST AP PORTABLE RADIOGRAPH: The cardiac, mediastinal and hilar contours are\n stable in appearance. The basilar atelectasis and layering right pleural\n effusion are again noted and grossly unchanged since the previous study. The\n two chest tubes overlie the right lung apex, without evidence of pneumothorax.\n Nasogastric tube tip extends below the level of the diaphragm. The\n endotracheal tube tip is approximately 4 to 5 cm above the carina. The third\n chest tube is again noted with the tip overlying the right cardiophrenic angle\n region. There is a possible small left pleural effusion. The dual lead\n pacemaker tips overlie the right atrium and ventricle. The osseous structures\n are unremarkable. Right internal central venous catheter extends to the level\n of the mid to upper SVC.\n\n IMPRESSION:\n 1) Unchanged bibasilar atelectasis/consolidation.\n 2) Unchanged small right pleural effusion and possible small left pleural\n effusion.\n 3) Satisfactory positioning of three right-sided chest tubes, without\n evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832392, "text": " 2:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: PNEUMONIA,RT PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year male with pleural effusion, s/p tap\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old man with pleural effusions status post thoracentesis.\n\n COMPARISON: , 4:49 AM.\n\n CHEST AP PORTABLE UPRIGHT: There are severe bilateral pleural effusions\n greater on the right than on the left. Compared to prior study the right side\n appears slightly improved. The left-sided pleural effusion appears to be\n increased. Again dual-lead pacemaker is noted.\n\n IMPRESSION: Continued large pleural effusion on right which appears slightly\n improved compared to previous study. Worsened left pleural effusion which is\n moderate in size. There is no evidence of pneumothorax.\n\n" }, { "category": "ECG", "chartdate": "2130-08-09 00:00:00.000", "description": "Report", "row_id": 294854, "text": "Regular tachycardia - mechanism uncertain - consider atrial tachycardia or\npossible atrial flutter with 2:1 response\nRight bundle branch block\nLeft axis deviation - left anterior fascicular block\nDiffuse ST-T wave abnormalities - Cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , A-V paced rhythm absent\n\n" }, { "category": "ECG", "chartdate": "2130-08-07 00:00:00.000", "description": "Report", "row_id": 294855, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" } ]

[ { "category": "ECG", "chartdate": "2125-08-10 00:00:00.000", "description": "Report", "row_id": 298627, "text": "Sinus rhythm. Normal tracing. Compared to tracing #1 low QRS voltages are not\nseen on the current tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2125-08-10 00:00:00.000", "description": "Report", "row_id": 298628, "text": "Sinus rhythm. Low QRS voltages in the limb leads. Compared to the previous\ntracing of criteria for low limb lead voltages are seen on the current\ntracing.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-02-07 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 783151, "text": " 10:14 AM\n C-SPINE, TRAUMA Clip # \n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman found on floor. C-spine films at OSH clear, although lateral\n views somewhat poor.\n\n thanks, \n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n WET READ: CCqc WED 10:39 AM\n negative\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 year old female found on the floor. Assess for fracture.\n\n TECHNIQUE: C-spine, trauma series.\n\n FINDINGS: Please note that some of these images are limited due to\n difficulties with patient positioning. The prevertebral soft tissues are\n unremarkable. There is loss of the normal cervical lordosis. C6 and C7 are\n not well seen, even in the swimmer's view. Allowing for these limitations,\n vertebral body heights is preserved. There is narrowing of the C4-5 disc\n interspace. Degenerative changes are apparent throughout the cervical spine.\n However, there is no evidence of fracture, subluxation, or dislocation.\n\n IMPRESSION: Negative C-spine in this limited examination.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-07 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 783152, "text": " 10:15 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: eval for CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman found on floor. Rales on exam, please eval for CHF.\n\n\n thanks, \n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n WET READ: CCqc WED 10:42 AM\n negative\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 y/o female found down.\n\n SINGLE AP UPRIGHT VIEW CHEST\n\n COMPARISONS: None.\n\n FINDINGS: The cardiac and mediastinal contours are within normal limits.\n There is tortuosity of the aorta. The pulmonary vasculature is not engorged.\n The lungs appear clear with no confluent areas of opacification. There are no\n pleural effusions. The visualized osseous structures are notible for\n degenerative changes involving the acromioclavicular joints bilaterally.\n\n IMPRESSION: No acute cardiopulmonary abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-07 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 783194, "text": " 4:10 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: 76 yr old woman s/p fall with right frontal bleed and hx of\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n REASON FOR THIS EXAMINATION:\n 76 yr old woman s/p fall with right frontal bleed and hx of left frontal\n meningioma resection in past needs head CT with and without contrast and CTA of\n Head and neck, please do I- head first then do CTA head and Neck then do I+ of\n head\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Known right frontal bleed in a patient status post fall.\n History of left frontal meningioma resection.\n\n TECHNIQUE: CT of the head without and with intravenous contrast.\n\n No prior studies available for comparison.\n\n FINDINGS: Two large heterogeneous areas are noted in the right frontal lobe\n and right temporal lobe consistent with hemorrhage. There is effacement of\n the adjacent sulci. There is shift of normally midline structures to the\n right with mass effect on the right lateral ventricle and subfalcine\n herniation. There is minimal effect on the basal cisterns. There is also\n subdural hemorrhage noted along the right convexity, adjacent to the right\n petrous ridge and extending along the right tentorium. There is also evidence\n of a smaller subdural hematoma anterior to the left frontal lobe. Post\n contrast images demonstrate no areas of enhancement and no areas of\n extravasation.\n\n A cranial defect is noted along the anterior left vertex with fixation\n consistent with known meningioma resection. No other osseous abnormalities\n are identified. The mastoid air cells and paranasal sinuses are clear. No\n soft tissue abnormalities are seen.\n\n IMPRESSION:\n 1. Large right frontal and temporal hemorrhage with mass effect resulting in\n leftward shift of normally midline structures and subfalcine herniation.\n 2. There is also subdural hemorrhage along the right convexity and right\n tentorium. Also a small subdural is noted anterior to the left frontal lobe.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-07 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 783195, "text": " 4:11 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: HX LEFT FRONTAL MENINGIOMA RESECTION, RT FRONTAL BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with right frontal bleed. History of left\n frontal meningioma resection in the past.\n\n TECHNIQUE: CTA images were obtained from C3 vertebral body level to the\n vertex. 100 cc of Optiray was administered intravenously. Optiray was\n administered for fast bolus CTA. 3D reconstructed images were then performed\n and reviewed.\n\n CTA OF THE HEAD: Note is again made of a large intraparenchymal hemorrhage in\n the right frontal and temporal lobes, with associated surrounding edema,\n midline shift and subfalcine herniation. There is thin subdural hematoma\n spanning the right frontal lobe as described on the CT study performed at the\n same time.\n\n Normal contrast opacification is demonstrated of the major branches of the\n circle of . The right middle cerebral artery appears mildly displaced\n anteriorly by the intraparenchymal hemorrhage in the right temporal lobe.\n There is no evidence of vascular malformation that can be associated with\n cerebral hemorrhage.\n\n Extensive vascular calcifications are noted of both carotid arteries and\n vertebral arteries. The left internal carotid artery is diffusely narrowed\n with irregular lumen throughout the imaged course, which is from the proximal\n internal carotid artery to the supraclinoid region. The right internal\n carotid artery also demonstrates segmental luminal irregularity associated\n with mural calcifications. The left internal carotid artery is almost\n completely obstructed at the skull base, with only minimal amount of trickling\n contrast in the lumen. In the superior neck, the vessel is not opacified.\n\n The patient is status post left frontal craniotomy. Soft tissue hematoma is\n noted posterior to the left parietal region, consistent with a history of\n fall. There is no significant cervical lymph adenopathy.\n\n IMPRESSION:\n 1. Extensive intracranial hemorrhage, midline shift, and subfalcine\n herniation.\n 2. There is no evidence of vascular malformation associated with hemorrhage.\n 3. Atherosclerotic disease of both internal carotid arteries. The left\n internal carotid artery demonstrates luminal narrowing and irregularity\n throughout, almost its entire visualized course. Please note that the carotid\n bifurcations are not included on this study. Carotid artery Doppler\n ultrasound can be performed for better evaluation when the patient is\n stabilized if clinically indicated.\n\n (Over)\n\n 4:11 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: HX LEFT FRONTAL MENINGIOMA RESECTION, RT FRONTAL BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2153-02-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 783240, "text": " 10:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute change in responsiveness,to see the extent of bleed,\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n\n REASON FOR THIS EXAMINATION:\n acute change in responsiveness,to see the extent of bleed,\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 year old woman with acute change in responsiveness with\n history of right frontal bleed.\n\n TECHNIQUE: Non-contrast axial images of the head.\n\n Comparison: head CT\n\n FINDINGS: The large right frontal and temporal lobe hemorrhage is unchanged.\n The right subdural hemorrhage is also unchanged. There is persistent\n subfalcine herniation with leftward shift of normally mid-line structures. The\n ventricles and -white matter interface are unchanged in appearance, with\n moderate compression of the right lateral ventricle. There are no new areas of\n intracranial hemorrhage. The basal cistern is not effaced. There are subtle\n areas of hypoattenuation in the periventricular white matter which is\n consistent with old microvascular disease.\n\n Osseous structures once again reveal cranial defect along the anterior left\n vertex. The soft tissues are unremarkable.\n\n IMPRESSION:\n No significant change since one day prior. Persistent right frontal and\n temporal lobe hemorrhage with right-sided subdural hematoma. No new areas of\n hemorrhage and no evidence of brain herniation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-02-08 00:00:00.000", "description": "Report", "row_id": 1538890, "text": "NURSING PROGRESS NOTE 0700-1500\nPLS REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE\" SECTION OF CAREVIEW. THANKS.\n" }, { "category": "Nursing/other", "chartdate": "2153-02-07 00:00:00.000", "description": "Report", "row_id": 1538888, "text": "Nursing Progress Note\n->\n\nS/O\nNEURO: Pt arrived from ER, agitated, pulling on Foley with both hands. Nurse pried both hands off Foley, upon which pt clasped nurse's hand tightly with both hands. Pt moving BLE equally, strongly pulling BLE up to abd, sitting bolt upright in \"Indian-style\" pose, moving legs freely. Pt unable to follow commands of any sort, rare intelligble statement. Haldol 5mg IV given x 1 with positive sedation, and pt was somnolent during neuro exams with NSICU and Stroke teams. Brought to CT while somnolent, transferred to CT scanner table and pt became agitated, combative, restless. Transferred back to bed, anesthesia stat paged, and pt sedated by anesthesia with 150mg propofol over 75 minutes while EKG, BP, resp status and SpO2 were monitered. Upon return to NSICU, pt became agitated again and was given a third dose of Haldol 5mg IV with minimal effect, grabbing relentlessly at Foley despite bilateral soft wrist restraints being in place.\n\nPt loaded with 1Gm Dilatin IV.\n\nSee flow sheet for neuro signs.\n\nDiscussed with daughter pt's BLE neuropathy-- daughter states she is not sure but thinks pt was taking neurontin, states that neuropathy is a source of great discomfort for pt to the point that it keeps her up many nights in a row.\n\nAlso, pt quit smoking 3 weeks PTA after a 60 year hx and \"cutting back to 2 PPD about 3 years ago\". Discussed with the NSICU team re: using a nicotine patch, which was declined by Dr d/t withdrawal from cigs having a lifespan of less than 3 weeks.\nCV: NSR-ST. Arrived on 0.5mg Labetolol gtt, but SBP 130's upon arrival, so Labetolol not infused since arrival.\n\nRESP: LS clear to intermittently rhonchorous. No distress on room air. Placed on venti mask 100% for propofol sedation, weaned to nc 2 LPM with SpO2>96%.\n\nGI: NPO. Vomited coffe grounds upon arrival; started on Pepcid IV. No further emesis; no anti-emetics given. BS positive. Abd soft, non-tender.\n\nFEN: BS elevated, treated -> see flow sheet and MARs.\n\nGU: U/O qs. Pt consisting pulling at Foley. Discussed with pt's daughter re: possibly d/c'ing Foley and using Attends to manage pt's incontinence if Foley is source of unremitting discomfort thta pt cannot rest.\n\nSKIN: Petechia appearance on feet, hands and forearms. Daughter states pt has had this for a long time.\n\nPSYCHOSOC: Proxy in chart. DNR/DNI wished expressed explicitly by pt to daughter and will be maintained unless short-term intubation required for diganostic procedure or pt aspirates and short-term intubation will return pt to a quality of life where she can return to pre-admission status. See NSICU note in chart re: DNR/DNI.\n\nA/P\nF/U on CT results; have results relayed to daughter. Discuss treatment plan with daughter and team as daughter states pt had explicitly expressed desire to be DNI/DNR.\n\nMonitor QTc for Haldol tx; see .\n\nMaintain comfort and safety.\n\nContinue current care.\n" }, { "category": "Nursing/other", "chartdate": "2153-02-08 00:00:00.000", "description": "Report", "row_id": 1538889, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT VERY AT START OF SHIFT, KICKING LEGS OFF OF BED, ICKING AT LINES, AND COMBATIVE WITH CARE, HR UP TO 120S. RECEIVED 5MG IV HALDOL AS ORDERED. PT MINIMALLY RESPONSIVE THROUGH NOC. PERRL. DOES NOT OPEN EYES SPONTANEOUSLY, TO PAIN, OR TO OTHER STIMULI. MAEW, LOCALIZES PAIN, PURPOSEFUL MOVEMENTS, BUT DOES NOT FOLLOW COMMANDS. NONVERBAL. SEVERAL EPISODES OVERNOC OF BRIEF ?AGGITATION VS. SZ ACTIVITY. SICU RES INFORMED AT APPROX 10PM AND IN TO SEE PT. NSURG RES INFORMED AT 6AM. PT NOTED TO HAVE SHAKING OF WHOLE BODY, OCCASIONAL BACK ARCHING ON BED, OR ATTEMPPTING TO SIT UP IN BED, USUALLY ACCOMPANIED BY INCREASE IN HR, LASTING ONLY 1-3 MINUTES EACH. DILANTIN LEVEL THIS AM DRAWN JUST PRIOR TO 4AM DOSE, 18.\nRESP: LS COARSE, BUT PT SNORING. O2 SATS 100% ON 2LNC.\nCV: AFEBRILE. NSR TO ST WITH AGGITATION/EVENTS. SBP STABLE. RECEIVED 5MG IV LOPRESSOR X'S 1 AS ORDERED WITH TEMPORARY DECREASE IN HR THIS EVE.\nGI: ABD FLAT. NO APPARENT TENDERNESS.\nGU: ADEQUATE U/O VIA FOLEY.\nENDO: FSBG COVERED PER RISS.\nSKIN: ? RASH AT RUE EXTENDING FROM FINGERS TO SLEEVE LINE. PINK, BUT NOT RAISED. PER DTR, THIS DISCOLORATION HAS BEEN PRESENT SINCE EARLY AM .\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY WITHOUT SEDATION IF POSSIBLE. EMOTIONAL SUPPORT TO FAMILY.\n" }, { "category": "ECG", "chartdate": "2153-02-07 00:00:00.000", "description": "Report", "row_id": 167186, "text": "Baseline artifact. Sinus rhythm. Probably normal ECG, although baseline\nartifact makes interpretation somewhat difficult.\n\n" } ]

[ { "category": "ECG", "chartdate": "2113-06-22 00:00:00.000", "description": "Report", "row_id": 201023, "text": "Sinus rhythm. Since the previous tracing of precordial lead placement\nappears to be somewhat different and the rate is slower. The electrocardiogram\nis otherwise, unchanged and is within normal limits.\n\n" }, { "category": "Radiology", "chartdate": "2113-06-25 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 916482, "text": " 10:01 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: post-bronchoscopy appearance, ?effusion for tap\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with trach resection/reconstruction s/p bronchoscopy\n \n REASON FOR THIS EXAMINATION:\n post-bronchoscopy appearance, ?effusion for tap\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheal resection and reconstruction status post bronchoscopy,\n evaluate effusion for tap.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: Since the previous examination of several hours earlier, there is\n little interval change in the radiographic appearance of the chest. A\n right-sided chest tube is in place with tip terminating at the right lung\n apex. Heart size within normal limits with stable slight prominence of the\n superior mediastinal contour. Small bilateral pleural effusions are seen,\n unchanged. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-06-25 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 916440, "text": " 3:36 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: Change since this morning's xray after vigorous chest PT?\n Admitting Diagnosis: TRACHEOBRONCHOMALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with trach resection, reconstruction , now with\n collapsed R middle lobe\n REASON FOR THIS EXAMINATION:\n Change since this morning's xray after vigorous chest PT?\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON .\n\n HISTORY: Tracheal resection. Collapsed right middle lobe.\n\n IMPRESSION: PA and lateral chest compared to 9:38 a.m. today and :\n\n Moderate-sized right pleural loculation unchanged. Apical chest tube\n unchanged in position. No appreciable pneumothorax. Mild atelectasis right\n midlung unchanged. Stable mild mediastinal widening. Left lung clear. Heart\n size normal.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-06-24 00:00:00.000", "description": "Report", "row_id": 1428903, "text": "CSRU NURSING PROGRESS NOTE\nS:\"I'M OK\"\nO:S/P TRACHIOBRONCHOPLASTY OF BOTH MAINSTEMS W/ STENT REMOVAL.\nPT ALERT AND ORIENTED, MAE\nPAIN CONTROLED W/ EPIDURAL HYDROMORPHONE AT 8ML/HR. EPIDURAL CATH BETWEEN T4-5, INTACT, DRESSING D&I.\nRESP:TOL DB+C, EXPECTORATED TAN COLOR SECRETIONS X1, LOOSE COUGH. COARSE BS BILAT. SATS 96%. R PCT SITE W/O CREPITUS. SM AMTS OF SANG DRAINAGE.\nCV:SR TO 110 ST NO VEA, SBP 90-110S. PT FEBRILE W/ TEMP UP TO 101.6 ORALLY. MD GIVEN, BCX2 SENT, U/A SENT.\nGI:NPO\nGU;U/O ABOUT 20CC/HR. REPORTED TO THORASIC RESIDENT. IV FLUID TO REMAIN AT 75CC/HR.\nA/P:PLAN FOR BRONCHOSCOPY TODAY, CONTINUE PAIN MGT.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-06-23 00:00:00.000", "description": "Report", "row_id": 1428901, "text": "SEE CAREVUE FOR OBJECTIVE DATA.\n\nReceived from the OR at 1530. See ICU admission data sheet for PMH/meds.\n\nDX: tracheobronchomalacia(unknown origin)\n\nUnderwent trachaelplasty/post trach splinting via thoracotomy,removal of a stent that was placed last week,rigid and flex bronchoscopy.\nReversed in the OR and was extubated. No issues in the OR. However, pt has a small airway and if re-intubation is required it is to be done with a fiberoptic scope and only 1-2cc's of air in ETT. RT aware.\n\nArrives awake but sleepy-easily arousable,following commands. NSR/ST.\nNo ectopy noted. Weaning O2 to maintain adequate sat. See flowsheet for details.\nL/S-coarse. Pulmonary toileting with much encouragement. Remains sleepy. ABG 7.28/56/128 upon arrival to unit. Chest tube to 20 cm of suction. No crepitus. No airleak. Dressing intact. CXR completed upon arrival to unit.\nEpidural cath T4-T5-hydromorphone .1% at 6cc's an hour. Pt painfree.\nCathether intact and dressing intact.\nAdeqaute urine output. LR at 75cc's an hour.\nMg repleted(1.7).\n\nFamily in and updated.\n\nContinue current POC. Pulmonary toileting,pain control,maintain and support hemodynamics.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-06-23 00:00:00.000", "description": "Report", "row_id": 1428902, "text": "PATIENT'S EPIDURAL INCREASED FROM 6CC TO 100CC FOR I/1HR. PER DR. THEN DECREASED BACK TO 8CC/HR .PATIENT'S PAIN LESS AFTER MED INCREASED, GIVEN NEB TREATMENT THEN DEEP BREATHING,COUGHING, LOOSE COUGH BUT NOT RAISING. ABG SENT. PATIENT SLIGHTLY TACHY AT 100-105 NEED FOR BOLUS DESPITE MAINTENANCE AT 75CC/HR, CONTINUE TO MONITOR U/O CLOSELY!!!ICA BEING RECHECKED. IN AM ALONG WITH LABS DRAW VANCO RANDOM LEVEL. NPO AFTER MIDNIGHT!!!!\n" } ]

[ { "category": "Radiology", "chartdate": "2185-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796762, "text": " 9:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out pneumonia vs atelectasis\n Admitting Diagnosis: RECTAL, VAGINAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with acute Pulse ox desaturation\n REASON FOR THIS EXAMINATION:\n rule out pneumonia vs atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63 y/o woman with acute oxygen desaturation, rule out pneumonia vs.\n atelectasis.\n\n AP PORTABLE SUPINE CHEST AT 21:00: Comparison is made to prior portable chest\n dated , at which time the patient was intubated and had right IJ venous\n catheter in place. Those lines are not present. There is no significant\n change in the appearance of the chest. It's an expiratory film, and\n consequently, there are increased markings and subsegmental atelectasis at\n both bases. There is no gross failure or acute infiltrate seen.\n\n IMPRESSION: Poor inspiration. No acute infiltrate or congestive failure\n noted.\n\n" }, { "category": "Echo", "chartdate": "2185-09-07 00:00:00.000", "description": "Report", "row_id": 68045, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 66\nWeight (lb): 165\nBSA (m2): 1.84 m2\nBP (mm Hg): 104/60\nStatus: Inpatient\nDate/Time: at 11:08\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size. No left atrial mass/thrombus\nseen (best excluded by transesophageal echocardiography).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\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 appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The estimated pulmonary artery systolic pressure is\nnormal.\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.\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 and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\nIMPRESSION: Normal study.\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": "Nursing/other", "chartdate": "2185-09-04 00:00:00.000", "description": "Report", "row_id": 1601500, "text": "NURSING PROGRESS NOTE 7P-7A\nPT. S/P PROCTECTOMY POST OP DAY #3.\n\nPT. ALERT AND ORIENTED, MOVING ALL EXTREMITIES. FOLLOWS COMMANDS. ABLE TO TURN IN BED WITH MIN. ASSISTANCE.\n\nCV: CONT IN AFIB. RATE UP TO 120'S. RESTARTED DILT GTT, INCREASED RATE TO 15 MG/HR. HR NOW 75-80 AFIB NO VEA NOTED. REPLETED K WITH 40 MEQ PO POTASSIUM.. UNABLE TO TAKE SECOND DOSE OF 40 MEQ DUE TO NAUSEA. BP STABLE 98-102/40'S. DENIES CP WITH AFIB RHYTHM.\n\nRESP: O2 SATS 97% ON 5L NC. DESATS TO 88-90% ON RA. LUNGS HAVE FAINT CRACKLES IN BASES. NON-PRODUCTIVE STRONG LOOSE COUGH.\n\nGU: URINE CLEAR YELLOW ~ 30-50 CC/HR.\n\nGI: TAKING SIPS OF WATER WELL. ONE EPISODE OF NAUSEA WITH SMALL AMTS OF WHITE EMESIS AFTER ATTEMPTING TO SIT ON SIDE OF BED. GIVEN ZOFRAM 4 MG IV WITH RELIEF FROM NAUSEA. PRODUCING LARGE AMTS OF GAS THROUGH ILEOSTOMY WITH LARGE AMT OF LIQUID BROWN STOOL. STOMA SITE C&D. WILL NEED OSTOMY NURSE CONSULT.\n\nSLIGHT IMPROVEMENT IN PAIN CONTROL WITH FENTANYL PCA. SEE PAIN MANAGEMENT FLOWSHEET FOR DATA.\nPERINEAL INCISION C&D, SMALL AMT OF ECCHYMOSIS NOTED AROUND INCISION SITE. SMALL AMTS OF SANG. DRAINAGE NOTED ON PERI-PAD. CHANGED X2.\n\nA: STABLE S/P SURGERY, IMPROVED PAIN RELIEF WITH PCA\n\nP: CONT TO FOLLOW LYTES, CONT DILT GTT FOR AFIB\n" }, { "category": "Nursing/other", "chartdate": "2185-09-04 00:00:00.000", "description": "Report", "row_id": 1601501, "text": "CCU NPN 7A-7P\nNPN cont:\nPain: PCA fent changed to po percocet, has done well with 2 tabs q 4 hrs. Amb in x2 today, sat in chair with cushion x1hr. Has more pain with sitting. removed 1 sucture from L buttock, discomfort improve some. Cont with scant serosang drainage form perianal incision. JP with minimal drainage.\n\nresp: sats up to 97% on RA when OOB or amb, while in bed she lies on R side for comfort, sats drop to low 90's and she needs 2L NC to keep sats 93%. Sats improve with DB, encoraging C& DB. Cont to have crackles at R base.\n\nSoc: husband visited, updated.\n\nID: low grade T 99.4po, Foley dc'd at Noon, voided only 50cc so far. Getting up to commode.\n\nAcid/base: Remains alkolotic, seen by renal, recomended Diamox, ordered for 250mg q12hr for 24 hrs. Check lytes tonight after she gets dose. Most likely cause of alkalosis is from GI loses.\n\nEndo: BS's running higher todau, po intake increasing, will need to increase ins coverage, ?restart NPH.\n\nA/P: hemodynamically stable, back in NSR, off IV dilt, now on PO. Doing well on perc, PCA off. tolerating increased activity.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-09-03 00:00:00.000", "description": "Report", "row_id": 1601497, "text": "nursing progress note\n63 Y/O FEMALE ADMITTED TO CCU (SICU BORDER) FOR CLOSE MONITORING AFTER BECOMING UNRESPONSIVE FOLLOWING DILAUDED DOSE. SHE HAD RECEIVED 2 MG IV DILAUDED AND WAS FOUND 20 MINUTES LATER UNRESPONSIVE WITH O2 SAT 68% ON RA, SHE WAS PLACED ON 10 L FACE MASK AND GIVEN NARCAN .4 MG IN DIVIDED DOSES. ABG DONE, CO2 ELEVATED. TRANSFERED TO CCU. PT. ARRIVED LETHARGIC, AROUSABLE, ORIENTED X3, MOVING ALL EXTREMITIES.\n\nCV: HR 80'S NSR WITH OCC PVC NOTED. BP STABLE. SEE FLOWSHEET FOR VS\n\nRESP: O2 CHANGED TO NC 6L FROM FACE MASK, NOW ON 4L VIA NC. LUNGS CLEAR. DENIES SOB. FOLLOWING ABG AS CO2 AND HCO3 ELEVATED. GIVEN NARCAN .4 MG IVP X1.\n\nGI: ILEOSTOMY DRAINING LOOSE BROWN STOOL. + BOWEL SOUNDS, NOT FEELING HUNGRY. C/O THIRST.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE.\n\nENDO: FOLLOWING BLOOD SUGARS WITH SSRI\n\nWOUND: RECTAL DRESSING INTACT, JP DRAINAGE 20 CC, BLOODY.\n\nPAIN: C/O OF BACK DISCOMFORT, REPOSITIONED FOR COMFORT, TORADOL 15 MG IV GIVEN Q 6HRS WITH SOME RELIEF FORM PAIN.\n\nA: S/P PERINEAL PROCTECTOMY\n\nP: FOLLOW ABG, URINE OUTPUT, CONT TORADOL Q 6HRS ATC, ? TRANSFER TO FLOOR TODAY\n" }, { "category": "Nursing/other", "chartdate": "2185-09-03 00:00:00.000", "description": "Report", "row_id": 1601498, "text": "CCU Nursing Progress Note\nS: \"I have a headache, backache and my bum hurts\"\nO: C/O above throughout most of am. Torodol without effect, given Tylenol 650mg pox1 with minimal relief. MD's vss. Given 100mcgs Fentanyl with good pain control. Pain decreased from to 0. Fentanyl has worn off in approx 90min. PCA Fentanyl begun with pt dose 12.5mcgs q6min up to 50mcgs/hr. Bolused with 25mcgs to begin, and pt has had good control with only 12.5mcgs x2.\nt max 100.1po\nHR 83-91 NSR with rare PVC's\nBP 102-126/50-64\nResp 13-20 with clear ls. o2face mask is mostly @ her neck, so changed to 4ln/p with sat 95%\nAbd soft with +bs and working ileostomy. Foley cath to clear amber urine 20-50cc/hr.\nPeripad changed x2 for small amt serosang. drainage. Jp patent and working from perineal area.\nHct this am 25.8, transfused with 1UPRBC's.\nA: Pain control with PCA\nP: Repeat HCT post transfusion, Monitor peri area for increase or change in drainage, Increase activity as pt tolerate, OOB if able. Cont pain control with PCA\n" }, { "category": "Nursing/other", "chartdate": "2185-09-03 00:00:00.000", "description": "Report", "row_id": 1601499, "text": "CCU NPN 2-7pm\nPain: pt has had better pain control with PCA Fent. Remains on IV Toredol as well. JP draining sm amt serosang fluid. Pt stood for several minutes, unable to sit on bottom d/t discomfort from JP drain. Vaginal drainage sm amd serosang. Pad changed x1.\n\nResp: 4L NC, sats 92-97%, LS clear with crackles at R base, do not clear with coughing. ABG drawn: 78/48/7.46/8/35, cont to have met alkalosis, ?etiology.\n\nGI: ileostomy draining brown liq. Appetite poor, taking fair amt fluids, sm amt fruit.\n\nGU: foley, UO >30cc/hr.\n\nHeme: HCT drawn after PRBC's was 27.6\n\nID: low grade T 99.3po. WBC 13.6\n\nCV: HR initially 80's NSR, with freq PVC's, then began having freq APC's, then went into a.fib rate 120-140's, pt asymptomatic. Given 5mg IV lopressorx3 with little effect. BP remained stable. Given 15mg IV Dilt, HR down to 80-90's a.fib, started Dilt gtt. 2nd surgical resident came by, stopped Dilt, gave 10mg IV lopressor and has ordered 25mg po bid. Pt HR has remained 100-116 A.fib.\n\nA/P: Better pain control with PCA, new A.fib, now on Lopressor po. Cont to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2185-09-04 00:00:00.000", "description": "Report", "row_id": 1601502, "text": "CCU NPN 7A-7P\nCV: this am on Dilt gtt at 15mg/hr, HR 70's a.fib, converted to NSR at 8AM. IV dilt changed to po 60mg qid. Has remained in NSR. BP 90-115/40-50.\n" }, { "category": "Nursing/other", "chartdate": "2185-09-05 00:00:00.000", "description": "Report", "row_id": 1601503, "text": "CCU Nursing Progress Note 7p-7a\nS: \"It's been 4 days now, you would think I would feel better\"\n\nO: Please see careview for complete VS/ additional objective data\n\nNeuro: AAOx3. MAE. Overall weak. C/o sharp stabbing pain associated w/ movement at perianal incisional site when OOB to commode. Otherwise pain is reported to be at rest. Given Percocet Q4 while awake and Ketorolac q6 hrs. Pt still awake at Midnight. Given 5mg Ambien w/ gd effect. Pt slept w/ minimal interruption until 0600.\n\nCV: Hemodynamically stable. Tele-> NSR. No ectopy noted. No additional episodes of afib. Pt remains off IV Diltiazem and continues to receive 60mg PO QID. HR 65-93. NBP 95-107/45-54. MAPS>61. Pt denies any CP/discomfort. AM labs still pending.\n\nResp: LS cta. RR 12-19. Breathing nml and unlabored. Pt denies SOB. O2 sats 92-98%. pt initially 94-97% on 2L NC. ^ O2 requirements while pt asleep. O2 sats only 90%. ^ O2 to 4L and sats improved. Unable to wean back to 2L w/o drop in O2 sats. Encouraged pt . Performed incentive spirometry exercises w/ improved O2 sats. Vt 1500.\n\nGI/GU: Abd soft. Nontender. +BS. Stooling via ileostomy bag. Ileostomy site pink and wnl. Drained 250cc guiac negative brown stool. Stool sent on prior shift too viscous to run test for lytes. Appetite improving per report. Pt tolerated clr liquids and po meds w/o difficulty . Pt receives Viokase tid w/ meals but pt requested 1 tablet as well w/ po meds and milk at 00 and 06 for low pancreatic enzymes. Given Diomox IV BID.\nPt up to commode x2 voiding cyu 125-175cc. Pt currently 2.2L negative LOS.\n\nEndo: IDDM. BS 150-187. Required minimal coverage per sliding scale. FS QID.\n\nID: Low grade temp. Tmax 99.1 po. No abx at this time.\n\nMisc: Perianal incision cont to remain painful for pt when moving. Tx w/ analgesics. Incision approximated w/ scant amts of sersang drainage. JP in L buttocks minimal drainage (17cc).\n\nSocial: Daughter called and updated by RN and then spoke w/pt. Very supportive and concerned w/ mother's current status.\n\nA/P: S/P ileostomy . To CCU after becoming unresponsive after receiving Dilaudid. S/P repair to recto-vaginal fistula and protectomy. While in CCU went into Afib but converted yesterday am following IV and po Diltiazem. Pt c/o pain at incisional site w/ mvmt. DC'd Fentanyl PCA yest and effectively managing pain w/ Percocet q4hrs and Toradol. Cont Diomox x24hrs and follow enzymes and ileostomy output and replete w/ NS if necessary. Cont on RISS. W/ ^ appetite need adjustment in SS and additional coverage w/ NPH. Cont to ambulate as tolerated. Cont to encourage and incentive spirometry and wean O2 as indicated. Cont to support pt. Called out to floor once a bed becomes available. Transfer note completed.\n" }, { "category": "ECG", "chartdate": "2185-09-03 00:00:00.000", "description": "Report", "row_id": 162281, "text": "Atrial fibrillation with rapid ventricular response\nInferior/lateral ST-T changes are nonspecific\nRepolarization changes may be partly due to rate/rhythm\nSince previous tracing, atrial fibrillation is new\n\n" } ]

[ { "category": "Radiology", "chartdate": "2174-02-09 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1182358, "text": " 7:27 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with persistent hypoxia, despite high flow O2, tachycardia,\n found unresponsive,\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 7:59 AM\n Right middle lobe consolidation. No pulmonary embolism.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with persistent hypoxia and tachycardia. Found\n unresponsive.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired through the chest with and without IV\n contrast. Multiplanar reformations were obtained and reviewed.\n\n CT OF THE CHEST WITH IV CONTRAST:\n\n The thyroid gland is unremarkable. There is no axillary or mediastinal\n lymphadenopathy by CT size criteria. The heart and great vessels are\n unremarkable. The pulmonary arteries are patent down to subsegmental level.\n The lungs show right middle lobe scarring but no nodules or effusions are\n noted.\n\n Although this examination was not intended for subdiaphragmatic evaluation the\n partially imaged abdomen appears unremarkable.\n\n OSSEOUS STRUCTURES:\n\n The visible osseous structures show no suspicious lytic or blastic lesions or\n fractures.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n 2. Right middle lobe atelectasis vs parenchymal scarring.\n\n" }, { "category": "Radiology", "chartdate": "2174-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1182342, "text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute CT process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with decreased O2 sat, eval for acute CT process\n REASON FOR THIS EXAMINATION:\n acute CT process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with decreased O2 sat; evaluate for acute\n cardiothoracic process.\n\n COMPARISON: None available.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are well expanded and clear. The cardiomediastinal silhouette,\n hilar contours and pleural surfaces are normal. No pleural effusions or\n pneumothoraces are present.\n\n IMPRESSION:\n\n No acute intrathoracic process. The concurrent CT shows a right middle lobe\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2174-02-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1182343, "text": " 4:42 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AMS, unresponsive\n REASON FOR THIS EXAMINATION:\n please eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf WED 5:39 AM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with altered mental status, unresponsive.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n Multiplanar reformations were obtained and reviewed.\n\n FINDINGS: No acute hemorrhage, large vascular territorial infarct, shift of\n midline structures, edema or mass effect is present. The ventricles and sulci\n are normal in size and configuration. A mucus-retention cyst is noted in the\n right maxillary sinus; otherwise, the visualized paranasal sinuses, middle ear\n cavities and mastoid air cells are well aerated.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "ECG", "chartdate": "2174-02-09 00:00:00.000", "description": "Report", "row_id": 256338, "text": "Probable sinus tachycardia. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2203-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228609, "text": " 2:07 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT placement\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM, AT 13:59\n\n CLINICAL INDICATION: History of respiratory failure with endotracheal tube\n placement, check location.\n\n Comparison is made to the patient's previous study dated at 9:21.\n\n Portable semi-erect chest film, at 13:59, is submitted.\n\n IMPRESSION:\n\n Endotracheal tube and right internal jugular central line are unchanged in\n position. The nasogastric tube has been advanced and now the tip is within\n the stomach and the side port is probably just beneath the gastroesophageal\n junction. There has been interval improvement in mild pulmonary edema. More\n focal patchy opacity at the left base persists which could reflect a\n combination of compressive atelectasis and/or pleural effusion, although\n pneumonia cannot be entirely excluded. No pneumothorax is seen. Overall\n cardiac and mediastinal contours are difficult to assess due to the airspace\n process.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228567, "text": " 9:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? OG tube placement\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with new OG tube\n REASON FOR THIS EXAMINATION:\n ? OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM, at 921.\n\n CLINICAL INDICATION: Status post orogastric tube placement, check position.\n\n Comparison is made to the patient's prior study dated at 5 a.m.\n\n A single portable semi-erect chest film at 921 is submitted.\n\n IMPRESSION:\n\n Endotracheal tube and right internal jugular central line are unchanged in\n position. Interval placement of a nasogastric tube with its tip at the\n gastroesophageal junction. Advancement would be recommended at this time. The\n recommendation for advancement of the nasogastric tube was conveyed by phone\n to the patient's house staff, , in the intensive care unit on \n at 1:12 p.m.. There is worsening interstitial and pulmonary edema.\n Persistent opacity at left base may represent a combination of atelectasis and\n pleural effusion, although pneumonia cannot be entirely excluded. No\n pneumothorax is seen.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228530, "text": " 3:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man intubated with RIJ\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM, AT 4:26 AM\n\n CLINICAL INDICATION: 79-year-old intubated. Check line placement.\n\n Comparison is made to the patient's previous study dated at 22:12.\n\n Portable supine chest film at 5 a.m. is submitted.\n\n IMPRESSION:\n 1. Endotracheal tube unchanged in position. Right internal jugular central\n line has its tip in the proximal right atrium, unchanged. There is a\n worsening airspace process at the left base, which may reflect atelectasis in\n the setting of a pleural effusion. However, pneumonia and/or aspiration\n should also be considered. Improvement in mild pulmonary edema with residual\n mild interstitial edema. Persistent low lung volumes. Overall, cardiac and\n mediastinal contours are difficult to assess given the patient rotation on the\n current examination.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-19 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1228608, "text": " 2:07 PM\n PORTABLE ABDOMEN Clip # \n Reason: check OG tube placement and Foley placement\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n check OG tube placement and Foley placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL PLAIN FILM, AT 14:05\n\n CLINICAL INDICATION: 79-year-old with respiratory failure, check orogastric\n tube placement and Foley placement.\n\n A portable supine abdominal plain film is submitted.\n\n IMPRESSION:\n\n There is some overlying artifact and motion on the study. A percutaneous\n nephrostomy tube appears to be projecting over the left mid abdomen. No\n nasogastric tube or Foley catheter is visualized. Calcification in the right\n hemipelvis is felt to most likely represent a phlebolith. Degenerative\n changes are seen in the spine. No acute bony abnormality. There is scattered\n air in nondistended loops of colon.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228416, "text": " 11:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 79M with fever, tachycardia and abdominal pain at Lt nephrostomy site\n since last night. Clinical Question: eval for abscess or other infectious\n source of abdominal pain and sepsis\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Fever, tachycardia and abdominal pain in left nephrostomy site.\n\n COMPARISONS: Radiographs from and CT torso from .\n\n TECHNIQUE: Chest, portable AP upright.\n\n FINDINGS: The heart is mild to moderately enlarged. The mediastinal and\n hilar contours appear unchanged. As seen previously, the right trachea is\n bowed rightward but not significantly changed since the prior CT which showed\n no significant associated abnormality. There is a similar patchy left basilar\n opacity obscuring the left heart border and hemidiaphragm which is perhaps\n somewhat increased. A small pleural effusion cannot be excluded. There is\n minimal background prominence of pulmonary vascularity but similar to\n baseline.\n\n IMPRESSION: Increased left basilar opacity, which may be associated with\n atelectasis, although pneumonia cannot be excluded by this study.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228503, "text": " 10:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: tube placement\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man requiring intubation\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 2212\n\n CLINICAL INDICATION: 79-year-old requiring intubation, check tube placement.\n\n Comparison is made to the patient's prior study at 1506.\n\n Portable supine chest film at 2212 is submitted.\n\n IMPRESSION:\n\n 1. Interval placement of an endotracheal tube with its tip 4.8 cm above the\n carina. Right internal jugular central line continues to have its tip in the\n proximal right atrium. There is increasing opacity at the left base which may\n represent a combination of atelectasis and pleural effusion. There is likely\n worsening pulmonary edema. Overall cardiac and mediastinal contours are\n difficult to assess given marked patient rotation on the current examination.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-18 00:00:00.000", "description": "CHG NEPHROTOMY/PYLOSTOMY TUBE", "row_id": 1228499, "text": " 5:49 PM\n PERC NEPHROSTO Clip # \n Reason: please replace nephrostomy tube\n Admitting Diagnosis: UROSEPSIS\n Contrast: OMNIPAQUE Amt: 35\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with metastatic prostate ca w/ nephrostomy tube out of place\n REASON FOR THIS EXAMINATION:\n please replace nephrostomy tube\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Left percutaneous nephrostomy tube placement: .\n\n INDICATION: 79 year-old man with metastatic prostate cancer and left ureteral\n obstruction, now presenting with a dislodged left nephrostomy tube.\n\n OPERATOR: Dr (attending radiologist).\n\n ANESTHESIA: The patient arranged intubated and sedated fromt he ICU.\n\n TECHNIQUE/FINDINGS:\n\n After the risks and benefits of the procedure were explained to the patient,\n written informed consent was obtained. The patient was positioned prone on\n the angiography table and his left flank was prepped and draped in standard\n sterile fashion. A pre-procedure timeout was performed.\n\n Under ultrasound guidance, a left mid pole calyx was cannulated with a\n 21-gauge needle. Contrast injection demonstrated that access was at the\n infundibular level. Under fluoroscopic guidance, a left interpolar calyx was\n accessed with a second 21-gauge needle. Contrast injection confirmed position\n of the second access needle, and the first access needle was removed. A 0.018\n wire was advanced into the renal pelvis. The needle was exchanged for an\n AccuStick sheath. The wire was removed. Blood-tinged urine drained from the\n catheter, and a sample was obtained for microbiologic analysis. Antegrade\n nephrostogram demonstrated moderate right hydronephrosis and proximal\n hydroureter. Contrast did not pass beyond the mid ureter. The wire, inner\n dilator, and metallic shaft of the AccuStick sheath were removed, and a\n Amplatz wire was advanced into the renal pelvis. An 8 French dilator was used\n to dilate the tract over the Amplatz wire. This was followed by successful\n placement of the 8 French locking loop nephrostomy tube into the left renal\n pelvis. Contrast was injected confirming this location. The catheter was\n secured to the skin with a 0 silk stitch and Flextrac device. The catheter\n was placed to external bag drainage.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION:\n (Over)\n\n 5:49 PM\n PERC NEPHROSTO Clip # \n Reason: please replace nephrostomy tube\n Admitting Diagnosis: UROSEPSIS\n Contrast: OMNIPAQUE Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Left percutaneous nephrostomy tube placement.\n\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2203-02-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1229013, "text": " 5:24 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval nephrostomy tube placement\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with left nephrostomy tube, recently exchanged, now with\n leakage at nephrostomy site\n REASON FOR THIS EXAMINATION:\n eval nephrostomy tube placement\n ______________________________________________________________________________\n WET READ: ASpf TUE 9:33 PM\n Left percutaneous nephrostomy appears unchanged in position overlying the left\n mid abdomen compared to the previous radiographs. Evaluation for position\n within the renal collecting system is limited (given the history of previous\n mal-positioning).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old man, with recently exchanged left nephrostomy tube. Now\n with leak at the nephrostomy site. Check for placement.\n\n COMPARISON: Multiple prior exams with the latest on .\n\n SINGLE PORTABLE ABDOMINAL RADIOGRAPH: The left nephrostomy tube with the\n pigtail is unchanged in position compared to the prior. There are two\n pill-like densities projecting on to the gastric bubble. There is\n non-obstructive bowel gas pattern. No evidence of free air is noted. The\n underlying osseous structures are grossly intact.\n\n IMPRESSION: Unchanged left nephrostomy tube position.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1228469, "text": " 3:11 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: R central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with hydronephrosis/ prostate CA\n REASON FOR THIS EXAMINATION:\n R central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with hydronephrosis and prostate cancer, now with\n recent central line placement.\n\n STUDY: Portable AP upright chest radiograph.\n\n COMPARISON: at 11:01 a.m.\n\n FINDINGS/IMPRESSION: The heart and mediastinal contours appeared to be\n enlarged, exaggerated by AP technique as well as probable fluid resuscitation.\n There has been interval placement of a right-sided IJ central venous catheter\n with its tip in the upper portion of the right atrium. The upper portions of\n the lungs are clear, although bibasilar opacities likely reflect portions of\n atelectasis and small bilateral pleural effusions. There is no pneumothorax\n or apical capping.\n\n" }, { "category": "Radiology", "chartdate": "2203-02-18 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1228441, "text": " 12:44 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 79M with fever, tachycardia and abdominal pain at Lt nephrostomy site\n since last night. Clinical Question: eval for abscess or other infectious\n source of abdominal pain and sepsis\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXPb FRI 2:10 PM\n Malpositioned left percutaneous nephrostomy tube with pigtail coiled in the\n posterolateral perinephric fat. Severe left hydroureteronephrosis. Extensive\n perinephric fat stranding and fascial thickening concerning for pyelonephritis\n in an obstructed collecting system.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, tachycardia, and abdominal pain at left percutaneous\n nephrostomy site since the previous night. The patient had a left distal\n ureteric obstruction from metastatic prostate cancer with a percutaneous\n nephrostomy tube placed under fluoroscopic guidance on .\n\n COMPARISON: CTA chest from , bone scan from , and fluoroscopic images from percutaneous nephrostomy tube placement on\n . CT abdomen and pelvis from .\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases through the pubic\n symphysis were acquired without IV or p.o. contrast administration.\n Multiplanar reformats were performed to degenerate coronal and sagittal image\n series.\n\n FINDINGS:\n\n LOWER CHEST: The heart appears minimally enlarged. The lung bases feature\n atelectasis and subtle ground-glass opacity, with thickening of the basal\n pleura, more prominent on the left.\n\n ABDOMEN: There is a moderate-sized hiatal hernia. The stomach and duodenum\n are collapsed, limiting evaluation. Evaluation of abdominal structures is\n limited by lack of contrast administration. However, the liver, pancreas,\n adrenal glands, and spleen appear normal. The patient is status post\n cholecystectomy.\n\n A percutaneous nephrostomy tube can be seen entering from the left flank. The\n pigtail is coiled within the lateral perinephric fat (3:44). There is\n moderate-to-severe hydroureteronephrosis, similar to the prior studies prior\n to the nephrostomy placement. There is now extensive perinephric fat\n stranding and thickening of the pararenal fascia. There is no large\n retroperitoneal fluid collection. The bilateral kidneys have small exophytic\n (Over)\n\n 12:44 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n posterior structures, are incompletely characterized on this unenhanced study,\n but demonstrate stability from and have the density of simple cysts. The\n intra-abdominal loops of small and large bowel appear normal. There is a\n small fat-containing umbilical hernia. There is no intra-abdominal free fluid\n or air.\n\n Again noted is a soft tissue density, unchanged from the prior examination,\n which likely represents the obstructing soft tissue mass previously\n characterized (3:56). The abdominal aorta contains sparse atherosclerotic\n calcification, and is of normal caliber. No new lymphadenopathy is identified\n on this limited non-contrast study.\n\n PELVIS: The sigmoid and pelvic loops of small and large bowel appear normal.\n A normal appendix is visualized. There is thickening of the anterior wall of\n the rectum and posterior wall of the bladder which are indistinguishable from\n the prostate. These structures are unchanged in appearance from the prior\n study.\n\n BONE WINDOWS: There is increased cortical density within the right pedicle\n and posterior ribs of T10 (3:16, 602B:45-39). This region showed increased\n radionuclide uptake on the bone scan from ; although there\n has been no recent change somewhat unusual metastatic disease could be\n considered. Similar findings involve the left medial eighth rib. There are\n stable degenerative changes of the thoracolumbar spine. No other destructive\n lesions concerning for malignancy are seen.\n\n IMPRESSION:\n\n 1. Misplaced left percutaneous nephrostomy catheter with the pigtail coiled\n in the lateral perinephric fat.\n\n 2. Moderate-to-severe left hydroureteronephrosis with extensive perinephric\n fat stranding and pararenal fascial thickening. This could represent\n pyelonephritis in a closed urinary collecting system, or post-surgical changes\n from the recent procedure and displacement of the catheter; although a small\n amount of extravasated urine cannot be excluded as contributing to this\n appearance there is not substantial fluid collection.\n\n 3. Stable thickening of the soft tissues adjacent to the prostate, likely\n representing prostate cancer, with unchanged paraaortic mass causing left\n ureteric malignant obstruction.\n\n 4. Sclerotic appearance of right posterior 10th rib, and adjacent pedicle of\n the T10 vertebra, with increased uptake seen on bone scan in , which may\n represent an old traumatic injury, however, raises concern for unusual\n appearance of bony metastatic disease given the patient's history of\n metastatic prostate cancer. A bone scan would be helpful to evaluate further\n (Over)\n\n 12:44 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n if clinically indicated and attention to the site in imaging follow-up is also\n recommended. Similar findings are noted in the left eighth rib.\n\n\n\n" }, { "category": "ECG", "chartdate": "2203-02-21 00:00:00.000", "description": "Report", "row_id": 180568, "text": "Sinus rhythm. Occasional ventricular premature beats. Compared to the previous\ntracing of there is no change.\n\n" }, { "category": "ECG", "chartdate": "2203-02-18 00:00:00.000", "description": "Report", "row_id": 180569, "text": "Sinus tachycardia with non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of no diagnostic change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2148-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170772, "text": " 7:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for acute disease\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man preop for PEG\n REASON FOR THIS EXAMINATION:\n please eval for acute disease\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PEG placement for acute surgery.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, patient has received a\n nasogastric tube. The tube shows a normal course, the tip of the tube is not\n visible on the image. No evidence of complications, notably no pneumothorax.\n\n No pleural effusions. No pulmonary edema. No pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-17 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 1170953, "text": " 7:24 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with stroke. Nurse calf measures 37\" / Right calf\n 34.5\", no warmth or erythema. Pt seems to be signaling discomfort in LLE, but\n aphasic.\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: ASpf 7:44 PM\n No DVT in left lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with stroke. Question of left lower extremity\n DVT.\n\n COMPARISON: None available.\n\n FINDINGS:\n\n -scale and color Doppler images of the right and left common femoral, left\n superficial femoral, left popliteal and left proximal calf veins were\n obtained. There is wall-to-wall flow with normal response to compression and\n augmentation in all visible veins.\n\n IMPRESSION:\n\n No DVT in the left lower extremity.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2148-12-16 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1170712, "text": " 1:03 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: 69 year old man with stroke and swallowing problems, speech\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with stroke and swallowing problems, speech asked to get video\n swallow\n REASON FOR THIS EXAMINATION:\n 69 year old man with stroke and swallowing problems, speech asked to get video\n swallow\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Stroke and swallowing difficulties.\n\n SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was\n performed in conjunction with the speech and swallow division. Multiple\n consistencies of barium were administered. Barium passed freely through the\n oropharynx without evidence of obstruction. Aspiration was seen with nectars.\n\n IMPRESSION: Aspiration of nectar consistency. For details please refer to\n speech and swallow note in OMR.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1170247, "text": " 8:57 AM\n PORTABLE ABDOMEN Clip # \n Reason: NGT placement\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with stroke, NGT placed\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:42 AM\n Nasogastric tube tip projects over region of the stomach\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Stroke, nasogastric tube placement.\n\n COMPARISON: CT .\n\n FINDINGS: A single portable supine view of the abdomen was obtained. A\n nasogastric tube follows the standard course with the tip projecting over the\n region of the stomach. Limited evaluation of the bowel gas pattern is grossly\n unremarkable without evidence of obstruction or ileus.\n\n IMPRESSION: Nasogastric tube tip projects over region of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "ED STROKE CTA HEAD & NECK WITH PERFUSION", "row_id": 1170209, "text": " 2:10 AM\n ED STROKE CTA HEAD & NECK WITH PERFUSION Clip # \n Reason: RT SIDE WEAKNESS\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with R sided weakness\n REASON FOR THIS EXAMINATION:\n ? CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:07 AM\n 1. No hemorrhage.\n 2. Hyperdense appearance of the Left ICA and Left MCA, concerning for\n thrombosis.\n CTA:\n 1. There is thrombosis of the left cervical ICA extending to the terminal\n portion of ICA,. thrombus in the left MCA, M1 and M2 segments, with narrowing\n of the distal branches.\n 2. Few section of the cervical portion of R ICA have a fillind defect,\n question thrombus/ dissection.\n 3.Posterior circualtion is patent.\n 3 D recons pending. CTP pending.\n CTP: MTT is increased in the entire L MCA territory, with mild decrease in the\n cerebral blood volume and cerebral blood flow.\n WET READ VERSION #1 2:56 AM\n 1. No hemorrhage.\n 2. Hyperdense appearance of the Left ICA and Left MCA, concerning for\n thrombosis.\n CTA:\n 1. There is thrombosis of the left cervical ICA extending to the terminal\n portion of ICA,. thrombus in the left MCA, M1 and M2 segments, with narrowing\n of the distal branches.\n 2. Few section of the cervical portion of R ICA have a fillind defect,\n question thrombus/ dissection.\n 3.Posterior circualtion is patent.\n 3 D recons pending. CTP pending.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with CVA, for further evaluation.\n\n TECHNIQUE: Multidetector axial CT of the brain was performed without\n intravenous contrast followed by rapid axial imaging from the aortic arch\n through the brain after infusion of intravenous contrast. Images were\n processed on a separate workstation with display of curved reformats, 3D\n volume-rendered images, and maximum intensity projections. Perfusion imaging\n was performed through the brain.\n\n FINDINGS:\n\n HEAD CT:\n\n There is a dense MCA sign on the left, highly suggestive of an acute\n (Over)\n\n 2:10 AM\n ED STROKE CTA HEAD & NECK WITH PERFUSION Clip # \n Reason: RT SIDE WEAKNESS\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n thrombosis. There is no evidence of an intracranial hemorrhage, mass effect\n or edema. The midline structures are central. The ventricles and sulci\n appear unremarkable. There is no visible stroke on the non-contrast CT.\n\n CTA HEAD AND NECK:\n\n The visualized aortic arch and common carotid arteries appear unremarkable\n except for minimal atherosclerosis at the carotid bifurcation. The left\n internal carotid artery is occluded completely in its proximal course and the\n remaining course of the left internal carotid artery, both cervical and\n intracranial does not demonstrate contrast opacification. There is also a\n filling defect in the left middle cerebral artery. The left A1 is diminutive\n in caliber, though demonstrates opacification with contrast, from the\n contralateral side. The cervical and intracranial course of the right\n internal carotid artery and its branches are widely patent. The left\n vertebral artery demonstrates apparent narrowing at its origin, which could be\n artifactual due to partial volume averaging. The remaining cervical and\n intracranial course of the left vertebral artery and its branches is widely\n patent. The right vertebral artery in its cervical and intracranial course is\n widely patent. The basilar artery and its intracranial branches are widely\n patent.\n\n CT PERFUSION: There is increased mean transit time and decreased blood flow\n and blood volume in most of the territory supplied by the left MCA consistent\n with infarction.\n\n IMPRESSION:\n\n 1. Acute infarction involving most of the territory of the left middle\n cerebral artery as seen on the perfusion imaging.\n\n 2. Extensive thrombosis of the cervical and intracranial course of the\n internal carotid artery with thrombus extension into the left middle cerebral\n artery.\n\n 3. Apparent narrowing at the origin of the left vertebral artery which is not\n fully assessed due to artifact from partial volume averaging.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1170285, "text": ", NMED MICU 12:11 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: characterization of stroke\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with Left MCA infarction\n REASON FOR THIS EXAMINATION:\n characterization of stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Extensive acute left MCA infarct with occlusion of the left MCA M1 and M2\n branches. No hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1170284, "text": " 12:11 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: characterization of stroke\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with Left MCA infarction\n REASON FOR THIS EXAMINATION:\n characterization of stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:17 PM\n Extensive acute left MCA infarct with occlusion of the left MCA M1 and M2\n branches. No hemorrhage.\n\n PFI VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with left MCA infarct. Characterize stroke.\n\n COMPARISON: Head CT, .\n\n TECHNIQUE: Multiplanar, multisequence brain imaging was performed without\n intravenous contrast.\n\n FINDINGS: Diffusion imaging demonstrates an extensive left MCA territory\n infarct without associated hemorrhage. There is subtle FLAIR abnormality at\n this time indicating the acute nature of the infarct. T2 sequences\n demonstrate lack of the normal flow void in the left MCA, particularly the M1\n and M2 segments.\n\n There is no other area of infarct. There is no edema, mass or mass effect.\n Ventricles and sulci are normal in size and configuration. Other intracranial\n flow voids are unremarkable.\n\n IMPRESSION: Extensive acute left MCA infarct . No hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1170365, "text": " 2:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: post-tPA protocol, please do it between 3-4am on \n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man now s/p tPA with left MCA stroke\n REASON FOR THIS EXAMINATION:\n post-tPA protocol, please do it between 3-4am on \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with left MCA stroke status post TPA treatment.\n\n COMPARISON: CT head without contrast and an MR head without\n contrast .\n\n FINDINGS: There is expected evolution of the left MCA infarct. Tiny punctate\n foci of hyperdensity seen along the left temporoparietal cortex within the\n infarct could represent petechial hemorrhages. There is mild mass effect on\n the frontal of the left lateral ventricle. No shift of midline\n structures is seen. The basal cisterns are normal in configuration. The\n mastoid air cells and paranasal sinuses are clear.\n\n IMPRESSION:\n 1. Evolving left MCA territory infarct. Minimal mass effect on the frontal\n of the left lateral ventricle is new.\n 2. Subtle foci of hyperdensity within the infarcts may suggest petechial\n hemorrhages.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1170248, "text": ", NMED MICU 8:57 AM\n PORTABLE ABDOMEN Clip # \n Reason: NGT placement\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with stroke, NGT placed\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n PFI REPORT\n Nasogastric tube tip projects over region of the stomach\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1170214, "text": " 3:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: NEW HA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with TPA now headache\n REASON FOR THIS EXAMINATION:\n eval for hemorrhagic conversion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:03 AM\n No hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with known left MCA stroke, status post TPA\n treatment, complains of headache, to rule out hemorrhagic conversion.\n\n COMPARISON: A CT of the head done earlier today at 2:10 a.m.\n\n TECHNIQUE: MDCT helical images were acquired through the head without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema or\n mass effect. Hyperdensity of the left MCA and ICA are still seen in the\n current study although evaluation is limited due to presence of contrast from\n prior CTA. The ventricles and sulci are mildly prominent, consistent with\n age-related involutional changes. The basal cisterns are normal.\n\n Minimal opacification of the right mastoid sinus is seen. The paranasal\n sinuses are clear.\n\n IMPRESSION: In this patient with known left MCA stroke, status post TPA\n treatment, there is no hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1170230, "text": " 8:07 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: hemorrhagic conversion. Please do at 8 AM\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with large L MCA stroke s/p tPA\n REASON FOR THIS EXAMINATION:\n hemorrhagic conversion. Please do at 8 AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:26 PM\n PFI: Evolving left MCA stroke with cytotoxic edema seen in the left basal\n ganglia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male with large left MCA stroke status post TPA.\n Evaluate for hemorrhagic conversion.\n\n COMPARISON: CT head without contrast from at 3:44 a.m. as well as\n CT of the head and neck with perfusion from , performed at 2:10\n a.m.\n\n TECHNIQUE: MDCT obtained of the head without contrast.\n\n FINDINGS:\n\n There are new hypodensities seen in the left putamen, the left caudate as well\n as loss of -white differentiation along the insula consistent with\n evolving left MCA stroke. There is a dense left MCA seen confirming this.\n There is no mass effect or shift of normally midline structures. No evidence\n of extraaxial or intraparenchymal hemorrhage.\n\n There is no fracture. The nasal sinuses are clear.\n\n IMPRESSION:\n\n Evolving MCA stroke with hypodensity seen in the left putamen, left caudate as\n well as loss of -white differentiation at the insula, all consistent for\n evolving left MCA stroke.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1170231, "text": ", NMED MICU 8:07 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: hemorrhagic conversion. Please do at 8 AM\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with large L MCA stroke s/p tPA\n REASON FOR THIS EXAMINATION:\n hemorrhagic conversion. Please do at 8 AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Evolving left MCA stroke with cytotoxic edema seen in the left basal\n ganglia.\n\n\n" }, { "category": "Echo", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 61693, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nHeight: (in) 71\nWeight (lb): 202\nBSA (m2): 2.12 m2\nBP (mm Hg): 154/81\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 10:25\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Prominent Eustachian valve\n(normal variant).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. Prolonged\n(>250ms) transmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\nPatient was unable to cooperate with maneuvers. Suboptimal image quality -\npoor echo windows. Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - patient unable to cooperate.\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%). There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets are mildly thickened (?#). There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. No pathologic valvular\nabnormality seen.\n\nCompared with the report of the prior study (images unavailable for review) of\n, mild symmetric LVH is seen on the current study.\n\n\n" }, { "category": "ECG", "chartdate": "2148-12-12 00:00:00.000", "description": "Report", "row_id": 114490, "text": "Sinus rhythm. Biatrial abnormality. Right bundle-branch block. Left axis\ndeviation. Left anterior fascicular block. Diffuse non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of there\nis no diagnostic change.\n\n" } ]

[ { "category": "ECG", "chartdate": "2159-09-15 00:00:00.000", "description": "Report", "row_id": 149470, "text": "A-V sequential pacing. Compared to the previous tracing the pacing mode has\nchanged.\nTRACING #7\n\n" }, { "category": "ECG", "chartdate": "2159-09-15 00:00:00.000", "description": "Report", "row_id": 149471, "text": "Atrial sensed ventricular paced rhythm. Compared to the previous tracing the\nrate and rhythm have changed.\nTRACING #6\n\n" }, { "category": "ECG", "chartdate": "2159-09-15 00:00:00.000", "description": "Report", "row_id": 149472, "text": "Wide complex tachycardia. Underlying ventricular paced rhythm appears\nintermittent. However, this cannot be conclusively stated on the basis of this\ntracing. Sinus tachycardia versus atrial tachycardia is suggested. Compared to\nthe previous tracing the rate and rhythm have changed.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2159-09-14 00:00:00.000", "description": "Report", "row_id": 149473, "text": "Atrial fibrillation. Ventricular paced rhythm. Occasional ventricular premature\nbeats. Compared to the previous tracing there is no change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2159-09-14 00:00:00.000", "description": "Report", "row_id": 149474, "text": "Atrial fibrillation. Ventricular paced rhythm. Compared to the previous tracing\nthe pacing is more regular.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2159-09-14 00:00:00.000", "description": "Report", "row_id": 149475, "text": "Atrial fibrillation with occasional paced beats. Compared to the previous\ntracing the pacing is new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2159-09-14 00:00:00.000", "description": "Report", "row_id": 149476, "text": "Atrial fibrillation. Left bundle-branch block. Occasional ventricular premature\nbeats. Compared to the previous tracing of there is no change.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2159-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390723, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645\n .\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains AV paced with occasional PVC/PAC\n Action:\n Continues on amiodarone gtt.\n Response:\n Without further VT. Therapeutic PTT.\n Plan:\n D/C amiodarone gtt in am. Start po amiodarone.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Self extubated @ approx 0400.\n Action:\n Placed on 100% NRB.\n Response:\n Sats 100%. Post extubation ABG-7.35/57/269/4/33. breath\n sounds=diminished.\n Plan:\n Encourage C&DB. Attempt to further diurese.\n Renal failure/Heart Failure (CHF)\n Assessment:\n Slowly rising bun/creat-am\ns35/1.9. without significant response to\n diuretic-lasix 120mg. k stable @ 4.7.\n Action:\n Lasix 120mg iv @ 0000 & 0600.\n Response:\n Without significant response to 0000 lasix. Awaiting response to 0600\n lasix.\n Plan:\n Contin present rx. ?diuril/lasix if no response to 0600 lasix dose.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n *****Blood Sugars remain <100-without rx @ present*****\n" }, { "category": "Physician ", "chartdate": "2159-09-16 00:00:00.000", "description": "EP Note", "row_id": 390728, "text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Pt self extubated at 4am today and\n has done well.\n Pt has remained in NSR all day with BiV pacing with SBP running from\n 80's on sedation to 110 extubated and off sedation. No other evidence\n of VT.\n ICD VT detection reduced to 130 per Dr. in case it was slow\n VT.\n Medications\n Unchanged\n Physical Exam\n General appearance: sleepy, arousable\n BP: 139 / 84 mmHg\n HR: 84 bpm\n Tmax C last 24 hours: 37 C\n Tmax F last 24 hours: 98.6 F\n T current C: 36.9 C\n T current F: 98.4 F\n Previous day:\n Intake: 1,244 mL\n Output: 637 mL\n Fluid balance: 607 mL\n Today:\n Intake: 136 mL\n Output: 250 mL\n Fluid balance: -114 mL\n HEENT: (Jugular veins: positive to mid neck)\n Cardiovascular: (Auscultation: RRR + systolic murmur)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: + BS soft)\n Neurological: (Orientation: arousable)\n Extremities:\n Right: (Edema: +)\n Left: (Edema: +)\n Labs\n 301\n 10.4\n 67\n 1.9\n 29\n 4.7\n 35\n 96\n 135\n 33.2\n 12.3\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 05:06 PM\n 09:56 PM\n 01:20 AM\n 04:07 AM\n WBC\n 11.0\n 14.2\n 12.3\n Hgb\n 10.0\n 10.5\n 10.4\n Hct (Serum)\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n INR\n 3.3\n PTT\n 150.0\n 80.5\n 62.3\n Na+\n 137\n 134\n 132\n 133\n 135\n K + (Serum)\n 4.9\n 4.2\n 5.4\n 4.8\n 4.7\n K + (Whole blood)\n 5.8\n Cl\n 98\n 96\n 94\n 96\n 96\n HCO3\n 23\n 28\n 28\n 26\n 29\n BUN\n 24\n 28\n 32\n 35\n Creatinine\n 1.5\n 1.6\n 1.8\n 1.9\n Glucose\n 77\n 71\n 50\n 62\n 67\n CK\n 186\n 162\n CK-MB\n 5\n 5\n Troponin T\n 0.08\n ABG: 7.35 / 57 / 269 / / 4 Values as of 04:56 AM\n Assessment and Plan\n HEART FAILURE (CHF), SYSTOLIC, CHRONIC - continue diuresis with\n lasix. hold dig and given rising Cr. Will d/w Dr. \n about reinitiating AceI once Cr stabilizes. Currently BiV pacing with\n good BP. I/o -100cc. Hopefully with better BP now, he'll start to\n diurese better. If iv lasix still not working later today, may\n consider adding HCTZ.\n VENTRICULAR TACHYCARDIA, NON-SUSTAINED (NSVT) - conitnue IV amio load\n and then switch to oral amio 400 daily for now. Dr. was\n thinking about possibly switching back to sotalol at some time, will\n d/w with Dr. .\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - extubated\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - suspect\n hypoperfusion. hold dig and spirolactone for now.\n Afib - no coumadin with history of GI bleed in past. Continue heparin\n for now and monitor h/h\n IMPAIRED SKIN INTEGRITY\n" }, { "category": "Physician ", "chartdate": "2159-09-16 00:00:00.000", "description": "EP Note", "row_id": 390729, "text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Pt self extubated at 4am today and\n has done well.\n Pt has remained in NSR all day with BiV pacing with SBP running from\n 80's on sedation to 110 extubated and off sedation. No other evidence\n of VT.\n ICD VT detection reduced to 130 per Dr. in case it was slow\n VT.\n Medications\n Unchanged\n Physical Exam\n General appearance: sleepy, arousable\n BP: 139 / 84 mmHg\n HR: 84 bpm\n Tmax C last 24 hours: 37 C\n Tmax F last 24 hours: 98.6 F\n T current C: 36.9 C\n T current F: 98.4 F\n Previous day:\n Intake: 1,244 mL\n Output: 637 mL\n Fluid balance: 607 mL\n Today:\n Intake: 136 mL\n Output: 250 mL\n Fluid balance: -114 mL\n HEENT: (Jugular veins: positive to mid neck)\n Cardiovascular: (Auscultation: RRR + systolic murmur)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: + BS soft)\n Neurological: (Orientation: arousable)\n Extremities:\n Right: (Edema: +)\n Left: (Edema: +)\n Labs\n 301\n 10.4\n 67\n 1.9\n 29\n 4.7\n 35\n 96\n 135\n 33.2\n 12.3\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 05:06 PM\n 09:56 PM\n 01:20 AM\n 04:07 AM\n WBC\n 11.0\n 14.2\n 12.3\n Hgb\n 10.0\n 10.5\n 10.4\n Hct (Serum)\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n INR\n 3.3\n PTT\n 150.0\n 80.5\n 62.3\n Na+\n 137\n 134\n 132\n 133\n 135\n K + (Serum)\n 4.9\n 4.2\n 5.4\n 4.8\n 4.7\n K + (Whole blood)\n 5.8\n Cl\n 98\n 96\n 94\n 96\n 96\n HCO3\n 23\n 28\n 28\n 26\n 29\n BUN\n 24\n 28\n 32\n 35\n Creatinine\n 1.5\n 1.6\n 1.8\n 1.9\n Glucose\n 77\n 71\n 50\n 62\n 67\n CK\n 186\n 162\n CK-MB\n 5\n 5\n Troponin T\n 0.08\n ABG: 7.35 / 57 / 269 / / 4 Values as of 04:56 AM\n Assessment and Plan\n HEART FAILURE (CHF), SYSTOLIC, CHRONIC - continue diuresis with\n lasix. hold dig and given rising Cr. Will d/w Dr. \n about reinitiating AceI once Cr stabilizes. Currently BiV pacing with\n good BP. I/o -100cc. Hopefully with better BP now, he'll start to\n diurese better. If iv lasix still not working later today, may\n consider adding HCTZ.\n VENTRICULAR TACHYCARDIA, NON-SUSTAINED (NSVT) - conitnue IV amio load\n and then switch to oral amio 400 daily for now. Dr. was\n thinking about possibly switching back to sotalol at some time, will\n d/w with Dr. .\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - extubated\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - suspect\n hypoperfusion. hold dig and spirolactone for now.\n Afib - no coumadin with history of GI bleed in past. Continue heparin\n for now and monitor h/h\n IMPAIRED SKIN INTEGRITY\n ------ Protected Section ------\n Pt interviewed and examined. I agree with Dr. \ns H+P, A+P.\n Self-extubated. Renal function worsening. benefit from AVJ\n ablation to manage afib/RVR. Will defer to Dr. .\n ------ Protected Section Addendum Entered By: , MD\n on: 07:28 ------\n" }, { "category": "Physician ", "chartdate": "2159-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390731, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 11:32 PM\n INVASIVE VENTILATION - STOP 04:29 AM\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 04:38 AM\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 800 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Dextrose 50% - 03:15 PM\n Furosemide (Lasix) - 06:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 76 (70 - 80) bpm\n BP: 132/91(103) {103/76(85) - 138/97(109)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,244 mL\n 155 mL\n PO:\n TF:\n IVF:\n 474 mL\n 155 mL\n Blood products:\n Total out:\n 637 mL\n 440 mL\n Urine:\n 587 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 607 mL\n -285 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/57/269/29/4\n Ve: 7.3 L/min\n PaO2 / FiO2: 538\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 67 mg/dL\n 1.9 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 35 mg/dL\n 96 mEq/L\n 135 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n Glucose\n 77\n 71\n 50\n 62\n 67\n Other labs: PT / PTT / INR:32.5/62.3/3.3, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.5 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension.\n .\n # Hypotension: Most likely related to unstable rhythm of atrial\n fibrillation with rapid ventricular response and rate related left\n bundle. Unclear why internal ICD did not fire for rhythm. S/p\n attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity.\n - Attempt to maintain sinus rhythm with amiodarone\n - Blood cultures\n - Antibiotics if spikes\n - Small fluid boluses PRN, pressors as needed\n - Hold spironolactone, sotalol and ace-I for now\n .\n # RHYTHM: The patient has a history of Afib, h/o VT, now with several\n episodes of VT and Afib with RVR s/p external dc/cv. Pt now in sinus\n rhythm with intermittent pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - Continue home digoxin\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Received\n 100mg of IV lasix in transit, however no urine output currently.\n - monitor UOP, concern for ARF in the setting of hypotension\n - daily weights and strict I&Os - lasix PRN\n - continue home Simvastatin\n - continue home Midodrine, Digoxin for inotropic support\n - Hold Spiranolactone in the setting of hypotension\n - consider starting low dose ACE-I\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior.\n - Cycle enzymes today - may be elevated secondary to DC/CV\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol.\n - Recheck K\n - Administer kayexalate\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin SS\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: wife Phone: \n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2159-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390736, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 11:32 PM\n INVASIVE VENTILATION - STOP 04:29 AM\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 04:38 AM\n Climbed out of bed to stand this morning, independently.\n Denies chest pain/pressure, SOB, pain.\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 800 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Dextrose 50% - 03:15 PM\n Furosemide (Lasix) - 06:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 76 (70 - 80) bpm\n BP: 132/91(103) {103/76(85) - 138/97(109)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,244 mL\n 155 mL\n PO:\n TF:\n IVF:\n 474 mL\n 155 mL\n Blood products:\n Total out:\n 637 mL\n 440 mL\n Urine:\n 587 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 607 mL\n -285 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/57/269/29/4\n Ve: 7.3 L/min\n PaO2 / FiO2: 538\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 67 mg/dL\n 1.9 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 35 mg/dL\n 96 mEq/L\n 135 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n Glucose\n 77\n 71\n 50\n 62\n 67\n Other labs: PT / PTT / INR:32.5/62.3/3.3, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.5 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension.\n .\n # Hypotension: Most likely related to unstable rhythm of atrial\n fibrillation with rapid ventricular response and rate related left\n bundle. Unclear why internal ICD did not fire for rhythm. S/p\n attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity.\n - Attempt to maintain sinus rhythm with amiodarone\n - Blood cultures\n - Antibiotics if spikes\n - Hold spironolactone, sotalol and ace-I for now\n .\n # RHYTHM: The patient has a history of Afib, h/o VT, now with several\n episodes of VT and Afib with RVR s/p external dc/cv. Pt now in sinus\n rhythm with intermittent pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - Continue home digoxin\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Now\n putting out urine to lasix; Cr rising.\n - monitor UOP, concern for ARF in the setting of hypotension and rising\n Cr\n - daily weights and strict I&Os - lasix PRN\n - continue home Simvastatin\n - continue home Midodrine, Digoxin for inotropic support\n - Hold Spiranolactone in the setting of hypotension\n - consider starting low dose ACE-I\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior.\n - Cycle enzymes today - may be elevated secondary to DC/CV\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol.\n - Recheck K\n - Administer kayexalate\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin SS\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: wife Phone: \n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2159-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390741, "text": "TITLE:\n Chief Complaint:\n None.\n 24 Hour Events:\n ARTERIAL LINE - START 11:32 PM\n INVASIVE VENTILATION - STOP 04:29 AM\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 04:38 AM\n Climbed out of bed to stand this morning, independently.\n Denies chest pain/pressure, SOB, pain.\n Confused as to location.\n After extubation, BP has been higher and diuresis s/p lasix has been\n significant.\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 800 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Dextrose 50% - 03:15 PM\n Furosemide (Lasix) - 06:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 76 (70 - 80) bpm\n BP: 132/91(103) {103/76(85) - 138/97(109)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 1,244 mL\n 155 mL\n PO:\n TF:\n IVF:\n 474 mL\n 155 mL\n Blood products:\n Total out:\n 637 mL\n 440 mL\n Urine:\n 587 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 607 mL\n -285 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/57/269/29/4\n Ve: 7.3 L/min\n PaO2 / FiO2: 538\n Physical Examination\n GEN: appears sleepy, NAD\n CV: RRR, no m/r/g\n PULM: rales b/l at bases\n EXTR: mild b/l edema appreciated\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 67 mg/dL\n 1.9 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 35 mg/dL\n 96 mEq/L\n 135 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n Glucose\n 77\n 71\n 50\n 62\n 67\n Other labs: PT / PTT / INR:32.5/62.3/3.3, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.5 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension in the\n setting of VT.\n .\n # Hypotension: Most likely related to unstable rhythm of wide-complex\n tachycardia, namely VT. Unclear why internal ICD did not fire for\n rhythm (EP changed pacer settings yesterday based upon this concern).\n S/p attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity. Now patient\ns hypotension significantly improved s/p\n extubation.\n - Attempt to maintain sinus rhythm with amiodarone\n - Blood cultures\n - Antibiotics if spikes\n - Hold spironolactone, sotalol, digoxin and ace-I for now d/t\n hypotension and renal failure\n .\n # RHYTHM: The patient has a history of Afib, h/o VT, now with several\n episodes of VT and Afib with RVR s/p external dc/cv. Pt now in sinus\n rhythm with pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - d/c digoxin (d/t renal failure)\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Now\n putting out significant urine to lasix; Cr rising.\n - goal I\ns & O\ns: >1L out today; use lasix gtt to titrate to this goal\n - monitor UOP, concern for ARF in the setting of hypotension and rising\n Cr\n - daily weights and strict I&Os\n - continue home Simvastatin, midodrine, spinolocatone\n - d/c digoxin d/t renal failure\n - consider starting low dose ACE-I; as cardiologist first\n - electrolytes\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior. Cardiac enzymes peaked and now\n downtrending.\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol, and kayexelate. Corrected today.\n - electrolytes\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n - on heparin gtt\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition: Heart healthy diet now that extubated.\n Glycemic Control: Regular insulin SS\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP: no longer intubated\n Comments:\n Communication: Comments: wife Phone: \n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2159-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390742, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but pt w/hypotension in setting of rapid HR\n slow VT - ICD not firing, increased dyspnea Pt intubated/ x1 200\n joules into SR-AV paced rhythm and transferred to CCU for further\n mgmt.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas PVC\ns, short\n non-sustained runs VT\n Action:\n IV Amiodaraone gtt D/C\nd at 0845\n Amio 400mg po daily given\n Response:\n No further episodes sustained VT or ICD firings since admission\n Plan:\n Cont po Amio as ordered\n Cards attending Dr to reassess in AM.\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt stable s/p self-extubation early AM\n Action:\n O2 weaned to 2l n/c\n Response:\n ABG 7.41/43/118/28/2; lungs clear except diminished/rales at bases;\n sats 99-100% on 2l\n Plan:\n Cont diuresis overnight., follow sats, lung sounds, ABG\ns as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 35/1.9 in AM\n Action:\n Lasix 120mg IV at 0600\n Response:\n diuresing >100cc/hr since 0700\n Plan:\n follow lytes, BUN/Cr; strict I/O\ns goal negative 1-1.5 liters.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n BP 110-130/systolic throughout day\n Action:\n Response:\n Auto-diuresing with improved BP\n Plan:\n Cont to follow for now.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife\n Action:\n cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours while in bed, , heels kept on pillows\n off bed. Wound dressing daily. Increase activity as tolerated.\n" }, { "category": "Nursing", "chartdate": "2159-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390713, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas PVC\ns, short\n non-sustained runs\n Action:\n Amiodarone bolus completed PTA, Amiodaraone gtt started at 1mg x 6hr,\n now decreased to 0.5mg x 18hours\n Response:\n No further episodes VT or ICD firings since admission\n Plan:\n Cont Amiodarone At 0.5 mg IV x total 18 hours then convert to po/ngt\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Stable on present vent settings with sats 99-100%\n Action:\n Decreased to 50% from 100% on admission, PEEP down to 5 fom 10, no\n further changes made today, ABG/A-line attempted unsuccessfully\n Response:\n Stable on present settings\n Plan:\n Attempt diuresis overnight and plan to extubate in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr up to 1.5 from 1.2 earlier today; K+ 6.2 in am, lactate 7\n Action:\n Lasix 100mg IV at 0700\nthen Lasix 120mg IV at 1700; received Insulin\n 10mg iv, 1 amp D50, 1 amp ca gluconate, 1 amp Na Bicarb at 0700;\n fingersticks monitored throughout day ranging 60-80\ns received 1/2amp\n D50 2 subsequent times last FS 73\n Response:\n 200-300ml u/o then minimal urine output throughout day after first dose\n lasix, minimal urine out since second dose; K+ down to 4.5 after\n Kayexalate 30gm then ^ 5.4\n repeat Kayexalate\n Plan:\n Assess response to Lasix, attempt diuresis, follow lytes and assess\n response to Kayexalate; Follow BUN/Cr\n Cont q1hr FS\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n" }, { "category": "Nursing", "chartdate": "2159-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390715, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas PVC\ns, short\n non-sustained runs\n Action:\n Amiodarone bolus completed PTA, Amiodaraone gtt started at 1mg x 6hr,\n now decreased to 0.5mg x 18hours\n Response:\n No further episodes VT or ICD firings since admission\n Plan:\n Cont Amiodarone At 0.5 mg IV x total 18 hours then convert to po/ngt\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Stable on present vent settings with sats 99-100%\n Action:\n Decreased to 50% from 100% on admission, PEEP down to 5 from 10, no\n further changes made today, ABG/A-line attempted unsuccessfully;\n sedated with Fentanyl 50mcgs/Midazolam 1mg/hr continuous drips\n Response:\n Stable on present vent settings\n pt appears comfortable on present sedation but is easily arrousable\n and follows commands, MAE\n Plan:\n Attempt diuresis overnight and plan to extubate in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr up to 1.5 from 1.2 earlier today; K+ 6.2 in am, lactate 7\n Action:\n Lasix 100mg IV at 0700\nthen Lasix 120mg IV at 1700; received Insulin\n 10mg iv, 1 amp D50, 1 amp ca gluconate, 1 amp Na Bicarb at 0700;\n fingersticks monitored throughout day ranging 60-80\ns received 1/2amp\n D50 2 subsequent times last FS 73\n Response:\n 200-300ml u/o then minimal urine output throughout day after first dose\n lasix, minimal urine out since second dose; K+ down to 4.5 after\n Kayexalate 30gm then ^ 5.4\n repeat Kayexalate\n Plan:\n Assess response to Lasix, attempt diuresis, follow lytes and assess\n response to Kayexalate; Follow BUN/Cr\n Cont q1hr FS\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n Hypotensive high 70\ns to low 90\ns/syst\n baseline 80-90/\n Action:\n Sedation decreased\n Response:\n BP remains marginal but close to baseline\n Plan:\n Cont to follow for now.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n" }, { "category": "Nursing", "chartdate": "2159-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390744, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but pt w/hypotension in setting of rapid HR\n slow VT - ICD not firing, increased dyspnea Pt intubated/ x1 200\n joules into SR-AV paced rhythm and transferred to CCU for further\n mgmt.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas-freq PVC\ns, short\n non-sustained runs VT\n Action:\n IV Amiodaraone gtt D/C\nd at 0845\n Amio 400mg po daily given; Heparin\n gtt^800units/hr\n Response:\n No further episodes sustained VT or ICD firings since admission\n PTT 66.5\n Plan:\n Cont po Amio as ordered\n Cards attending Dr to reassess in AM.\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt stable s/p self-extubation early AM\n Action:\n O2 weaned to 2l n/c\n Response:\n ABG 7.41/43/118/28/2; lungs clear except diminished/rales at bases;\n sats 99-100% on 2l\n Plan:\n Cont diuresis overnight., follow sats, lung sounds, ABG\ns as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 35/1.9 in AM\n Action:\n Lasix 120mg IV at 0600\n Response:\n diuresing >100cc/hr since 0700\n Plan:\n follow lytes, BUN/Cr; strict I/O\ns goal negative 1-1.5 liters.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n BP 110-130/systolic throughout day\n Action:\n Response:\n Auto-diuresing with improved BP\n Plan:\n Cont to follow for now.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife\n Action:\n cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours while in bed, , heels kept on pillows\n off bed. Wound dressing daily. Increase activity as tolerated.\n" }, { "category": "Nursing", "chartdate": "2159-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390710, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645.\n" }, { "category": "Nursing", "chartdate": "2159-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390711, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas PVC\ns, short\n non-sustained runs\n Action:\n Amiodarone bolus completed PTA, Amiodaraone gtt started at 1mg x 6hr,\n now decreased to 0.5mg x 18hours\n Response:\n No further episodes VT or ICD firings since admission\n Plan:\n Cont Amiodarone At 0.5 mg IV x total 18 hours then convert to po/ngt\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Stable on present vent settings with sats 99-100%\n Action:\n Decreased to 50% from 100% on admission, PEEP down to 5 fom 10, no\n further changes made today, ABG/A-line attempted unsuccessfully\n Response:\n Stable on present settings\n Plan:\n Attempt diuresis overnight and plan to extubate in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr up to 1.5 from 1.2 earlier today; K+ 6.2 in am, lactate 7\n Action:\n Lasix 100mg IV at 0700\nthen Lasix 120mg IV at 1700; received Insulin\n 10mg iv, 1 amp D50, 1 amp ca gluconate, 1 amp Na Bicarb at 0700;\n fingersticks monitored throughout day\n Response:\n 200-300ml u/o then minimal urine output throughout day after first dose\n lasix, minimal urine out since second dose; K+ down to\n Plan:\n Assess response to Lasix, attempt diuresis, follow lytes,\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2159-09-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 390699, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: 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: Pending procedure /\n OR\n" }, { "category": "Nursing", "chartdate": "2159-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390789, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. During that time, he experienced decreased\n exercise tolerance and worsening DOE.\n Admitted to 3 via ED after multiple ICD firings\n Sotalol\n restarted but overnight pt w/hypotension, increased dyspnea with rapid\n rhythm\n - pt intubated\n cardioverted into SR from ? slow VT\n paced rhythm and transferred to CCU at 0645 .\n CV\n Pt maintained on Heparin gtt. PO amiodarone started . HR AV\n paced, V paced w/ occ pvc\ns. K+ and Mg replaced. BP stable via aline\n 92-120/70\n Resp\n Pt self-extubated and has been on 2ln/p w/ crackles bibase\n to\n up. O2 sats 99%.\n GU\n Foley cath draining clear yellow urine.\n GI\n Appetite good for NAS low chol diet. LBM \n Activity\n OOB to chair w/ one assist. Pt slightly unsteady on feet.\n Encouraged pt to call nsg for transfers.\n Skin\n Chronic l foot ulcer. Chronic venous changes LLE. Bilat pedal\n edema.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains AV paced with occasional PVC/PAC\ns. BP 92-120/60-70\ns. PTT\n supra therapeautic on 1000units/hr Heparin.\n Action:\n Amiodarone started . Heparin decreased to 800 units/hr.\n Response:\n Without further VT.\n Plan:\n Continue present med management.\n Renal failure/Heart Failure (CHF)\n Assessment:\n BUN/Creat 35/1.7 Cont w/ BBR. u/o <40cc/hr.\n Action:\n Response:\n Overall LOS negative output.\n Plan:\n ? lasix\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n" }, { "category": "Nursing", "chartdate": "2159-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390791, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. During that time, he experienced decreased\n exercise tolerance and worsening DOE.\n Admitted to 3 via ED after multiple ICD firings\n Sotalol\n restarted but overnight pt w/hypotension, increased dyspnea with rapid\n rhythm\n - pt intubated\n cardioverted into SR from ? slow VT\n paced rhythm and transferred to CCU at 0645 .\n CV\n Pt maintained on Heparin gtt. PO amiodarone started . HR AV\n paced, V paced w/ occ pvc\ns. K+ and Mg replaced. BP stable via aline\n 92-120/70\n Resp\n Pt self-extubated and has been on 2ln/p w/ crackles bibase\n to\n up. O2 sats 99%.\n GU\n Foley cath draining clear yellow urine.\n GI\n Appetite good for NAS low chol diet. LBM \n Activity\n OOB to chair w/ one assist. Pt slightly unsteady on feet.\n Encouraged pt to call nsg for transfers.\n Skin\n Chronic l foot ulcer. Chronic venous changes LLE. Bilat pedal\n edema.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains AV paced with occasional PVC/PAC\ns. BP 92-120/60-70\ns. PTT\n supra therapeautic on 1000units/hr Heparin.\n Action:\n Amiodarone started . Heparin decreased to 800 units/hr.\n PTT 54.8 on 800units. Heparin increased to 900units/hr at 1530.\n Response:\n Without further VT.\n Plan:\n Continue present med management.\n PTT and lytes at 9:30pm\n Renal failure/Heart Failure (CHF)\n Assessment:\n BUN/Creat 35/1.7 Cont w/ BBR. u/o <40cc/hr. Rales bibase.\n Action:\n Daily lasix dose restarted.\n Response:\n Overall LOS negative output.\n Plan:\n Cont monitor i/o and lung assessment.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n AICD FIRING\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 113.8 kg\n Daily weight:\n 113.3 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Precautions:\n PMH: Anemia, GI Bleed, Smoker\n CV-PMH: Arrhythmias, CAD, CHF, MI, Pacemaker\n Additional history: acute systolic heart failure with EF 20%\n hypothyroidism sec to amiodarone toxicity - on Levothyroxine\n L heel ulcer\n depression/insomnia\n elevated INR - ? secondary to liver congestion\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:95\n D:65\n Temperature:\n 97.2\n Arterial BP:\n S:112\n D:76\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,863 mL\n 24h total out:\n 1,015 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 06:15 AM\n Potassium:\n 3.2 mEq/L\n 06:15 AM\n Chloride:\n 93 mEq/L\n 06:15 AM\n CO2:\n 29 mEq/L\n 06:15 AM\n BUN:\n 35 mg/dL\n 06:15 AM\n Creatinine:\n 1.7 mg/dL\n 06:15 AM\n Glucose:\n 117 mg/dL\n 06:15 AM\n Hematocrit:\n 31.3 %\n 06:15 AM\n Finger Stick Glucose:\n 78\n 06:00 PM\n Valuables / Signature\n Patient valuables: Upper dentures in pt\ns mouth.\n Other valuables: NO GLASSES W/ PT\n Clothes: sent w/ pt\n / Money:\n w/ pt, no money\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 622\n Transferred to: 326\n Date & time of Transfer: 1800\n" }, { "category": "Nursing", "chartdate": "2159-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390792, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. During that time, he experienced decreased\n exercise tolerance and worsening DOE.\n Admitted to 3 via ED after multiple ICD firings\n Sotalol\n restarted but overnight pt w/hypotension, increased dyspnea with rapid\n rhythm\n - pt intubated\n cardioverted into SR from ? slow VT\n paced rhythm and transferred to CCU at 0645 .\n CV\n Pt maintained on Heparin gtt. PO amiodarone started . HR AV\n paced, V paced w/ occ pvc\ns. K+ and Mg replaced. BP stable via aline\n 92-120/70\n Resp\n Pt self-extubated and has been on 2ln/p w/ crackles bibase\n to\n up. O2 sats 99%.\n GU\n Foley cath draining clear yellow urine.\n GI\n Appetite good for NAS low chol diet. LBM \n Activity\n OOB to chair w/ one assist. Pt slightly unsteady on feet.\n Encouraged pt to call nsg for transfers.\n Skin\n Chronic l foot ulcer. Chronic venous changes LLE. Bilat pedal\n edema.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains AV paced with occasional PVC/PAC\ns. BP 92-120/60-70\ns. PTT\n supra therapeautic on 1000units/hr Heparin.\n Action:\n Amiodarone started . Heparin decreased to 800 units/hr.\n PTT 54.8 on 800units. Heparin increased to 900units/hr at 1530.\n Response:\n Without further VT.\n Plan:\n Continue present med management.\n PTT and lytes at 9:30pm\n Renal failure/Heart Failure (CHF)\n Assessment:\n BUN/Creat 35/1.7 Cont w/ BBR. u/o <40cc/hr. Rales bibase.\n Action:\n Daily lasix dose restarted.\n Response:\n Overall LOS negative output.\n Plan:\n Cont monitor i/o and lung assessment.\n Impaired Skin Integrity\n Assessment:\n Venous ulcers l foot, dsgs l ball of foot\n Action:\n Foot cleansed w/ water, wound gel and dsd applied.\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n AICD FIRING\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 113.8 kg\n Daily weight:\n 113.3 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Precautions:\n PMH: Anemia, GI Bleed, Smoker\n CV-PMH: Arrhythmias, CAD, CHF, MI, Pacemaker\n Additional history: acute systolic heart failure with EF 20%\n hypothyroidism sec to amiodarone toxicity - on Levothyroxine\n L heel ulcer\n depression/insomnia\n elevated INR - ? secondary to liver congestion\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:95\n D:65\n Temperature:\n 97.2\n Arterial BP:\n S:112\n D:76\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,863 mL\n 24h total out:\n 1,015 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 06:15 AM\n Potassium:\n 3.2 mEq/L\n 06:15 AM\n Chloride:\n 93 mEq/L\n 06:15 AM\n CO2:\n 29 mEq/L\n 06:15 AM\n BUN:\n 35 mg/dL\n 06:15 AM\n Creatinine:\n 1.7 mg/dL\n 06:15 AM\n Glucose:\n 117 mg/dL\n 06:15 AM\n Hematocrit:\n 31.3 %\n 06:15 AM\n Finger Stick Glucose:\n 78\n 06:00 PM\n Valuables / Signature\n Patient valuables: Upper dentures in pt\ns mouth.\n Other valuables: NO GLASSES W/ PT\n Clothes: sent w/ pt\n / Money:\n w/ pt, no money\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 622\n Transferred to: 326\n Date & time of Transfer: 1800\n" }, { "category": "Physician ", "chartdate": "2159-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390786, "text": "TITLE:\n Chief Complaint: Recurrent ICD firing, hypotension\n 24 Hour Events:\n -Initiated Amiodarone 400mg daily\n -Digoxin d/c'ed for renal failure\n -Decision for further EP intervention will be made after Haffagee\n returns Mon\n -(-)1.9L without Lasix drip (never needed, not given)\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 72 (70 - 79) bpm\n BP: 103/64(74) {86/47(58) - 132/93(320)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 113.3 kg (admission): 113.8 kg\n Height: 73 Inch\n Total In:\n 904 mL\n 306 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 304 mL\n 66 mL\n Blood products:\n Total out:\n 3,645 mL\n 415 mL\n Urine:\n 3,645 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,741 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.41/43/118/31/2\n PaO2 / FiO2: 295\n Physical Examination\n GEN: appears sleepy, NAD\n CV: RRR, no m/r/g\n PULM: clear anteriorly\n ABD: soft, NT, ND, +BS\n EXTR: mild b/l edema appreciated, chronic vascular changes on L side\n appear unchanged, R side slightly warmer than L.\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 133 mg/dL\n 1.9 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 38 mg/dL\n 93 mEq/L\n 133 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n 12:45 PM\n 06:01 PM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n 28\n Glucose\n 77\n 71\n 50\n 62\n 67\n 133\n Other labs: PT / PTT / INR:34.5/61.2/3.5, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension in the\n setting of VT.\n .\n # Hypotension: Most likely related to unstable rhythm of wide-complex\n tachycardia, namely VT. Unclear why internal ICD did not fire for\n rhythm (EP changed pacer settings yesterday based upon this concern).\n S/p attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity. Now patient\ns hypotension significantly improved s/p\n extubation.\n - Attempt to maintain sinus rhythm with amiodarone, will f/u EP recs\n today\n - follow cxs, fever curve.\n - Hold spironolactone, sotalol, digoxin and ace-I for now d/t\n hypotension and renal failure\n .\n # RHYTHM: Pt now in sinus rhythm with pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - d/c digoxin (d/t renal failure)\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Now\n putting out significant urine to lasix; Cr rising.\n - goal I\ns & O\ns: >1L out today; use lasix gtt to titrate to this goal\n - monitor UOP, concern for ARF in the setting of hypotension and rising\n Cr\n - daily weights and strict I&Os\n - continue home Simvastatin, midodrine, spinolocatone\n - d/c digoxin d/t renal failure\n - consider starting low dose ACE-I; as cardiologist first\n - electrolytes\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior. Cardiac enzymes peaked and now\n downtrending.\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol, and kayexelate. Corrected today.\n - electrolytes\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n - on heparin gtt\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2159-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390787, "text": "TITLE:\n Chief Complaint: Recurrent ICD firing, hypotension\n 24 Hour Events:\n -Initiated Amiodarone 400mg daily\n -Digoxin d/c'ed for renal failure\n -Decision for further EP intervention will be made after Haffagee\n returns Mon\n -(-)1.9L without Lasix drip (never needed, not given)\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 72 (70 - 79) bpm\n BP: 103/64(74) {86/47(58) - 132/93(320)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 113.3 kg (admission): 113.8 kg\n Height: 73 Inch\n Total In:\n 904 mL\n 306 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 304 mL\n 66 mL\n Blood products:\n Total out:\n 3,645 mL\n 415 mL\n Urine:\n 3,645 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,741 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.41/43/118/31/2\n PaO2 / FiO2: 295\n Physical Examination\n GEN: appears sleepy, NAD\n CV: RRR, no m/r/g\n PULM: clear anteriorly\n ABD: soft, NT, ND, +BS\n EXTR: mild b/l edema appreciated, chronic vascular changes on L side\n appear unchanged, R side slightly warmer than L.\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 133 mg/dL\n 1.9 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 38 mg/dL\n 93 mEq/L\n 133 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n 12:45 PM\n 06:01 PM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n 28\n Glucose\n 77\n 71\n 50\n 62\n 67\n 133\n Other labs: PT / PTT / INR:34.5/61.2/3.5, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension in the\n setting of VT.\n .\n # Hypotension: Most likely related to unstable rhythm of wide-complex\n tachycardia, namely VT. Unclear why internal ICD did not fire for\n rhythm (EP changed pacer settings yesterday based upon this concern).\n S/p attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity. Now patient\ns hypotension significantly improved s/p\n extubation.\n - Attempt to maintain sinus rhythm with amiodarone, will f/u EP recs\n today\n - follow cxs, fever curve.\n - Hold spironolactone, sotalol, digoxin and ace-I for now d/t\n hypotension and renal failure\n .\n # RHYTHM: Pt now in sinus rhythm. Dig d/c\nd d/t renal failure, will\n continue to hold for now. EP recently adjusted settings to better\n sense v-tach.\n - Continue heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - monitor on telemetry\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Now\n putting out significant urine to lasix; Cr rising.\n - continue aggresived diuresis goal I\ns & O\ns: >1L out today; will use\n lasix gtt to titrate to this goal\n - monitor UOP, concern for ARF in the setting of hypotension and rising\n Cr\n - daily weights and strict I&Os\n - continue home Simvastatin, midodrine, spinolocatone\n - consider starting low dose ACE-I\n - electrolytes\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior. Cardiac enzymes peaked and now\n downtrending.\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol, and kayexelate. Currently stable.\n - electrolytes\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Relatively stable. Will continue to monitor.\n - continue to monitor\n - add iron studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n - on heparin gtt\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition: heart healthy\n Glycemic Control:\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: To floor today\n" }, { "category": "Physician ", "chartdate": "2159-09-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 390671, "text": "Chief Complaint: hypotension\n HPI:\n 61 year old male with a history of coronary artery disease s/p MI and\n CABG, chronic systolic heart failure, recurrent VT s/p ICD placement\n and atrial fibrillation who initially presented with recurrent ICD\n firing on with the last at 3pm on the day prior to admission.\n This was in the setting of self discontinuing sotalol 2 weeks prior.\n In that time, he had noted decreased exercise tolerance and worsening\n dyspnea on exertion. He typically can walk half a block but on\n admission could only walk around his home. On admission, he denied\n chest pain, fevers, chills, worsening lower extremity edema, orthopnea\n or PND but does endorse worsening nocturia. His ICD has since fired 8\n times in 12 hours. He has never had repeated firings before.\n .\n In the ED, initial vitals were T: 97.8 BP: 150/98 HR: 73 RR: 18 O2: 99%\n on RA. EKG showed atrial fibrillation with rapid response in the 140s\n with intermittent demand pacing, intraventricular conduction delay left\n bundle branch block pattern, no gross ischemic changes, no change from\n prior dated . Two episodes of vtach in the ED without firing. EP\n recommended rate control of his RVR and some lasix. He received\n diltiazem 10 mg IV x 1 and lasix 80 mg IV x 1.\n .\n During his admission, he became increasingly short of breath. He was\n treated for volume overload with lasix and restarted on sotalol. On\n the night of transfer, he went back into atrial fibrillation with rapid\n ventricular response with rate related left bundle. His blood\n pressures were in the 60's to 80's systolic. He was given an IV\n Amiodarone bolus and DC/CV emergently after elective intubation for\n airway protection for tenuous status.\n .\n On arrival to the CCU, the patient's vital signs were 93, 101/52, 19,\n 88% on vent. He was intubated, sedated, in sinus and intermittently\n paced and hemodynamically stable. His labs returned with a K of 6.2\n and glucose of 48. Calcium gluconate, glucose, insulin, albuterol and\n sodium bicarbonate were administered. Fentanyl and midazolam were\n started for sedation. He was also continued on IV amiodarone drip to\n maintain sinus rhythm, despite history of hypothyroidism with\n amiodarone.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,900 units/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Furosemide (Lasix) - 07:00 AM\n Dextrose 50% - 07:03 AM\n Insulin - Regular - 07:05 AM\n Sodium Bicarbonate 8.4% (Amp) - 07:09 AM\n Heparin Sodium - 07:40 AM\n Other medications:\n Home medications:\n Sotalol 120 mg (not taking at home)\n Digoxin 125 mcg daily, 250mcg on alternative days\n Ativan 2 mg QHS\n Ambien 10 mg QHS\n Levothyroxine 50 mcg daily\n Midodrine 5 mg TID\n Simvastatin 40 mg daily\n Lasix 40mg daily\n Spiranolactone 25mg daily\n Bupoprion 50mg daily?\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia\n 2. CARDIAC HISTORY:\n - Coronary Artery Disease s/p 5 vessel CABG in \n - Anterior MI \n - Chronic systolic heart failure (EF 20% by last echocardiogram)\n - History of VT s/p BiV pacer and ICD placement in now s/p\n multiple device changes most recently in .\n - Atrial Fibrillation (not on anticoagulation secondary to GI\n bleeding)\n -CABG: Five vessel CABG in \n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD: Concerto biventricular ICD placed in .\n He has three leads. The RV lead is a 6943 implanted , . The atrial lead is a Guidant 4464 also implanted in \n . His LV lead is a 4193 implanted in and\n the ICD device was implanted in .\n 3. OTHER MEDICAL HISTORY:\n -Large UGIB in thought to be secondary to a combination of\n gastritis, nsaids, and coumadin (required intubation and tracheostomy\n secondary to MRSA ventilator associated pneumonia)\n -Left hip arthritis\n -Hypothyroidism\n -Osteomyelolitis on L foot\n Father died of MI at age 52\n Occupation:\n Drugs: denies\n Tobacco: Smoked cigarettes daily for 20 years, quit 2 months ago\n Alcohol:\n Other: He lives in with his wife and two children\n Review of systems:\n Flowsheet Data as of 08:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 91 (91 - 93) bpm\n BP: 94/53(63) {94/52(63) - 101/53(63)} mmHg\n RR: 20 (19 - 20) insp/min\n SpO2: 100%\n Total In:\n 323 mL\n PO:\n TF:\n IVF:\n 73 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 273 mL\n Respiratory\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: 10 cmH2O\n FiO2: 100%\n PIP: 27 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: 7.38/41/30/22/-1\n Ve: 13.7 L/min\n PaO2 / FiO2: 30\n Physical Examination\n GENERAL: somnolent, but arousable.\n HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma.\n NECK: JV pressure to the level of the mandible, pt has known TR\n CARDIAC: irregularly irregular rhythm, tachy. No m/r/g.\n LUNGS: Resp were labored, using accessory muscles. bilateral crackles\n half way up lung fields. ICD pocket w/o erythema, warmth or any sign of\n infection\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: cool, not cyanotic. No femoral bruits. erythema on L\n anterior leg, no drainage or tenderness. healing ulcer on R foot\n Labs / Radiology\n 292 K/uL\n 10.0 g/dL\n 5.8 mEq/L\n 32.0 %\n 11.0 K/uL\n [image002.jpg]\n \n 2:33 A10/17/ 07:03 AM\n \n 10:20 P10/17/ 07:56 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.0\n Hct\n 32.0\n Plt\n 292\n TC02\n 25\n Other labs: Lactic Acid:7.4 mmol/L\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension.\n .\n # Hypotension: Most likely related to unstable rhythm of atrial\n fibrillation with rapid ventricular response and rate related left\n bundle. Unclear why internal ICD did not fire for rhythm. S/p\n attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity.\n - Attempt to maintain sinus rhythm with amiodarone\n - Blood cultures\n - Antibiotics if spikes\n - Small fluid boluses PRN, pressors as needed\n - Hold spironolactone, sotalol and ace-I for now\n .\n # RHYTHM: The patient has a history of Afib, h/o VT, now with several\n episodes of VT and Afib with RVR s/p external dc/cv. Pt now in sinus\n rhythm with intermittent pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - Continue home digoxin\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Received\n 100mg of IV lasix in transit, however no urine output currently.\n - monitor UOP, concern for ARF in the setting of hypotension\n - daily weights and strict I&Os - lasix PRN\n - continue home Simvastatin\n - continue home Midodrine, Digoxin for inotropic support\n - Hold Spiranolactone in the setting of hypotension\n - consider starting low dose ACE-I\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior.\n - Cycle enzymes today - may be elevated secondary to DC/CV\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol.\n - Recheck K\n - Administer kayexalate\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: wife Phone: \n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2159-09-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 390672, "text": "Chief Complaint: hypotension\n HPI:\n 61 year old male with a history of coronary artery disease s/p MI and\n CABG, chronic systolic heart failure, recurrent VT s/p ICD placement\n and atrial fibrillation who initially presented with recurrent ICD\n firing on with the last at 3pm on the day prior to admission.\n This was in the setting of self discontinuing sotalol 2 weeks prior.\n In that time, he had noted decreased exercise tolerance and worsening\n dyspnea on exertion. He typically can walk half a block but on\n admission could only walk around his home. On admission, he denied\n chest pain, fevers, chills, worsening lower extremity edema, orthopnea\n or PND but does endorse worsening nocturia. His ICD has since fired 8\n times in 12 hours. He has never had repeated firings before.\n .\n In the ED, initial vitals were T: 97.8 BP: 150/98 HR: 73 RR: 18 O2: 99%\n on RA. EKG showed atrial fibrillation with rapid response in the 140s\n with intermittent demand pacing, intraventricular conduction delay left\n bundle branch block pattern, no gross ischemic changes, no change from\n prior dated . Two episodes of vtach in the ED without firing. EP\n recommended rate control of his RVR and some lasix. He received\n diltiazem 10 mg IV x 1 and lasix 80 mg IV x 1.\n .\n During his admission, he became increasingly short of breath. He was\n treated for volume overload with lasix and restarted on sotalol. On\n the night of transfer, he went back into atrial fibrillation with rapid\n ventricular response with rate related left bundle. His blood\n pressures were in the 60's to 80's systolic. He was given an IV\n Amiodarone bolus and DC/CV emergently after elective intubation for\n airway protection for tenuous status.\n .\n On arrival to the CCU, the patient's vital signs were 93, 101/52, 19,\n 88% on vent. He was intubated, sedated, in sinus and intermittently\n paced and hemodynamically stable. His labs returned with a K of 6.2\n and glucose of 48. Calcium gluconate, glucose, insulin, albuterol and\n sodium bicarbonate were administered. Fentanyl and midazolam were\n started for sedation. He was also continued on IV amiodarone drip to\n maintain sinus rhythm, despite history of hypothyroidism with\n amiodarone.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,900 units/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Furosemide (Lasix) - 07:00 AM\n Dextrose 50% - 07:03 AM\n Insulin - Regular - 07:05 AM\n Sodium Bicarbonate 8.4% (Amp) - 07:09 AM\n Heparin Sodium - 07:40 AM\n Other medications:\n Home medications:\n Sotalol 120 mg (not taking at home)\n Digoxin 125 mcg daily, 250mcg on alternative days\n Ativan 2 mg QHS\n Ambien 10 mg QHS\n Levothyroxine 50 mcg daily\n Midodrine 5 mg TID\n Simvastatin 40 mg daily\n Lasix 40mg daily\n Spiranolactone 25mg daily\n Bupoprion 50mg daily?\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Dyslipidemia\n 2. CARDIAC HISTORY:\n - Coronary Artery Disease s/p 5 vessel CABG in \n - Anterior MI \n - Chronic systolic heart failure (EF 20% by last echocardiogram)\n - History of VT s/p BiV pacer and ICD placement in now s/p\n multiple device changes most recently in .\n - Atrial Fibrillation (not on anticoagulation secondary to GI\n bleeding)\n -CABG: Five vessel CABG in \n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD: Concerto biventricular ICD placed in .\n He has three leads. The RV lead is a 6943 implanted , . The atrial lead is a Guidant 4464 also implanted in \n . His LV lead is a 4193 implanted in and\n the ICD device was implanted in .\n 3. OTHER MEDICAL HISTORY:\n -Large UGIB in thought to be secondary to a combination of\n gastritis, nsaids, and coumadin (required intubation and tracheostomy\n secondary to MRSA ventilator associated pneumonia)\n -Left hip arthritis\n -Hypothyroidism\n -Osteomyelolitis on L foot\n Father died of MI at age 52\n Occupation:\n Drugs: denies\n Tobacco: Smoked cigarettes daily for 20 years, quit 2 months ago\n Alcohol:\n Other: He lives in with his wife and two children\n Review of systems:\n Flowsheet Data as of 08:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 91 (91 - 93) bpm\n BP: 94/53(63) {94/52(63) - 101/53(63)} mmHg\n RR: 20 (19 - 20) insp/min\n SpO2: 100%\n Total In:\n 323 mL\n PO:\n TF:\n IVF:\n 73 mL\n Blood products:\n Total out:\n 0 mL\n 50 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 273 mL\n Respiratory\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: 10 cmH2O\n FiO2: 100%\n PIP: 27 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: 7.38/41/30/22/-1\n Ve: 13.7 L/min\n PaO2 / FiO2: 30\n Physical Examination\n GENERAL: somnolent, but arousable.\n HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma.\n NECK: JV pressure to the level of the mandible, pt has known TR\n CARDIAC: irregularly irregular rhythm, tachy. No m/r/g.\n LUNGS: Resp were labored, using accessory muscles. bilateral crackles\n half way up lung fields. ICD pocket w/o erythema, warmth or any sign of\n infection\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: cool, not cyanotic. No femoral bruits. erythema on L\n anterior leg, no drainage or tenderness. healing ulcer on R foot\n Labs / Radiology\n 292 K/uL\n 10.0 g/dL\n 5.8 mEq/L\n 32.0 %\n 11.0 K/uL\n [image002.jpg]\n \n 2:33 A10/17/ 07:03 AM\n \n 10:20 P10/17/ 07:56 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.0\n Hct\n 32.0\n Plt\n 292\n TC02\n 25\n Other labs: Lactic Acid:7.4 mmol/L\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension.\n .\n # Hypotension: Most likely related to unstable rhythm of atrial\n fibrillation with rapid ventricular response and rate related left\n bundle. Unclear why internal ICD did not fire for rhythm. S/p\n attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity.\n - Attempt to maintain sinus rhythm with amiodarone\n - Blood cultures\n - Antibiotics if spikes\n - Small fluid boluses PRN, pressors as needed\n - Hold spironolactone, sotalol and ace-I for now\n .\n # RHYTHM: The patient has a history of Afib, h/o VT, now with several\n episodes of VT and Afib with RVR s/p external dc/cv. Pt now in sinus\n rhythm with intermittent pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - Continue home digoxin\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Received\n 100mg of IV lasix in transit, however no urine output currently.\n - monitor UOP, concern for ARF in the setting of hypotension\n - daily weights and strict I&Os - lasix PRN\n - continue home Simvastatin\n - continue home Midodrine, Digoxin for inotropic support\n - Hold Spiranolactone in the setting of hypotension\n - consider starting low dose ACE-I\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior.\n - Cycle enzymes today - may be elevated secondary to DC/CV\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol.\n - Recheck K\n - Administer kayexalate\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: wife Phone: \n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Attending\ns Note\n I reviewed data and Agree with Dr.\ns Note.\n Pt is known to me for considerable time and has AF with CHB and Rec\n VT,S/P BIV- ICD.\n He runs BP of 80-90 systolic.Has advanced Ischemic cardiomyopathy.\n For some reason he has stopped taking Lasix and Sotalol since \n !\n Had Amio induced Thyrotoxicosis in past and is now Hypothyroid.\n Thus would continue IV Amio and plan to extubate when gases permit\n Will reprogram ICD to detect Slow VT and Pacing Rx\n \n ------ Protected Section Addendum Entered By: \n on: 09:07 ------\n" }, { "category": "Nursing", "chartdate": "2159-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390682, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645.\n" }, { "category": "Nursing", "chartdate": "2159-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390773, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but overnight pt w/hypotension, increased\n dyspnea with rapid rhythm\n early this AM intubated\n cardioverted into\n SR from ? slow VT\n AV paced rhythm and transferred to CCU at 0645\n .\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains AV paced with occasional PVC/PAC\n Action:\n On po amiodarone.\n Response:\n Without further VT.\n Plan:\n Continue present management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Self extubated . tolerating extubation.\n Action:\n O2 via 2l nc.\n Response:\n Sats 100%. breath sounds=diminished.\n Plan:\n Encourage C&DB. Diuresing.\n Renal failure/Heart Failure (CHF)\n Assessment:\n Slowly rising bun/creat.\n Action:\n Response:\n Diursing. Overall I&O negative.\n Plan:\n Contin present rx.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n *****AM Labs sent*****\n" }, { "category": "Physician ", "chartdate": "2159-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390774, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Initiated Amiodarone 400mg daily\n -Digoxin d/c'ed for renal failure\n -Decision for further EP intervention will be made after Haffagee\n returns Mon\n -(-)1.9L without Lasix drip (never needed, not given)\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 72 (70 - 79) bpm\n BP: 103/64(74) {86/47(58) - 132/93(320)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 113.3 kg (admission): 113.8 kg\n Height: 73 Inch\n Total In:\n 904 mL\n 306 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 304 mL\n 66 mL\n Blood products:\n Total out:\n 3,645 mL\n 415 mL\n Urine:\n 3,645 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,741 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.41/43/118/31/2\n PaO2 / FiO2: 295\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 133 mg/dL\n 1.9 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 38 mg/dL\n 93 mEq/L\n 133 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n 12:45 PM\n 06:01 PM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n 28\n Glucose\n 77\n 71\n 50\n 62\n 67\n 133\n Other labs: PT / PTT / INR:34.5/61.2/3.5, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), SYSTOLIC, CHRONIC\n VENTRICULAR TACHYCARDIA, NON-SUSTAINED (NSVT)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2159-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 390776, "text": "TITLE:\n Chief Complaint: Hypotension\n 24 Hour Events:\n -Initiated Amiodarone 400mg daily\n -Digoxin d/c'ed for renal failure\n -Decision for further EP intervention will be made after Haffagee\n returns Mon\n -(-)1.9L without Lasix drip (never needed, not given)\n Allergies:\n Penicillins\n Anaphylaxis;\n Amiodarone\n hypothyroidism;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 72 (70 - 79) bpm\n BP: 103/64(74) {86/47(58) - 132/93(320)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Wgt (current): 113.3 kg (admission): 113.8 kg\n Height: 73 Inch\n Total In:\n 904 mL\n 306 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 304 mL\n 66 mL\n Blood products:\n Total out:\n 3,645 mL\n 415 mL\n Urine:\n 3,645 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,741 mL\n -109 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.41/43/118/31/2\n PaO2 / FiO2: 295\n Physical Examination\n GEN: appears sleepy, NAD\n CV: RRR, no m/r/g\n PULM: rales b/l at bases\n EXTR: mild b/l edema appreciated\n Labs / Radiology\n 301 K/uL\n 10.4 g/dL\n 133 mg/dL\n 1.9 mg/dL\n 31 mEq/L\n 3.4 mEq/L\n 38 mg/dL\n 93 mEq/L\n 133 mEq/L\n 33.2 %\n 12.3 K/uL\n [image002.jpg]\n 07:03 AM\n 07:56 AM\n 11:08 AM\n 03:20 PM\n 09:56 PM\n 11:16 PM\n 04:07 AM\n 04:56 AM\n 12:45 PM\n 06:01 PM\n WBC\n 11.0\n 14.2\n 12.3\n Hct\n 32.0\n 35.9\n 33.2\n Plt\n 292\n 300\n 301\n Cr\n 1.5\n 1.6\n 1.8\n 1.9\n 1.9\n TropT\n 0.08\n TCO2\n 25\n 29\n 33\n 28\n Glucose\n 77\n 71\n 50\n 62\n 67\n 133\n Other labs: PT / PTT / INR:34.5/61.2/3.5, CK / CKMB /\n Troponin-T:162/5/0.08, Lactic Acid:3.6 mmol/L, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 61 year old male with a h/o CAD s/p MI and CABG in , chronic\n systolic heart failure (EF 20%), recurrent VT s/p ICD placement and\n atrial fibrillation transferred to the CCU for hypotension in the\n setting of VT.\n .\n # Hypotension: Most likely related to unstable rhythm of wide-complex\n tachycardia, namely VT. Unclear why internal ICD did not fire for\n rhythm (EP changed pacer settings yesterday based upon this concern).\n S/p attempted internal and successful external DC/CV with resolution of\n hypotension and restoration of sinus rhythm intermittently paced.\n Concerning for infectious process as well given erythematous left lower\n extremity. Now patient\ns hypotension significantly improved s/p\n extubation.\n - Attempt to maintain sinus rhythm with amiodarone\n - Blood cultures\n - Antibiotics if spikes\n - Hold spironolactone, sotalol, digoxin and ace-I for now d/t\n hypotension and renal failure\n .\n # RHYTHM: The patient has a history of Afib, h/o VT, now with several\n episodes of VT and Afib with RVR s/p external dc/cv. Pt now in sinus\n rhythm with pacing.\n - Heparin gtt for anticoagulation\n - Continue amiodarone to maintain sinus rhythm\n - Will hold sotalol for now, may decide to restart and stop amiodarone\n - monitor on telemetry\n - d/c digoxin (d/t renal failure)\n - f/u EP recs\n .\n # PUMP: The patient has an EF of 20% on echo in , likely ischemic\n cardiomyopathy in the setting of anterior MI in 95. The patient was\n being treated for decompensated failure on the service with\n lasix. CXR on admission to CCU shows mild volume overload. Now\n putting out significant urine to lasix; Cr rising.\n - goal I\ns & O\ns: >1L out today; use lasix gtt to titrate to this goal\n - monitor UOP, concern for ARF in the setting of hypotension and rising\n Cr\n - daily weights and strict I&Os\n - continue home Simvastatin, midodrine, spinolocatone\n - d/c digoxin d/t renal failure\n - consider starting low dose ACE-I; as cardiologist first\n - electrolytes\n .\n # CORONARIES: The patient has a known history of CAD s/p 5 vessel CABG\n in and anterior MI in . This episode is unlikely to be an\n acute MI given no chest pain prior. Cardiac enzymes peaked and now\n downtrending.\n - Continue aspirin and simvastatin\n .\n # Hyperkalemia: Likely secondary to poor perfusion state.\n Administered calcium gluconate, glucose, insulin, sodium bicarb and\n albuterol, and kayexelate. Corrected today.\n - electrolytes\n .\n # Hypothyroidism: to Amiodarone toxicity, currently no symptoms.\n Restarted amiodarone emergently, will decide when to stop and restart\n sotalol.\n - continue home Levothyroxine\n .\n # LLE Erythema and R heel ulcer: concerning for site of infection. If\n the patient has an elevated temp or drops pressure again will consider\n starting Vanc for MRSA coverage.\n - wound care\n .\n # Insomnia: stable\n - continue home Ativan PRN and Ambien\n .\n # Depression: stable. per pt, was switched to half-dose because he was\n dc'd on it completely upon last hospital discharge. so, psychiatrist\n started half dose to taper it.\n - continue buproprion 50mg \n - sw c/s for med noncompliance\n .\n # Anemia: Hct 36 today, at baseline.\n - continue to monitor\n - consider Fe studies\n .\n # Elev INR: unclear etiology (perhaps to hepatic congestion from\n heart failure), off anticoagulation bc of h/o GIB\n - continue to monitor\n - check LFTs\n - on heparin gtt\n .\n # FEN: low Na cardiac diet\n .\n # ACCESS: PIV's\n .\n # PROPHYLAXIS: SC Heparin, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:15 AM\n 20 Gauge - 08:16 AM\n Arterial Line - 11:32 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2159-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390780, "text": "Heart failure (CHF), Systolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2159-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 390781, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. During that time, he experienced decreased\n exercise tolerance and worsening DOE.\n Admitted to 3 via ED after multiple ICD firings\n Sotalol\n restarted but overnight pt w/hypotension, increased dyspnea with rapid\n rhythm\n - pt intubated\n cardioverted into SR from ? slow VT\n paced rhythm and transferred to CCU at 0645 .\n CV\n Pt maintained on Heparin gtt. PO amiodarone started . HR AV\n paced, V paced w/ occ pvc\ns. K+ and Mg replaced. BP stable via aline\n 92-120/70\n Resp\n Pt self-extubated and has been on 2ln/p w/ crackles @\n bases. O2 sats 99%.\n GU\n Foley cath draining clear yellow urine.\n GI\n Appetite good for NAS low chol diet. LBM \n Activity\n OOB to chair w/ one assist. Pt slightly unsteady on feet.\n Encouraged pt to call nsg for transfers.\n Skin\n Chronic l foot ulcer. Chronic venous changes LLE. Bilat pedal\n edema.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains AV paced with occasional PVC/PAC\ns. BP 92-120/60-70\ns. PTT\n supra therapeautic on 1000units/hr Heparin.\n Action:\n Amiodarone started . Heparin decreased to 800 units/hr.\n Response:\n Without further VT.\n Plan:\n Continue present med management.\n Renal failure/Heart Failure (CHF)\n Assessment:\n BUN/Creat 35/1.7 Cont w/ BBR. u/o <40cc/hr.\n Action:\n Response:\n Overall LOS negative output.\n Plan:\n ? lasix\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife ? cellulitis\n Action:\n Foot cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours, heels kept on pillows off bed. Wound\n dressing daily.\n" }, { "category": "Nursing", "chartdate": "2159-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390760, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but pt w/hypotension in setting of rapid HR\n slow VT - ICD not firing, increased dyspnea Pt intubated/ x1 200\n joules into SR-AV paced rhythm and transferred to CCU for further\n mgmt.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas-freq PVC\ns, short\n non-sustained runs VT\n Action:\n IV Amiodaraone gtt D/C\nd at 0845\n Amio 400mg po daily given; Heparin\n gtt^800units/hr\n Response:\n No further episodes sustained VT or ICD firings since admission\n PTT 66.5\n Plan:\n Cont po Amio as ordered\n Cards attending Dr to reassess in AM.\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt stable s/p self-extubation early AM\n Action:\n O2 weaned to 2l n/c\n Response:\n ABG 7.41/43/118/28/2; lungs clear except diminished/rales at bases;\n sats 99-100% on 2l\n Plan:\n Cont diuresis overnight., follow sats, lung sounds, ABG\ns as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 35/1.9 in AM\n Action:\n Lasix 120mg IV at 0600\n Response:\n diuresing >100cc/hr since 0700\n Plan:\n follow lytes, BUN/Cr; strict I/O\ns goal negative 1-1.5 liters.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n BP 110-130/systolic throughout day\n Action:\n no changes\n Response:\n Auto-diuresing with improved BP\n Plan:\n Cont to follow for now.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife\n Action:\n cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours while in bed, , heels kept on pillows\n off bed. Wound dressing daily. Increase activity as tolerated.\n" }, { "category": "Nursing", "chartdate": "2159-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390761, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but pt w/hypotension in setting of rapid HR\n slow VT - ICD not firing, increased dyspnea Pt intubated/ x1 200\n joules into SR-AV paced rhythm and transferred to CCU for further\n mgmt.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas-freq PVC\ns, short\n non-sustained runs VT\n Action:\n IV Amiodaraone gtt D/C\nd at 0845\n Amio 400mg po daily given; Heparin\n gtt^800units/hr\n Response:\n No further episodes sustained VT or ICD firings since admission\n PTT 66.5\n Plan:\n Cont po Amio as ordered\n Cards attending Dr to reassess in AM.\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt stable s/p self-extubation early AM\n Action:\n O2 weaned to 2l n/c\n Response:\n ABG 7.41/43/118/28/2; lungs clear except diminished/rales at bases;\n sats 99-100% on 2l\n Plan:\n Cont diuresis overnight., follow sats, lung sounds, ABG\ns as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 35/1.9 in AM\n Action:\n Lasix 120mg IV at 0600\n Lasix gtt ordered but not started as goal uop\n of >150ml/hr achieved spontaneously\n Response:\n diuresing >100cc/hr since 0700\n Plan:\n follow lytes, BUN/Cr; strict I/O\ns goal negative 1-1.5 liters.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n BP 110-130/systolic throughout day\n Action:\n no changes\n Response:\n Auto-diuresing with improved BP\n Plan:\n Cont to follow for now.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife\n Action:\n cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours while in bed, , heels kept on pillows\n off bed. Wound dressing daily. Increase activity as tolerated.\n" }, { "category": "Nursing", "chartdate": "2159-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 390762, "text": "61 year old male with hx CAD, s/p MI and CABG, chronic systolic heart\n failure, recurrent VT s/p ICD placement and Afib; initially presented\n with recurrent ICD firing on in the setting of self-d/cing\n sotalol 2 weeks ago. In that time, he had decreased exercise tolerance\n and worsening DOE. Admitted to 3 via ED after multiple ICD\n firings\n Sotalol restarted but pt w/hypotension in setting of rapid HR\n slow VT - ICD not firing, increased dyspnea Pt intubated/ x1 200\n joules into SR-AV paced rhythm and transferred to CCU for further\n mgmt.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Remains in AV paced rhythm s/p PTA with occas-freq PVC\ns, short\n non-sustained runs VT\n Action:\n IV Amiodaraone gtt D/C\nd at 0845\n Amio 400mg po daily given; Heparin\n gtt^800units/hr\n Response:\n No further episodes sustained VT or ICD firings since admission\n PTT 66.5\n Plan:\n Cont po Amio as ordered\n Cards attending Dr to reassess in AM.\n Follow lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt stable s/p self-extubation early AM\n Action:\n O2 weaned to 2l n/c\n Response:\n ABG 7.41/43/118/28/2; lungs clear except diminished/rales at bases;\n sats 99-100% on 2l\n Plan:\n Cont diuresis overnight., follow sats, lung sounds, ABG\ns as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 35/1.9 in AM\n Action:\n Lasix 120mg IV at 0600\n Lasix gtt ordered but not started as goal uop\n of >150ml/hr achieved spontaneously\n Response:\n diuresing >100cc/hr since 0700\n Plan:\n follow lytes, BUN/Cr\n pnd from 1800; strict I/O\ns goal negative 1-1.5\n liters\n already almost 2L negative for day.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n BP 110-130/systolic throughout day\n Action:\n no changes\n Response:\n Auto-diuresing with improved BP\n Plan:\n Cont to follow for now.\n Impaired Skin Integrity\n Assessment:\n Chronic L foot ulcer\n see flow sheet for description\n per pt\ns wife,\n has had ulcer for months\n Heels and elbows with blanching redness\n Chronic venous changes bilat legs L>R; L calf with chronic redness per\n wife\n Action:\n cleansed and dressed\n Response:\n Unchanged\n Plan:\n Cont to follow; Turns q 2hours while in bed, , heels kept on pillows\n off bed. Wound dressing daily. Increase activity as tolerated.\n" }, { "category": "Radiology", "chartdate": "2159-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102891, "text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneuomonia, lead placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with AICD firing\n REASON FOR THIS EXAMINATION:\n ?pneuomonia, lead placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male with AICD firing. Here to assess for pneumonia and\n lead position.\n\n COMPARISON: Chest radiographs, most recently of . CT abdomen/ pelvis\n of .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: A right pectoral pacemaker power pack is\n redemonstrated, with unchanged position of right atrial pacer and right\n ventricular defibrillator leads on the single AP view. Also old abandoned\n AICD and epicardial leads are unchanged, projecting over the right and left\n heart, respectively. The patient is status post CABG. Other lines projecting\n over the patient are probably external to the patient. Right internal jugular\n central venous catheter has been removed.\n\n Moderate-to-severe cardiomegaly is relatively unchanged. There is again\n increase in perihilar and bibasilar opacities, probably representing pulmonary\n edema, although underlying infection cannot be excluded. The upper lungs are\n relatively clear. Appearance is not dissimilar to that seen on . The\n right lateral sulcus is excluded, but there may be tiny bilateral pleural\n effusions. No pneumothorax is seen.\n\n IMPRESSIONS:\n 1. Unchanged position of pacing and defibrillator leads.\n 2. Marked cardiomegaly unchanged. Now with mild pulmonary edema and low lung\n volumes, although underlying infection is not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2159-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103068, "text": " 7:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 yo gentlemen with supraventricular tachycardia, recently\n Admitting Diagnosis: AICD FIRING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with recent desaturation, recurrent supraventricular\n tachycardia\n REASON FOR THIS EXAMINATION:\n 61 yo gentlemen with supraventricular tachycardia, recently code blue with\n decreas\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Ventricular tachycardia with recent arrest.\n\n Findings:There is a new ET tube in place with its tip 4.3 cm above the carina.\n Views of the lower chest and costophrenic angles are not included on the\n study, the position of the right-sided pacing wire tips are not visualized\n Cardiomegaly is unchanged with bibasilar atelectasis and a right pleural\n effusion, mild fluid overload is unchanged.\n\n IMPRESSION:\n No new consolidation or pneumothorax. Mild vascular congestion and right\n pleural effusion unchanged with presence of moderate cardiomegaly.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-08-29 00:00:00.000", "description": "UGI SGL CONTRAST W/ KUB", "row_id": 876988, "text": " 1:28 PM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: ? FLOW/ ? LEAK S/P GASTRIC BYPASS\n Admitting Diagnosis: MORBID OBESTIY/SDA\n Contrast: CONRAY Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with s/p open roux-en-y gastric bypass \n REASON FOR THIS EXAMINATION:\n ? flow ? leak ** can be done in a..m, doesnt have to be a.m. SICU rounds**\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old female status post open Roux-en-Y gastric bypass on\n . Evaluate flow and assess for leak.\n\n COMPARISON: No comparisons.\n\n TECHNIQUE/FINDINGS: Modified upper GI. _____ scout film shows surgical skin\n clips overlying the midline of the abdomen and several surgical clips\n scattered throughout the abdomen. This also a Penrose drain located in the\n region of the anastomosis. Conray followed by sips of thin barium were used\n for the study. Contrast is seen to pass freely through the esophagus into the\n gastric pouch. There was no evidence of leak or stricture at the anastomotic\n site. Contrast passes easily out of the pouch through the gastrojejunal\n anastomosis. Delayed imaging shows the passage of contrast into the distal\n small bowel.\n\n IMPRESSION: Free passage of contrast through the gastrojejunal anastomosis\n into the distal small bowel. No evidence of leak or outlet obstruction.\n\n These findings were discussed with Dr. . from general surgery.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876641, "text": " 11:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post-op, eval ETT\n Admitting Diagnosis: MORBID OBESTIY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p gastric bypass surgery.\n REASON FOR THIS EXAMINATION:\n post-op, eval ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postop gastric bypass.\n\n COMPARISONS: None.\n\n Tip of the endotracheal tube is in adequate position 2.5 cm above the carina.\n There is a band of linear density in the mid right lung consistent with\n atelectasis. There is a denser band of density at the base of the left lung\n consistent with atelectasis as well. Similar findings are noted in the left\n mid lung field.\n\n IMPRESSION: Endotracheal tube in adequate position. Bilateral opacities\n consistent with atelectasis left more extensive than right.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-08-27 00:00:00.000", "description": "Report", "row_id": 1403785, "text": "Neuro sedated 80mcg/kg/min propofol and 50mcg/hr of fentanyl, pupils equal and reactive, flexes and withdraws to painful stimuli\ncvs HR 80-90 nsr without ectopy bp 132/-154/92 hct 39, mag repleted x2 skin w+d pp+4\nGI abd dsg serosang drainage JP 100cc sang drainage BS absent\ngu u/o >35cc qhr IVF LR at 200cc q hr\nresp 60/600/10/18 abg 7.37/44/123/0/26 lungs clear diminished at bases sx yellow tan secretions\nID temp max 100.4 on kefzol x 24hr\naccess 1 18g, 2 20g\nendo requiring ss insulin coverage\na. s/p gastric bypass \ndm2, +smoker\np. poss wean sedation to possibly extubate today, vigorous pulm toliet, monitor lytes replete, support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2193-08-27 00:00:00.000", "description": "Report", "row_id": 1403786, "text": "Respiratory Care:\nPatient's PEEP level was increased from 5 cm to 10 cm, and gradually the FIO2 was able to be decreased from 100% down to 50%. Last abg results (on FIO2 of 60%) revealed a mild compensated respiratory acidemia with good oxygenation.\n\nNo RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-27 00:00:00.000", "description": "Report", "row_id": 1403787, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/ASSESSMENTS/LAB INFO.\nPATIENT TAKEN OFF PROPOFOL AND AWOKE UNEVENTFULLY, VERY COOPERATIVE. FAMILY IN, PATIENT COMMUNICATING WITH THEM.\nWEANED FROM VENT TO CPAP 5/5 WITH GOOD GASES AND SATS, YET DID NOT HAVE CUFF LEAK. WILL TRY TO EXTUBATE TOMORROW. LASIX GIVEN FOR DIURESIS.\nWILL RESTART PROPOFOL, WEAN AGAIN EARLY IN AM.\nHO AWARE, WILL CHECK DURING SHIFT FOR DEVELOPING AIR LEAK.\nWILL CALL HO WITH ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-27 00:00:00.000", "description": "Report", "row_id": 1403788, "text": "resp. care\npt. remains intubated/vented. weaned to with good abg, but\nno cuff leak with ett. will rest on overnight and try again\nin a.m.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-28 00:00:00.000", "description": "Report", "row_id": 1403789, "text": "CONDITION UPDATE\nASSESSMENT:\n PATIENT SEDATED ON PROPOFOL AND FENTANYL GTTS. OPENS EYES TO VOICE AND MOVES ALL EXTREMITIES. HEART RATE 90'S-100'S SINUS TACH WITHOUT ECTOPY AND BLOOD PRESSURE REMAINS STABLE. HOURLY URINE APPROX 50CC; GIVEN LASIX DOSE WITH IMMEDIATE EFFECT BUT PATIENT STILL 2.5 LITERS POSITIVE FOR . LUNG SOUNDS COARSE, SUCTIONED EVERY ~ 3 HOURS FOR THICK WHITE SECRETIONS. ET CUFF DOWN, NO APPARENT LEAK. ABDOMINAL DRESSING DRY AND INTACT. NO NUTRITION YET. SLIDING SCALE INSULIN INCREASED FOR ELEVATED BLOOD SUGARS.\nPLAN:\n ? REPEAT DOSE OF LASIX THIS MORNING AND EXTUBATE IF PATIENT READY. CONTINUE WITH CLOSE MONITORING AND TREATMENT.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-28 00:00:00.000", "description": "Report", "row_id": 1403790, "text": "Respiratory Care:\nPatient required an increase in PSV due to increased hypercarbia. Morning abg results determined a partially compensated respiratory acidosis with excellent oxygenation. PSV increased from 10 cm to 14 cm.\n\nRSBI = 155.7 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-28 00:00:00.000", "description": "Report", "row_id": 1403791, "text": "FOCUS: STATUS UPDATE\nDATA:\nPROPOFOL SEDATION WEANED OFF THIS AM. PT. CALM, FOLLOWING ALL COMMANDS. CONTINUES ON FENTANYL DRIP.\n\nBREATHING TRIAL WITH ACCEPTABLE ABG AND RSBI OF 54. PT EXTUBATED BY DR. AND DR. USING A COOK CATHETER DUE TO HER DIFFICULT INTUBATION HX. COUGHING AND EXPECTORATING WITHOUT DIFFICULTY. SATS 96-100% WITH COOL NEB MASK. LUNGS BILAT COARSE, INSP. WHEEZES AT TIMES.\n\nINSULIN DRIP STARTED FOR PERSISTENT HIGH GLUCOSES.\n\nPLAN:\nTRANSFER TO FLOOR IN AM IF GLUCOSE STABLE. MONITOR HOURLY GLUCOSES.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-28 00:00:00.000", "description": "Report", "row_id": 1403792, "text": "RESPIRATORY CARE\nPT WEANED AND EXTUBATED OVER COOK CATH. WITHOUT INCIDENT TO AEROSOL FACETENT.\n" }, { "category": "Nursing/other", "chartdate": "2193-08-29 00:00:00.000", "description": "Report", "row_id": 1403793, "text": "data: vss. no c/o pain-fentanyl gtt 50mcg/hr. pt rec'd methylene blue\npo per orders-no methylene blue in jp seen-only sero-sang small amt.\nabd. soft-no bowel sounds heard.\npt cnr'ing thick white-using incentive . cs-clear diminished in bases.\nblood sugars controled on insulin gtt 2-4u/hr to keep bs<120.\n" } ]

[ { "category": "ECG", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 134508, "text": "Sinus rhythm. Diffuse low voltage. Early precordial R wave progression.\nCompared to the previous tracing of the Q-T interval has normalized.\nThe rate has increased and the anterior ST-T wave abnormalities have improved.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1384706, "text": "NPN 7P-7A\nSEE CAREVIEW FOR OBJECTIVE DATA\n\nPT. HAS REMAINED HEMODYNAMICALLY STABLE THROUGHOUT SHIFT. PLAN IS TO D/C PT. TO NE TODAY.\n\nNEURO: PT. IN \"VEGETATIVE STATE\". MINIMAL RESPONSE. PT. APPEARS COMFORTABLE.\n\nRESP: PT. REMAINS TRACHED AND ON VENT WITH PS 16/5 40%. BREATH SOUNDS COARSE THROUGHOUT. SUCTIONED FREQUENTLY FOR FROTHY YELLOW SECRETIONS. INCREASE WITH TURNING.\n\nCV: PT. NSR/SB WITH NO ECTOPY. SBP HIGH 90'S TO LOW 100'S. REMAINS OFF LEVOPHED. EDEMA NOTED. + PULSES. AFEBRILE.\n\nGI: GJ TUBE IN PLACE WITH ULTRACAL AT 50CC/HR (GOAL RATE) TOLERATING WELL. ABD. DISTENDED. BS+. PT. HAS HAD MULTIPLE LOOSE STOOLS THROUGHOUT SHIFT.\n\nGU: FOLEY WITH GOOD UO. CLEAR YELLOW.\n\nACCESS: R AC DL PICC PLECED YESTERDAY. SITE LOOKS GOOD. ALL TUBING CHANGED.\n\nPLAN: SINCE PICC PLACED YESTERDAY, PT. TO PROBABLY BE TRANSFERRED TO NE TODAY. CONT. WITH CURRENT POC. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1384707, "text": "Resp: pt on simv 10/500/15/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS are coarse bilaterally. Suctioned for moderate amounts of frothy yellow/white secretions. MDI's administered as ordered with no adverse reactions. Pt is vent dependent. No changes noc. Plan to be discharged today to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-11 00:00:00.000", "description": "Report", "row_id": 1384708, "text": "CORRECTION TO NPN\nPT. ON SIMV: 40%/500/10/5/15\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1384693, "text": "resp care\nremains trached/vented. converted back to PSV mode per team. pt tolerating fair with active prolonged exhalation, rhonchi and wheezing. bronchodilators increased to q3h without significant effect.sputum initially thick ,becoming more frothy ..to receive lasix. psv increased to assist pt with wob, Dr. would prefer increased ps level vs. ac mode.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1384694, "text": "1900-0700 rn notes micu\n\nneuro: no changes in neuro status, remaines lightly on Fentanyl 25mcg/hr and Versed 1mg/hr, pt does not follow commands,occas opens eyes to pain, minimal response to pain stimul.pt shivers and become flushed during reposition and suction.\n\nresp: remains trached on vent mode CPAP/ps 40%/peep5/PS16, spont RR10-16, no vent changes made overnight. LS coarse bilat, with occas wheezing, that resolved with nebs, suction moderate amount yellow/thick secretion.sat 98-100%. ABG morning: 7.40/42/120/27.\n\ncv: HR 70's, NSR, no ectopy. pt off pressors. pt received LAsix 10mg IV at 1900, at 2100 ABP dropped to 79-88/50's with MAP 56-58, MD notified, goal MAP 55-60, second dose of LAsix 10mg IV held, overnight ABP 88-92/50's with MAP 60-67. CVP 13-18. pt neg 600cc for 24 hr. morning labs pending\n\ngi/gu: foley's been changed yesterday to 20fr d/t leakage, u/o 80-200cc/hr, urine yellow with sedement. ABD soft/dist, BS +, no BM this shift given Senna PO.cont TF at goal 50cc/hr, tollerates good.\n\nid: Afebrile, Tmax 98.8, cont VAnco/Meropenem IV.\n\nskin: red rash under left breast, muconazol cream apllied, red abrasion at g-j tube, bacitracin apllied and DSD.\n\nsocial: DNR, not DNI, no contact from family overnight.\n\nplan: cont monitoring neuro/resp/cardio status\n keep MAP 55-60\n cont CPAP/PS\n possible PICC line placement on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1384687, "text": "NPN 7P-7A\nSEE CAREVIEW FOR OBJECTIVE DATA.\n\nPT. WAS STARTED ON T-FEEDS LAST EVENING AND TOLERATING WELL. SHE WAS GIVEN A FLUID BOLUS AT 2200 FOR DECREASED UO. HER OUTPUT HAS INCREASED SINCE THAT BOLUS. OTHERWISE PT. HAS HAD UNEVENTFUL SHIFT. NO CONTACT WITH FAMILY THIS SHIFT.\n\nNEURO: PT. REMAINS SEDATED ON VERSED - 1.0MG/HR AND FENTANYL 30MCG/HR. SHE DOES OPEN HER EYES BUT HAS MINIMAL RESPONSE. PURPOSEFUL MVMT NOTED. APPEARS COMFORTABLE\n\nRESP: NO VENT CHANGES MADE THIS SHIFT. SHE REMAINS TRACHED AND ON AC 500X12 / 40%/5. BREATH SOUNDS COARSE BILAT. DIMINISHED IN BASES. SUCTIONED FOR MODERATE AMOUNTS OF THICK YELLOW SECRETIONS.\n\nCV: PT. NSR/SB. UNABLE TO WEAN PT. FROM LEVOPHED. SHE REMAINS ON 0.03MCG/KG/MIN. SBO HIGH 90'S TO LOW 100'S. MAP > 60. + PULSES. GENERALIZED EDEMA NOTED. AFEBRILE.\n\nGI: GJ TUBE IN PLACE. ULTRACAL STARTED LAST EVENING AT 10CC/HR. TO BE INCREASED 10CC Q4H. TOLERATING WELL AT THIS TIME. NO BM\n\nGU: FOLEY IN PLACE WITH 10-40CC OUT PER HOUR. YELLOW WITH SEDIMENT NOTED.\n\nSKIN: SEE CAREVIEW.\n\nACCESS: R SCTL , L RADIAL A-LINE\n\nPLAN: CONT. WITH ANTIBIOTIC THERAPY. ATTEMPT TO WEAN LEVOPHED AS TOLERATED. PT. REMAINS DNR/DNI. AM LABS PENDING AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1384688, "text": "NPN 1900 - 0700\n\nNEURO:MIN RESPONSIVE TO NOXIOUS STIM.LIGHTLY SEDATED ON FENT AND VERSED.\n\nRESP:VENT CHANGED TO PS 16/5 40% RR 20-24 , SUCTIONED FOR MOD AMT THICK YELLOW SECRETIONS. SPEC SENT . OCC BILAT WHEEZES HEARD, CLEARED W/ MDI. LUNGS COARSE THROUGHOUT, DIM AT BASES.MAINT SATS 96-99%.\n\nC/V: ST NO ECTOPY, OFF LEVOPHED SINCE 9AM.\n\nF/E/N:CONT TO EXTREMITY EDEMA,AND ANASARCA. FOLEY CATH CHANGED FOR LEAKAGE, UO ~ 50CC HR, PASSING FLATUS, NO STOOL. TOL TF 40CC/HR.GOAL IS .5 L NEG FOR TODAY, START DIURESSES LATER TODAY.\n\nPLAN: CONT MECH VENT, CONT AB TX, MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 1384689, "text": "Respiratory Therapist\nBreath sounds diminished on the left, slight wheezes on the right lung, suctioned intermittently for moderate thick yellow secretions, treated tree time with combivent and once with albuterol, switched at 1015 am from AC to cpap 5 psv 16 doing well sat 96 to 100, sputum specimen sent to lab for culture and sensitivity, patient will continue to receive ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1384702, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: sepsis hx/o MRSA sputum\n56 yo pt w/ Down's, reportedly vegetative state x 3 yrs; non communicative; dementia, sz d/o (improved w/ trileptic), freq UTI's, paraplegia, dysphagia--feeding tube, C3-4 spinal fusion; skin fungal infection x several months; trach/peg;\n\ncomes in for fevers/sepsis;\nis receiving IV ABx of Meropenum for GNR;\n\nrt subclav placed in ER --as of yesterday, very reddened, +small amt exudate at insertion site, drssg changed yesterday and this a.m. at 04:30;\n\nleft radial a-line dc'd yesterday ;\n\nb/p borderline at times, therefore goal for diurese loosened; (no lasix given);\n\npt given senna and lactulose 2 days ago d/t no stool, then had continual diarrhea/stooling x 36 hrs, slowed down this night;\n\nreceiving tube feeds as ordered;\n\nmycostatin ointment and powder alternately ordered and applied to skin fungal areas;\n\nthis a.m.'s labs w/out significant change, except for decreased in WBC this a.m. in 3K's;\n\nPLAN:\n1) pt to receive PICC line in IR today/Monday (unable to do at )\n2) return to NE after placement of PICC\n3) stool sent for c-diff pending\n4) skin care\n5) brother HCP, sister also involved\n6) IV Abx (note allergies)\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1384703, "text": "Respiratory Therapy\nPt remains trached #7 H2O filled cff no leak. Vent set on SIMV 500X10 15/5 .4. Tolerated well. RRR in sync W setting. BS coarse W diffuse wheezes, tight. Sx for mod to copious amts thick white to pale yellow secretions. MDI's as ordered W good effect. Plan: maintain vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1384704, "text": "NPN 0700-1900\nNeuro: Neuro status remains without changes. Pt. has episodes of shaking when Turned that resolves when Pt. setteled. Does not follow commands.\n\nResp: Pt. remains on PS 16/5 and 40% FiO2. Suctioned for small to moderate amount of thick whitish sputum.\n\nCV; BP remains stable ranging 86-136/34-87. HR 57-88 NSR with no ectopy. Cont. with generalized edema. R SC TLC D/C'ed today and tip sent for cx due to redness on insertion site. Pt. to IR today for PICC an double lumen R AC PICC placed. Blood return positive in both lumens. IR nurse flushed both lines with Heparin.\n\nGI: TF at goal with no residuals. Abd. remanis distended and firm with BS+. Pt. is oozing small amount of stool with every stool. C-diff neg from .\n\nGU: Foley cath draining adequate amounts of clear yellow urine. Pt. cont. to remain + 8.4L for LOS.\n\nSkin: Mycostatin powder to groin and under R breast a/o. Coccyx red but intact. Barrier cream to coccyx.\n\nID: T max 99.2 at 1700. Pt. cont. on Meropenem for Psudomones in sputum. Pt. needs to finish 14 day course. Today id Day 7.\n\nSocial: Pt.'s brother and sister in to visit. Both updated on pt. condition and plan of care. Pt. is a DNR.\n\nPlan: NE siani in to evaluate Pt. Possible transfer on if bed avlb.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-10 00:00:00.000", "description": "Report", "row_id": 1384705, "text": " Care\nPt remained on simv settings without changes. Pt traveled to IR for PICC line placement without incident. Pt continues to have large amts of yellow secrections increased with movement. Plan to return to rehab after line placement.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1384683, "text": "Resp Care Note:\n\nPt cont trached sedated and on mech vent as per Carevue. Lung sounds scat coarse wheeze bilat; suct mod th pale yellow sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required . Pt required sedation; without it or if she is allowed to awaken ventilation is significantly impaired[pt fights vent/RR ^/O2 sats fall. Cont mech vent.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1384684, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 84/55-124/51. SB/SR WITH HR RANGING FROM 48-79, NO ECTOPY NOTED. CVP 27 WITH BED FLAT AND TRANSDUCER LEVEL AND ZEROED. LEVOPHED REMAINS ON, TITRATED DOWN FROM 0.069 TO 0.053MIC/KG/MIN.\n\nRESP: TRACH. AC40%/500/12/5PEEP. LUNGS COARSE THROUGHOUT WITH DIM BASES. SX Q 2-3HR FOR SM AMTS OF THICK YELLOW SPUTUM. SAO2 M96-100%.\n\nNEURO: GTTS HAVE REMAINED OFF PT WITH VERSED TOTAL OF 2MG AND FENTANYL TOTAL OF 40MIC. PT HAS BEEN VENT DEPENDANT FOR PAST 5 YEARS. VEGATATIVE STATE FOR 3 YEARS. PUPILS REMAIN SLUGGISH. OPENS EYES WITH TURNING.\n\nGI/GU: FOLEY CATH PATENT DRAINING CLEAR YELLOW URINE IN LOW AMTS. PT RECIEVED NS BOLUS 250CC TO IMPROVE U/O. ABD SOFT, OBESE WITH +BS. G TUBE SITE WITH CLEAR YELLOW DRAINAGE. NO STOOL THIS SHIFT.\n\nSKIN: PT GETTING NYSTATIN MICONAZOLE CR TO YEAST AREAS UNDER BREAST AND IN GROIN.\n\nPLAN: CONT WITH RESP SUPPORT. WEAN LEVOPHED AS B/P IMPROVES. UPDATE FAMILY WITH ANY CHANGES IN COND.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1384685, "text": "Respiratory Therapist\nBreath sounds bilaterally diminished, suctioned intermittently for moderate thick yellowish secretions, afebrile but WBC 13 consistent with bacterial infection, while awake patient is restless, becomes tachypneic, tachycardic and causes ventilator asynchrony, now is on Versed, Fentanyl and Levophed, stays constantly into Sinus Bradycardia HR ranged from 48 to 59, patient is often hypotensive, treated tree times with combivent inhalers. Patient went to Angioplasty to have Ruled-Out a leak through her Gastric tube, no leak revealed, sat ranged 96 to 100 patient remains into vegetative stated, no ABGs drawn during the shift, patient will continue to receive ventilatory support and be closely monitored.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 1384686, "text": "NPN 1900 -0700\n\nNEURO:MIN RESPONSIVE TO PAINFUL STIM. DOES NOT TRACK OR FOLLOW COMMANDS.NO SZ ACTIVITY NOTED.PT BACK ON FENT AND VERSED GTTS.\n\nRESP: ON A/C 500X12 40% PEEP 5 , MAINT SATS 96-99%. SX FOR MOD AMTS THICK YELLOW SECRETIONS.UNABLE TO TOL PSV AT THIS TIME.\n\nC/V:SB-SR NO ECTOPY. UNABLE TO WEAN LEVO OFF TODAY. A-LINE PLACED FOR MORE ACCURATE BP. GOAL IS FOR MAP > 60.\n\nF/E/N: UO @ 35-50CCHR, G/J TUBE RELACED TODAY IN ANGIO VIA FLUERO.NO EXTRAVCATIO OR TUNNELING NOTED. TUBE IS OK FOR USE.NO STOOL THIS SHIFT.\n\nPLAN: CONT MECH VENT SUPPORT, CONT AB TX, EMOTIONAL SUPPORT FOR FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1384698, "text": "Respiratory Therapy\nPt remains trached #10 water filled . on PSV. BS coarse wheezes on Lt scattered on Rt. Sx mod amt thin white secretions W SPC. MDI's as ordered W good effect. Plan: continue ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1384699, "text": "BS rhonchi; no changes with MDI's. Sx'd frequently for copious amounts of moderately thick white secretions with some improvement in both BS and breathing discomfort. PSV weaned to 15 to match her settings at outside institution.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1384700, "text": "ADD 1800 Changed to SIMV for occasional periods of apnea.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1384701, "text": "NPN 0700-1900\nNeuro: Pt remains minimally responsive, appears to open eyes to name calling, does not track speaker. Continues w/myoclonic response to position changes, noted seizure activity twice after position changes that lasted <1min w/eyes deviating to right, bilateral arm twitching, resolved spontaneously, however, medicated w/.5mg ativan IV x 2. afebrile. Restraints d/c'd today as no purposeful movements noted, no attempts made to extubate or d/c lines.\nCV: Continues w/borderline b/ps, see flowsheet for details, good urine output, HR 60s, SR. Right TLC red @ site, await PICC placement in IR tomorrow to continue antbx rx. (L) radial a-line d/ by MD today.\nResp: Weaned to PSV 15, ABG good, noted 2 episodes of apnea today and pt switched to IMV mode ventilation. Suctioned for large amts white secretions. Coarse upper airways, clear lower, some crackles ausc this morning but clear now.\nGI: tube feeds @ goal infusing, no apirates noted, however, noted bile leaking around g-tube site. Site excoriated and appears fungal, nystatin powder applied. Continues w/frequent bowel movements, abd soft, distended, BS+\nGU: foley catheter appeared to slip out w/turning, there was no tension on catheter w/balloon intact. Foley replaced w/aseptic technique and no difficulty, leaking noted and 4cc added to balloon w/leaking stopped.\nSkin: Multiple skin tears noted w/fungal noted under both axilla, both breasts, perineal area. Anasarca persists. Fungal areas rx w/nystatin powder PRN. Aquaphor cream to perianal area, duoderm dressing fell off w/ position changes, no open areas noted, no dressing applied. Cont w/POC as above.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1384679, "text": "ADMISSION NOTE:\n\n\nTHE PT IS A 56Y/O FEMALE WHO LIVE AT A REHAB. TODAY SHE HAD TEMPS 103.3 W/ BS 70'S. SHE WAS TAKE TO , WHERE SHE WAS STARTED ON DOPA. SHE RECIEVED 2L NS. CXR RUL INFLATRATE. AT SHE RECIEVED LEVOQUIN. SHE WAS TX TO ED, SHE RECIEVED 2L NS, AND VANCO/GENTA. A SEPSIS LINE WAS PLACED.\n\nPMH: DOWNS SYNDROME,DEMENTIA,SEIZURE DISORDER,C3-C4 SPINAL FUSION, PARAPARIS, DYSPHAGIA, G TUBE, DIVERTICULITIS,CHRONIC INCONTINENCE,UTI,CHRONIC LOOSE STOOL,MRSA SPUTUM. TRACH 4L IR 24% FACEMASK,SEVERE FUNGAL SKIN INFECTION.\n\nALLERGIES: PENICILLIN,SULFA,ERYTHORMYCIN,DILANTIN\n\n\nNEURO: SHE IS TRACHED AND HAS BEEN VENT DEPENDANT FOR 5YEARS. SHE HAS BEEN INS A VEGATATIVE STATE FOR 3YEARS. SHE IS SEDATED ON FENTANYL/VERSED. ON ADMISSION TO THE . SHE RECIEVE ATIVAN 2MG WITHOUT EFFECT NOTED. HER RR REMAINED 45. MID AT TOTAL OF 20MG WAS GIVEN. WITHOUT EFFECT NOTED. HER RR REMAINED 45 WITH B/P 144/78 HR 120. AFTER FENT 50MCG WITH GIVEN IV PUSH. HER SBP DROP 88-90'S. HER RR 20'S. HR 85-90'S. HER PUPILS 3MM SLUGGISH BILAT. SHE DID MOVE HER LEFT ARM, AND HER RIGHT LEG. SHE OPEANS HER EYES TO TURNING IN THE BED.\n\nRESP: VENT SETTINGS AC 40X500X20 W 5 PEEP. LS RONCHI/DIMINSHED BILAT. SECREATIONS ARE CLEAR WHEN SHE IS SX. SHE HAS CLEAR ORAL SECREATIONS. O2 SAT 100% ON 40%.\n\nCV: NSR NO ECTOPY NOTED. HR 80-90'S. SBP 88-100'S. CVP 12-15. SVO2 49-60\n\nGI/GU: HER G TUBE IS TO GRAVITY. THE DRAINAGE IS CLEAR YELLOW. ABD LARGE ROUND + BS. SHE HAS A SOFT SMALL STOOL. FOLEY CATH WITH 30-50CC/HR OF UA.\n\nSKIN: HER SKIN HAS MULTIPLE AREARS WHICH ARE BROKEN DOWN. UNDER BILAT BREAST. HER COCCYX HAS A STAGE 2. A DUODERM WAS PLACED, AND HER BACK IS PINK.\n\nPOC: VENT SUPPORT. SHE IS ON VANCO AND LEVO RUL INFILTRATE.\nSHE IS ON HER SECOND UNTI OF PPC HCT 25. SHE HAS HCT DUE AT 0900 AND THAN 8 HOURS AFTER THAT ONE. THE SEPTIC PROTOCOL WILL BE OVER AT 0930. SHE HAS MICONAZOLE ORDERED.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1384680, "text": "ADDENDUM:\n\nHCT AFTER THE FIRST UNIT OF PRBC 30. SHE IS ON HER SECOND UNIT NOW. CALCIUM 6.6. NOW SHE HAS UP CALCIUM GLUCONATE 2G IV X1. NEUTRO PHOS 2PACKS WAS GIVNEN PHOS 2.2. SHE WILL NEED KCL K 3.8, AND MAG MAG 1.7. SHE DID HAVE A QUESTION OF SEIZURE ACTIVITY. THE ICU TEAM IS AWARE. HER FEET WAS SHAKEING, AND HER LEFT HAND WAS MOVEING UP IN A RIDIG MOTION.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1384681, "text": "Respiratory Care\nPt remains on ventilatory support as noted in Carevue. Weaning rate this shift to 12bpm despite lessening sedation. MDI's PRN.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-04 00:00:00.000", "description": "Report", "row_id": 1384682, "text": "11 AM-11 PM Nsg Progress Note\nRESP: pt remains vented on AC 40% /500/12 5 Peep, O2 sats 98% suctioned q 2-3 hrs for thick tan secretions. lungs w/ coarse breath sounds. on combivent prn. trach care done - trach site reddened,\n\nCV/FLUIDS: bp labile, dropping to 80's, pt received 500 cc NS bolus x 2, cvp up to 19-20 pt started on Levophed - currently at .030 mcg/kg/min, bp 98/59 HR~ 50's SB no vea noted. CVP~13-15 UO~30 cc/hr pt + 7 liters since admission. lactate 1.2-1.3\n\nID: afebrile WBC 8.3 remains on Vanco and Meropenem. urine cx sent\non contact precautions, MRSA\nGI: peg site - reddened, draining OB + brownish fluid, (coffee grounds) area cleaned - no further drainage from site. barrier cream applied around peg. pt to have peg checked in IR tomorrow \n\nNEURO: pt was on a Versed gtt @ 2mg/hr, and a Fentanyl gtt @ 25 mcg/hr, weaned off. pt just requiring prn boluses of Fentanyl, pt remains sedated, will opens eyes spont. no other movements, pupils 3 mm, react sluggish to light. pt nonverbal,\n\nSKIN: duoderm intact on coccyx, nystatin under breasts, barrier cream around peg. pt turned freq. trach site old reddened skin area cleansed with NS - trach care done.\n\nPLAN: continue w/ vent support, pulm toilet. cont. Levophed, NS boluses, want cvp~15 monitor UO, pt is NPO - to have peg checked by IR in the morning. cont. antibx. for pneumonia.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1384695, "text": "NPN 0700-1900\nNeuro: Pt. with Down syndrome, baseline dementia, Trached and vent dependent from NH. Sedetion turned off for \"wake up\" this AM and Pt. openes eyes but does not follow commands, no spontanous movements noted. This is Pt.'s baseline. Pupils equal round and reactive to light. Grimice and shaking whole body when turned ? responce to discomfort. Medicated with Ativan 0.5 mg PRN for turning with good responce.\n\nCV; BP improving 86-118/44-64 with MAP>55. HR 60's-80's NSR with no ectopy. BP and HR up when turning. Generalized edema noted as fluid status positive for LOS. Access is R SC TLC and L a-line. Pt. scheduled for PICC in IR on Monday.\n\nResp; Pt. remains on 16/5 with 40% and tolerating well. RR easy 10's-20's. O2 sat 96-100%. Pt. suctioned Q2-3 hr for small to moderate amount of thick yellowish sputum. LS coarse. No ABG this shift. No CXR today.\n\nGI: GT intact with TF at goal and no residuals. Flushed with 50 cc of H2O q 8 hr. FS BS WNL, no SS insulin ordered. Follow daily serum glucose level opose to FS q 6 hr. No BM this shift. Medicated with lactulose with no stool at this time. Abd. distended and firm, BS active.\n\nGU; Foley cath in place and draining adequate amounts of clear yellow urine. Urine output increasing ? auto diureseing. Fluid status +0.17L since midnight and +8.9L for LOS. No Lasix at this time.\n\nID: Sputum from grew out pseudomonas and gram neg. rods. Sensitivities pending. Pt. on meropenem and vanco d/c'ed. pt. remain afebrile and WBC 5.4 this AM. Other cx. pending.\n\nSkin: Duoderm to coccyx intact. Fungal rash to R breast with micanazole cream applied. GT dressing intact. Pt. repositioned Q3 hr. SCD on.\n\nSocial; Pt. is DNR. No contact from family this shift.\n\nPlan: Awaiting PICC placement in IR on Monday. Follow up on sputum sencitivities for appropriate abx. coverage. Cont. to monitor BP. Diurese to decrease edema.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-07-08 00:00:00.000", "description": "Report", "row_id": 1384696, "text": "Repiratory care\npt remains on psv 16/5 4O% without changes. Pt continues to have copious amts of thick secrections with rotations. Plan to continue support as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-09 00:00:00.000", "description": "Report", "row_id": 1384697, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: sepsis\n56 yo w/ down's; trach, feeding tube; c3-4 spinal fusion; paraplegia;\nhx MRSA sputum; fungal infections--skin;\n\npt off sedation yesterday morning; remains minimally responsive w/ opening eyes, no verbalizaion, no communication of any kind;\n\nhemodynamically stable; NSR 80's-90's; does become hypertensive when 'bothered' for cares;\n\nresp--remains on PS 16/5 0.40; requires approx q3 hr suctioning for whitish med thin secretions;\n\nskin-- under left , -area red; foley in use; mycostatin ointment ordered and received; will ask for mycostatin powder for peri-area;\n\ng-i--tube feeds at goal; received senna early yest a.m., and lactulose yesterdy--stooled all night;\n\naccess--rt subclav ; left radial aline; both with good wave forms;\n\na.m. labs much the same as yesterday morning;\n\nPLAN:\n1) urine output to be approx 100 cc/hr, lasix prn to assist\n2) ativan as ordered q 4 hrs--especially for turning\n3) stool sent for c-diff--pending\n4) abx (meropenum) for GNR\n5) tube feeds at goal--50 mls/hr\n6) PICC Monday in IR (unable to do )--then d/c back to NE \n7) pt's brother is HCP\n8) senna once every day to avoid lactulose\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1384690, "text": "NPN 7P-7A\nSEE CAREVIEW FOR OBJECTIVE DATA\n\nLEVOPHED RESTARTED AT 0200 FOR SBP IN 70'S WITH MAP IN MID 50'S. TITRATED TO KEEP MAP >60.\n\nNEURO: PT. SEDATED ON VERSED AND FENTANYL. FENTANYL DECREASED TO 25MCG D/T LOW BP. PT. REMAINS WITH MINIMAL RESPONSE TO STIMULI. PUPILS EQUAL AND REACTIVE. PT. APPEARS COMFORTABLE.\n\nRESP: PT. REMAINS WITH TRACH. SHE WAS SWITCHED BACK TO ASSIST CONTROL FROM PRESSURE SUPPORT LAST EVENING D/T INCREASED WORK OF BREATHING. VENT SETTINGS: AC 500X12 40% PEEP 5. BREATH SOUNDS COARSE THROUGHOUT. OCCASSIONAL EXP. WHEEZES WHICH RESOLVE WITH MDI'S. PT. SUCTIONED FREQUENTLY FOR THICK TAN/YELLOW/GREEN SECRETIONS. SEEM TO INCREASE WITH TURNING. SAMPLE SENT TO LAB.\n\nCV: PT. NSR/ST WITH NO ECTOPY. PT. ON LEVOPHED AT 0.03MCG/KG/MIN. TITRATING TO KEEP MAP>60. PULSES WEAK AND THREADY. EDEMA NOTED THROUGHOUT BODY. AFEBRILE\n\nGI: PT. WITH GJ TUBE. ULTRACAL AT 50CC/HR (GOAL RATE) TOLERATING WELL. NO RESIDUALS. NO BM BUT PASSING GAS.\n\nGU: FOLEY CHANGED AGAIN TO #18 FRENCH AND URINE CONTINUES TO LEAK AROUND CATHETER. MORE FLUID ADDED TO BALLOON WITHOUT EFFECT. MDS AWARE. THEREFORE, OUTPUT INNACCURATE.\n\nSKIN: MLTPL. ISSUES. MICONAZOLE CHANGED TO CREAM.\n\nACESS: R SCTL - ALL TUBINGS CHANGED.\n\nPLAN: ATTEMPT TO WEAN PRESSORS AS PT. TOLERATES TO KEEP MAP > 60. CONT. WITH ANTIBIOTIC THERAPY. MONITOR RESP/CV STATUS CLOSELY. PT. DNR/DNI. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1384691, "text": "Respiratory Therapy\nPt remains trached W #7 W water-filled cuff. No leak at this time.Returned to A/C from PSV after pt presented W increased WOB, tachypnia. Pt turned Q2 hrs in conjunction W frequent suctioning for thick creamy yellow/green, tan secretions. Spec sent to lab. MDI's as ordered. BS clear w occasional exp wheezes on rt, Coarse rhonrhi with diffuse I&E wheezes on lt diminished @ base. BS greatly improved mainly on the left afterturning, suction & MDI's.Plan: wean to settings pt is on in long term skilled nursing facility\n" }, { "category": "Nursing/other", "chartdate": "2152-07-07 00:00:00.000", "description": "Report", "row_id": 1384692, "text": "NPN 1900 -0700\n\nNEURO:LIGHTLY SEDATED ON FENTYNAL AND VERSED.DOES NOT FOLLOW COMMANDS OR TRACK, THIS IS PT BASELINE .POS COUGH AND GAG. WILL OCC OPEN EYES, SHIVER AND BECOME FLUSHED DURING NSG CARE THAT BE UNCOMFORTABLE.\n\nRESP:CURRENTLY ON PSV 16/5 40% W/ RR 18-20, Tv's 4-500.SX FOR THIN YELLOW/WHITE SECRETIONS.MAINT SATS 96-99%.CONT TO USE ACCESSORY MUSCLES DURING RESPIRATIONS\n\nC/V: SR NO ECTOPY .OFF PRESSORS SINCE 0830, MAINT BP 100'S SYSTOLICALLY .GOAL IS FOR MAP BETWEEN 55-60.\n\nF/E/N: HYPERVOLEMIC, FOLEY FOUNG TO BE LEAKING AGAIN. CHANGED TO 20G.UO ~ 50-100CC HR. RECIEVED 10MG LASIX IV @ 1900.GOAL IS TO PT AS LONG AS HER BP CAN TOLERATE. TF @ GOAL NO STOOL.\n\nSKIN: RASH UNDER L BREAST HAS LEFT SKIN RED AND CRACKED. MICONAZOLE CREAM APPLIES TO THE AREA AS WELL AS TO PANUS AND GROIN AREA.OPEN AREA @ G TUBE SITE @ ~ 1100, CLEANSED W/ SOAP AND H20, BACITRACIN AND DSD APPLIED.\n\nPLAN: CONT ON PSV, GENTLE DIURESSES,CONT AB TX , MONITOR HEMODYNAMICS ,PICC UNDER FLEURO POSSIBLY MONDAY.\n" }, { "category": "Radiology", "chartdate": "2152-07-10 00:00:00.000", "description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)", "row_id": 922217, "text": " 4:05 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place double lumen picc\n Admitting Diagnosis: SEPSIS\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 56 year old woman with sepsis, need long term abx\n REASON FOR THIS EXAMINATION:\n please place double lumen picc\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Five-French dual lumen PICC line placement via right brachial vein\n approach, ultrasound-guided venopuncture.\n\n INDICATION: IV access required.\n\n RADIOLOGISTS: Drs. and , the Attending Radiologist, present and\n supervising the entire procedure.\n\n INFORMED CONSENT: Procedure and informed consent was obtained and placed in\n the medical record.\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition\n material and appropriate informed consent. Once the above was verified, the\n patient was positioned in supine fashion on a special procedures table with\n the right arm abducted and externally rotated. A tourniquet was applied to\n the upper arm. The right arm was prepped and draped from the axilla to the\n antecubital fossa. Utilizing ultrasound guidance, an uneventful venopuncture\n of the right brachial vein was performed. Hardcopy ultrasound images are\n available both prior to and after venopuncture documenting vessel patency. A\n guidewire was advanced to the level of the superior vena cava using\n fluoroscopic guidance. The intravascular length of the catheter to be placed\n was so determined. The catheter was tailored at the 41 cm mark and delivered\n using modified Seldinger technique to the level of the lower superior vena\n cava using fluoroscopic guidance. Both lumens of the catheter were flushed and\n heparin locked per protocol. The catheter was secured with a StatLock device.\n The catheter was then overlaid with a Tegaderm occlusive patch. Patient\n tolerated the procedure well without complication.\n\n ANESTHESIA: 1% Xylocaine, 3 cc total local infiltration.\n\n IMPRESSION:\n\n Status-post successful 5-French dual lumen PICC line placement via right\n brachial vein approach. Catheter is ready to employ. Final cath length is 41\n cm. Tip is the lower superior vena cava.\n\n\n (Over)\n\n 4:05 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place double lumen picc\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-05 00:00:00.000", "description": "CATHETER, DRAINAGE", "row_id": 921554, "text": " 2:15 PM\n PERC G/J TUBE CHECK Clip # \n Reason: EXCHANGE FOLEY TO G-J TUBE\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * REPOSITION GASTRIC TUBE INTO D PERC PLCMT ENTROCLYSIS TUBE *\n * -52 REDUCED SERVICES CATHETER, DRAINAGE *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with downs syndrome, vent dependent, here with fever of\n unknown source\n REASON FOR THIS EXAMINATION:\n ? extravisation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old woman with Down's syndrome, ventilator dependent, with\n fever of unknown source.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Dr. and Dr.\n , the attending physician, was present and supervising. The\n patient's abdomen was prepped and draped in standard sterile fashion. 5 cc of\n contrast were administered to the percutaneous gastric Foley catheter. This\n demonstrated appropriate positioning of the catheter within the stomach,\n without evidence of extravasation. The Foley was subsequently removed after\n deflation of the balloon. A Kumpe catheter was then advanced into the stomach\n through the tract. With gradual withdrawal of the catheter and injection of\n contrast, a son was performed which demonstrated passage of contrast\n through the tract into the stomach with no evidence of extravasation. Using\n an MPA catheter and wire, access was obtained through the stomach,\n duodenum, and into the jejunum. An 18 French dual lumen gastrojejunostomy\n tube was subsequently advanced. The balloon was inflated with 20 cc of\n saline. Injection of the gastric and jejunal ports demonstrated appropriate\n positioning of the tube. The site was dressed. The patient tolerated the\n procedure well and there were no immediate post-procedure complications.\n\n IMPRESSION:\n\n 1) Son of the percutaneous gastric tract demonstrating no evidence of\n contrast extravasation.\n\n 2) Successful placement of 18 French dual lumen gastrojejunostomy tube. The\n jejunal port can be used for tube feeds at any time. The gastric port can be\n open to gravity drainage or aspiration if necessary.\n\n\n\n\n\n (Over)\n\n 2:15 PM\n PERC G/J TUBE CHECK Clip # \n Reason: EXCHANGE FOLEY TO G-J TUBE\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2131-04-17 00:00:00.000", "description": "MRA NECK W&W/O CONTRAST", "row_id": 1191637, "text": " 10:06 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST\n Reason: please evaluate for underlying etiology, evidence of mass le\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with right frontal hemorrhage\n REASON FOR THIS EXAMINATION:\n please evaluate for underlying etiology, evidence of mass lesions, vascular\n lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRI brain, MRA head and neck. The MRI brain is with and without\n gadolinium.\n\n INDICATION: Right frontal hemorrhage.\n\n COMPARISON: head CT without contrast from an outside institution\n with the images scanned into our system for review.\n\n TECHNIQUE: Multiplanar, multisequence MRI of the brain was performed with and\n without gadolinium. 3D time-of-flight MRA of the head was performed.\n Post-gadolinium MRA of the neck was also performed. Multiplanar reformatted\n images were provided.\n\n FINDINGS:\n\n MRI BRAIN: The right frontal hematoma is similar in size to the recent CT, 4\n cm in greatest (AP) dimension. Layering blood products are seen within the\n hematoma. There is no definite adjacent subarachnoid blood. The blood\n products is of different age, but is predominantly subacute. On the gradient\n echo sequence, there are scattered foci of subcortical susceptibility. In\n addition, there is diffuse prominence of the ventricles. There is\n ventriculomegaly, slightly out of proportion to sulcal prominence, with\n underlying microvascular disease manifested by scattered chronic lacunar\n infarcts and adjacent FLAIR/T2 hyperintensities, also involving the pons.\n There is no appreciable enhancement associated with the hematoma. There is no\n abnormal intracranial enhancement.\n\n MRA HEAD: The left vertebral artery is dominant. There is no evidence of\n large vessel occlusion. There is moderate atherosclerotic irregularity of the\n cavernous carotids, but no focal high-grade stenosis. Patent bilateral\n posterior communicating arteries are seen. The P1 segments provide dominant\n supply to the P2 segments bilaterally.\n\n MRA NECK: Two dimensional axial time-of-flight images through the neck were\n also obtained. There is no flow-limiting stenosis within the neck. The left\n vertebral artery is dominant. The right probably terminates as the PICA.\n There is three-vessel aortic arch.\n\n (Over)\n\n 10:06 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST\n Reason: please evaluate for underlying etiology, evidence of mass le\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Right frontal parenchymal hematoma similar in size to the recent CT,\n subacute. The scattered foci of susceptibility within the subcortical white\n matter and other regions is suggestive of cerebral amyloid angiopathy as an\n etiology. Hypertension is less likely. There is no evidence of mass or other\n underlying structural lesion. However, continued followup is suggested until\n resolution and to ensure the hematoma is not obscuring an underlying lesion.\n 2. Moderate intracranial atherosclerosis.\n 3. No flow-limiting disease within the neck.\n\n" }, { "category": "ECG", "chartdate": "2131-04-19 00:00:00.000", "description": "Report", "row_id": 244819, "text": "Normal sinus rhythm. Within normal limits. Compared to the previous tracing\nof no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2131-04-17 00:00:00.000", "description": "Report", "row_id": 245042, "text": "Sinus rhythm. Early precordial QRS transition is non-specific and may be\nnormal variant. Since the previous tracing of early precordial\nQRS transition is present.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2154-07-06 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 876374, "text": " 1:14 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: verify central line placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multiple trauma decreased breath sounds R\n\n REASON FOR THIS EXAMINATION:\n verify central line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE.\n\n INDICATION: 19-year-old man with multiple trauma.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study at 2:06 a.m.\n\n Bilateral chest tubes remain in place. No pneumothorax is seen. The\n previously identified pneumomediastinum and subcutaneous emphysema of the\n chest walls have been improving.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n nasogastric tube terminates in the gastric body. The right subclavian IV\n catheter terminates in the SVC.\n\n Again note is made of comminuted fracture of the right mid clavicle.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876331, "text": " 1:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm pathology\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multiple trauma decreased breath sounds R\n\n REASON FOR THIS EXAMINATION:\n r/o pulm pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man with multiple trauma.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The tip of the endotracheal tube is identified 1 cm above the carina.\n Bilateral chest tubes remain in place. There is continued extensive\n subcutaneous emphysema and pneumomediastinum, which are not changed.\n\n The nasogastric tube terminates in the gastric body. There is continued\n opacity in both lungs, indicating probably a combination of contusion and\n aspiration. No apparent pneumothorax is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-06 00:00:00.000", "description": "P SKULL (AP, TOWNES & LAT) TRAUMA PORT", "row_id": 876387, "text": " 3:03 PM\n SKULL (AP, & LAT) TRAUMA PORT Clip # \n Reason: assess for metallic fb\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with s/p mvc w/ ? FB left eye\n REASON FOR THIS EXAMINATION:\n assess for metallic fb\n ______________________________________________________________________________\n FINAL REPORT\n SKULL, AP AND LATERAL.\n\n INDICATION: 19-year-old man with status post MVC foreign body.\n\n COMMENTS: AP and lateral radiographs of the skull are reviewed. Again note\n is made of extensive fractures around the left orbit and sinus opacification\n of the left ethmoid and maxillary sinus, which have been described in the CT\n scan yesterday. Please refer to the report of the CT scan performed .\n\n There is ET tube seen. No apparent metallic foreign body is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876432, "text": " 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multiple trauma bilat chest tubes\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE.\n\n INDICATION: 19-year-old man with multiple trauma.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The previously identified extensive subcutaneous emphysema and\n pneumomediastinum have been gradually improving. Bilateral chest tubes remain\n in place. No apparent pneumothorax is identified.\n\n Again, note is made of fracture of the right mid clavicle. The tip of the\n endotracheal tube is identified at the thoracic inlet. A nasogastric tube\n terminates in the gastric body. The right subclavian IV catheter remains in\n place.\n\n There is continued opacity in both lungs, indicating combination of aspiration\n and contusion. The heart is normal in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 876264, "text": " 1:45 PM\n CT ABDOMEN W/CONTRAST; -76 BY SAME PHYSICIAN # \n CT PELVIS W/CONTRAST; -76 BY SAME PHYSICIAN\n 150CC NONIONIC CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n CT RECONSTRUCTION\n Reason: eval for intrabdominal injury\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mvc\n\n REASON FOR THIS EXAMINATION:\n eval for intrabdominal injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, followup of free fluid in the abdomen.\n\n Comparison is made to the CT scan performed earlier on the same day.\n\n TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis was performed\n following administration of 150 cc of intravenous Optiray contrast. Coronal\n and sagittal reformations were also obtained.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The visualized lung bases\n demonstrate evidence of bilateral chest tubes. Trace pneumothoraces are seen,\n right greater left. There is again demonstrated pneumomediastinum and\n subcutaneous air tracking along the flanks bilaterally, left greater than\n right. Dependent consolidations and pulmonary contusions are again\n demonstrated. The liver, spleen, pancreas, adrenals, kidneys, gallbladder,\n and visualized loops of abdominal large and small bowel are within normal\n limits. A small amount of air is noted within the duodenum, appearing\n intraluminal. An NG tube is present within the stomach. The pancreas\n enhances homogeneously. There is again identified a small amount of free\n fluid, which appears less focal on the current study and now seen best along\n the paracolic gutters bilaterally. There is no free intraperitoneal air seen.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters, urinary\n bladder, rectum, sigmoid, and prostate are within normal limits. A trace\n amount of free fluid is seen tracking into the pelvis. There is a right groin\n femoral venous line present. A Foley catheter is present within the bladder.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions. No\n fractures are identified.\n\n IMPRESSION:\n 1. Homogeneous enhancement of the pancreas. No free intraperitoneal air.\n 2. Stable amount of nonfocal diffuse free fluid in the abdomen, appearing to\n have shifted in configuration compared to the prior study.\n 3. Tiny bilateral pneumothoraces.\n 4. Pneumomediastinum and subcutaneous emphysema.\n (Over)\n\n 1:45 PM\n CT ABDOMEN W/CONTRAST; -76 BY SAME PHYSICIAN # \n CT PELVIS W/CONTRAST; -76 BY SAME PHYSICIAN\n 150CC NONIONIC CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n CT RECONSTRUCTION\n Reason: eval for intrabdominal injury\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 876215, "text": " 8:11 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: fx/bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with mvc\n REASON FOR THIS EXAMINATION:\n fx/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe FRI 10:07 AM\n no fractures through carotid-containing structures.\n complex fractures through left orbit including: left lamina papyracea;\n inferior orbital wall and probable prolapse of orbital fat/hematoma into left\n maxillary sinus; left lateral orbital wall; superior orbital wall.\n prolapse of left globe with globe hematoma.\n no identifiable fractures through left optic canal.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man with recent motor vehicle collision. Eye pain.\n\n TECHNIQUE: CT axial images through the sinuses, with coronal and sagittal\n reformats.\n\n FINDINGS: There are extensive fractures involving the left orbit and\n maxillary sinus. There are fractures through walls of the orbit, including\n the lamina papyracea, the superior wall, the lateral wall, the inferior wall\n and the left zygoma. A fracture is also seen through the left nasal bone,\n although it appears to spare the nasolacrimal duct. The inferior floor of\n fracture shows possible small amount of prolapse of orbital contents into the\n maxilla, although the inferior rectus muscle appears to stay within the orbit.\n In the superior aspect of the orbit, a hypodensity reflects probable bone\n fragment within the orbit itself. Additionally, the globe is distorted in\n shape; there is high-density material within the posterior aspect, reflecting\n blood within the globe; blood is seen in the retrobulbar space; and the\n lateral medial rectal muscles appear somewhat distorted. The globe itself\n shows some proptosis, and the lens appears to be detached. In the inferior\n portion, there is an extensive amount of radiopaque foreign body within the\n subcutaneous tissues, and a large soft tissue defect is seen over the superior\n aspect of the orbit, over the left frontal sinus.\n\n The other facial bones appear intact, and although there is extensive\n opacification of the left ethmoid air cells, the other air cells, sphenoid\n sinuses, right maxillary sinus and mastoid air cells appear patent. Air is\n seen dissecting along the longus muscles.\n\n IMPRESSION:\n 1. Extensive facial fractures involving the left orbit, with apparent globe\n rupture, retrobulbar hemorrhage, fracture of every orbital wall and extensive\n foreign bodies and a soft tissue defect surrounding the region.\n 2. No other fractures identified; other sinuses appear clear.\n\n (Over)\n\n 8:11 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: fx/bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Preliminary findings were relayed to the ED dashboard at the time of\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "L TIB/FIB (AP & LAT) LEFT", "row_id": 876217, "text": " 8:42 AM\n TIB/FIB (AP & LAT) LEFT; FEMUR (AP & LAT) LEFT Clip # \n HIP UNILAT MIN 2 VIEWS LEFT; FOOT AP,LAT & OBL LEFT\n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p MVC\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC. Rule out fracture.\n\n FINDINGS: These five exams consist of AP view of the pelvis, AP and lateral\n of the femur, AP and lateral view of the left knee and tibia as well as AP,\n lateral, and oblique view of the left foot.\n\n There is a transverse fracture through the proximal left femoral shaft with\n medial and superior displacement of the distal fragment. . There are several\n small fracture fragments seen at the fracture site.\n\n There is a cortical defect in the anterior cortex of the mid tibial shaft.\n There is no extension through the cortex.\n\n There is a divergent type Lisfranc fracture dislocation of the left foot with\n complete medial dislocation of the first metatarsal with the medial cuneiform.\n There is a fracture of the base of the 2nd metatarsal with lateral\n displacement. A fracture of the 5th metatarsal base is also seen. Evaluation\n of the base of the 3rd and 4th metatarsals are limited.\n\n IMPRESSION:\n 1. Left proximal femoral shaft fracture with overriding of the fracture\n fragments as described above.\n 2. Left tibia cortical defect.\n 3. Complete medial dislocation of the 1st metatarsal with the medial\n cuneiform and fractures of the base of the 2nd and 5th metatarsals with\n lateral displacement. Further evaluation with CT maybe helpful.\n\n These findings were communicated to Dr. on at approx.\n 10am.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 876210, "text": " 7:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: fx/bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n fx/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe FRI 9:51 AM\n extensive facial fractures with left globe hemorrhage, proptosis, fracture of\n lateral orbital wall.\n sinusitis\n no bleed in intracranial space\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year man with facial trauma after MVC. Query\n intracranial manifestations.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: No hydrocephalus, shift of normally midline structures, intra- or\n extraaxial hemorrhage, or acute major vascular territorial infarct is\n identified. Osseous structures are remarkable for the multiple facial\n fractures as identified in the CT sinuses of the same day. No fractures are\n identified in the calvarium. There is a large soft tissue defect along the\n left frontal region, with radiopaque foreign bodies embedded within the skin,\n gas in the subcutaneous tissue, and rupture/hemorrhage, and prolapse of the\n orbit. Another soft tissue defect is seen along the right frontal scalp.\n\n IMPRESSION: No acute intracranial pathology. Please see CT of the sinuses of\n the same day for details regarding the facial fractures and orbit involvement.\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 876211, "text": " 7:39 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n fx/dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe FRI 9:59 AM\n extensive subcutaneous emphysema tracking along anterior paraspinal muscles\n and anterior superior chest wall; extensive pneumomediastinum.\n fracture of left t1 transverse process.\n fracture of right 1st rib.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man status post motor vehicle collision, pain.\n\n TECHNIQUE: CT scan of the cervical spine with coronal and sagittal reformats.\n\n FINDINGS: No fractures are identified in the cervical spine, which maintains\n normal alignment. However, there are fractures seen in the left transverse\n process of C7, T1, and the right first rib. Additionally, small foci of air\n within the spinal canal are seen at this level.\n\n The patient is intubated with nasogastric tube. Extensive subcutaneous\n emphysema is seen dissecting along the longus muscles superiorly, down\n the anterior paraspinal muscles, and into the anterior chest, mediastinum, and\n into the thorax. Small pneumothoraces are identified, and the lungs show\n consolidations. A chest tube is seen on the left.\n\n IMPRESSION:\n 1. No fractures of the cervical spine; however, there are fractures of the\n left transverse processes of C7, T1, right first rib.\n\n 2. Extensive subcutaneous emphysema dissecting along the anterior neck and\n into the chest wall, with pneumomediastinum, bilateral pneumothoraces.\n\n 3. Small foci of air within the spinal canal, suggesting breach of the spinal\n canal at some point. Correlation with CT torso of the same day suggested.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 876212, "text": " 7:40 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: hemorrhage\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n TRAUMA TORSO:\n\n There is no comparison exam.\n\n CLINICAL HISTORY: Status post MVA.\n\n TECHNIQUE: Axial MDCT images of the torso were obtained with IV contrast\n enhancement.\n\n CT CHEST FINDINGS: The mediastinum is clear. There is no intimal flap seen\n in the thoracic aorta. There is no pericardial effusion. There is no pleural\n effusion. Lung windows demonstrate a right pneumothorax extending from the\n level of the carina to the base of the right hemithorax. There is a left\n chest tube present. There is a small left residual apical pneumothorax and a\n smaller focal pneumothorax in the medial left hemithorax at the level of the\n main pulmonary artery. There are ground glass opacities bilaterally most\n consistent with a lung contusion in this setting. There is atelectasis of the\n subsegmental portions of the lungs posteriorly. The tip of the ET tube is\n above the carina.\n\n There is pneumomediastinum. The mediastinal structures are not deviated.\n\n There is a large amount of subcutaneous emphysema best seen outlining the left\n pectoralis muscle. There is a fracture of the right 1st rib. There is a\n fracture of the left C7 transverse process and the left C7-T1 facet joint\n which are described in the separately dictated CT C-spine. Also noted is a\n displaced fracture of the left scapula.\n\n CT ABDOMEN FINDINGS: The liver, spleen, adrenal glands, and kidneys are\n unremarkable. There is periportal edema in the liver consistent with recent\n IV hydration. There is free fluid present in the mid abdomen in the lesser\n sac in pouch and tracking along the pancreas and second and third\n portions of the duodenum. No pancreatic laceration is noted. The pancreas\n enhances homogeneously. There is no pneumoperitoneum. There is no\n extravasation of IV contrast noted.\n\n CT PELVIS FINDINGS: There is no pelvic free fluid. There is gas in the\n urinary bladder secondary to the Foley catheter placement presumably. A right\n femoral venous catheter is present. There is no pelvic fracture.\n\n (Over)\n\n 7:40 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: hemorrhage\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) Right pneumothorax. Tiny left pneumothorax. The left chest tube is\n appropriately placed. There is no mediastinal shift.\n\n 2) Pneumomediastinum. Subcutaneous emphysema.\n\n 3) No evidence of aortic dissection. 4) Bilateral pulmonary contusions.\n\n 5) Fractures involving C7 and T1 as dictated above. Please see the separately\n dictated cervical spine for more details. No other spine fractures are noted\n on this study.\n\n 6) A fracture of the left scapula extending close to the left glenohumeral\n joint. No other spine fractures demonstrated on this study.\n\n 7) Free fluid in the abdomen raises the possibility of injury to the pancreas\n or duodenum. Although no such injury is seen on this study there should be a\n low threshold for repeat CT evaluation of the abdomen if the patient's\n clinical condition deteriorates. There is no pneumoperitoneum.\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "LO FEMUR (AP & LAT) LEFT IN O.R.", "row_id": 876300, "text": " 6:41 PM\n FEMUR (AP & LAT) LEFT IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.; FOOT 2 VIEWS LEFT IN O.R.\n -77 BY DIFFERENT PHYSICIAN\n : TRAUMA PT. W/MULT. INJURIES. LT.IM RODDING OF LT. FEMORAL FX AND LT.FOOT CLOSED REDUCTION W/ RERCUT. PINS INSERTION\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL HISTORY: Left femoral fracture fixation and left foot closed\n reduction.\n\n Six intraoperative views of the left femur and two intraoperative views of the\n left foot are presented for interpretation from .\n\n Left mid shaft femur fracture has been fixed with an intramedullary rod and\n proximal and distal cannulated screws. Multiple mid shaft fracture fragments\n are well apposed, and alignment is nearly anatomic.\n\n Pin placement is seen through the first metatarsal and cuneiform bones into\n the cuboid. A second pin has been placed through the first, second, and third\n metatarsals. Alignment appears grossly anatomic in the left foot after pin\n placement.\n\n IMPRESSION: Fixation of left femoral fracture and percutaneous pin placement\n through the medial aspect of the Lisfranc joint.\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 876207, "text": " 7:32 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n FINDINGS: The two studies include an AP view of the chest and an AP view of\n the pelvis.\n\n CHEST: The right clavicular fracture, right rib fractures, and left scapular\n fractures seen on the CT scan are not well seen on this limited AP chest x-ray\n due to overlying trauma board and incomplete visualization of the osseous\n structures. There is an ET tube with the tip approximately at the carina and\n could be pulled back. An NG tube is seen with the tip in the stomach. There\n is also a left-sided chest tube with the tip in the left apex. There is\n subcutaneous air on the left, outlining the pectoralis major muscle. The\n mediastinal and cardiac silhouette appear within normal limits. There is no\n definite sign of pneumothorax on these limited views.\n\n IMPRESSION: Right clavicular, right rib, and left scapular fracture that were\n seen on the CT are not clearly visualized on this AP view.\n\n HIP: There are no fractures seen in the pelvis. There is a left femoral\n shaft fracture with proximal and medial displacement of the distal fracture\n fragment. The sacroiliac and pubic symphysis joints are intact.\n\n IMPRESSION: Displaced and overriding left proximal femoral shaft fracture.\n\n" }, { "category": "Radiology", "chartdate": "2154-07-06 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 876393, "text": " 4:32 PM\n MR CERVICAL SPINE Clip # \n Reason: please assess for fx, please include T1\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with s/p mvc w/ ? c7 & t1 fx\n REASON FOR THIS EXAMINATION:\n please assess for fx, please include T1\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the cervical spine.\n\n CLINICAL INFORMATION: The patient with motor vehicle accident and question of\n C7-T1 fracture.\n\n TECHNIQUE: T1-, T2-, and inversion recovery as well as gradient echo,\n sagittal, and T2-axial images of the cervical spine were acquired. Correlation\n was made with the CT examination of .\n\n FINDINGS: At the craniocervical junction and from C2-T4 level, the vertebral\n alignment is normal. The vertebral bodies and discs demonstrate normal signal\n and there is no evidence of marrow edema or fracture identified. The facet\n joints are well aligned. The ligamentous structures appear intact without\n evidence of disruption. There is no abnormal signal seen within the\n ligamentous structures. The vertebral flow voids are bilaterally maintained.\n The prevertebral soft tissue thickness is maintained. The spinal cord\n demonstrates normal signal intensities. Soft tissue changes are seen within\n the sphenoid sinus, which could be related to intubation.\n\n IMPRESSION: No abnormal signal is seen within the vertebral bodies or\n ligamentous structures in the cervical region. The vertebral alignment is\n maintained. No intraspinal fluid collection or hematoma is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876676, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p d/c L CT, PTX?\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multiple trauma bilat chest tubes\n\n REASON FOR THIS EXAMINATION:\n s/p d/c L CT, PTX?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Left-sided chest tube removal.\n\n There has been removal of a left-sided chest tube and development of a small\n left apical pneumothorax. Right subclavian vascular catheter and right-sided\n chest tube remain in place. There has been apparent interval removal of both\n nasogastric tube and endotracheal tube. Cardiac and mediastinal contours are\n stable. There is increasing patchy opacity within the left retrocardiac\n region, partially obscuring the descending thoracic aortic interface. Right\n basilar opacity is not significantly changed. Subcutaneous emphysema persists\n in the left chest wall, and note is again made of a right clavicular fracture.\n\n IMPRESSION:\n 1. Small left apical pneumothorax following chest tube removal.\n 2. Bibasilar opacities, with interval worsening in the left lower lobe.\n\n Findings communicated to Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2154-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876278, "text": " 3:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Check chest tube position, s/p bronchoscopy/EGD\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multiple trauma\n REASON FOR THIS EXAMINATION:\n Check chest tube position, s/p bronchoscopy/EGD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Multiple trauma. Check chest tube position.\n\n PORTABLE AP CHEST AT 15:21: Comparison is made to the torso CT scan from\n earlier the same day. Endotracheal tube tip is at the level of the thoracic\n inlet. NG tube is in stomach. Bilateral apical chest tubes are present.\n There is no definite pneumothorax although there is extensive subcutaneous\n emphysema. There is extensive pneumomediastinum with sharply demarcated right\n and left cardiac borders. There is a displaced fracture of the distal right\n clavicle.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-07-06 00:00:00.000", "description": "Report", "row_id": 1287465, "text": "RESP CARE: Pt recieved from OR intubated with 7.0ETT/24 lip, on AC all noc. SEE CAREVUE FOR SPECIFICS. Lungs very din RLL/Coarse, Dim LLL. Bilat chest tubes in place/ ABGs acceptable. ALB MDI given with good effect. Plat pressures low. Continue full support\n" }, { "category": "Nursing/other", "chartdate": "2154-07-06 00:00:00.000", "description": "Report", "row_id": 1287466, "text": "Nursing Progress Note\nS/ pt readmitted from OR to TSICU, OR procedures performed are as follows: left femoral IM nail, I&D left tibia,closed reduction, perc. pinning L 2nd metatarsal, repair of foreheadlacs, left scleral wound closure, repositioning of uveal tissue, exploration and repair of left ruptured globe.\n pt initially paralysed from OR procedure, pt on propofol and fentanyl gt, pt now able to respond to verbal stimuli, follws commands with all extremities. Pt is nodding head appropriately to questions. Rt pupil is reactive to light, left eye is covered. Pt cervical collar remains intact and logroll precautions have been maintained\n pt is hemodynamicaly stable, except after pt has been resedated after neuro assessment, . Pt becomes hypotensive and has required 250cc bolus x2. IVF is at 125cc hr of RL.Hct is 27.5 INR 1.3. he remains in NSR with pedal pulses palpable bilaterally. Feet initially cold but warming. Compression sleeves on.\n pt remains ventialted, TV increased to 600 with rate of 20 , peep of 8 , FIO2 decreased from 100% to 40 % with sats of 100%. Breath sounds decreased on rt side with insp wheeze, inhalers started. pt has mod amt of bloody secretions when suctioned. Pt has bilaterally CT draining small amts of serosanguinous drainage, no airleaks noted.\n pt has oral gastric tube to low constant suction, no draining small amt of brown drainage, abd is soft.\n pt u/o is adequate.\nskin- pt has abraisions and lacs on arms and legs, all have minimal drainage, skin lacs on face are pink with small amt of serosanguinous drainage and are open to air. Left eye , remains covered with eye shield. Pt has 3 wounds from rodding procedure , dsg are intact with serosaguinous draiange. left foot appears to be casted with ace wrap, toes have good cap fill. skin on back and buttucks is intact.\nsocial- pt entire family in to visit when he returned form OR, pt mother took family to htel to get some rest. Pt uncle stayed and came in to visit this Am. pt family inormed of operative procedures from both opthamology and orthopedics.\nA/ pt is stable, tol decrease in FIO2 to 40% with good ABG and decreased lactate of 2. Pt neuro intact. Cont with plan of care, pt will still need facial fractures repaired and further surgery on left foot. Nutrition, sliding scale coverage, need for sc heparin needs to be addressed.\n" }, { "category": "Nursing/other", "chartdate": "2154-07-06 00:00:00.000", "description": "Report", "row_id": 1287467, "text": "NPN 0700-1900\n Events- MRI of cervical spine done. Plastics sutured more areas of scalp at bedside.\n\n Pt easily arousable on 60mcg/kg/min of propofol and able to FCs and MAEs. Throughoutday gradually needed to increase sedation. Pt awoke at one point and reaching for ETT requiring 3 people to safely restrain him. MD have not cleared TLS yet despite several requests, unclear why/plan to do so? MRI of C-spine done, HO did not want TLS when specifially asked as it was mentioned in rounds thia am.\nOpthamology- Want OD to remain moist at all times, erythromycin and lacrilube ointment to alternate one every 2hrs. However eye staying pretty well lubricated with amt applied much\nResp- No vent changes, ABGs pending. Lungs clear with decreased bases and scant secretions. Sats 98-100%, RR 20-24.\n\nCV- BP labile at times (see carevue), esp with increased sedation. HCT dropping 27-22.4, one pending, and HO aware, not wanting to transfuse until under 21 despite labile BP. SR-ST. Temp varies 2 degrees between rectal vs oral/axillary. Lytes repleted and new set pending.\nSkin w/d, impairements as documented. TLC inserted and placement confirmed. Fem line to be d/c'd.\n\nGI/GU- Abd soft, +BS. OGT in place, brown to ?dark blood in drainage.\nTeam not wanting to feed in case of duodenal injury, yesterday CT scan of abd done x2 and UGI endoscopy. Foley patent with good UO. No stool.\n\nPlan- Remove fem line, clear TLS asap due to pt intubated with pulm contusions and large amt facial swelling who would greatly benefit from elevated HOB. Clarify plan from Ortho and any other possible sx on foot.\n" }, { "category": "Nursing/other", "chartdate": "2154-07-07 00:00:00.000", "description": "Report", "row_id": 1287468, "text": "Resp Care Note, Pt remains on current vent settings with good ABG'S. Sedated with propofol and fentanyl.Temp 100.8 .Given MDI'S prn. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2154-07-07 00:00:00.000", "description": "Report", "row_id": 1287469, "text": "Nursing Progress Note\nS/O- Review of Systems\n pt initially in 110 mcg/kg/min of propofol after returning from MRI, after giving nursing care to pt, propofol decreased to 85 mcg/kg/min,. Fentanyl remains at 125mcg/hr. pt has remained sedated except during periods of care where he has required increased propofol to keep him from sittin up and attempting to pull ET tube. pt has not opened his rt eye, Pupil is reactive briskly, he follows commands with all extremities, weakly with left toes. C collar remains on,logroll precautions cont to be maintained.\n pt has been hemodynamically stable, required 2 units of packed cells for hct of 21, up to 25 after both transfusions, clotting studies pending. lytes being repleted. CVP 10. pedal pulses palpable, feet and hands are now warm.\nResp- no vent changes made , pt has metabolic alkolosis with ph of 7.50 and PCO2 of 37-40. pt has no secretions when suctioned breath sounds are clear. Chest tubes are draining min amts of serosanquinous drainage.\n pt OG tube remains to low constant suction, abd is soft with hypoactive bowel sounds, OG drainage is brown.\n pt tmax is 101, pt remains on gentamycin and cefazolin, gent trough sent\nendo- pt has not required insulin coverage.\nskin- Pt lacs on arms and legs are pink with min to no drainage. cast remains on left foot. Dsg over left upper leg are intact, mid leg wound has developed large ecchymotic area. Facial wound is red and still oozing serosaquinous drainage. bacitracin applied and head was redressed. Left eye has been keep moist with erythromycin ointment and eye patch reapplied.\nsocial- pt family and friends in to visit throughout the evening hours. Pt mom was updated with progress. She seems to be doing well and has many family supports.\nA/P- Evaluate need for continued logroll precautions, need for nutrition. Cont to follow hct. Discuss plan for further surgery on left foot, facial fractures and left eye. Cont to monitor , assess and support.\n" }, { "category": "Nursing/other", "chartdate": "2154-07-07 00:00:00.000", "description": "Report", "row_id": 1287470, "text": "NPN 0700-1900\n Pt extubated.\n\nNeuro- intact. No memory of accident and explained accident and injuries to pt. Tearful at times esp when discussing injury to eye and poor prognosis but most update, very talkative and joking with family and friends. he was an \"idiot\" and very worried his grandfather is angry at him, but whole family very loving and supportive. Weak movements of BUEs in part due to pain. PAin med changed to MSO4 PCA.\n\n Pt weaned and extubated at 1150. Placed on 40% face tent and increased to 60% when sats in low 90s. Cont albuteral PRN wheezing. Pt has mod strong cough and able to expectorate think yellow blood tinged secretions.\n\nCV- SR-ST. Aline dampening, good blood return, cuff on. Stable BP, see carevue for #s. T max 101.4 and BC drawn from lines and periperal stick. Urine sent, needs sputum. Skin w/d. Bacitracin to head lacs and DSD applied. Boggy hematoma/collection under top and left side of scalp. HCT 22 at 9am but 25 again in afternoon(no intervention). IVF changed to D51/2NS with 20KCL at 80cc/h.\n\nGI/GU- Abd soft, hypo BS. TAking clear liquids well, no c/o nausea. Intact gag, no signs aspiration. No BM. Adeq UO. OGT removed with extubation.\n\nSocial- Family spoke with plastics, opthamology and ICU team. Very happy with pt progress.\n\nPlan- To OR with Dr on Thursday for L foot. Needs gent trough and peak around next dose. Optho suggests checking L eye with pen light when lube. Transfer to floor tomorrow if remains this stable.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-07-08 00:00:00.000", "description": "Report", "row_id": 1287471, "text": "Nursing Progress Note\nS/O- Revies of Systems\nNeuro- intact, moving all extremities purposefully and to command, min movement in left toes. pt is alert and oriented.C collar maintained.\n pt in NSR with stable hemodynamics, hct stable.palpable pedal pulses.\n pt has remained extubated with good sats,on face tent at 15l. pt cooperates with Coughing and deep breathing, productive of thick brown sputm, specimen sent for culture. Chest tubes remain in place with min amts of serosang drainage.\n pt taking only water and when he increased from sips to approx 100cc intake he c/o nausea. abd remains soft with hypoactive bowel sounds, no stool passed.\n - pt is spontaneously diuresing >200cc hr, IVF at 80cc hr, magnesium being repleted.\nendo- sugars WNL.\n pt is now afebrile, cont on gent and cefazolin, gent peaklevel sent.\nskin- no change in skin, wounds are pink and healing, bacitracin applied to facial sutures.\neye- pt eye is less edematous and he cont to see light from fashlight when shield is off.\npain-PCA being used for pain, not always effectively, slleps and wakens with lots of pain and it takes a fair amt of time with PCA to get pain under control.\nSocial- lots of family and friends, friends have been told that they can no longer stay at the hospital at night, that needs to sllep and not be disturbed as well as they also need to get some rest. does like having a family member sit with him at times.\nA/ pt is doing very well and should be ready for transfer to floor. Visiting limits need to be established for friends. Cont with plan of care\n\n" }, { "category": "Nursing/other", "chartdate": "2154-07-05 00:00:00.000", "description": "Report", "row_id": 1287463, "text": "Admit Note\n Pt is an 19yo unrestrained driver s/p rollover, found in back seat of the car. Trnasfer from OSH after intubation and L PTX needle decompression (in field) and CT insertion. Pt injuries include evulsion of L face and scalp, L ruptured globe with fx of every wall, fx L nasal bone and L zygoma with multiple foriegn bodies and retrobulbar hemmorhage. Bilateral Pneumothorax, first rib fx with subcutaneous air, C7 transverse process fx, C7-T1 facet joint fx,pneumomediastinum, displaced L scapula fx, free fluid in abdomen, L femur shaft fx, cortical defect mid tibia, Lisfranc fx complex of foot ( first metatarsal with complete medial displaced, metatarsal dislocated with fx across.\n\nPMHx- Exercise induced asthma when in highschool, hernia repair and tonsilectomy as an infant.\n\nALL- Codeine\n\n pt arrived to ICU and required pain meds and better sedation. R CT placed. Opthomolgy consult done, plastics at bedside for exploration and suturing of facial evulsion, bronchscopy with post CXR and endoscopy done, repeat abd CT with oral and IV contrast. Pt to OR at 1800 for femur rodding and opthomology will stablize orbit and globe.\n\n Pt has no head injury on CT. When light on sedation moves all extremeties, well sedated on propofol and fentanyl gtt for procedures.\n\nResp- On A/C with no vent changes due to constnat procedures and traveling. ABGs with Metabolic acidosis with improvement after fluid bolus. Lungs diminished throughout, scant secretions. CTs intact with serosang drainage, no creptis felt.\n\nCV- ST. Aline placed and higher than cuff by 40 points. Closer correlation with lower BPs. T-max 103.6, tylenol suppository given. Lytes repleted and set pending. Anesthesia aware may need more repleting. Skin warm and dry. Minor lacs and abrasions on RLE and R arm. Small lac on R hand overvring finger knuckle which Dr place steristrips over, appeared to be to bone. BP occassionally labile with sedation and total 3l fluid bolus given.\n\nGI/GU- OGT replaced after endoscopy and placement confirmed on CXR and with air. Small amt bilious drainage. Abd soft, +BS. Foley patent with adeq UO. Pt had repeat Abd CT and endoscopy to r/o injury after intial CT had shown free air, all negative.\n\n Pt is a sophmore at a college in NJ. Father deceased years ago, mom, brother and sister live in . Pt mpm denies drug or tobacco hx but does drink alcohol socially. Pt had left Mom's at 11pm to play cards with friends last night nd accident occured at 0430. ETOH 150s.\n\n Pt to OR at 1800 for ortho and optamology procedures.\n" }, { "category": "Nursing/other", "chartdate": "2154-07-05 00:00:00.000", "description": "Report", "row_id": 1287464, "text": "Social Work\nSW met with pt's mother this evening to provide support and obtain social info. Pt is in surgery for mult fx this evening. Pt's family (mult immediate and extended members) are all here awaiting the results. mother, , reported that pt is a very intelligent young man who will be going into his sophomore year of college (Drew) in NJ this Fall. Pt is studying Arabic International Relations and was due for an internship with the United Nations. Pt has one brother, a sister, and a girlfriend who attends college elsewhere. father has been deceased for some time, which states has made her more prepared to handle this situation. Pt's family all reside in NH, but is staying in the local Best Western for the time being. SW provided contact info and will be following , however, is aware of weekend SW for support.\n" } ]

[ { "category": "Echo", "chartdate": "2143-04-30 00:00:00.000", "description": "Report", "row_id": 85626, "text": "PATIENT/TEST INFORMATION:\nIndication: Preoperative assessment AVR\nHeight: (in) 68\nWeight (lb): 202\nBSA (m2): 2.05 m2\nBP (mm Hg): 132/82\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 13:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild global LV\nhypokinesis. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Moderate AS\n(area 1.0-1.2cm2) Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Trivial MR.\n\nTRICUSPID VALVE: No TS. Mild [1+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild global left ventricular\nhypokinesis (LVEF = 50 %) more prominent in the inferior/posterior walls.\nThere is no ventricular septal defect. Right ventricular chamber size is\nnormal. with borderline normal free wall function. The aortic root is mildly\ndilated at the sinus level. The aortic valve leaflets are severely\nthickened/deformed. There is moderate aortic valve stenosis (valve area\n1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Trivial mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2143-05-02 00:00:00.000", "description": "Report", "row_id": 85625, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Atrial fibrillation. Chest pain. Hypertension. Palpitations. Shortness of breath. Syncope.\nStatus: Inpatient\nDate/Time: at 09:19\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. No\nthrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, 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. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. Calcified tips of\npapillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: The patient was under general anesthesia throughout the\nprocedure. The patient received antibiotic prophylaxis. The TEE probe was\npassed with assistance from the anesthesioology staff using a laryngoscope. No\nTEE related complications. Results were personally reviewed with the MD caring\nfor the patient.\n\nConclusions:\nPRE-CPB:1. The left atrium is mildly dilated. No thrombus is seen in the left\natrial appendage.\n2. No atrial septal defect is seen by 2D or color Doppler.\n3. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed (LVEF= 40 %).\n5. Right ventricular chamber size and free wall motion are normal.\n6. The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque. There are simple atheroma in the\ndescending thoracic aorta.\n7. There are three aortic valve leaflets. The aortic valve leaflets are\nseverely thickened/deformed. There is critical aortic valve stenosis (valve\narea <0.8cm2). Mild (1+) aortic regurgitation is seen.\n8. Mild (1+) mitral regurgitation is seen.\n9. There is a trivial/physiologic pericardial effusion.\nDr. was notified in person of the results.\n\nPOST-CPB: On infusion of phenylephrine. AV pacing briefly. Well-seated\nbioprosthetic valve in the aortic position. Trivial central AI, no\nparavalvular leak. Peak gradient is 16 mmHg with a cardiac output of 5.5\nL/min. MR remains 1+. The aortic contour is normal post decannulation.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-05-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1234921, "text": " 11:28 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate new line\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p AVR, RIJ changed over wire to TLC\n REASON FOR THIS EXAMINATION:\n evaluate new line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic valve replacement. New right internal jugular\n triple-lumen catheter.\n\n COMPARISONS: .\n\n FINDINGS: The patient has been extubated. A new right internal jugular\n catheter terminates in the mid SVC. There is no pneumothorax. Low lung\n volumes and obscuration of left heart border are likely due to voume loss from\n recent surgery. There is no pleural effusion. The Swan-Ganz catheter has\n been removed. The mediastinal drain is still in place.\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2143-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235058, "text": " 11:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx after CT removal\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with AVR\n REASON FOR THIS EXAMINATION:\n ? ptx after CT removal\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: The patient is status post median sternotomy and aortic valve\n replacement. Interval removal of midline drain with no evidence of\n pneumothorax or pneumomediastinum. Stable post-operative appearance of the\n cardiomediastinal contours. Slight worsening of retrocardiac atelectasis and\n persistent small left pleural effusion. Probable small right pleural effusion\n as well.\n\n" }, { "category": "Radiology", "chartdate": "2143-04-29 00:00:00.000", "description": "MANDIBLE (PANOREX ONLY)", "row_id": 1234396, "text": " 8:39 PM\n MANDIBLE (PANOREX ONLY) Clip # \n Reason: r/o dental issues\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n r/o dental issues\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preop AVR. Assess dental infections.\n\n A single Panorex view of the mandible shows single remaining maxillary and\n mandibular incisor teeth. No bone destruction and the partially visualized\n maxillary sinuses are normally aerated.\n\n" }, { "category": "Radiology", "chartdate": "2143-04-29 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1234395, "text": " 8:39 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man\n REASON FOR THIS EXAMINATION:\n pre-op AVR\n ______________________________________________________________________________\n WET READ: JBRe TUE 5:55 AM\n Enlarged left atrium. No acute process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pre-operative for aortic valve surgery.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: Lung volumes are normal. Normal size of the cardiac silhouette.\n Moderate tortuosity of the thoracic aorta. No pneumonia, no pulmonary edema.\n No pleural effusions. No lung nodules or masses.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-05-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1234785, "text": " 1:11 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: cardiac surgery fast track. eval for ptx, effusions. cvicu p\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p AVR\n REASON FOR THIS EXAMINATION:\n cardiac surgery fast track. eval for ptx, effusions. cvicu provider is \n - please page her if there is concern with findings\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cardiac surgery fast-track, evaluate for effusion or\n pneumothorax.\n\n TECHNIQUE: A semi-erect portable chest view was read in comparison with prior\n radiographs from .\n\n FINDINGS:\n\n A Swan-Ganz catheter through the right internal jugular approach terminates\n approximately at the level of main pulmonary artery. Endotracheal tube tip\n ends 3 cm above the carina and is appropriate. Orogastric tube is seen to end\n just above the gastroesophageal junction. Consider advancing it further by\n 8-9 cm for appropriate seating. Pleural effusion if any is minimal on the\n left side. There is no pleural effusion on the right side. There are no lung\n opacities of concern. The heart size is top normal. There is no widening of\n the mediastinum. Bilateral hila are normal. There are two mediastinal drain\n chest tubes ending in the lower mediastinal compartment.\n\n Dr. conveyed the findings regarding the orogastric tube with nurse,\n , on at approximately 3:16 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-04-30 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1234430, "text": " 7:46 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: hx of dizziness\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man pre-op AVR\n REASON FOR THIS EXAMINATION:\n hx of dizziness\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with a history of aortic valve regurgitation,\n with dizziness, for preoperative evaluation for carotid artery stenosis.\n\n COMPARISON: None.\n\n BILATERAL CAROTID ULTRASOUND: scale and color Doppler son was\n performed of the right and left ICA, CCA, ECA, and vertebral arteries.\n\n On the right, mild heterogeneous plaque is seen within the ICA bulb.\n Antegrade flow is seen within the vertebral artery. Following velocity\n measurements were obtained: Proximal ICA 94/26 cm/sec, mid ICA 59/14 cm/sec,\n distal ICA 86/24 cm/sec, CCA 74/20 cm/sec, ECA 84 cm/sec, vertebral artery 46\n cm/sec, right ICA/CCA ratio 1.27.\n\n LEFT: Mild heterogeneous plaque is seen within the proximal ICA/bulb.\n Antegrade flow is seen within the vertebral artery. Following velocity\n measurements were obtained: Proximal ICA 79/19 cm/sec, mid ICA 54/13 cm/sec,\n distal ICA 78/20 cm/sec, CCA 72/18 cm/sec, ECA 89 cm/sec, vertebral artery 57\n cm/sec, left ICA/CCA ratio 1.1.\n\n IMPRESSION: Findings consistent with less than 40% stenosis bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-05-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1235132, "text": " 11:50 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u LLL process\n Admitting Diagnosis: AORTIC STENOSIS\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with avr/maze\n REASON FOR THIS EXAMINATION:\n f/u LLL process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST X-RAY OF \n\n COMPARISON: radiograph.\n\n FINDINGS: The patient is status post recent median sternotomy and aortic\n valve surgery. Cardiomediastinal contours are stable in the postoperative\n period. Atelectasis in the left retrocardiac region has slightly improved\n since the previous examination. Right retrocardiac atelectasis is unchanged.\n Small bilateral pleural effusions are present, left greater than right.\n\n IMPRESSION: Improving left retrocardiac atelectasis. Persistent small\n pleural effusions, left greater than right.\n\n\n" }, { "category": "ECG", "chartdate": "2143-05-02 00:00:00.000", "description": "Report", "row_id": 220442, "text": "Sinus rhythm. Left atrial abnormality. A-V conduction delay. Non-specific\nST-T wave changes. Compared to the previous tracing of sinus rhythm is\nrecorded.\n\n" }, { "category": "ECG", "chartdate": "2143-04-29 00:00:00.000", "description": "Report", "row_id": 220443, "text": "Atrial fibrillation with premature ventricular complex. Leftward axis.\nEarly R wave transition. Non-specific ST segment changes in the lateral\nand high lateral leads. Compared to the previous tracing of sinus\nrhythm is no longer present.\n\n" } ]