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[ { "category": "Nursing", "chartdate": "2164-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549809, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549811, "text": "87yof with h/o HTN, DM2, recent STE AMI +trop 39.5 on ,\n treated medically without heart cath. Echo at that time revealed LVEF\n 30% with anterior AK, several septal HK, apical HK, and mid-inferior\n wall moderate HK. Treated for LLL pneumonia and UTI at that time and\n went to rehab . While at rehab she developed chest pain and SOB\n and was transferred cath lab for anterior STE. Heart cath\n revealed: pLMCA mild dissection with 40% mid and 40% distal, mLAD 99%\n complex lesion, 80% Ramus, mLCX 100% with late filling of OM, mRCA 100%\n complex lesion with R>L collaterals, dRCA 80% with L>R collaterals. No\n PCI and cardiac surgery to be consulted today. Transferred to the CCU\n for close monitoring\n .\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 90\ns. No c/o chest pain or SOB although pt feels more comfortable\n with oxygen on. Right femoral groin stable without bleeding or\n hematoma. Feet warm and pedal pulses weakly palpable.\n Action:\n Received lopressor 25mg at 2100 for persistent HR >90. Increased\n lopressor dose at midnight to 50mg three times a day.\n Response:\n HR decreased into the 70\ns after increase dose of lopressor, SBP\n remained stable\n Plan:\n Continue to monitor for further chest pain. Goal to keep HR <80. Hold\n Lisinopril in lieu of lopressor. Continue to keep pt and family aware\n of POC as discussed in multi disciplinary rounds.\n" }, { "category": "Physician ", "chartdate": "2164-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 549813, "text": "Chief Complaint:\n 24 Hour Events:\n SHEATH - START 09:54 AM\n EKG - At 10:33 AM\n SHEATH - STOP 11:04 AM\n CARDIAC CATH - At 11:34 AM\n 3vd\n CARDIAC CATH - At 11:34 AM\n metoprolol titrated up to 50mg and HR decreased from 90's tp 70's.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 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: 36.7\nC (98\n HR: 80 (73 - 92) bpm\n BP: 100/55(66) {81/44(56) - 120/83(86)} mmHg\n RR: 15 (4 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 1,702 mL\n 54 mL\n PO:\n 800 mL\n TF:\n IVF:\n 902 mL\n 54 mL\n Blood products:\n Total out:\n 2,045 mL\n 90 mL\n Urine:\n 2,045 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n -343 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 9.8 g/dL\n 174 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 141 mEq/L\n 28.6 %\n 8.0 K/uL\n [image002.jpg]\n 10:01 AM\n 05:27 PM\n WBC\n 8.0\n Hct\n 28.6\n Plt\n 320\n Cr\n 0.8\n TropT\n 1.05\n 0.90\n Glucose\n 174\n Other labs: PT / PTT / INR:15.3/43.9/1.3, CK / CKMB /\n Troponin-T:44/3/0.90, Ca++:9.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n 87-year-old woman with history of HTN, DM2 was transferred from OSH\n after having recurrent chest pain s/p anterolateral MI 1 week ago, with\n cath showing 3-vessel disease, being medically managed per patient's\n wish.\n # CORONARIES: mid-LAD infarct and old interfior MI per ECG. Cath showed\n 3-vessel disease. Not CABG candidate given patient's wish and advanced\n age.\n - continue metoprolol, ASA, clopidogrel, lisinopril, statin; titrate BB\n to HR in the 50s if BP permits\n - consider adding on nitrates by discharge\n - continue telemetry for now\n - post-cath groin check\n .\n # PUMP: recent echo showed EF 30% with anterior wall akinesis, several\n septal hypokinesis, apical hypokinesis, and mid-inferior wall moderate\n hypokinesis; no valvular abnormality. Stable BP currently. No evidence\n of heart failure.\n - continue ACEI and BB\n .\n # RHYTHM: sinus, no active issue\n .\n # HTN:\n - continue BB, ACEI for now\n .\n # DM2:\n - hold metformin and glyburide while in hospital\n - start insulin s.s.\n - diabetic diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2164-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 549828, "text": "87yof with h/o HTN, DM2, recent STE AMI +trop 39.5 on ,\n treated medically without heart cath. Echo at that time revealed LVEF\n 30% with anterior AK, several septal HK, apical HK, and mid-inferior\n wall moderate HK. Treated for LLL pneumonia and UTI at that time and\n went to rehab . While at rehab she developed chest pain and SOB\n and was transferred cath lab for anterior STE. Heart cath\n revealed: pLMCA mild dissection with 40% mid and 40% distal, mLAD 99%\n complex lesion, 80% Ramus, mLCX 100% with late filling of OM, mRCA 100%\n complex lesion with R>L collaterals, dRCA 80% with L>R collaterals. No\n PCI and cardiac surgery to be consulted today. Transferred to the CCU\n for close monitoring\n .\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 90\ns. No c/o chest pain or SOB although pt feels more comfortable\n with oxygen on. Right femoral groin stable without bleeding or\n hematoma. Feet warm and pedal pulses weakly palpable.\n Action:\n Received lopressor 25mg at 2100 for persistent HR >90. Increased\n lopressor dose at midnight to 50mg three times a day.\n Response:\n HR decreased into the 70\ns after increase dose of lopressor, SBP\n remained stable\n Plan:\n Continue to monitor for further chest pain. Goal to keep HR <80. Hold\n Lisinopril in lieu of lopressor. Continue to keep pt and family aware\n of POC as discussed in multi disciplinary rounds.\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n STEMI\n Code status:\n Height:\n 63 Inch\n Admission weight:\n 62.7 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH: Angina, CAD, Hypertension, MI\n Additional history: recent pna and uti\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:57\n Temperature:\n 98.4\n Arterial BP:\n S:113\n D:54\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 84 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 81 mL\n 24h total out:\n 345 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:50 AM\n Potassium:\n 3.8 mEq/L\n 05:50 AM\n Chloride:\n 101 mEq/L\n 05:50 AM\n CO2:\n 31 mEq/L\n 05:50 AM\n BUN:\n 25 mg/dL\n 05:50 AM\n Creatinine:\n 1.0 mg/dL\n 05:50 AM\n Glucose:\n 220 mg/dL\n 05:50 AM\n Hematocrit:\n 31.4 %\n 05:50 AM\n Finger Stick Glucose:\n 288\n 05:00 PM\n Valuables / Signature\n Patient valuables: Dentures: (Upper, Lower )\n Other valuables: partial bottom\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 8am\n" }, { "category": "Nursing", "chartdate": "2164-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549786, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n ST elevation in V1 and V2\n Action:\n Pt went to cath lab was found to have 3vd, cardiac monitoring initiated\n , labs obtained, weight obtained on arrival, sheath removed from right\n groin all pulses evaluated site inspected and monitor, ecg obtained.\n Assessed for chest pain, o2 4liters via nc, pt received welcome packet,\n cardiac teaching done\n Response:\n Pt has remained in nsr hr 91, trop1.05, right groin site clean dry\n intact small hematoma at site, pulses dopplerable, ecg showed st\n elevation in leads v1 and v2, o2 sats have been 92 on 2 liters, pt\n understands some cardiac teaching needs reinforcement\n Plan:\n Continue c bedrest, continue teaching pt and family memebers, maintain\n o2 sats >95%, next ckmb due\n" }, { "category": "Nursing", "chartdate": "2164-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549787, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n ST elevation in V1 and V2\n Action:\n Pt went to cath lab was found to have 3vd, cardiac monitoring initiated\n , labs obtained, weight obtained on arrival, sheath removed from right\n groin all pulses evaluated site inspected and monitor, ecg obtained.\n Assessed for chest pain, o2 4liters via nc, pt received welcome packet,\n cardiac teaching done\n Response:\n Pt has remained in nsr hr 91, trop1.05, right groin site clean dry\n intact small hematoma at site, pulses Doppler able, ecg showed st\n elevation in leads v1 and v2, o2 sats have been 92 on 2 liters, pt\n understands some cardiac teaching needs reinforcement\n Plan:\n Continue c bed rest, continue teaching pt and family members, maintain\n o2 sats >95%, next ckmb due , continue to monitor pulses in feet\n" }, { "category": "Nursing", "chartdate": "2164-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549789, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n ST elevation in V1 and V2\n Action:\n Pt went to cath lab was found to have 3vd, cardiac monitoring initiated\n , labs obtained, weight obtained on arrival, sheath removed from right\n groin all pulses evaluated site inspected and monitor, ecg obtained.\n Assessed for chest pain, o2 4liters via nc, pt received welcome packet,\n cardiac teaching done\n Response:\n Pt has remained in nsr hr 91, trop1.05, right groin site clean dry\n intact small hematoma at site, pulses Doppler able, ecg showed st\n elevation in leads v1 and v2, o2 sats have been 92 on 2 liters, pt\n understands some cardiac teaching needs reinforcement\n Plan:\n Continue c bed rest, continue teaching pt and family members, maintain\n o2 sats >95%, next ckmb due , continue to monitor pulses in feet\n pt will be evaluated for CABG.\n Impaired Skin Integrity\n Assessment:\n Pink coccyx\n Action:\n Pt repositioned frequently aloe vesta cream applied\n Response:\n Area not pink\n Plan:\n Continue to frequently turn applied aloe vesta cream to skin\n" }, { "category": "Physician ", "chartdate": "2164-02-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 549777, "text": "Chief Complaint: recurrent chest pain, s/p anterolateral MI one week\n ago\n HPI:\n 87-year-old woman with history of HTN, DM2 was transferred from OSH\n after having recurrent chest pain s/p anterolateral MI 1 week ago. On\n patient presented to OSH with chest pain, found to have STE in\n V1 and V2. Because she presented 36 hours after the event, she did not\n undergo emergent catherization. Did not receive any thrombolytics.\n Treated with heparin gtt for 48 hours, ASA, metoprolol, and\n simvastatin. Troponin peaked at 39.54. Echo showed EF of 30% with\n anterior wall akinesis, several septal hypokinesis, apical hypokinesis,\n and mid-inferior wall moderate hypokinesis; no valvular abnormality.\n Lisinopril was continued. Diltiazem was switched to metoprolol.\n Clopidogrel was added.\n .\n Of note, patient was also found to have a LLL pneumonia, treated with\n ceftriaxone and azithromycin. She had an E. coli UTI treated with\n ceftriaxone. Patient was discharged to rehab on .\n .\n On patient had recurrent dull, substernal chest pain with mild\n dyspnea, presented to Hospital, was trasferred to for\n cath. Cath revealed 3-vessel disease; hence, no PCI was done. Per\n patient's wish, no CABG is considered, and she is being managed\n medically.\n .\n .\n On arrival to the CCU patient had stable vitals, alert, awake,\n chest-pain free.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 325 mg qday\n clopidogrel 75 mg qday\n glyburide 5 mg qday\n metoprolol 25 mg \n MVI\n simvastatin 40 mg qday\n levoflox 750 mg qday (last dose )\n lisinopril 10 mg qday\n metformin 500 mg \n calcium 1200 mg qday\n vitamin D 800 units qday\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS:: Diabetes (+), Dyslipidemia (+), Hypertension\n (+)\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: none\n -PACING/ICD: none\n 3. OTHER PAST MEDICAL HISTORY: stroke\n No family history of early MI, otherwise non-contributory\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n On review of systems, she reports history of \"small\" stroke 5-6 years\n ago. Denies any history of deep venous thrombosis, pulmonary embolism,\n bleeding at the time of surgery, myalgias, joint pains, cough,\n hemoptysis, black stools or red stools. She denies recent fevers,\n chills or rigors. She denies exertional buttock or calf pain.\n .\n Cardiac review of systems is notable for dull chest pain, but no\n dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle\n edema, palpitations, syncope or presyncope.\n Flowsheet Data as of 11:02 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 86 (84 - 86) bpm\n BP: 131/63(90) {123/63(90) - 131/94(103)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 100%\n Height: 63 Inch\n Total In:\n 76 mL\n PO:\n TF:\n IVF:\n 76 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -863 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n VS: T 97.7, BP 108/80, HR 86, RR 24, O2 sat 100%4L NC\n GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 9 cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. 2/6 systolic murmur at apex. No thrills, lifts. No S3 or\n S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB from anterior with no\n crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Labs / Radiology\n 320 K/uL\n 9.8 g/dL\n 174 mg/dL\n 0.8 mg/dL\n 23 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 141 mEq/L\n 28.6 %\n 8.0 K/uL\n [image002.jpg]\n \n 2:33 A12/28/ 10:01 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 8.0\n Hct\n 28.6\n Plt\n 320\n Cr\n 0.8\n Glucose\n 174\n Other labs: PT / PTT / INR:15.3/43.9/1.3, Ca++:9.0 mg/dL, Mg++:1.7\n mg/dL, PO4:3.6 mg/dL\n Imaging: 2D-ECHOCARDIOGRAM: (OSH) EF of 30% with anterior wall\n akinesis, several septal hypokinesis, apical hypokinesis, and\n mid-inferior wall moderate hypokinesis; no valvular abnormality\n .\n CARDIAC CATH: right dominant\n LCMA: proximal mild dissection, 40% mid, 40% distal\n LAD: 99% complex mid\n LCx: 80% ramus, 100% mild circumflex with late filling of major OM\n RCA: complex 100% mid, 80% distal\n ECG: sinus rhythm, rate 95 bpm, nl axis, STE in V1-V2, Q waves in III\n Assessment and Plan\n 87-year-old woman with history of HTN, DM2 was transferred from OSH\n after having recurrent chest pain s/p anterolateral MI 1 week ago, with\n cath showing 3-vessel disease, being medically managed per patient's\n wish.\n # CORONARIES: mid-LAD infarct and old interfior MI per ECG. Cath showed\n 3-vessel disease. Not CABG candidate given patient's wish and advanced\n age.\n - continue metoprolol, ASA, clopidogrel, lisinopril, statin; titrate BB\n to HR in the 50s if BP permits\n - consider adding on nitrates by discharge\n - continue telemetry for now\n - post-cath groin check\n .\n # PUMP: recent echo showed EF 30% with anterior wall akinesis, several\n septal hypokinesis, apical hypokinesis, and mid-inferior wall moderate\n hypokinesis; no valvular abnormality. Stable BP currently. No evidence\n of heart failure.\n - continue ACEI and BB\n .\n # RHYTHM: sinus, no active issue\n .\n # HTN:\n - continue BB, ACEI for now\n .\n # DM2:\n - hold metformin and glyburide while in hospital\n - start insulin s.s.\n - diabetic diet\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Sheath - 09:54 AM\n 20 Gauge - 09:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2164-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549778, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n ST elevation in V1 and V2\n Action:\n Pt went to cath lab was found to have 3vd, cardiac monitoring initiated\n , labs obtained, weight obtained on arrival, sheath removed from right\n groin all pulses evaluated site inspected and monitord, ecg obtained\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 549788, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n ST elevation in V1 and V2\n Action:\n Pt went to cath lab was found to have 3vd, cardiac monitoring initiated\n , labs obtained, weight obtained on arrival, sheath removed from right\n groin all pulses evaluated site inspected and monitor, ecg obtained.\n Assessed for chest pain, o2 4liters via nc, pt received welcome packet,\n cardiac teaching done\n Response:\n Pt has remained in nsr hr 91, trop1.05, right groin site clean dry\n intact small hematoma at site, pulses Doppler able, ecg showed st\n elevation in leads v1 and v2, o2 sats have been 92 on 2 liters, pt\n understands some cardiac teaching needs reinforcement\n Plan:\n Continue c bed rest, continue teaching pt and family members, maintain\n o2 sats >95%, next ckmb due , continue to monitor pulses in feet\n" }, { "category": "Physician ", "chartdate": "2164-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 549829, "text": "Chief Complaint:\n 24 Hour Events:\n - cardiac cath -> 3-vessel disease; medically managed\n - metoprolol titrated up to 50mg and HR decreased from 90's tp 70's.\n - no more chest pain\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 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: 36.7\nC (98\n HR: 80 (73 - 92) bpm\n BP: 100/55(66) {81/44(56) - 120/83(86)} mmHg\n RR: 15 (4 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 1,702 mL\n 54 mL\n PO:\n 800 mL\n TF:\n IVF:\n 902 mL\n 54 mL\n Blood products:\n Total out:\n 2,045 mL\n 90 mL\n Urine:\n 2,045 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n -343 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 9.8 g/dL\n 174 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 141 mEq/L\n 28.6 %\n 8.0 K/uL\n [image002.jpg]\n 10:01 AM\n 05:27 PM\n WBC\n 8.0\n Hct\n 28.6\n Plt\n 320\n Cr\n 0.8\n TropT\n 1.05\n 0.90\n Glucose\n 174\n Other labs: PT / PTT / INR:15.3/43.9/1.3, CK / CKMB /\n Troponin-T:44/3/0.90, Ca++:9.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n 87-year-old woman with history of HTN, DM2 was transferred from OSH\n after having recurrent chest pain s/p anterolateral MI 1 week ago, with\n cath showing 3-vessel disease, being medically managed per patient's\n wish.\n # CORONARIES: mid-LAD infarct and old interfior MI per ECG. Cath showed\n 3-vessel disease. Not CABG candidate given patient's wish and advanced\n age.\n - continue metoprolol, ASA, clopidogrel, lisinopril, statin; titrate BB\n to HR in the 50s if BP permits\n - consider adding on nitrates by discharge\n - continue telemetry for now\n - post-cath groin check\n .\n # PUMP: recent echo showed EF 30% with anterior wall akinesis, several\n septal hypokinesis, apical hypokinesis, and mid-inferior wall moderate\n hypokinesis; no valvular abnormality. Stable BP currently. No evidence\n of heart failure.\n - continue ACEI and BB\n .\n # RHYTHM: sinus, no active issue\n .\n # HTN:\n - continue BB, ACEI for now\n .\n # DM2:\n - hold metformin and glyburide while in hospital\n - start insulin s.s.\n - diabetic diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 549830, "text": "Chief Complaint:\n 24 Hour Events:\n - cardiac cath -> 3-vessel disease; medically managed\n - metoprolol titrated up to 50mg and HR decreased from 90's tp 70's.\n - no more chest pain\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:23 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: 36.7\nC (98\n HR: 80 (73 - 92) bpm\n BP: 100/55(66) {81/44(56) - 120/83(86)} mmHg\n RR: 15 (4 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 1,702 mL\n 54 mL\n PO:\n 800 mL\n TF:\n IVF:\n 902 mL\n 54 mL\n Blood products:\n Total out:\n 2,045 mL\n 90 mL\n Urine:\n 2,045 mL\n 90 mL\n NG:\n Stool:\n Drains:\n Balance:\n -343 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 9 cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. 2/6 systolic murmur at apex. No thrills, lifts. No S3 or\n S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB from anterior with no\n crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: DP 1+ PT 1+\n Left: DP 1+ PT 1+\n Labs / Radiology\n 308 K/uL\n 10.5 g/dL\n 220 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 25 mg/dL\n 101\n 138 mEq/L\n 31.4 %\n 8.7 K/uL\n [image002.jpg]\n 10:01 AM\n 05:27 PM\n WBC\n 8.0\n Hct\n 28.6\n Plt\n 320\n Cr\n 0.8\n TropT\n 1.05\n 0.90\n Glucose\n 174\n Other labs: PT / PTT / INR:15.3/43.9/1.3, CK / CKMB /\n Troponin-T:44/3/0.90, Ca++:9.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 87-year-old woman with history of HTN, DM2 was transferred from OSH\n after having recurrent chest pain s/p anterolateral MI 1 week ago, with\n cath showing 3-vessel disease, being medically managed per patient's\n wish.\n # CORONARIES: mid-LAD infarct and old interfior MI per ECG. Cath showed\n 3-vessel disease. Not CABG candidate given patient's wish and advanced\n age.\n - continue metoprolol, ASA, clopidogrel, lisinopril, statin; continue\n to titrate BB to HR in the 50s if BP permits\n - consider adding on nitrates by discharge\n - continue telemetry for now\n # PUMP: recent echo showed EF 30% with anterior wall akinesis, several\n septal hypokinesis, apical hypokinesis, and mid-inferior wall moderate\n hypokinesis; no valvular abnormality. Stable BP currently. No evidence\n of heart failure.\n - continue ACEI and BB\n # RHYTHM: sinus, no active issue\n # HTN:\n - continue BB, ACEI for now\n # DM2:\n - hold metformin and glyburide while in hospital\n - continue insulin s.s.\n - diabetic diet\n ICU Care\n Nutrition: cardiac-healthy, diabetic diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:55 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI, OK to resuscitate with shocks, chest compressions,\n pressors\n Disposition: cardiology floor\n" }, { "category": "ECG", "chartdate": "2164-02-13 00:00:00.000", "description": "Report", "row_id": 243305, "text": "Sinus rhythm. Prior inferior myocardial infarction. Prior anteroseptal\nmyocardial infarction. Compared to the previous tracing of the\nischemic appearing ST-T wave abnormalities persist without diagnostic\ninterim change. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2164-02-12 00:00:00.000", "description": "Report", "row_id": 243306, "text": "Sinus rhythm with normal axis and intervals. Q waves are present in\nleads III, aVF and V1-V3 consistent with anteroseptal and inferior\nmyocardial infarction, age undetermined. ST-T wave abnormalities are present\nin leads I, aVL and V4-V6 consistent with myocardial ischemia. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2191-07-20 00:00:00.000", "description": "Report", "row_id": 200490, "text": "Atrial fibrillation with rapid ventricular response\nLeftward axis\nPoor R wave progression - cannot rule out anteroseptal infarct\nInferior T wave changes are nonspecific\nSince previous tracing of , rate is increased\n\n" }, { "category": "ECG", "chartdate": "2191-07-16 00:00:00.000", "description": "Report", "row_id": 200491, "text": "Probable atrial fibrillation with slow ventricular response. No previous\ntracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-07-17 00:00:00.000", "description": "Report", "row_id": 1410800, "text": "NURSING ADMISSION NOTE:\n\nPt is an 88YO female, resident of , admitted after an unwitnessed fall. In EW pt was confused, hypoxic, febrile, with elevated lactate and WBC. CXR showed CHF, ? bilateral LL pnx. Pt was given Tylenol, abx, and Lasix; head, neck and c-spine cleared by CT. Transferred to MICU for further care.\n\nALL: Ampicillin, Aldactone, Percocet, Simvastatin, Codeine, Motrin\n\nPROXY: son (H); (C)\n\nVALUABLES: Clothing and 2 yellow metal bracelets in marked bag at bedside. Son to take all belongings home.\n\nCODE STATUS: Per son, in discussion with attending, pt is DNR/DNI\n\nPMH: afib, NIDDM, HTN, AS, osteoporosis, dementia\n\nROS:\nNEURO: Pt is somewhat lethargic but easily aroused; sleeping in naps. Only complaint is feeling hungry (refused offers of jello or custard). Appear somewhat HOH. Oriented to self only (baseline); f/c, cooperative, MAE. A bit restless at times, occasionally pulling off mask. Bed alarm on for safety.\nRESP: Reportedly left EW with sats 96% on 5L NC. Arrived to MICU with sats 85% on same O2. Required 100% CN via mask to keep sats >92%. Able to wean to 50% later in shift after further diuresis. Still quickly desats with O2 off. LS CTA upper, diminished lower (poor effort). Given another 20mg dose of Lasix early this AM; TFB nearly 1L negative for LOS. RR initially 30's, now 20's. CXR pending from this AM.\nC-V: HR low 100's, afib, no ectopy. BP mostly 140's-150's (160's now, due for AM meds soon). K 3.5; given 60meq PO KCl with 2nd dose of Lasix; AM labs pending. CK's ~400, but MB and Trop - X 2.\nID: Afebrile, WBC now WNL; all cx pending. No abx ordered here.\nGI: Belly benign; med formed brown stool.\nGU: Good response to Lasix; BUN slightly elevated, creat WNL.\nENDO: Minimal insulin requirements.\nHEME: no active issues\nSKIN: Bilateral knee bruising; abrasions on both elbows and R wrist; stage 1 decub on coccyx. See Carevue for details.\nACCESS: PIV X 2.\nSOCIAL: son visited and was updated by MD and RN. He states he is the proxy but does not have paperwork with him.\n\nA: improving resp status\n\nP: continue to diurese as ordered; wean O2 as able; encourage PO's; OOB to chair; skin care; fall precautions; anticipate possible c/o later today.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-07-17 00:00:00.000", "description": "Report", "row_id": 1410801, "text": "Nursing progress notes \nReview of systems:\n\nNeuro: pt alert and oriented to self, month year and knows she is in the hospital, however she easily forgets and at times does not seem to understand simple questions. She is HOH. pt oob throughout shift and ambulated w/ PT around unit x 2 via holding on to wheelchair. tolerated well. (she will need assistance w/ any ambulation d/t hx of frequent falls)\n\nResp: ls clear w/ diminished bases. 02 weaned to 3 liters nc. sats 96%\npcxr today looks slightly improved per micu team\n\nCv: this am tele afib 120s after lopressor 100mg and diltiazem 180mg xl hrt rate down to 80s. sbp 99-150s. son concerned w/ sbp 90s and stated the pcp was supposed to wean lopressor down. micu team aware lopressor decreased to 75mg to start tonight. hrt sounds S1S2 w/ systolic murmur. pedal pulses +2 w/ slight pedal edema. lasix 40mg ivp given this am at 1100 d/t low uop 7cc/hr uop picked up to 40-60cc/hr after lasix.\n\ngi: abd soft bs+ no stool this shift. pt taking 80-100% of diet she can feed herself but needs help setting up w/ her tray. pt refused her zantac this am.\n\ngu: foley draining yellow urine as stated above. awaiting urine c/s. pt was recently dx w/ uti and was on levaquin at .\n\nskin: abrasions noted on bilat knees and elbows d/t fall and skin tear noted on right wrist. elbows and wrist covered w/ dsd. she aslo has pink coccyx she has been sitting on a foam cushion in a chair most of the shift. (1000-present)\n\nendo: pt refused her prednisone (for her temporal arteritis) and her glucaphage this am. she did take her glucaphage at 1200 w/ the encouragement by her son. bs 148/341/218 she has been covered by riss.\n\nid: all cx pending pt on levoquin q 24hr po\n\ncode: dnr/dni\n\nsocial: son and neice visited this afternoon and all questions where answered.\n\nPlan:\n\npt will need to go to rehab before returning to the dementia unit in .\n\ncont to wean 02 as tolerated.\n\nplace bed alarm on when pt in bed\n\npt c/o and awaiting bed placement.\n\nmonitor fingersticks\n\nmonitor bp (d/t decrease in dose tonight)\n" }, { "category": "Radiology", "chartdate": "2191-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925520, "text": " 2:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with\n REASON FOR THIS EXAMINATION:\n hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female with hypoxia.\n\n COMPARISON: None.\n\n AP UPRIGHT CHEST RADIOGRAPH:\n\n There are bilateral pleural effusions, left greater than right. There are\n moderates sized perihilar opacities. There is some mild cephalization of the\n pulmonary vasculature. These findings are consistent with moderate CHF.\n Aortic knob calcifications are present.\n\n IMPRESSION:\n\n Moderate CHF with bilateral pleural effusions. Cannot exclude underlying\n pneumonia within the lower lobes.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2191-07-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 925569, "text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?progression of CHF, PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman hx of tight AS, w/SOB, increased confusion and lethargy, now\n febrile\n REASON FOR THIS EXAMINATION:\n ?progression of CHF, PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 88-year-old woman with history of aortic stenosis. Patient with\n shortness of breath, confusion, and lethargy.\n\n FINDINGS: Comparison is made to the previous study from .\n\n Cardiac silhouette is enlarged. There is calcification of the thoracic aorta,\n unchanged. Mitral annulus calcification is also seen. There are again seen\n persistent pleural effusions, right side greater than left, which are\n unchanged. There is pulmonary edema which is also stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-07-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 925513, "text": " 1:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FELL, AGITATED, PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with\n REASON FOR THIS EXAMINATION:\n 88 yo female who fell\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JWK SAT 2:35 PM\n No hemorrhage or mass effect\n Bilateral periventricular and subcortical chronic microvascular ischemia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female who fell.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of the\n normally midline structures. There are severe bilateral periventricular and\n subcortical white matter hypodensities consistent with chronic microvascular\n ischemia. There is a small left basal ganglial infarct. There is diffuse\n osteopenia, limiting evaluation for acute fractures. A lucency within the\n left parietal bone is likely degenerative in nature. The paranasal sinuses\n and mastoid air cells are well aerated.\n\n IMPRESSION:\n\n 1. No hemorrhage or mass effect.\n\n 2. Severe periventricular and subcortical white matter hypodensities\n consistent with chronic microvascular ischemia.\n\n Findings conveyed to the ER at the electronic dashboard.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-07-16 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 925514, "text": " 1:25 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FELL, ABRASIONS, AGITATED, ? C SPINE FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with\n REASON FOR THIS EXAMINATION:\n 88 yo female who fell\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female status post fall.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: MDCT axial images of the cervical spine were obtained with\n multiplanar reformats.\n\n FINDINGS: On sagittal images, the skull base to T6 vertebral bodies are\n visualized. There are no prevertebral soft tissue abnormalities. There is no\n fracture or abnormal alignment. There are moderate degenerative changes of\n the cervical spine manifested by joint space narrowing and anterior\n osteophytes. CT does not provide intrathecal detail comparable to MRI.\n However, there are no gross thecal sac abnormalities.\n\n Incidental note is made of bilateral pleural effusions and mild biapical\n pleural scarring. There is mild pulmonary edema as well as aortic\n calcifications.\n\n IMPRESSION:\n\n 1. No fracture or abnormal alignment.\n\n 2. Moderate degenerative change of the cervical spine.\n\n These findings were conveyed to the ER via electronic dashboard at the time of\n dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926075, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u pleural effusion\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman hx of tight AS, w/SOB, increased confusion and lethargy,\n now w/febrile, f/u pleural effusion\n\n REASON FOR THIS EXAMINATION:\n f/u pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of aortic stenosis with shortness of breath and increasing\n altered mental status. Evaluate for pleural effusions.\n\n PORTABLE AP CHEST RADIOGRAPH: Compared to prior radiograph from , given difference in technique, there is no significant change of the\n right-sided pleural effusion. Small left-sided pleural effusion remains\n unchanged. Stable appearance of bibasilar atelectasis. No new\n consolidations. Heart size remains mildly enlarged with upper zone\n redistribution of pulmonary blood flow consistent with mild CHF. The\n mediastinal and hilar contours are stable.\n\n IMPRESSION: Unchanged right-sided pleural effusion and cephalization of\n pulmonary blood flow consistent with mild CHF.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 480052, "text": "TITLE:\n Chief Complaint: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort and shortness of breath, admitted for\n hypotension.\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n -On arrival to the MICU, continued substernal, ascending, burning chest\n pain similar to past GERD and tightness/feeling that there was\n something stuck in the throat.\n -She received 500 cc of IVF on the floor, a total of 3L IVF\n -Hct was down at admission 33 and to 30.8 overnight.\n -Guaiac was performed and negative.\n -Cardiac enzymes negative.\n -GI cocktail was given with some resolution of substernal burning but\n persistent feeling as though there was something in her throat this AM.\n Reports continued dizziness.\n -L shoulder and upper arm pain that worsens with movement, new this AM,\n but she has h/o intermittent L arm pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:12 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems: 1 month history of feeling as if something is\n caught in her throat. Dysphagia to hard foods, with no difficulties\n with soft foods and liquids. Anxiety with worsening insomnia, headaches\n and anxious mood for past month per daughter; patient denies feelings\n of anxiety.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 71 (70 - 81) bpm\n BP: 95/54(64) {86/50(59) - 105/62(70)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 71 mL\n PO:\n TF:\n IVF:\n 518 mL\n 71 mL\n Blood products:\n Total out:\n 830 mL\n 210 mL\n Urine:\n 230 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: RA\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Alert and oriented.\n HEENT: Oropharynx clear. Patchy alopecia.\n Chest: Distant heart sounds, regular rate and rhythm, no w/r/g. TTP at\n sternum and shoulder this AM.\n Resp: Clear to ausculatation bilaterally\n Abd: Soft, non-distended, BS+, TTP at epigastrium but improved from\n admission.\n Skin: Warm, well-perfused. 2+ DP. No cyanosis or edema.\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n WBC were 6.0, Hct down from 33.0 in ED, 30.7 last night, 39.1 two weeks\n ago. Plts were 306 in ED.\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK 103 / CKMB 3 / Troponin-T<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph: 49.3 %,\n Mono:5.3 %, Eos:2.9 %, Lactic Acid:1.2 (was 2.7 in the ED) mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 53 y/o F with a PMH of fibromyalgia and hypertension presenting with\n chest discomfort, shortness of breath, admitted for hypotension now\n with relative hypotension post IVF.\n .\n 1) HYPOTENSION: Unclear etiology at this time. SBP stable in 100-110s\n this AM, but this BP is likely relative hypotensive given her h/o HTN.\n However, she remains well-perfused on exam, with Cr and lactate within\n normal limits.\n *Initial concern for ACS, aortic dissection, or PE, but CE negative and\n stable, ECG unchanged from prior, and CTA negative. Arm pain could\n represent atypical CP, but likely MSK/fibromyalgia since it is\n exacerbated with movement and consistent with past arm pain.\n *Volume depletion is possible but pt does not seem overtly volume down\n on exam or labs. Bun and Cr within normal limits. Some improvement in\n ED with 2.6L of IVF but little change with final 500cc in MICU followed\n by autodiuresis, which indicates adequate fluid status but persistent\n relative hypotension.\n *Minimal evidence of significant infection-- no fever, tachycardia. WBC\n down and lymphocytosis this AM, and recently has felt\nunwell,\n viral infection is possible. However, vasodilation due to infection is\n unlikely since she does not meet SIRS criteria aside from WBC. BCx and\n UCx pending. Abx held give lack of evidence of infection.\n *Blood loss possible in this patient with GERD symptoms and Hct down\n from 39.1 on and down overnight. Thus, GI bleed in setting of\n gastritis is possible, but she denies changes to bowel movement and\n guaiac was negative. Type and screen sent.\n * Medication effect from metoprolol and lisinopril less likely since\n patient was adamant about adhering to the prescribed doses.\n Nitroglycerin effect unlikely to cause prolonged hypotension.\n *Adrenal insufficiency is possible given hypotension and borderline low\n sodium.\n -Outpatient anti-hypertensives held\n - Continue IVF bolus to maintain MAP >60. No indication for pressors\n due to adequate perfusion and unclear etiology.\n -Check cortisol.\n -Guaiac stool\n - Trend Hct\n - Follow up final read CTA\n - Follow up blood and urine cultures.\n 2) CHEST DISCOMFORT: Likely due to GERD given ascending retrosternal\n burn, throat pain/tightness c/w prior experiences with GERD. GI\n cocktail with some effect. +/-MSK or costochondritis, especially given\n arm pain this AM.\n *As noted, cardiac etiology less likely given unchanged EKG and\n negative CE. However, other cardiac etiologies including unstable\n angina, coronary vasospasm. A pharmacologic sestamibi stress test or\n similar CVD work up may be warranted given recent increase in health\n care visits/hospitalizations associated with chest pain.\n *Significant anxiety given loss of job could exacerbate chest pain and\n cause sensation of SOB, throat tightness, weakness.\n *Dysphagia to hard solids with history of GERD is suspicious for\n esophageal stricture/adhesion or esophageal spasm. EGD or barium\n swallow for stricture or other causes of dysphagia may be warranted,\n either in the in- or outpatient setting.\n - Antihypertensives held in setting of hypotension.\n - Continue outpatient Tramadol for pain.\n - Continue PPI.\n - Continue GI cocktail prn.\n - Consider sestimibi.\n - Consider EGD or barium swallow for dysphagia.\n - Consider SSRI +/- benzo as needed, likely defer to outpatient\n setting.\n 3) ANEMIA: Hct down from 39.1 on and down overnight. No clinical\n signs of poor perfusion, Cr stable. However, history of GERD could be\n associated with GI bleed in the setting of gastritis, although guaiac\n was negative. Hemolysis less likely given normal tbili.\n -Trend Hct as per above.\n -Transfuse Hct <25\n 4) ANXIETY/DEPRESSION: Worse in past 6 months following loss of her\n job, with worsening insomnia, headaches and anxious mood (per daughter,\n patient does not endorse) in the last month. No outpatient anxiolytics.\n -Defer to outpatient care providers, but would consider outpatient\n start of SSRI.\n 5) FIBROMYALGIA: continue gabapentin and nortriptyline\n 6) FEN - regular diet, replete lytes PRN\n 7) Ppx - heparin sc, pneumoboots\n 8) ACCESS - PIV X2\n 9) DISPO - Pending above, call out to medical floor.\n ICU Care\n Nutrition: regular diet, replete lytes PRN\n Glycemic Control: not required\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: heparin SC, pneumoboots\n Stress ulcer: PPI\n VAP: N/A\n Communication: Patient\n Code status: Full code\n Disposition: Pending above, call out to medical floor.\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 480055, "text": "TITLE:\n Chief Complaint: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort and shortness of breath, admitted for\n hypotension.\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n -On arrival to the MICU, continued substernal, ascending, burning chest\n pain similar to past GERD and tightness/feeling that there was\n something stuck in the throat.\n -She received 500 cc of IVF on the floor, a total of 3L IVF\n -Hct was down at admission 33 and to 30.8 overnight.\n -Guaiac was performed and negative.\n -Cardiac enzymes negative.\n -GI cocktail was given with some resolution of substernal burning but\n persistent feeling as though there was something in her throat this AM.\n Reports continued dizziness.\n -L shoulder and upper arm pain that worsens with movement, new this AM,\n but she has h/o intermittent L arm pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:12 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems: 1 month history of feeling as if something is\n caught in her throat. Dysphagia to hard foods, with no difficulties\n with soft foods and liquids. Anxiety with worsening insomnia, headaches\n and anxious mood for past month per daughter; patient denies feelings\n of anxiety.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 71 (70 - 81) bpm\n BP: 95/54(64) {86/50(59) - 105/62(70)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 71 mL\n PO:\n TF:\n IVF:\n 518 mL\n 71 mL\n Blood products:\n Total out:\n 830 mL\n 210 mL\n Urine:\n 230 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: RA\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Alert and oriented.\n HEENT: Oropharynx clear. Patchy alopecia.\n Chest: Distant heart sounds, regular rate and rhythm, no w/r/g. TTP at\n sternum and shoulder this AM.\n Resp: Clear to ausculatation bilaterally\n Abd: Soft, non-distended, BS+, TTP at epigastrium but improved from\n admission.\n Skin: Warm, well-perfused. 2+ DP. No cyanosis or edema.\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n WBC were 6.0, Hct down from 33.0 in ED, 30.7 last night, 39.1 two weeks\n ago. Plts were 306 in ED.\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK 103 / CKMB 3 / Troponin-T<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph: 49.3 %,\n Mono:5.3 %, Eos:2.9 %, Lactic Acid:1.2 (was 2.7 in the ED) mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 53 y/o F with a PMH of fibromyalgia and hypertension presenting with\n chest discomfort, shortness of breath, admitted for hypotension now\n with relative hypotension post IVF.\n .\n 1) HYPOTENSION: Unclear etiology at this time. SBP stable in 100-110s\n this AM, but this BP is likely relative hypotensive given her h/o HTN.\n However, she remains well-perfused on exam, with Cr and lactate within\n normal limits.\n *Initial concern for ACS, aortic dissection, or PE, but CE negative and\n stable, ECG unchanged from prior, and CTA negative. Arm pain could\n represent atypical CP, but likely MSK/fibromyalgia since it is\n exacerbated with movement and consistent with past arm pain.\n *Volume depletion is possible but pt does not seem overtly volume down\n on exam or labs. Bun and Cr within normal limits. Some improvement in\n ED with 2.6L of IVF but little change with final 500cc in MICU followed\n by autodiuresis, which indicates adequate fluid status but persistent\n relative hypotension.\n *Minimal evidence of significant infection-- no fever, tachycardia. WBC\n down and lymphocytosis this AM, and recently has felt\nunwell,\n viral infection is possible. However, vasodilation due to infection is\n unlikely since she does not meet SIRS criteria aside from WBC. BCx and\n UCx pending. Abx held give lack of evidence of infection.\n *Blood loss possible in this patient with GERD symptoms and Hct down\n from 39.1 on and down overnight. Thus, GI bleed in setting of\n gastritis is possible, but she denies changes to bowel movement and\n guaiac was negative. Type and screen sent.\n * Medication effect from metoprolol and lisinopril less likely since\n patient was adamant about adhering to the prescribed doses.\n Nitroglycerin effect unlikely to cause prolonged hypotension.\n *Adrenal insufficiency is possible given hypotension and borderline low\n sodium.\n -Outpatient anti-hypertensives held\n - Continue IVF bolus to maintain MAP >60. No indication for pressors\n due to adequate perfusion and unclear etiology.\n -Check cortisol.\n -Guaiac stool\n - Trend Hct\n - Follow up final read CTA\n - Follow up blood and urine cultures.\n 2) CHEST DISCOMFORT: Likely due to GERD given ascending retrosternal\n burn, throat pain/tightness c/w prior experiences with GERD. GI\n cocktail with some effect. +/-MSK or costochondritis, especially given\n arm pain this AM.\n *As noted, cardiac etiology less likely given unchanged EKG and\n negative CE. However, other cardiac etiologies including unstable\n angina, coronary vasospasm. Should follow up with outpatient\n cardiologist to see if catheterization is planned. A pharmacologic\n sestamibi stress test or similar CVD work up may be warranted given\n recent increase in health care visits/hospitalizations associated with\n chest pain.\n *Significant anxiety given loss of job could exacerbate chest pain and\n cause sensation of SOB, throat tightness, weakness.\n *Dysphagia to hard solids with history of GERD is suspicious for\n esophageal stricture/adhesion or esophageal spasm. EGD or barium\n swallow for stricture or other causes of dysphagia may be warranted,\n either in the in- or outpatient setting.\n - Antihypertensives held in setting of hypotension.\n - Continue outpatient Tramadol for pain.\n - Continue PPI.\n - Continue GI cocktail prn.\n - Follow up with outpatient cardiologist in re: ?planned cath. Consider\n sestimibi.\n - Consider EGD or barium swallow for dysphagia.\n - Consider SSRI +/- benzo as needed, likely defer to outpatient\n setting.\n 3) ANEMIA: Hct down from 39.1 on and down overnight. No clinical\n signs of poor perfusion, Cr stable. However, history of GERD could be\n associated with GI bleed in the setting of gastritis, although guaiac\n was negative. Hemolysis less likely given normal tbili.\n -Trend Hct as per above.\n -Transfuse Hct <25\n 4) ANXIETY/DEPRESSION: Worse in past 6 months following loss of her\n job, with worsening insomnia, headaches and anxious mood (per daughter,\n patient does not endorse) in the last month. No outpatient anxiolytics.\n -Defer to outpatient care providers, but would consider outpatient\n start of SSRI.\n 5) FIBROMYALGIA: continue gabapentin and nortriptyline\n 6) FEN - regular diet, replete lytes PRN\n 7) Ppx - heparin sc, pneumoboots\n 8) ACCESS - PIV X2\n 9) DISPO - Pending above, call out to medical floor.\n ICU Care\n Nutrition: regular diet, replete lytes PRN\n Glycemic Control: not required\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: heparin SC, pneumoboots\n Stress ulcer: PPI\n VAP: N/A\n Communication: Patient\n Code status: Full code\n Disposition: Pending above, call out to medical floor.\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 480056, "text": "TITLE:\n Chief Complaint: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort and shortness of breath, admitted for\n hypotension.\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n -On arrival to the MICU, continued substernal, ascending, burning chest\n pain similar to past GERD and tightness/feeling that there was\n something stuck in the throat.\n -She received 500 cc of IVF on the floor, a total of 3L IVF\n -Hct was down at admission 33 and to 30.8 overnight.\n -Guaiac was performed and negative.\n -Cardiac enzymes negative.\n -GI cocktail was given with some resolution of substernal burning but\n persistent feeling as though there was something in her throat this AM.\n Reports continued dizziness.\n -L shoulder and upper arm pain that worsens with movement, new this AM,\n but she has h/o intermittent L arm pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:12 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems: 1 month history of feeling as if something is\n caught in her throat. Dysphagia to hard foods, with no difficulties\n with soft foods and liquids. Anxiety with worsening insomnia, headaches\n and anxious mood for past month per daughter; patient denies feelings\n of anxiety.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 71 (70 - 81) bpm\n BP: 95/54(64) {86/50(59) - 105/62(70)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 71 mL\n PO:\n TF:\n IVF:\n 518 mL\n 71 mL\n Blood products:\n Total out:\n 830 mL\n 210 mL\n Urine:\n 230 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: RA\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Alert and oriented.\n HEENT: Oropharynx clear. Patchy alopecia.\n Chest: Distant heart sounds, regular rate and rhythm, no w/r/g. TTP at\n sternum and shoulder this AM.\n Resp: Clear to ausculatation bilaterally\n Abd: Soft, non-distended, BS+, TTP at epigastrium but improved from\n admission.\n Skin: Warm, well-perfused. 2+ DP. No cyanosis or edema.\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n WBC were 6.0, Hct down from 33.0 in ED, 30.7 last night, 39.1 two weeks\n ago. Plts were 306 in ED.\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK 103 / CKMB 3 / Troponin-T<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph: 49.3 %,\n Mono:5.3 %, Eos:2.9 %, Lactic Acid:1.2 (was 2.7 in the ED) mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 53 y/o F with a PMH of fibromyalgia and hypertension presenting with\n chest discomfort, shortness of breath, admitted for hypotension now\n with relative hypotension post IVF.\n .\n 1) HYPOTENSION: Unclear etiology at this time. SBP stable in 100-110s\n this AM, but this BP is likely relative hypotensive given her h/o HTN.\n However, she remains well-perfused on exam, with Cr and lactate within\n normal limits.\n *Initial concern for ACS, aortic dissection, or PE, but CE negative and\n stable, ECG unchanged from prior, and CTA negative. Arm pain could\n represent atypical CP, but likely MSK/fibromyalgia since it is\n exacerbated with movement and consistent with past arm pain.\n *Volume depletion is possible but pt does not seem overtly volume down\n on exam or labs. Bun and Cr within normal limits. Some improvement in\n ED with 2.6L of IVF but little change with final 500cc in MICU followed\n by autodiuresis, which indicates adequate fluid status but persistent\n relative hypotension.\n *Minimal evidence of significant infection-- no fever, tachycardia. WBC\n down and lymphocytosis this AM, and recently has felt\nunwell,\n viral infection is possible. However, vasodilation due to infection is\n unlikely since she does not meet SIRS criteria aside from WBC. BCx and\n UCx pending. Abx held give lack of evidence of infection.\n *Blood loss possible in this patient with GERD symptoms and Hct down\n from 39.1 on and down overnight. Thus, GI bleed in setting of\n gastritis is possible, but she denies changes to bowel movement and\n guaiac was negative. Type and screen sent.\n * Medication effect from metoprolol and lisinopril less likely since\n patient was adamant about adhering to the prescribed doses.\n Nitroglycerin effect unlikely to cause prolonged hypotension.\n *Adrenal insufficiency is possible given hypotension and borderline low\n sodium.\n -Outpatient anti-hypertensives held\n - Continue IVF bolus to maintain MAP >60. No indication for pressors\n due to adequate perfusion and unclear etiology.\n -Check cortisol.\n -Guaiac stool\n - Trend Hct\n - Follow up final read CTA\n - Follow up blood and urine cultures.\n 2) CHEST DISCOMFORT: Likely due to GERD given ascending retrosternal\n burn, throat pain/tightness c/w prior experiences with GERD. GI\n cocktail with some effect. +/-MSK or costochondritis, especially given\n arm pain this AM.\n *As noted, cardiac etiology less likely given unchanged EKG and\n negative CE. However, other cardiac etiologies including unstable\n angina, coronary vasospasm. Should follow up with outpatient\n cardiologist to see if catheterization is planned. A pharmacologic\n sestamibi stress test or similar CVD work up may be warranted given\n recent increase in health care visits/hospitalizations associated with\n chest pain.\n *Significant anxiety given loss of job could exacerbate chest pain and\n cause sensation of SOB, throat tightness, weakness.\n *Dysphagia to hard solids with history of GERD is suspicious for\n esophageal stricture/adhesion or esophageal spasm. EGD or barium\n swallow for stricture or other causes of dysphagia may be warranted,\n either in the in- or outpatient setting.\n - Antihypertensives held in setting of hypotension.\n - Continue outpatient Tramadol for pain.\n - Continue PPI.\n - Continue GI cocktail prn.\n - Follow up with outpatient cardiologist in re: ?planned cath. Consider\n sestimibi.\n - Consider EGD or barium swallow for dysphagia.\n - Consider SSRI +/- benzo as needed, likely defer to outpatient\n setting.\n 3) ANEMIA: Hct down from 39.1 on and down overnight. No clinical\n signs of poor perfusion, Cr stable. However, history of GERD could be\n associated with GI bleed in the setting of gastritis, although guaiac\n was negative. Hemolysis less likely given normal tbili.\n -Trend Hct as per above.\n -Transfuse Hct <25\n 4) ANXIETY/DEPRESSION: Worse in past 6 months following loss of her\n job, with worsening insomnia, headaches and anxious mood (per daughter,\n patient does not endorse) in the last month. No outpatient anxiolytics.\n -Defer to outpatient care providers, but would consider outpatient\n start of SSRI.\n 5) FIBROMYALGIA: continue gabapentin and nortriptyline\n 6) FEN - regular diet, replete lytes PRN\n 7) Ppx - heparin sc, pneumoboots\n 8) ACCESS - PIV X2\n 9) DISPO - Pending above, call out to medical floor.\n ICU Care\n Nutrition: regular diet, replete lytes PRN\n Glycemic Control: not required\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: heparin SC, pneumoboots\n Stress ulcer: PPI\n VAP: N/A\n Communication: Patient\n Code status: Full code\n Disposition: Pending above, call out to medical floor.\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 480040, "text": "TITLE:\n Chief Complaint: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort and shortness of breath, admitted for\n hypotension.\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n -On arrival to the MICU, continued substernal, ascending, burning chest\n pain similar to past GERD and tightness/feeling that there was\n something stuck in the throat.\n -She received 500 cc of IVF on the floor, a total of 3L IVF\n -Hct was down at admission 33 and to 30.8 overnight.\n -Guaiac was performed and negative.\n -Cardiac enzymes negative.\n -GI cocktail was given with some resolution of substernal burning but\n persistent feeling as though there was something in her throat this AM.\n Reports continued dizziness.\n -L shoulder and upper arm pain that worsens with movement, new this AM,\n but she has h/o intermittent L arm pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:12 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems: 1 month history of feeling as if something is\n caught in her throat. Dysphagia to hard foods, with no difficulties\n with soft foods and liquids.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 71 (70 - 81) bpm\n BP: 95/54(64) {86/50(59) - 105/62(70)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 71 mL\n PO:\n TF:\n IVF:\n 518 mL\n 71 mL\n Blood products:\n Total out:\n 830 mL\n 210 mL\n Urine:\n 230 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: RA\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Alert and oriented.\n HEENT: Oropharynx clear. Patchy alopecia.\n Chest: Distant heart sounds, regular rate and rhythm, no w/r/g. TTP at\n sternum and shoulder this AM.\n Resp: Clear to ausculatation bilaterally\n Abd: Soft, non-distended, BS+, TTP at epigastrium but improved from\n admission.\n Skin: Warm, well-perfused. 2+ DP. No cyanosis or edema.\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n WBC were 6.0, Hct down from 33.0 in ED, 30.7 last night, 39.1 two weeks\n ago. Plts were 306 in ED.\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK 103 / CKMB 3 / Troponin-T<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph: 49.3 %,\n Mono:5.3 %, Eos:2.9 %, Lactic Acid:1.2 (was 2.7 in the ED) mmol/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 53 y/o F with a PMH of fibromyalgia and hypertension presenting with\n chest discomfort, shortness of breath, admitted for hypotension now\n with relative hypotension post IVF.\n .\n 1) Hypotension: Unclear etiology at this time. SBP stable in 100-110s\n this AM, but this BP is likely relative hypotensive given her h/o HTN.\n However, she remains well-perfused on exam, with Cr and lactate within\n normal limits.\n *Initial concern for ACS, aortic dissection, or PE, but CE negative and\n stable, ECG unchanged from prior, and CTA negative. Arm pain could\n represent atypical CP, but likely MSK/fibromyalgia since it is\n exacerbated with movement and consistent with past arm pain.\n *Volume depletion is possible but pt does not seem overtly volume down\n on exam or labs. Bun and Cr within normal limits. Some improvement in\n ED with 2.6L of IVF but little change with final 500cc in MICU followed\n by autodiuresis, which indicates adequate fluid status but persistent\n relative hypotension.\n *Minimal evidence of significant infection-- no fever, tachycardia. WBC\n down and lymphocytosis this AM, and recently has felt\nunwell,\n viral infection is possible. However, vasodilation due to infection is\n unlikely since she does not meet SIRS criteria aside from WBC. BCx and\n UCx pending. Abx held give lack of evidence of infection.\n *Blood loss possible in this patient with GERD symptoms and Hct down\n from 39.1 on and down overnight. Thus, GI bleed in setting of\n gastritis is possible, but she denies changes to bowel movement and\n guaiac was negative. Type and screen sent.\n * Medication effect from metoprolol and lisinopril less likely since\n patient was adamant about adhering to the prescribed doses.\n Nitroglycerin effect unlikely to cause prolonged hypotension.\n *Adrenal insufficiency is possible given hypotension and borderline low\n sodium.\n -Outpatient anti-hypertensives held\n - Continue IVF bolus to maintain MAP >60. No indication for pressors\n due to adequate perfusion and unclear etiology.\n -Check cortisol.\n -Guaiac stool\n - Trend Hct\n - Follow up final read CTA\n - Follow up blood and urine cultures.\n 2) Chest Discomfort:\n Likely due to GERD given ascending retrosternal burn, throat\n pain/tightness c/w prior experiences with GERD. GI cocktail with some\n effect. +/-MSK or costochondritis, especially given arm pain this AM.\n *As noted, cardiac etiology less likely given unchanged EKG and\n negative CE. However, other cardiac etiologies including unstable\n angina, coronary vasospasm. A pharmacologic sestamibi stress test or\n similar CVD work up may be warranted given recent increase in health\n care visits/hospitalizations associated with chest pain.\n *Significant anxiety given loss of job could exacerbate chest pain and\n cause sensation of SOB, throat tightness, weakness.\n *Dysphagia to hard solids with history of GERD is suspicious for\n esophageal stricture/adhesion or esophageal spasm. EGD or barium\n swallow for stricture or other causes of dysphagia may be warranted,\n either in the in- or outpatient setting.\n - Antihypertensives held in setting of hypotension.\n - Continue outpatient Tramadol for pain.\n - Continue PPI.\n - Continue GI cocktail prn.\n - Consider sestimibi.\n - Consider EGD or barium swallow for dysphagia.\n - Consider SSRI +/- benzo as needed, likely defer to outpatient\n setting.\n .\n # Fibromyalgia: continue gabapentin and nortriptyline\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Prophy - heparin sc, pneumoboots\n .\n # Access - PIV X2\n .\n # Dispo - Pending above, call out to medical floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: heparin SC, pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient\n Code status: Full code\n Disposition: Pending above, call out to medical floor.\n" }, { "category": "Nursing", "chartdate": "2150-09-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 480041, "text": "The patient is a 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and hypotension.\n The patient reports that she began to feel increasingly unwell\n yesterday when she noted increased fatigue and did not leave her home.\n Today she noted dyspnea and dizziness while walking with her daughter.\n She had to stop frequently to catch her breath while walking home and\n had difficulty ambulating upstairs. She also reports difficulty\n swallowing secondary to throat tightness. She has had symptoms like\n this before, last time one week ago. She sleeps on four pillows nightly\n due to difficulty breathing. Denies PND. She called EMS for transport\n to the ED. On arrival to the ED she complained of chest pain with\n associated diaphoresis and shortness of breath.\n .\n In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She was\n given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg IV. EMS\n had been concerned about ECG and code STEMI was called. On arrival to\n ED, ECG was not felt to be consistent with acute ischemia. She\n underwent a FAST scan which was negative for pericardial effusion. CTA\n negative for PE or dissection. Her BP dropped to 80s after reciept of\n SL NTG. She was given 2L NS without response in BP. Her BP improved to\n 90s after 3rd L NS. She reported continued chest discomfort , which\n was reproducible upon palpation.\n UPDATE: Since admit to the MICU pt given an additional 500cc NS\n overnight. VSS. SBP now in the 110s-120s, maps in the 60s, HR\n 70s-80s, SR. CEs negative. EKG normal. Pt alert and oriented x 3. Pt\n is speaking, but speaks some English and is able to make her\n needs known. MAEs. LS CTA, o2 sats high 90s-100% on RA.\n Hypotension (not Shock)\n Assessment:\n VSS, SR. No ectopy. Possible etiology of hypotension may be related\n to decrease in po\ns w/ addition of SL nitro given in route to\n hospital. No acute ECG changes.\n Action:\n Checking HCT .\n Response:\n HCT stable.\n Plan:\n Recheck HCT @ 1400.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o dyshagia ( pt reports difficulty swallowing for past month now-\n mostly w/ solids vs liquids), eipigastric, and Lt chest/arm pain\n .\n Action:\n Given tramadol, gabapentin, & GI cocktail of\n Maalox/lidocain/diphenhydramine.\n Response:\n Pt reports some relief following pain meds.\n Plan:\n Cont w/ pain mgmt as needed, ? need for EGD/barium swallow in near\n future to r/o possibility of esophageal stricture vs bad GERD\n symptoms.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n CHEST PAIN;TELEMETRY\n Code status:\n Full code\n Height:\n Admission weight:\n 92.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension, MI\n Additional history: GERD, B/L carpel tunnel syndrome, lumbosacral\n radiculopathy, depression, fibromyalgia.\n s/p carpel tunnel release, cholecystecttomy, laser surgery on the rt\n eye.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\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 275 mL\n 24h total out:\n 690 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 05:10 AM\n Potassium:\n 4.7 mEq/L\n 05:10 AM\n Chloride:\n 107 mEq/L\n 05:10 AM\n CO2:\n 21 mEq/L\n 05:10 AM\n BUN:\n 8 mg/dL\n 05:10 AM\n Creatinine:\n 0.7 mg/dL\n 05:10 AM\n Glucose:\n 94 mg/dL\n 05:10 AM\n Hematocrit:\n 30.8 %\n 05:10 AM\n Valuables / Signature\n Patient valuables: clothes\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 6\n Transferred to: CC7\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 480049, "text": "Chief Complaint: severe chest pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (70 - 81) bpm\n BP: 100/56(66) {86/50(59) - 105/62(97)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 103 mL\n PO:\n TF:\n IVF:\n 518 mL\n 103 mL\n Blood products:\n Total out:\n 830 mL\n 310 mL\n Urine:\n 230 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n Gen obese woman lying in bed NAD, anxious\n HEENT: op dry,\n CV: RR no murmurs\n Chest: LLL rales which clear with cough\n ABd: obese soft NT +BS\n Ext: no edema\n Neuro: a and o x 3 cn 2-12 intact\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK / CKMB / Troponin-T:103/3/<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph:49.3 %, Mono:5.3\n %, Eos:2.9 %, Lactic Acid:1.2 mmol/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 1. Relative Hypotension: in setting of possible decreased pos\n and also received nitro in ED- however her relative hypotension was\n sustained and the lactate of 2.7 raised concern. She has responded to\n IVF\n and lactate has resolved. Her MAP is still lower than baseline\n but she hsows no signs of hypoperfusion\n 2. Atypical chest pain: neg CTA, no acute ECG changes, ruling\n out, consult her outpt Cards re if there is a plan for\n cath to answer question of old IMI on ecg and stuutering chest pain.\n Could she has CAD or vasospasm as an etiology\n 3. Anemia: stable, follow up\n 4. Dysphagia: DDX GERD, spasm, may need EGD to look for gastritis\n or barium for spasm , stricture\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: po diet\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: with pt\n status: Full code\n Disposition :Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2150-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 479929, "text": "his is a 53 yo F who presented to ED with c/o epigastric pain Lt chest\n pain diaphoretic ,headache,sore throat.Had 1 nitro in the field,\n became hypotensive down to 90's.In pt is afebrile, tox screen\n neg,CE normal,RR 15-16, Sats 100% on 2lit NCO2,CT head and chest neg.Pt\n sent to MICU for further monitoring.\n Hypotension (not Shock)\n Assessment:\n Pts BP is 90\ns systolic with MAP 60-70.c/o CP with score .Pt is\n alert oriented x3.\n Action:\n Pt had 2600 FB in ED\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 479931, "text": "his is a 53 yo F who presented to ED with c/o epigastric pain Lt chest\n pain diaphoretic ,headache,sore throat.Had 1 nitro in the field,\n became hypotensive down to 90's.In pt is afebrile, tox screen\n neg,CE normal,RR 15-16, Sats 100% on 2lit NCO2,CT head and chest neg.Pt\n sent to MICU for further monitoring.\n Hypotension (not Shock)\n Assessment:\n Pts BP is 80\ns systoli.c/o CP with score 10.Pt is alert oriented x3.Pt\n afebrile, WCC normal.C/o dizzynes.\n Action:\n Pt had 2600 FB in ED plus an additional 500 in MICU.BC sent.EKG\n done.Cycling enzymes.\n Response:\n BP upto 90\ns systolic with MAP 60-70.No changes in EKG.Cardiac enzymes\n wnl.\n Plan:\n Bolus eluids as needed to keep MAP >60. cycle enzymes.EKG with the next\n set of enzymes.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o constant lt chest pain, epigastric pain , back pain and sore\n throat.Of which back pain and CP pt always had.Pain score .\n Action:\n Pt had tramadol, gabapentin and Maalox .\n Response:\n Pt more comfortable now with pain score 5.\n Plan:\n Cont to monitor for pain,PRN tramadol and standing dose of gabapentin.\n" }, { "category": "Nursing", "chartdate": "2150-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 479982, "text": "his is a 53 yo F who presented to ED with c/o epigastric pain Lt chest\n pain diaphoretic ,headache,sore throat.Had 1 nitro in the field,\n became hypotensive down to 90's.In pt is afebrile, tox screen\n neg,CE normal,RR 15-16, Sats 100% on 2lit NCO2,CT head and chest neg.Pt\n sent to MICU for further monitoring.\n Hypotension (not Shock)\n Assessment:\n Pts BP is 80\ns systoli.c/o CP with score 10.Pt is alert oriented x3.Pt\n afebrile, WCC normal.C/o dizzynes.\n Action:\n Pt had 2600 FB in ED plus an additional 500 in MICU.BC sent.EKG\n done.Cycling enzymes.\n Response:\n BP upto 90\ns systolic with MAP 60-70.No changes in EKG.Cardiac enzymes\n wnl.\n Plan:\n Bolus eluids as needed to keep MAP >60. cycle enzymes.EKG with the next\n set of enzymes.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o constant lt chest pain, epigastric pain , back pain and sore\n throat.Of which back pain and CP pt always had.Pain score .\n Action:\n Pt had tramadol, gabapentin and Maalox .\n Response:\n Pt more comfortable now with pain score 5.\n Plan:\n Cont to monitor for pain,PRN tramadol and standing dose of gabapentin.\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 479989, "text": "TITLE:\n Chief Complaint: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and admitted for\n hypotension.\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n -increasingly unwell yesterday\n -day of admission,noted dyspnea and dizziness while walking with her\n daughter and ambulating up stairs.\n -difficulty swallowing secondary to throat tightness.\n -similar sx one week ago\n -EMS called and were concerned for STEMI based on EKG\n -In ED 10/10 chest pain with associated diaphoresis and shortness of\n breath. BP at the time was 106/60.\n -EKG with Q waves (2,3,AvF) c/w prior MI but no ST changes\n -CTA was negative for PE or dissection. FAST scan negative for\n pericardial effusion.\n -BP dropped to 80s after reciept of SL NTG.\n -GIven 3L IVF with improvement of SBP to 90s.\n .\n On arrival to the MICU, continued discomfort in her chest and throat\n tightness.\n -described pain as burning, substernal, ascending, like past GERD.\n -she received ______L of IVF with some BP response.\n -GI cocktail was given.\n -Hct was down at admission from 38 to 33 and to 30.8 overnight.\n -Guaiac was performed and negative.\n -CE enzymes negative.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 71 (70 - 81) bpm\n BP: 95/54(64) {86/50(59) - 105/62(70)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 71 mL\n PO:\n TF:\n IVF:\n 518 mL\n 71 mL\n Blood products:\n Total out:\n 830 mL\n 210 mL\n Urine:\n 230 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n General Appearance: Alert and oriented\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK / CKMB / Troponin-T:103/3/<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph:49.3 %, Mono:5.3\n %, Eos:2.9 %, Lactic Acid:1.2 mmol/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 53 y/o F with a PMH of fibromyalgia and hypertension presenting with\n chest discomfort, shortness of breath and hypotension.\n .\n # Hypotension: Unclear etiology at this time.\n -Initial concern for ACS or Aortic Dissection or PE but CE negative,\n ECG unchanged from prior and CTA negative. CE followed and were\n negative.\n -BP dropped following receipt of SL ntg however time course seems too\n long to attribute to single dose of ntg along and no aortic valve\n pathology that might exacerbate effect.\n -Could consider medication effect from metoprolol and lisinopril\n however the patient does not recall taking additional meds and has been\n stable on current doses for some time.\n -Complaint of tightness in chest and throat raises concern for allergic\n reaction however no clear evidence of this on exam, no wheezing and\n duration of symptoms does not fit acute anaphylaxis.\n -Pt does not seem overtly volume down on exam or labs.\n -Minimal evidence of significant infection-- no fever. WBC down and\n lymphocytosis this AM, pharyngitis, so viral infection is possible. BCx\n and UCx pending. Abx held give lack of evidence of infection.\n -Pt with GERD symptoms and HCT 33 down from prior, consider GI bleed in\n setting of gastritis. Type and screen sent. Guaiac negative.\n -Anti-HTN held\n - Continue IVF bolus to maintain MAP >60\n - Continue to cycle CE X3\n - Repeat HCT to rule out GI bleed\n - Follow up final read CTA\n - Follow up blood and urine cultures.\n - Repeat lactate\n .\n # Chest Discomfort:\n Likely due to GERD given ascending retrosternal burn, throat\n pain/tightness c/w prior experiences with GERD.\n +/-MSK or costochondritis. GI cocktail given.\n -cardiac etiology possible given evidence of prior inferior ischemia on\n ECG but without current EKG changes and negative EC.\n -Significant anxiety given loss of job could exacerbate chest pain and\n cause sensation of SOB, throat tightness, weakness.\n - Antihypertensives held in setting of hypotension.\n - Trial NSAIDs for MSK pain\n - Consider anxiolytic as needed, with consideration for SSRI in\n outpatient setting.\n .\n # Fibromyalgia: continue gabapentin and nortriptyline\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Prophy - heparin sc\n .\n # Access - PIV X2\n .\n # Dispo - Pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 480009, "text": "Chief Complaint: severe chest pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (70 - 81) bpm\n BP: 100/56(66) {86/50(59) - 105/62(97)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 103 mL\n PO:\n TF:\n IVF:\n 518 mL\n 103 mL\n Blood products:\n Total out:\n 830 mL\n 310 mL\n Urine:\n 230 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n Gen obese woman lying in bed NAD, anxious\n HEENT: op dry,\n CV: RR no murmurs\n Chest: LLL rales which clear with cough\n ABd: obese soft NT +BS\n Ext: no edema\n Neuro: a and o x 3 cn 2-12 intact\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK / CKMB / Troponin-T:103/3/<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph:49.3 %, Mono:5.3\n %, Eos:2.9 %, Lactic Acid:1.2 mmol/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 1. Relative Hypotension: in setting of possible decreased pos\n and also received nitro in ED- likely bottomed her out. Has responded\n to IVF\n and lactate has resolved.\n 2. Atypical chest pain: neg CTA, no acute ECG changes, ruling\n out, consult her outpt Cards re if there is a plan for\n cath to answer\n 3. Anemia: stable, follow up\n 4. Dysphagia: DDX GERD, spasm, may need EGD to look for gastritis\n or barium for spasm , stricture\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: po diet\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: with pt\n status: Full code\n Disposition :Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2150-09-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 480025, "text": "The patient is a 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and hypotension.\n The patient reports that she began to feel increasingly unwell\n yesterday when she noted increased fatigue and did not leave her home.\n Today she noted dyspnea and dizziness while walking with her daughter.\n She had to stop frequently to catch her breath while walking home and\n had difficulty ambulating upstairs. She also reports difficulty\n swallowing secondary to throat tightness. She has had symptoms like\n this before, last time one week ago. She sleeps on four pillows nightly\n due to difficulty breathing. Denies PND. She called EMS for transport\n to the ED. On arrival to the ED she complained of chest pain with\n associated diaphoresis and shortness of breath.\n .\n In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She was\n given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg IV. EMS\n had been concerned about ECG and code STEMI was called. On arrival to\n ED, ECG was not felt to be consistent with acute ischemia. She\n underwent a FAST scan which was negative for pericardial effusion. CTA\n negative for PE or dissection. Her BP dropped to 80s after reciept of\n SL NTG. She was given 2L NS without response in BP. Her BP improved to\n 90s after 3rd L NS. She reported continued chest discomfort , which\n was reproducible upon palpation.\n UPDATE: Since admit to the MICU pt given an additional 500cc NS\n overnight. VSS. SBP now in the 110s-120s, maps in the 60s, HR\n 70s-80s, SR. CEs negative. EKG normal. Pt alert and oriented x 3. Pt\n is speaking, but speaks some English and is able to make her\n needs known. MAEs. LS CTA, o2 sats high 90s-100% on RA.\n Hypotension (not Shock)\n Assessment:\n VSS, SR. No ectopy.\n Action:\n Checking HCT .\n Response:\n HCT stable.\n Plan:\n Recheck HCT @ 1400.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o dyshagia, eipigastric, and Lt chest/arm pain .\n Action:\n Given tramadol, gabapentin, & Maalox/lidocain/diphenhydramine\n cocktail.\n Response:\n Pt reports some relief following pain meds.\n Plan:\n Cont w/ pain mgmt as needed, ? need for EGD/barium swallow in near\n future to r/o possibility of esophageal stricture vs bad GERD\n symptoms.\n" }, { "category": "Nursing", "chartdate": "2150-09-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 480027, "text": "The patient is a 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and hypotension.\n The patient reports that she began to feel increasingly unwell\n yesterday when she noted increased fatigue and did not leave her home.\n Today she noted dyspnea and dizziness while walking with her daughter.\n She had to stop frequently to catch her breath while walking home and\n had difficulty ambulating upstairs. She also reports difficulty\n swallowing secondary to throat tightness. She has had symptoms like\n this before, last time one week ago. She sleeps on four pillows nightly\n due to difficulty breathing. Denies PND. She called EMS for transport\n to the ED. On arrival to the ED she complained of chest pain with\n associated diaphoresis and shortness of breath.\n .\n In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She was\n given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg IV. EMS\n had been concerned about ECG and code STEMI was called. On arrival to\n ED, ECG was not felt to be consistent with acute ischemia. She\n underwent a FAST scan which was negative for pericardial effusion. CTA\n negative for PE or dissection. Her BP dropped to 80s after reciept of\n SL NTG. She was given 2L NS without response in BP. Her BP improved to\n 90s after 3rd L NS. She reported continued chest discomfort , which\n was reproducible upon palpation.\n UPDATE: Since admit to the MICU pt given an additional 500cc NS\n overnight. VSS. SBP now in the 110s-120s, maps in the 60s, HR\n 70s-80s, SR. CEs negative. EKG normal. Pt alert and oriented x 3. Pt\n is speaking, but speaks some English and is able to make her\n needs known. MAEs. LS CTA, o2 sats high 90s-100% on RA.\n Hypotension (not Shock)\n Assessment:\n VSS, SR. No ectopy. Possible etiology of hypotension may be related\n to decrease in po\ns w/ addition of SL nitro given in route to\n hospital. No acute ECG changes.\n Action:\n Checking HCT .\n Response:\n HCT stable.\n Plan:\n Recheck HCT @ 1400.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o dyshagia ( pt reports difficulty swallowing for past month now-\n mostly w/ solids vs liquids), eipigastric, and Lt chest/arm pain\n .\n Action:\n Given tramadol, gabapentin, & GI cocktail of\n Maalox/lidocain/diphenhydramine.\n Response:\n Pt reports some relief following pain meds.\n Plan:\n Cont w/ pain mgmt as needed, ? need for EGD/barium swallow in near\n future to r/o possibility of esophageal stricture vs bad GERD\n symptoms.\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 479999, "text": "TITLE:\n Chief Complaint: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and admitted for\n hypotension.\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n -increasingly unwell yesterday\n -day of admission,noted dyspnea and dizziness while walking with her\n daughter and ambulating up stairs.\n -difficulty swallowing secondary to throat tightness.\n -similar sx one week ago\n -EMS called and were concerned for STEMI based on EKG\n -In ED 10/10 chest pain with associated diaphoresis and shortness of\n breath. BP at the time was 106/60.\n -EKG with Q waves (2,3,AvF) c/w prior MI but no ST changes\n -CTA was negative for PE or dissection. FAST scan negative for\n pericardial effusion.\n -BP dropped to 80s after reciept of SL NTG.\n -GIven 3L IVF with improvement of SBP to 90s.\n .\n On arrival to the MICU, continued discomfort in her chest and throat\n tightness.\n -described pain as burning, substernal, ascending, like past GERD.\n -she received ______L of IVF with some BP response.\n -Hct was down at admission 33 and to 30.8 overnight.\n -Guaiac was performed and negative.\n -CE enzymes negative.\n -GI cocktail was given with some resolution of substernal burning but\n persistent feeling as though there was something in her throat this AM.\n -also with pain L shoulder and upper arm with movement.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 71 (70 - 81) bpm\n BP: 95/54(64) {86/50(59) - 105/62(70)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 71 mL\n PO:\n TF:\n IVF:\n 518 mL\n 71 mL\n Blood products:\n Total out:\n 830 mL\n 210 mL\n Urine:\n 230 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n General Appearance: Alert and oriented.\n HEENT: Oropharynx clear. Patchy alopecia.\n Chest: Distant heart sounds, regular rate and rhythm, no w/r/g. TTP at\n sternum and shoulder this AM.\n Resp: Clear to ausculatation bilaterally\n Abd: Soft, non-distended, BS+, TTP at epigastrium but improved from\n admission.\n Skin: Warm, well-perfused. 2+ DP. No cyanosis or edema.\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n WBC were 6.0, Hct down from 33.0 in ED, 30.7 last night, 39.1 two weeks\n ago. Plts were 306 in ED.\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK 103 / CKMB 3 / Troponin-T<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph:49.3 %, Mono:5.3\n %, Eos:2.9 %, Lactic Acid:1.2 (was 2.7 in the ED) mmol/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 53 y/o F with a PMH of fibromyalgia and hypertension presenting with\n chest discomfort, shortness of breath and hypotension.\n .\n # Hypotension: Unclear etiology at this time.\n -Initial concern for ACS or Aortic Dissection or PE but CE negative,\n ECG unchanged from prior and CTA negative. CE negative and stable. Arm\n pain could represent atypical CP, but likely MSK bc exacerbated with\n movement.\n -Medication effect: BP dropped following receipt of SL ntg however time\n course seems too long to attribute to single dose of ntg along and no\n aortic valve pathology that might exacerbate effect.\n -- metoprolol and lisinopril however the patient does not recall taking\n additional meds and has been stable on current doses for some time.\n -Pt does not seem overtly volume down on exam or labs. Bun and Cr\n within normal limits. Some response to IVF but still hypotensive after\n ______ L\n -Minimal evidence of significant infection-- no fever. WBC down and\n lymphocytosis this AM, pharyngitis, so viral infection is possible. BCx\n and UCx pending. Abx held give lack of evidence of infection.\n -Pt with GERD symptoms and HCT 33 down from prior and down overnight.\n Consider GI bleed in setting of gastritis. Type and screen sent. Guaiac\n negative.\n -Anti-HTN held\n - Continue IVF bolus to maintain MAP >60. Use of pressors if MAP<60\n unclear since etiology is unknown and risk of SIRS is low.\n -Trend lactate.\n -Guaiac stool\n -Q12H Hct\n - Follow up final read CTA\n - Follow up blood and urine cultures.\n .\n # Chest Discomfort:\n Likely due to GERD given ascending retrosternal burn, throat\n pain/tightness c/w prior experiences with GERD. GI cocktail with some\n effect.\n +/-MSK or costochondritis, especially given arm pain this AM.\n -as noted, cardiac etiology less likely given unchanged EKG and\n negative CE\n -Significant anxiety given loss of job could exacerbate chest pain and\n cause sensation of SOB, throat tightness, weakness.\n - Antihypertensives held in setting of hypotension.\n - Consider anxiolytic as needed, with consideration for SSRI in\n outpatient setting.\n .\n # Fibromyalgia: continue gabapentin and nortriptyline\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Prophy - heparin sc\n .\n # Access - PIV X2\n .\n # Dispo - Pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2150-09-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 480006, "text": "Chief Complaint: severe chest pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 08:17 PM\n NASAL SWAB - At 09:34 PM\n BLOOD CULTURED - At 05:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (70 - 81) bpm\n BP: 100/56(66) {86/50(59) - 105/62(97)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,118 mL\n 103 mL\n PO:\n TF:\n IVF:\n 518 mL\n 103 mL\n Blood products:\n Total out:\n 830 mL\n 310 mL\n Urine:\n 230 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,288 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n ABd\n Ext\n Neuro\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 107 mEq/L\n 136 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 07:12 PM\n 10:04 PM\n 05:10 AM\n WBC\n 3.9\n Hct\n 30.7\n 30.8\n Plt\n 236\n Cr\n 0.7\n TropT\n <0.01\n <0.01\n Glucose\n 94\n Other labs: CK / CKMB / Troponin-T:103/3/<0.01, ALT / AST:29/26, Alk\n Phos / T Bili:52/0.2, Differential-Neuts:42.0 %, Lymph:49.3 %, Mono:5.3\n %, Eos:2.9 %, Lactic Acid:1.2 mmol/L, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt\n status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2150-09-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 479908, "text": "Chief Complaint: Hypotension\n HPI:\n History taken with use of Spanish interpretor. The patient is a 53 y/o\n F with a PMH of fibromyalgia and hypertension presenting with chest\n discomfort, shortness of breath and hypotension. The patient reports\n that she began to feel increasingly unwell yesterday when she noted\n increased fatigue and did not leave her home. Today she noted dyspnea\n and dizziness while walking with her daughter. She had to stop\n frequently to catch her breath while walking home and had difficulty\n ambulating up stairs. She also reports difficulty swallowing secondary\n to throat tightness. She has had symptoms like this before, last time\n one week ago. She sleeps on four pillows nightly due to difficulty\n breathing. Denies PND. She called EMS for transport to the ED. On\n arrival to the ED she complaints of chest pain with associated\n diaphoresis and shortness of breath.\n .\n In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She was\n given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg IV. EMS\n had been concerned about ECG and code STEMI was called. On arrival to\n ED, ECG was not felt to be consistent with acute ischemia. She\n underwent a FAST scan which was negative for pericardial effusion. CTA\n negative for PE or dissection. Her BP dropped to 80s after reciept of\n SL NTG. She was given 2L NS without response in BP. Her BP improved to\n 90s after 3rd L NS. She reported continued chest discomfort , which\n was reproducible upon palpation of the sternum.\n .\n On arrival to the MICU, the patient complains of continued discomfort\n in her chest and throat.\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 Fluticasone 50 mcg Spray, 2 puff daily\n Gabapentin 300 mg Capsule TID\n Lisinopril 10 mg Tablet daily\n Metoprolol Tartrate 25 mg Tablet \n Nitroglycerin 0.3 mg Tablet, Sublingual PRN\n Nortriptyline 50 mg Capsule QHS\n Tramadol 50 mg Tablet one or two Tablet(s) by mouth daily as needed\n Aspirin 325 mg Tablet daily\n Loratadine 10 mg Tablet daily\n Nicotine 7 mg/24 hour Patch 24 hr\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n GERD\n Bilateral carpal tunnel syndrome.\n Hypertension\n Lumbosacral radiculopathy.\n Depression.\n Fibromyalgia.\n .\n PAST SURGICAL HISTORY:\n Carpal tunnel release\n Cholecystectomy.\n Laser surgery on the right eye\n Mother died with liver disease. Father died at 45 with a heart\n attack. One brother died with renal failure\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Current tobacco use with 5 cig/daily. No EtOH or IVDU. The\n patient is currently unemployed. She is a widow, her husband was\n alcoholic and committed suicide three years ago. She lives with\n youngest daughter.\n Review of systems:\n Flowsheet Data as of 10:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 73 (71 - 81) bpm\n BP: 99/62(70) {86/50(59) - 99/62(70)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,100 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 730 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,370 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n Vitals: T 97.3, BP 87/51, RR 16, O2 100% 2L\n GEN: alert, oriented X3, NAD\n HEENT: MMM, OP clea\n CV: RRR, nl s1/s2, no MRG, palpable, reproducible tenderness along\n sternum, pulses palp 2+ radial, PT/DP\n RESP: CTAB, no WRR\n ABD: soft, NT/ND, NABS\n EXT: no edema\n Labs / Radiology\n 306\n 113\n 0.9\n 10\n 24\n 101\n 4.3\n 136\n 33.0\n 6.0\n [image002.jpg]\n \n 2:33 A8/25/ 07:12 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 WBC\n 6.0\n Hct\n 33.0\n Plt\n 306\n TropT\n <0.01\n Other labs: PT / PTT / INR:INR 1.0, CK / CKMB / Troponin-T:109/3/<0.01,\n Amylase / Lipase:/30, Lactic Acid:2.7\n Fluid analysis / Other labs: ECG:NSR 75bpm, nl axis/intervals, Qwaves\n II/III/AVF and V4-V6, no ST/Tchanges, no change from prior\n .\n RADIOLOGY:\n CTA CHEST - prelim - Limited / technique No PE in the\n main-primary-lobal-proximal segmental arteries. Subsegmental PE not\n excluded. Aberrant right subcalvian artery. Cardiomegaly\n .\n CT HEAD - prelim - Limited / motion No definite ICH\n .\n TTE: - The left atrium and right atrium are normal in cavity\n size. Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). The estimated cardiac index\n is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall\n motion are normal. The diameters of aorta at the sinus, ascending and\n arch levels 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. The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion.\n IMPRESSION: Normal biventricular cavity sizes with preserved global and\n regional biventricular systolic function.\n .\n Imaging: Serum Tox Screen - negative\n Assessment and Plan\n ASSESSMENT & PLAN: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and hypotension.\n .\n # Hypotension: Unclear etiology at this time. Initial concern for ACS\n or Aortic Dissection or PE however CE negative, ECG unchanged from\n prior and CTA negative. BP dropped following receipt of SL ntg however\n time course seems too long to attribute to single dose of ntg along and\n no aortic valve pathology that might exacerbate effect. Could consider\n medication effect from metoprolol and lisinopril however the patient\n does not recall taking additional meds and has been stable on current\n doses for some time. Complaint of tightness in chest and throat raises\n concern for allergic reaction however no clear evidence of this on\n exam, no wheezing and duration of symptoms does not fit acute\n anaphylaxis. Pt does not seem overtly volume down on exam or labs.\n Additionally, no evidence of infection by symptoms, fever or WBC count.\n Pt with GERD symptoms and HCT 33 down from prior, consider GI bleed in\n setting of gastritis\n - Continue IVF bolus to maintain MAP >60\n - Continue to cycle CE X3\n - Repeat HCT to rule out GI bleed, send T&S\n - Repeat ECG with next set CE\n - Follow up final read CTA\n - Send blood and urine cultures, hold on antibiotics for now given no\n evidence of infection\n - Hold antihypertensives\n - Repeat lactate\n .\n # Chest Discomfort: Unclear etiology. The patient has reproducible\n chest pain over sternum suggestive of MSK or costochondritis. Describes\n burning and gas in chest and throat associated with chest pain, though\n not currently may suggest component of GERD. Additionally, consider\n cardiac etiology given evidence of prior inferior ischemia on ECG. RF\n for CAD include family history, HTN, tobacco use however symptoms are\n atypical to be anginal.\n - Holding BB for now given hypotension\n - Trend CE X3\n - Trial GI cocktail\n - Trial NSAIDs for MSK pain\n .\n # Fibromyalgia: continue gabapentin and nortriptyline\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Prophy - heparin sc\n .\n # Access - PIV X2\n .\n # Dispo - Pending above\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2150-09-08 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 479909, "text": "Chief Complaint: Hypotension\n HPI:\n History taken with use of Spanish interpretor. The patient is a 53 y/o\n F with a PMH of fibromyalgia and hypertension presenting with chest\n discomfort, shortness of breath and hypotension. The patient reports\n that she began to feel increasingly unwell yesterday when she noted\n increased fatigue and did not leave her home. Today she noted dyspnea\n and dizziness while walking with her daughter. She had to stop\n frequently to catch her breath while walking home and had difficulty\n ambulating up stairs. She also reports difficulty swallowing secondary\n to throat tightness. She has had symptoms like this before, last time\n one week ago. She sleeps on four pillows nightly due to difficulty\n breathing. Denies PND. She called EMS for transport to the ED. On\n arrival to the ED she complaints of chest pain with associated\n diaphoresis and shortness of breath.\n .\n In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She was\n given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg IV. EMS\n had been concerned about ECG and code STEMI was called. On arrival to\n ED, ECG was not felt to be consistent with acute ischemia. She\n underwent a FAST scan which was negative for pericardial effusion. CTA\n negative for PE or dissection. Her BP dropped to 80s after reciept of\n SL NTG. She was given 2L NS without response in BP. Her BP improved to\n 90s after 3rd L NS. She reported continued chest discomfort , which\n was reproducible upon palpation of the sternum.\n .\n On arrival to the MICU, the patient complains of continued discomfort\n in her chest and throat.\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 Fluticasone 50 mcg Spray, 2 puff daily\n Gabapentin 300 mg Capsule TID\n Lisinopril 10 mg Tablet daily\n Metoprolol Tartrate 25 mg Tablet \n Nitroglycerin 0.3 mg Tablet, Sublingual PRN\n Nortriptyline 50 mg Capsule QHS\n Tramadol 50 mg Tablet one or two Tablet(s) by mouth daily as needed\n Aspirin 325 mg Tablet daily\n Loratadine 10 mg Tablet daily\n Nicotine 7 mg/24 hour Patch 24 hr\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n GERD\n Bilateral carpal tunnel syndrome.\n Hypertension\n Lumbosacral radiculopathy.\n Depression.\n Fibromyalgia.\n .\n PAST SURGICAL HISTORY:\n Carpal tunnel release\n Cholecystectomy.\n Laser surgery on the right eye\n Mother died with liver disease. Father died at 45 with a heart\n attack. One brother died with renal failure\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Current tobacco use with 5 cig/daily. No EtOH or IVDU. The\n patient is currently unemployed. She is a widow, her husband was\n alcoholic and committed suicide three years ago. She lives with\n youngest daughter.\n Review of systems:\n Flowsheet Data as of 10:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 73 (71 - 81) bpm\n BP: 99/62(70) {86/50(59) - 99/62(70)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,100 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 730 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,370 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n Vitals: T 97.3, BP 87/51, RR 16, O2 100% 2L\n GEN: alert, oriented X3, NAD\n HEENT: MMM, OP clea\n CV: RRR, nl s1/s2, no MRG, palpable, reproducible tenderness along\n sternum, pulses palp 2+ radial, PT/DP\n RESP: CTAB, no WRR\n ABD: soft, NT/ND, NABS\n EXT: no edema\n Labs / Radiology\n 306\n 113\n 0.9\n 10\n 24\n 101\n 4.3\n 136\n 33.0\n 6.0\n [image002.jpg]\n \n 2:33 A8/25/ 07:12 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 WBC\n 6.0\n Hct\n 33.0\n Plt\n 306\n TropT\n <0.01\n Other labs: PT / PTT / INR:INR 1.0, CK / CKMB / Troponin-T:109/3/<0.01,\n Amylase / Lipase:/30, Lactic Acid:2.7\n Fluid analysis / Other labs: ECG:NSR 75bpm, nl axis/intervals, Qwaves\n II/III/AVF and V4-V6, no ST/Tchanges, no change from prior\n .\n RADIOLOGY:\n CTA CHEST - prelim - Limited / technique No PE in the\n main-primary-lobal-proximal segmental arteries. Subsegmental PE not\n excluded. Aberrant right subcalvian artery. Cardiomegaly\n .\n CT HEAD - prelim - Limited / motion No definite ICH\n .\n TTE: - The left atrium and right atrium are normal in cavity\n size. Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). The estimated cardiac index\n is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall\n motion are normal. The diameters of aorta at the sinus, ascending and\n arch levels 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. The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion.\n IMPRESSION: Normal biventricular cavity sizes with preserved global and\n regional biventricular systolic function.\n .\n Imaging: Serum Tox Screen - negative\n Assessment and Plan\n ASSESSMENT & PLAN: 53 y/o F with a PMH of fibromyalgia and hypertension\n presenting with chest discomfort, shortness of breath and hypotension.\n .\n # Hypotension: Unclear etiology at this time. Initial concern for ACS\n or Aortic Dissection or PE however CE negative, ECG unchanged from\n prior and CTA negative. BP dropped following receipt of SL ntg however\n time course seems too long to attribute to single dose of ntg along and\n no aortic valve pathology that might exacerbate effect. Could consider\n medication effect from metoprolol and lisinopril however the patient\n does not recall taking additional meds and has been stable on current\n doses for some time. Complaint of tightness in chest and throat raises\n concern for allergic reaction however no clear evidence of this on\n exam, no wheezing and duration of symptoms does not fit acute\n anaphylaxis. Pt does not seem overtly volume down on exam or labs.\n Additionally, no evidence of infection by symptoms, fever or WBC count.\n Pt with GERD symptoms and HCT 33 down from prior, consider GI bleed in\n setting of gastritis\n - Continue IVF bolus to maintain MAP >60\n - Continue to cycle CE X3\n - Repeat HCT to rule out GI bleed, send T&S\n - Repeat ECG with next set CE\n - Follow up final read CTA\n - Send blood and urine cultures, hold on antibiotics for now given no\n evidence of infection\n - Hold antihypertensives\n - Repeat lactate\n .\n # Chest Discomfort: Unclear etiology. The patient has reproducible\n chest pain over sternum suggestive of MSK or costochondritis. Describes\n burning and gas in chest and throat associated with chest pain, though\n not currently may suggest component of GERD. Additionally, consider\n cardiac etiology given evidence of prior inferior ischemia on ECG. RF\n for CAD include family history, HTN, tobacco use however symptoms are\n atypical to be anginal.\n - Holding BB for now given hypotension\n - Trend CE X3\n - Trial GI cocktail\n - Trial NSAIDs for MSK pain\n .\n # Fibromyalgia: continue gabapentin and nortriptyline\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Prophy - heparin sc\n .\n # Access - PIV X2\n .\n # Dispo - Pending above\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 08:16 PM\n 18 Gauge - 08:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n Brief comments:\n 53 yo woman with fibromyalgia, HTN, GERD, depression and frequent\n medical attention for atypical chest pain and headaches, recently\n evaluated for EKG demonstrating Q waves in inf and lat distribution\n with normal echo. Presented today following 2 days of feeling dizzy,\n weak, with throat tightness and chest pain and had two episodes of\n vomiting yesterday. She has chronic GERD sxs, chronic HA and chronic\n chest discomfort. Now denies nausea, vomiting. Her greatest complaint\n is dyspnea, though she appears to be comfortably breathing and is\n speaking in full sentances with 100% SpO2 on room air. She became\n hypotensive after receiving NTG sublingual, but remains mildly\n hypotensive despite 3L NS. BP now 95/55. She took her usual metoprolol\n and lisinopril prior to presenting to hospital, but denies any extra\n doses or new meds.\n CT poor quality but unremarkable with no infiltrates, effusions,\n pericardial effusion, significant LAD. There may be some ground glass\n but difficult to differentiate from motion artifact.\n My exam sig for temp 97 BP 95/55 HR 70s 100% RA.\n Flattened affect but responsive to questions in full sentances (in\n Spanish). No dyspnea or stridor. No cough. No tracheal deviation. No\n rashes or joint inflammation. Frequent throat clearing. Distant heart\n sounds. Lungs with inspiratory crackles\n up bilaterally. No wheezes.\n Midepigastric tenderness, mild. No peritoneal signs. No LE edema\n whatsoever.\n Labs unremarkable except lactate 2.7 and hct 33% ( from 39% after 3L\n NS), UA negative.\n Confusing picture in a patient with frequent nonspecific symptoms. Her\n epigastric pain and tenderness and chest discomfort and even throat\n irritation can all be potentially explained by GERD which is untreated.\n This obviously does not explain her hypotension and mildly elevated\n lactate. Most likely hypovolemia from nausea, vomiting, anorexia. Other\n possible explanations include GI bleed, sepsis, viral syndrome, CHF,\n strongly doubt anaphylaxis or drug effect.\n Repeat hct\n Repeat lactate\n Guaiac stool (just completed and negative)\n Pending urine and blood cx\n GI cocktail\n Hold all antihypertensives including nitrates\n 40 minutes critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 23:00 ------\n" }, { "category": "ECG", "chartdate": "2150-09-08 00:00:00.000", "description": "Report", "row_id": 197864, "text": "Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but\nclinical correlation is suggested. Compared to the previous tracing of same\ndate no significant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2150-09-08 00:00:00.000", "description": "Report", "row_id": 197865, "text": "Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but\nclinical correlation is suggested. Compared to the previous tracing of same\ndate no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2150-09-08 00:00:00.000", "description": "Report", "row_id": 197866, "text": "Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but\nclinical correlation is suggested. Compared to the previous tracing of same\ndate no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2150-09-08 00:00:00.000", "description": "Report", "row_id": 197867, "text": "Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but\nclinical correlation is suggested. Compared to the previous tracing of \nno significant change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2150-09-08 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1094927, "text": " 2:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: PE? dissection?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with severe chest pain and hypotension. negative cardiac\n enzymes and ekg.\n REASON FOR THIS EXAMINATION:\n PE? dissection?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHfd TUE 4:51 PM\n Limited / technique\n\n No PE in the main-primary-lobal-proximal segmental arteries. Subsegmental PE\n not excluded. Aberrant right subcalvian artery.\n Cardiomegaly\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Chest pain.\n\n COMPARISON: Chest radiograph from same day.\n\n TECHNIQUE: Multidetector axial CT images of the chest were obtained before\n and after administration of IV contrast per routine pulmonary embolism\n protocol. Coronal and sagittal reformatted images were also submitted for\n interpretation.\n\n FINDINGS:\n Noncontrast images show no intramural hematoma.\n\n There is no evidence of filling defect within the main, primary, lobar or\n large segmental branches of the pulmonary artery. The evaluation of\n subsegmental pulmonary arteries is severely limited due to technique and\n timing of contrast administration. There is a small amount of fluid within\n the pericardial recess. The aorta appears grossly unremarkable with no\n evidence of aneurysmal dilatation or dissection. The heart is mildly\n enlarged. There is no pericardial effusion. There is no mediastinal, hilar,\n or axillary lymphadenopathy. Incidentally noted, there is right aberrant\n subclavian artery present. There is mild dependent atelectatic changes in\n both lung bases. The upper abdominal organs including partially visualized\n liver, spleen, pancreas appear grossly unremarkable.\n\n Osseous structures demonstrate degenerative changes. There is no acute\n displaced fracture.\n\n IMPRESSION:\n\n Limited study due to technique. No definite pulmonary embolism within the\n main, primary, lobar or large segmental branches of the pulmonary artery.\n\n Cardiomegaly.\n\n (Over)\n\n 2:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: PE? dissection?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Incidentally noted aberrant right subclavian artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-09-10 00:00:00.000", "description": "UGI AIR W/O KUB", "row_id": 1095209, "text": " 9:55 AM\n UGI AIR W/O KUB Clip # \n Reason: reason for dysphagia?\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with dysphagia and history of GERD\n REASON FOR THIS EXAMINATION:\n reason for dysphagia?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dysphagia, nasal regurgitation.\n\n BARIUM ESOPHAGRAM: Barium passes freely through the esophagus and there are\n normal primary peristaltic contractions. There is no significant retention in\n the valleculae or piriform sinuses. There is penetration into the vestibule\n with no aspiration into the airway. The cricopharyngeus impression is\n somewhat prominent; however, there is free passage of a 13-mm barium tablet.\n There is no hiatal hernia seen, and no gastroesophageal reflux demonstrated\n during the exam.\n\n IMPRESSION: Small amount of penetration into the vestibule. No aspiration\n into the airway. Prominent cricopharyngeus impression with free passage of a\n barium tablet.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1094905, "text": " 12:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval cardiopulm status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with CP\n REASON FOR THIS EXAMINATION:\n please eval cardiopulm status\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 53-year-old female with chest pain.\n\n COMPARISON: None.\n\n SINGLE FRONTAL VIEW OF THE CHEST: There is no evidence of pneumonia or CHF.\n There is no pneumothorax or pleural effusion. The heart is mildly enlarged.\n The aorta is tortuous. There is no definite acute displaced fracture.\n\n IMPRESSION:\n Cardiomegaly, otherwise no acute abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2150-09-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1094949, "text": " 4:27 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for ICH.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with head ache and chest pain\n REASON FOR THIS EXAMINATION:\n please assess for ICH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHfd TUE 4:39 PM\n\n Limited / motion\n No definite ICH\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 53-year-old female with headache.\n\n COMPARISON: None.\n\n TECHNIQUE: Multidetector CT images of the head were obtained without\n administration of IV contrast.\n\n FINDINGS:\n\n This study is severely limited due to motion artifact. There is no definite\n intracranial hemorrhage, mass effect or -white matter differentiation\n abnormality. The ventricles and extra-axial spaces are grossly within normal\n limits within the limitations of the study. Subcortical and periventricular\n white matter hypodensities likely represent chronic microvascular ischemic\n disease. There is no definite depressed skull fracture. The paranasal sinuses\n and mastoid air cells are grossly clear. The visualized orbits are grossly\n unremarkable.\n\n IMPRESSION:\n\n Limited study due to motion artifact.\n\n No definite acute intracranial abnormality.\n\n\n\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590524, "text": "Subdural hemorrhage (SDH)\n Assessment:\n -Pt sleepy throughout shift but easily arousable to voice. Oriented to\n name, children\ns names, year and per family knows the correct month of\n her calendar but thought it was Wednesday earlier in shift. Able to say\n in English that she\ns at Hospital. PERRL/sluggish 4 to 6\n mm. Normal strength in extremities, very little to no difference\n discernable in R versus L side. Pt turning herself in bed throughout\n shift. Following commands. Per family speech non-gargled or slurred.\n - Pt with clean incision on head and burr hole site clean and dry with\n dressing over it. C/o pain every few hours in head.\n Action:\n - Neuro checks changed to Q2. Neurosurg assessed patient\n around 2210 because she appeared more lethargic to this writer than\n prior assessments and team felt she was improving.\n - Dilaudid PRN\n - Keppra, Vanc and Gent administered as ordered\n Response:\n - Neuro exam remains unchanged. Patient getting better blocks of sleep\n now that neuro checks are changed to Q2. Pt reports headache improved\n after dilaudid. SBP maintained <140 without intervention.\n Plan:\n - Neuro checks Q2, SBP <140, keppra for seizure prophylaxis. OOB today,\n repeat head CT today.\n" }, { "category": "Physician ", "chartdate": "2185-09-05 00:00:00.000", "description": "Intensivist Note", "row_id": 590180, "text": "SICU ADMISSION NOTE\n HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on\n by Dr. who presents directly to the ED\n with 3 day history of progressively worsening R sided weakness\n and decrease sensation. On she was diagnosed with a\n subsegmental posterior PE and was started on Lovenox 50mg .\n Per daughter's translation, pt. noticed sl numbness to RU/L\n extremity with weakness and R foot drop. Denies confusion, visual\n changes, N/V or L sided deficits.\n Chief complaint:\n 3d of R sided weakness/numbness\n PMHx:\n PMH:\n 1. Hypercholesterolemia\n 2. Pulmonary Emboli \n PSH: resection of a planum sphenoidale chordoid meningioma on\n \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl\n 5. Calcium Carbonate\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. LeVETiracetam 9.\n Ondansetron 10. Senna 11. Simvastatin\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 12:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.1\nC (97\n T current: 36.1\nC (97\n HR: 56 (56 - 65) bpm\n BP: 115/64(78) {115/64(78) - 115/64(78)} mmHg\n RR: 15 (15 - 18) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 94 mL\n 33 mL\n PO:\n Tube feeding:\n IV Fluid:\n 94 mL\n 33 mL\n Blood products:\n Total out:\n 280 mL\n 0 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -186 mL\n 33 mL\n Respiratory support\n SPO2: 100%\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, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), No(t) Moves all\n extremities, (RUE: Weakness), (LUE: No(t) Weakness), (RLE: Weakness),\n (LLE: No(t) Weakness)\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 61 yo F with h/o meningioma s/p resection and h/o\n PE on lovenox presenting with left SD hematoma of multiple durations\n and midline shift.\n PLAN:\n Neuro: 1) SDH - Keppra 500mg for sz prophylaxis, SBP<140, Q1h neuro\n checks. OR tomorrow for craniotomy. Repeat HCT prior to OR. No need for\n acute drainage per neurosurg.\n CVS: HD stable. SBP < 140, currently in 110-120s.\n Pulm: H/o PE - off lovenox. No acute issues. Satting well on NC.\n GI: NPO for procedure. Colace, bisacodyl, senna for stool softening.\n FEN: NS + 20K at 75cc/hr, replete lytes prn.\n Renal: No active issues.\n Heme: Hct stable. INR 1.0. No need to reverse lovenox as last dose >\n 12h ago. Hold all anticoagulation.\n Endo: No active issues.\n ID: No active issues.\n TLD: PIV\n Wounds: -\n Imaging: CT in AM\n Prophylaxis: SCDs\n Consults: Neurosurg\n Code: Full\n Disposition: ICU\n ICU Care\n Lines:\n 18 Gauge - 10:43 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: none\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2185-09-05 00:00:00.000", "description": "Intensivist Note", "row_id": 590258, "text": "SICU ADMISSION NOTE\n HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on\n by Dr. who presents directly to the ED\n with 3 day history of progressively worsening R sided weakness\n and decrease sensation. On she was diagnosed with a\n subsegmental posterior PE and was started on Lovenox 50mg .\n Per daughter's translation, pt. noticed sl numbness to RU/L\n extremity with weakness and R foot drop. Denies confusion, visual\n changes, N/V or L sided deficits.\n Chief complaint:\n 3d of R sided weakness/numbness\n PMHx:\n PMH:\n 1. Hypercholesterolemia\n 2. Pulmonary Emboli \n PSH: resection of a planum sphenoidale chordoid meningioma on\n \n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4. Bisacodyl\n 5. Calcium Carbonate\n 6. Docusate Sodium 7. HYDROmorphone (Dilaudid) 8. LeVETiracetam 9.\n Ondansetron 10. Senna 11. Simvastatin\n 24 Hour Events:\n Admitted with SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 12:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.1\nC (97\n T current: 36.1\nC (97\n HR: 56 (56 - 65) bpm\n BP: 115/64(78) {115/64(78) - 115/64(78)} mmHg\n RR: 15 (15 - 18) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 94 mL\n 33 mL\n PO:\n Tube feeding:\n IV Fluid:\n 94 mL\n 33 mL\n Blood products:\n Total out:\n 280 mL\n 0 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -186 mL\n 33 mL\n Respiratory support\n SPO2: 100%\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, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), No(t) Moves all\n extremities, (RUE: Weakness), (LUE: No(t) Weakness), (RLE: Weakness),\n (LLE: No(t) Weakness)\n Labs / Radiology\n 363\n 92\n 0.7\n 26\n 4.2\n 6\n 113\n 146\n 32.4\n 3.6\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 61 yo F with h/o meningioma s/p resection and h/o\n PE on lovenox presenting with left SD hematoma of multiple durations\n and midline shift.\n PLAN:\n Neuro: 1) SDH - Keppra 500mg for sz prophylaxis, SBP<140, Q1h neuro\n checks. OR tomorrow for craniotomy. Repeat HCT prior to OR. No need for\n acute drainage per neurosurg.\n CVS: HD stable. SBP < 140, currently in 110-120s.\n Pulm: H/o PE - off lovenox\n most likely need IVC filter; Repeat LENI\n today. No acute issues. Satting well on NC.\n GI: NPO for procedure. Colace, bisacodyl, senna for stool softening.\n FEN: NS + 20K at 75cc/hr, replete lytes prn.\n Renal: No active issues.\n Heme: Hct stable. INR 1.0. No need to reverse lovenox as last dose >\n 12h ago. Hold all anticoagulation.\n Endo: No active issues.\n ID: No active issues.\n TLD: PIV\n Wounds: c/d/i\n Imaging: CT in AM\n Prophylaxis: SCDs\n Consults: Neurosurg\n Code: Full\n Disposition: ICU\n ICU Care\n Lines:\n 18 Gauge - 10:43 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: none\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32\n" }, { "category": "Rehab Services", "chartdate": "2185-09-05 00:00:00.000", "description": "Generic Note", "row_id": 590272, "text": "TITLE:\n Rehab Services-Occupational Therapy\n Consult received and appreciated. Spoke to Neurosurg team and pt not\n need foot splint as consulted for. Pt is going to the OR today for\n evacuation, will f/u and eval as able for R UE weakness. Please page\n as needed.\n" }, { "category": "Rehab Services", "chartdate": "2185-09-06 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 590460, "text": "Consult received and appreciated, per neurosurg patient is going to the\n OR today for IVC filter, not appropriate for PT/OT evals at this time.\n Will follow-up tomorrow for mobility assessment as appropriate.\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590607, "text": "HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on \n by Dr. who presents directly to the ED with 3 day\n history of progressively worsening R sided weakness and decrease\n sensation. On she was diagnosed with a subsegmental posterior PE\n and was started on Lovenox 50mg . Per daughter's translation, pt.\n noticed sl numbness to RU/L extremity with weakness and R foot drop.\n Denies confusion, visual changes, N/V or L sided deficits.\n resection of R frontal meningioma\n 8/17 L crani (subdural hematoma evacuation)\n IVC filter placed\n Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive (R side sluggish L side brisk)\n MAE equally with full strength\n denies blurred vision\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair/commode\n Ambulated around unit with PT/OT\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed per neurosurg, crani incision\n c/d/I no evidence of drainage\n tolerating diet, only eating sm amt of meal, able to swallow pills\n sbp < 140 throughout shift with no interventions needed\n med. size brown BM this morning\n tolerating activity OOB with supervision\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n continue activity OOB to chair/commode with support\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n 2mg Dilaudid PO X1\n Response:\n Pt reports pain is better after dilaudid\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590605, "text": "HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on \n by Dr. who presents directly to the ED with 3 day\n history of progressively worsening R sided weakness and decrease\n sensation. On she was diagnosed with a subsegmental posterior PE\n and was started on Lovenox 50mg . Per daughter's translation, pt.\n noticed sl numbness to RU/L extremity with weakness and R foot drop.\n Denies confusion, visual changes, N/V or L sided deficits.\n resection of R frontal meningioma\n 8/17 L crani (subdural hematoma evacuation)\n IVC filter placed\n Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive\n MAE equally with full strength\n denies visual changes\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair/commode\n Ambulated around unit with PT/OT\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed per neurosurg, crani incision\n c/d/I no evidence of drainage\n tolerating diet, only eating sm amt of meal, able to swallow pills\n sbp < 140 throughout shift with no interventions needed\n med size brown BM this morning\n tolerating activity, needs support/supervision\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n continue activity OOB to chair/commode with support\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n Dilaudid PRN\n Response:\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n" }, { "category": "Nursing", "chartdate": "2185-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590335, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt from , non-english speaking only. Children at bedside to\n translate at all times. Pt is alert and oriented x\ns 3. Per family\n speech is clear and behavior is appropriate though pt\nseems a bit\n slower than usual\n per family. Right side weaker than left -> pt able\n to lift and hold right upper and lower extremities, left upper and\n lower extremities have normal strength. Pupils are briskly reactive.\n Pupils are equal at times, but right can be .5mm larger than left\n (right ranging , left )\n neuro team is aware and difference\n attributed to prior cataract surgeries. Pt sent to o.r. at 1515 for\n crani/sdh evacuation. After returning from the o.r patient was\n restless and agitated, moving all extremities (left <right), pupils 2mm\n and non-reactive initially. Pt c/o of pain at incision site. Pt also\n c/o nausea. Sbp 120\ns-150\n Action:\n Pt received 0.125mg iv dilaudid x\ns 2 and 4mg iv zofran x\ns 1 with fair\n effect. Pt remains restless, but less so. Non-rebreather in place,\n hob 30 degrees, q 1 hour neuro checks, hydralazine x\ns 1 to keep sbp <\n 140. Neurology resident and sicu resident at bedside to\n evaluate restlessness/agitation/confusion.\n Response:\n Pt appeared more comfortable after dilaudid and zofran, though still\n restless/confused. Sbp improved to 130\ns with hydralazine, neuro\n status stable.\n Plan:\n Post op care, q 1 hour neuro checks, maintain sbp. Unable to obtain\n head ct immediately post op secondary to agitation, head ct asap.\n Non-rebreather x\ns 24 hours. Pt is npo after midnight for ivc filter\n placement.\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590575, "text": "Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive\n MAE equally with full strength\n denies visual changes\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed, crani incision c/d/I no evidence\n of drainage\n tolerating Pos, able to swallow pills\n sbp < 140 throughout shift with no interventions needed\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n Dilaudid given PRN\n Response:\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n" }, { "category": "Physician ", "chartdate": "2185-09-07 00:00:00.000", "description": "Intensivist Note", "row_id": 590586, "text": "SICU\n HPI:\n 61 yo F with h/o meningioma s/p resection and h/o PE on lovenox\n presenting with left SD hematoma of multiple durations and midline\n shift, now s/p evacuation of hematoma.\n Chief complaint:\n SDH\n PMHx:\n Hypercholesterolemia\n Pulmonary Emboli\n resection of a planum sphenoidale chordoid meningioma on \n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:50 AM\n Post operative day:\n POD#2 - s/p left crani (subdural hematoma evacuation)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Gentamicin - 02:09 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:20 PM\n Hydromorphone (Dilaudid) - 06:26 AM\n Other medications:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.2\nC (99\n HR: 80 (65 - 106) bpm\n BP: 95/67(73) {91/55(64) - 121/77(85)} mmHg\n RR: 22 (12 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.8 kg (admission): 66 kg\n Total In:\n 2,601 mL\n 788 mL\n PO:\n 150 mL\n 125 mL\n Tube feeding:\n IV Fluid:\n 2,451 mL\n 663 mL\n Blood products:\n Total out:\n 3,490 mL\n 810 mL\n Urine:\n 3,490 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -889 mL\n -23 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 274 K/uL\n 10.4 g/dL\n 102 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 6 mg/dL\n 112 mEq/L\n 144 mEq/L\n 32.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:54 AM\n 03:02 AM\n 01:15 AM\n WBC\n 3.6\n 10.0\n 5.8\n Hct\n 32.4\n 35.1\n 32.4\n Plt\n 363\n 387\n 274\n Creatinine\n 0.7\n 0.6\n 0.6\n Glucose\n 92\n 137\n 102\n Other labs: PT / PTT / INR:12.5/22.2/1.1, Differential-Neuts:61.2 %,\n Lymph:30.0 %, Mono:6.5 %, Eos:1.9 %, Ca:8.9 mg/dL, Mg:2.0 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 61 yo F with h/o meningioma s/p resection and h/o\n PE on lovenox presenting with left SD hematoma of multiple durations\n and midline shift, now s/p evacuation of hematoma and placement of IVC\n filter.\n PLAN:\n Neuro: 1) SDH s/p craniotomy and drainage - Keppra 500mg for sz\n prophylaxis, SBP<140, Q1h neuro checks. Postop HCT shows expected\n postop changes, repeat HCT shows no bleed\n CVS: HD stable. SBP < 140 Episode of SVT metoprolol 25\", Hydralazine\n prn. Will check Echo prior to DC\n Pulm: h/o PE - off lovenox. IVC filter yesterday. NC.\n GI: regular diet, famotidine.\n FEN: NS at 75cc/hr\n Renal: No active issues.\n Heme: Stable hematocrit, off all anticoagulation, s/p IVC filter\n placement\n Endo: No active issues.\n ID: Vanco/Gent x 48hrs.\n TLD: PIV\n Wounds: - clean\n Imaging: CT done, check official read. No bleeding seen.\n Prophylaxis: SCDs H2B bowel regimen\n Consults: , PT/OT\n Code: Full\n Disposition: ICU, to floor.\n Total time spent: 32 minutes\n" }, { "category": "Rehab Services", "chartdate": "2185-09-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 590590, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 432.1 /\n Reason of referral: evaluate, treat, and home safety evaluation\n History of Present Illness / Subjective Complaint: 61 y/o female adm\n with 3 day history of R sided weakness and sensory deficits.\n Found to have reaccumulation of L SDH with midline shift. s/p crani\n with evacuation of SDH on . Of note, patient had recent h/o PE on\n and was started on lovenox. Since patient can not be\n anticoagulated (2' rebleed), underwent IVC filter placement on .\n Past Medical / Surgical History: hypercholesterolemia, PE, meningioma\n s/p resection \n Medications: dilaudid, nicardipine, hydralazine, metoprolol\n Radiology: Head CT: increased R parietal hemorrhage, increased L\n subdural fluid accumulation\n Labs:\n 32.4\n 10.4\n 274\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist, SBP < 140\n Social / Occupational History: Very supportive family, daughter able to\n provide 24 hour care\n Living Environment: Lives with daughter, apartment, no\n elevator, + railing on all stairs\n Prior Functional Status / Activity Level: Baseline, independent and\n very active, no AD; PTA, ambulated with RW for a few weeks after\n discharge, then transitioned to ambulating without AD, independent with\n bathing/dressing, assist with cooking from daughter, R visual\n impairment\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O x 3, pleasant,\n very cooperative, Ethiopian-speaking, but following all commands given\n by daughter\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 90\n 114/74\n Sit\n /\n Activity\n 90\n /\n Stand\n /\n Recovery\n 104\n 103/60\n 95% RA\n Total distance walked: 60'\n Minutes: 4 min\n Pulmonary Status: NARD, CTA throughout\n Integumentary / Vascular: L craniotomy incision C/D, foley, R UE pIV\n Sensory Integrity: intact to LT throughout B UE and LE, no complaints\n of parasthesias\n Pain / Limiting Symptoms: c/o intermittent L sided headache\n Posture: unremarkable\n Range of Motion\n Muscle Performance\n WFL\n B UE except R shoulder flexor \n B DF , B quads , B hip flexors > , B hamstrings > \n Motor Function: moves all extremities in isolation, R visual field cut\n in R eye only\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Ambulated without AD x 60' with wide BOS, decreased\n step length, decreased cadence, reaching out for objects with B UE for\n balance.\n Rolling:\n T\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Seated: no LOB at EOB without UE support.\n Standing: statically, no LOB without UE support with CG; dynamically\n requires CG assist\n Education / Communication: Educated patient and daughter as to role of\n PT and OT, need to call for assist for mobility, and discharge plan.\n Communicated with RN as to patient status and d/c plan.\n Intervention: n/a\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Gait, Impaired\n 3.\n Knowledge, Impaired\n Clinical impression / Prognosis: 61 y/o female adm with L SDH s/p\n crani. Patient presents with above deficits consistent with\n nonprogressive CNS disorder. Anticipate that patient will make\n progress with PT in hospital and will be safe for discharge to home\n with daughter's supervision and follow up with home PT and home OT.\n Patient has excellent rehab potential given return of R sided function.\n Goals\n Time frame: 1 week\n 1.\n I sit to stand\n 2.\n I ambulation with RW x 200'\n 3.\n Ascend/descend 3 FOS with rail and supervision from daughter\n 4.\n Stand without UE support and reach out of BOS in all directions without\n LOB\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 2-4x/week x 1 week\n Gait training with RW --> cane\n Balance training without UE support\n Patient and family education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face Time: 10:28\n 10:57\n" }, { "category": "Rehab Services", "chartdate": "2185-09-07 00:00:00.000", "description": "Occupational Therapy Abbreviated Evaluation Note", "row_id": 590593, "text": "History\n Attending M.D.: \n Referral Date: \n Reason for Referral: Eval and treat\n Medical Dx / ICD - 9: 431\n Activity Orders: OOB with A\n HPI / Subjective Complaint: 61 year old female admit with L SDH\n with midline shift s/p crani with evacuation. Pt with recent history\n of PE on and lovenox. IVC placed .\n Past Medical / Surgical History: increased cholesterol, PE, meningioma\n s/p resecttion \n Social / Occupational / Environmental History: lives with daughter, 3\n flights of stairs, daughter does cooking, daughter home most of the\n time and will now be home with her all the time\n Baseline Occupational Performance ADL / IADL: I bathing and dressing,\n ambulating with walker, and uses furniture, R field cut from previous\n SDH\n Current Activities of Daily Living\n Grooming: (Supervision)\n UE Bathing: (Supervision)\n LE Bathing: (Supervision)\n UE Dressing: (Supervision)\n LE Dressing: (Supervision)\n Toileting: (Supervision)\n Aerobic Activity Response: Rest\n Rest HR: 90\n Rest BP: 114/74\n Aerobic Activity Response: Recovery\n Recovery HR: 90\n Recovery BP: 103/60\n Recovery O2 sat: 95 %\n Aerobic Activity Response\n Other Tests and Measures / Treatments: Rolling I\n supine to sit I\n sit to stand CG\n ambulation CG\n B UE except L shoulder flexion \n B UE intact to light touch\n pt aox3, able to follow multi-step commands, appropriate, able to make\n needs known\n Communication / Education: role of OT, home services\n communication with RN, co-treat with PT\n Diagnosis\n Diagnosis 1: decreased functional mobility\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: 61 year old female s/p crani for L SDH\n who present as above. Pt presented with R sided weakness which has now\n almost all resolved. Pt demonstrates slightly decreased balance for\n standing adls and functional mobility which will continue to be\n addressed by PT. Will defer further balance training to PT and pt safe\n for d/c home with daughter who can help as needed from OT standpoint.\n Recommend home OT to continue working on I in home environment.\n Goals: patient / family, objective, measurable\n Goal 1: socks\n Time Frame (expected attainment): met during eval\n Anticipated Discharge: Home\n Treatment Plan: Interventions; patient / family education, community\n resources:\n Treatment Plan: D/c acute OT\n Therapist Information\n Therapist's Name: \n Date: \n Time: 1028-1057\n Pager #: \n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590598, "text": "HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on \n by Dr. who presents directly to the ED with 3 day\n history of progressively worsening R sided weakness and decrease\n sensation. On she was diagnosed with a subsegmental posterior PE\n and was started on Lovenox 50mg . Per daughter's translation, pt.\n noticed sl numbness to RU/L extremity with weakness and R foot drop.\n Denies confusion, visual changes, N/V or L sided deficits.\n resection of R frontal meningioma\n 8/17 L crani (subdural hematoma evacuation)\n IVC filter placed\n Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive\n MAE equally with full strength\n denies visual changes\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair/commode\n Ambulated around unit with PT/OT\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed per neurosurg, crani incision\n c/d/I no evidence of drainage\n tolerating diet, able to swallow pills without problem\n sbp < 140 throughout shift with no interventions needed\n med size brown BM this morning\n tolerating activity, needs support/supervision\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n continue activity OOB to chair/commode with support\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n Dilaudid PRN\n Response:\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n" }, { "category": "Physician ", "chartdate": "2185-09-06 00:00:00.000", "description": "Intensivist Note", "row_id": 590390, "text": "SICU\n HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on\n by Dr. who presents directly to the ED\n with 3 day history of progressively worsening R sided weakness\n and decrease sensation. On she was diagnosed with a\n subsegmental posterior PE and was started on Lovenox 50mg .\n Per daughter's translation, pt. noticed sl numbness to RU/L\n extremity with weakness and R foot drop. Denies confusion, visual\n changes, N/V or L sided deficits.\n Chief complaint:\n weakness\n PMHx:\n PMH:\n 1. Hypercholesterolemia\n 2. Pulmonary Emboli\n PSH: resection of a planum sphenoidale chordoid meningioma on\n \n :\n 1. Lovenox SQ 60mg - last dose @ 9am on \n 2. Calcium with D Daily\n 3. Docusate 100 mg Daily\n 4. Percocet 5/325 mg PO, PRN\n 5. Zocor 20 mg Daily\n Current medications:\n 24 Hour Events:\n OR SENT - At 03:25 PM\n OR RECEIVED - At 05:40 PM\n ARTERIAL LINE - START 05:52 PM\n Post operative day:\n POD#1 - s/p left crani (subdural hematoma evacuation)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Gentamicin - 02:03 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 12:00 AM\n Hydromorphone (Dilaudid) - 02:00 AM\n Other medications:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 78 (54 - 112) bpm\n BP: 134/70(91) {101/52(73) - 145/72(101)} mmHg\n RR: 20 (12 - 42) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.2 kg (admission): 66 kg\n Total In:\n 3,256 mL\n 556 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,256 mL\n 556 mL\n Blood products:\n Total out:\n 3,200 mL\n 1,190 mL\n Urine:\n 2,770 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n -634 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, by report from family, oriented and\n appropriate when speaking in Ethiopian\n Labs / Radiology\n 387 K/uL\n 11.3 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 113 mEq/L\n 147 mEq/L\n 35.1 %\n 10.0 K/uL\n [image002.jpg]\n 04:54 AM\n 03:02 AM\n WBC\n 3.6\n 10.0\n Hct\n 32.4\n 35.1\n Plt\n 363\n 387\n Creatinine\n 0.7\n 0.6\n Glucose\n 92\n 137\n Other labs: PT / PTT / INR:12.5/22.2/1.1, Differential-Neuts:61.2 %,\n Lymph:30.0 %, Mono:6.5 %, Eos:1.9 %, Ca:9.6 mg/dL, Mg:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 61 yo F with h/o meningioma s/p resection and h/o\n PE on lovenox presenting with left SD hematoma of multiple durations\n and midline shift, now s/p evacuation of hematoma.\n Neurologic: SDH - Keppra 500mg for sz prophylaxis, SBP<140, Q1h\n neuro checks. OR tomorrow for craniotomy. postop HCT shows expected\n postop changes, repeat in AM\n Cardiovascular: HD stable. SBP < 140\n Pulmonary: H/o PE - off lovenox. No acute issues. Satting well on NC.\n Gastrointestinal / Abdomen: DAT in AM\n Nutrition:\n Renal: No active issues.\n Hematology: Stable hematocrit, off all anticoagulation, for IVC filter\n placement in AM (IR)\n Endocrine: No active issues.\n Infectious Disease: No active issues.\n Lines / Tubes / Drains: PIV\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:43 PM\n Arterial Line - 05:52 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2185-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590507, "text": "Subdural hemorrhage (SDH)\n Assessment:\n POD #2 L crani (subdural hematoma evacuation)\n alert and oriented X 3, family reports speech is clear\n patients family available to translate neuro checks\n pupils 3mm sluggishly reactive\n MAE with equal strength, follows commands\n Action:\n q1h neuro assessments\n CT scan done\n IVC filter placed through R femoral vein in angio, R knee immoblizer on\n until 1630 MD \n checks done as ordered\n diet advanced to sips as tolerated\n Response:\n pulses easily palpable, no bleeding at angio site, knee immobilizer now\n off\n neuro exam unchanged throughout the shift, able to give own consent for\n IVC procedure using telephone translator\n Ct showed no further bleeding per neurosurgery\n Tolerating sips\n Plan:\n repeat CT to be done tomorrow \n continue to monitor angio site and may advance activity OOB as\n tolerated\n PT/OT tomorrow\n Pain control (acute pain, chronic pain)\n Assessment:\n frequently complains of headache\n Action:\n Dilaudid 0.25mg q1h prn\n Response:\n pain relief from Dilaudid, pt able to rest comfortably\n Plan:\n continue to assess/treat headache as needed\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590576, "text": "HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on \n by Dr. who presents directly to the ED with 3 day\n history of progressively worsening R sided weakness and decrease\n sensation. On she was diagnosed with a subsegmental posterior PE\n and was started on Lovenox 50mg . Per daughter's translation, pt.\n noticed sl numbness to RU/L extremity with weakness and R foot drop.\n Denies confusion, visual changes, N/V or L sided deficits.\n resection of R frontal meningioma\n 8/17 L crani (subdural hematoma evacuation)\n IVC filter placed\n Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive\n MAE equally with full strength\n denies visual changes\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed, crani incision c/d/I no evidence\n of drainage\n tolerating Pos, able to swallow pills\n sbp < 140 throughout shift with no interventions needed\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n Dilaudid given PRN\n Response:\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590650, "text": "HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on \n by Dr. who presents directly to the ED with 3 day\n history of progressively worsening R sided weakness and decrease\n sensation. On she was diagnosed with a subsegmental posterior PE\n and was started on Lovenox 50mg . Per daughter's translation, pt.\n noticed sl numbness to RU/L extremity with weakness and R foot drop.\n Denies confusion, visual changes, N/V or L sided deficits.\n resection of R frontal meningioma\n 8/17 L crani (subdural hematoma evacuation)\n IVC filter placed\n Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive (R side sluggish L side brisk)\n MAE equally with full strength\n denies blurred vision\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair/commode\n Ambulated around unit with PT/OT\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed per neurosurg, crani incision\n c/d/I no evidence of drainage\n tolerating diet, only eating sm amt of meal, able to swallow pills\n sbp < 140 throughout shift with no interventions needed\n med. size brown BM this morning\n tolerating activity OOB with supervision\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n continue activity OOB to chair/commode with support\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n 2mg Dilaudid PO X1\n Response:\n Pt reports pain is better after dilaudid\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 66 kg\n Daily weight:\n 65.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: TAH (fibroids)\n cataract surgery ( R) ( L)\n Hx of suprasellar meningioma since was followed after cataract\n surgery in vision worsened in R eye\n Surgery / Procedure and date: bifrontal crani for menigoma\n resection\n L crani (subdural hematoma evacuation)\n IVC filter placed\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:56\n Temperature:\n 98.8\n Arterial BP:\n S:96\n D:64\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,893 mL\n 24h total out:\n 1,810 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 01:15 AM\n Potassium:\n 3.7 mEq/L\n 01:15 AM\n Chloride:\n 112 mEq/L\n 01:15 AM\n CO2:\n 27 mEq/L\n 01:15 AM\n BUN:\n 6 mg/dL\n 01:15 AM\n Creatinine:\n 0.6 mg/dL\n 01:15 AM\n Glucose:\n 102 mg/dL\n 01:15 AM\n Hematocrit:\n 32.4 %\n 01:15 AM\n Finger Stick Glucose:\n 107\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2185-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590501, "text": "Subdural hemorrhage (SDH)\n Assessment:\n POD #2 L crani (subdural hematoma evacuation)\n alert and oriented X 3, family reports speech is clear\n patients family available to translate neuro checks\n pupils 3mm sluggishly reactive\n MAE with equal strength, follows commands\n Action:\n q1h neuro assessments\n CT scan done\n IVC filter placed through R femoral vein in angio, R knee immoblizer on\n until 1630 MD \n checks done as ordered\n diet advanced to sips as tolerated\n Response:\n pulses easily palpable, no bleeding at angio site, knee immobilizer now\n off\n neuro exam unchanged throughout the shift, able to give own consent for\n IVC procedure using telephone translator\n Ct showed no further bleeding per neurosurgery\n Tolerating sips\n Plan:\n repeat CT to be done tomorrow \n continue to monitor angio site and may advance activity OOB as\n tolerated\n PT/OT tomorrow\n Pain control (acute pain, chronic pain)\n Assessment:\n frequently complains of headache\n Action:\n Dilaudid 0.25mg q1h prn\n Response:\n pain relief from Dilaudid, pt able to rest comfortably\n Plan:\n continue to assess/treat headache as needed\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590572, "text": "Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, pupils equal 4mm reactive\n MAE equally with full strength\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590574, "text": "Subdural hemorrhage (SDH)\n Assessment:\n alert, oriented X 3, family available for translation during neuro\n assessments, pupils equal 4mm reactive\n MAE equally with full strength\n denies visual changes\n goal sbp <140\n Action:\n q2h neuro assessments\n OOB to chair\n diet advanced to regular\n Response:\n neuro exam unchanged throughout shift\n burr hole site c/d/I, bandaid removed, crani incision c/d/I no evidence\n of drainage\n tolerating Pos, able to swallow pills\n sbp < 140 throughout shift with no interventions needed\n Plan:\n continue to monitor/assess neuro status\n monitor sbp goal < 140\n Pain control (acute pain, chronic pain)\n Assessment:\n complains of headache intermittently\n Action:\n Dilaudid given PRN\n Response:\n adequate pain control with Dilaudid PRN\n Plan:\n continue to assess/treat pain\n" }, { "category": "Nursing", "chartdate": "2185-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590388, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Alert, family report orientation x3.\n Frequent episodes of restlessness and irritability, removing O2 mask\n and compression sleeves\n C/o of intermittent headache.\n O2 100% NRB.\n Cranial incision wnl, burr hole draining small amount serosanguinous\n fluid.\n Action:\n Neuro exam q1hour.\n Head CT done, daughter accompanied for translation.\n Nicardipine gtts infused during CT only for adequate bp control during\n scanning.\n Dilaudid 0.25mg iv q2-3 hours for headache.\n Dsd applied to burrhole and changed x3.\n O2 100% NRB mask.\n Compression sleeves and stockings applied as ordered.\n Continuous nursing supervision and family translation required\n throughout shift.\n Npo since mn except for oral swabs.\n Response:\n Dr reports head CT improved.\n Patient neurologically stable, moving all extremities, strong but\n Lt>Rt. Pupils equal in size and reactivity.\n Verbalizing in Ethiopian, no slurring reported by family.\n Pain controlled and pt comfort optimized.\n O2 sats 99-100% consistently. Breath sounds clear.\n Plan:\n Continue close observation for safety and prevention of interference\n with treatments.\n Maintain SBP<140.\n IVC filter insertion planned for today.\n" }, { "category": "Physician ", "chartdate": "2185-09-07 00:00:00.000", "description": "Intensivist Note", "row_id": 590560, "text": "SICU\n HPI:\n 61 yo F with h/o meningioma s/p resection and h/o PE on lovenox\n presenting with left SD hematoma of multiple durations and midline\n shift, now s/p evacuation of hematoma.\n Chief complaint:\n SDH\n PMHx:\n Hypercholesterolemia\n Pulmonary Emboli\n resection of a planum sphenoidale chordoid meningioma on \n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:50 AM\n Post operative day:\n POD#2 - s/p left crani (subdural hematoma evacuation)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Gentamicin - 02:09 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:20 PM\n Hydromorphone (Dilaudid) - 06:26 AM\n Other medications:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.2\nC (99\n HR: 80 (65 - 106) bpm\n BP: 95/67(73) {91/55(64) - 121/77(85)} mmHg\n RR: 22 (12 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.8 kg (admission): 66 kg\n Total In:\n 2,601 mL\n 788 mL\n PO:\n 150 mL\n 125 mL\n Tube feeding:\n IV Fluid:\n 2,451 mL\n 663 mL\n Blood products:\n Total out:\n 3,490 mL\n 810 mL\n Urine:\n 3,490 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -889 mL\n -23 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 274 K/uL\n 10.4 g/dL\n 102 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 6 mg/dL\n 112 mEq/L\n 144 mEq/L\n 32.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:54 AM\n 03:02 AM\n 01:15 AM\n WBC\n 3.6\n 10.0\n 5.8\n Hct\n 32.4\n 35.1\n 32.4\n Plt\n 363\n 387\n 274\n Creatinine\n 0.7\n 0.6\n 0.6\n Glucose\n 92\n 137\n 102\n Other labs: PT / PTT / INR:12.5/22.2/1.1, Differential-Neuts:61.2 %,\n Lymph:30.0 %, Mono:6.5 %, Eos:1.9 %, Ca:8.9 mg/dL, Mg:2.0 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 61 yo F with h/o meningioma s/p resection and h/o\n PE on lovenox presenting with left SD hematoma of multiple durations\n and midline shift, now s/p evacuation of hematoma.\n PLAN:\n Neuro: 1) SDH s/p craniotomy and drainage - Keppra 500mg for sz\n prophylaxis, SBP<140, Q1h neuro checks. Postop HCT shows expected\n postop changes, repeat HCT shows improved SDH, will need 1 more HCT b/c\n of Lovenox\n CVS: HD stable. SBP < 140 Episode of SVT vs Afib metoprolol 25\",\n Hydralazine prn\n Pulm: h/o PE - off lovenox. IVC filter today. NC.\n GI: regular diet, famotidine.\n FEN: NS at 75cc/hr\n Renal: No active issues.\n Heme: Stable hematocrit, off all anticoagulation, s/p IVC filter\n placement\n Endo: No active issues.\n ID: Vanco/Gent x 48hrs.\n TLD: PIV\n Wounds: -\n Imaging: CT in AM\n Prophylaxis: SCDs H2B bowel regimen\n Consults: , PT/OT\n Code: Full\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2185-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590310, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt from , non-english speaking only. Children at bedside to\n translate at all times. Pt is alert and oriented x\ns 3. Per family\n speech is clear and behavior is appropriate though pt\nseems a bit\n slower than usual\n per family. Left side weaker than right -> pt able\n to lift and hold right upper and lower extremities, left upper and\n lower extremities have normal strength. Pupils are briskly reactive.\n Pupils are equal at times, but right can be .5mm larger than left\n (right ranging , left )\n neuro team is aware and difference\n attributed to prior cataract surgeries.\n Action:\n Q 1 hour neuro checks. Pt sent to o.r. at 1515 for crani and hematoma\n evacuation.\n Response:\n Pending\n Plan:\n Post op care, q 1 hour neuro checks, maintain sbp < 160, post op ct\n scan.\n" }, { "category": "Nursing", "chartdate": "2185-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590554, "text": "Subdural hemorrhage (SDH)\n Assessment:\n -Pt sleepy throughout shift but easily arousable to voice. Oriented to\n name, children\ns names, year and per family knows the correct month of\n her calendar but thought it was Wednesday earlier in shift. Able to say\n in English that she\ns at Hospital. PERRL/sluggish 4 to 6\n mm. Normal strength in extremities, very little to no difference\n discernable in R versus L side. Pt turning herself in bed throughout\n shift. Following commands. Per family speech non-gargled or slurred.\n - Pt with clean incision on head and burr hole site clean and dry with\n dressing over it. C/o pain every few hours in head.\n Action:\n - Neuro checks changed to Q2. Neurosurg assessed patient\n around 2210 because she appeared more lethargic to this writer than\n prior assessments and team felt she was improving.\n - Dilaudid PRN\n - Keppra, Vanc and Gent administered as ordered\n Response:\n - Neuro exam remains unchanged. Patient getting better blocks of sleep\n now that neuro checks are changed to Q2. Pt reports headache improved\n after dilaudid. SBP maintained <140 without intervention.\n Plan:\n - Neuro checks Q2, SBP <140, keppra for seizure prophylaxis. OOB today,\n repeat head CT today.\n" }, { "category": "Nursing", "chartdate": "2185-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590482, "text": "Subdural hemorrhage (SDH)\n Assessment:\n POD #2 L crani (subdural hematoma evacuation)\n alert and oriented X 3, family reports speech is clear\n patients family available to translate neuro checks\n pupils 3mm sluggishly reactive\n MAE with equal strength, follows commands\n Action:\n q1h neuro assessments\n CT scan done\n IVC filter placed through R femoral vein in angio, R knee immoblizer on\n MD \n checks done as ordered\n diet advanced to sips as tolerated\n Response:\n pulses easily palpable, no bleeding at angio site, knee immobilizer on\n neuro exam unchanged throughout the shift\n Ct showed no further bleeding per neurosurgery\n Plan:\n repeat CT to be done tomorrow \n continue pulse checks and activity per angio orders\n OOB PT/OT tomorrow\n Pain control (acute pain, chronic pain)\n Assessment:\n frequently complains of headache\n Action:\n Dilaudid 0.25mg q1h prn\n Response:\n pain relief from Dilaudid, pt able to rest comfortably\n Plan:\n continue to assess/treat headache as needed\n" }, { "category": "Nursing", "chartdate": "2185-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590378, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Alert, family report orientation x3.\n Frequent episodes of restlessness and irritability, removing O2 mask\n and compression sleeves\n C/o of intermittent headache.\n O2 100% NRB.\n Cranial incision wnl, burr hole draining small amount serosanguinous\n fluid.\n Action:\n Neuro exam q1hour.\n Head CT done, daughter accompanied for translation.\n Nicardipine gtts infused during CT only for adequate bp control during\n scanning.\n Dilaudid 0.25mg iv q2-3 hours for headache.\n Dsd applied to burrhole and changed x3.\n O2 100% NRB mask.\n Compression sleeves and stockings applied as ordered.\n Continuous nursing supervision and family translation required\n throughout shift.\n Response:\n Dr reports head CT improved.\n Patient neurologically stable, moving all extremities, strong but\n Lt>Rt. Pupils equal in size and reactivity.\n Verbalizing in Ethiopian, no slurring reported by family.\n Pain controlled and pt comfort optimized.\n O2 sats 99-100% consistently. Breath sounds clear.\n Plan:\n Continue close observation for safety and prevention of interference\n with treatments.\n Maintain SBP<140.\n IVC filter insertion planned for today.\n" }, { "category": "Nursing", "chartdate": "2185-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590187, "text": "61 yo Ethiopian F s/p resection of a R Frontal meningioma on\n by Dr. who presents directly to the ED\n with 3 day history of progressively worsening R sided weakness\n and decrease sensation. On she was diagnosed with a\n subsegmental posterior PE and was started on Lovenox 50mg .\n Per daughter's translation, pt. noticed sl numbness to RU/L\n extremity with weakness and R foot drop. Denies confusion, visual\n changes, N/V or L sided deficits.\n Chief complaint:\n 3d of R sided weakness/numbness\n PMHx:\n PMH:\n 1. Hypercholesterolemia\n 2. Pulmonary Emboli \n PSH: resection of a planum sphenoidale chordoid meningioma on\n \n Subdural hemorrhage (SDH)\n Assessment:\n Unequal pupils\n R side slightly weaker than L and slower to respond to commands on\n right side\n Decreased sensation on right side per daughter as translator\n Action:\n neuro checks\n BP <140 without intervention\n Keppra given\n UA and T+S sent in ER with CXR completed\n Response:\n Remains neurologically stable\n Plan:\n CT at 0500\n Cont q1 neuro checks\n SBP <140\n Keppra for seizure prophylaxis\n OR for evacuation\n ? treatment for PE in future\n" }, { "category": "Nursing", "chartdate": "2185-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590377, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Alert, family report orientation x3.\n Frequent episodes of restlessness and irritability, removing O2 mask\n and compression sleeves\n C/o of intermittent headache.\n O2 100% NRB.\n Action:\n Neuro exam q1hour.\n Head CT done, daughter accompanied for translation.\n Nicardipine gtts infused during CT only for adequate bp control during\n scanning.\n Dilaudid 0.25mg iv q2-3 hours for headache.\n O2 100% NRB mask.\n Compression sleeves and stockings applied as ordered.\n Continuous nursing supervision and family translation required\n throughout shift.\n Response:\n Dr reports head CT improved.\n Patient neurologically stable, moving all extremities, strong but\n Lt>Rt. Pupils equal in size and reactivity.\n Verbalizing in Ethiopian, no slurring reported by family.\n Pain controlled and pt comfort optimized.\n O2 sats 99-100% consistently. Breath sounds clear.\n Plan:\n Continue close observation for safety and prevention of interference\n with treatments.\n Maintain SBP<140.\n IVC filter insertion planned for today.\n" }, { "category": "Nursing", "chartdate": "2185-09-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 590224, "text": "61 yo Ethiopian F s/p resection of a R Frontal meningioma on\n by Dr. who presents directly to the ED\n with 3 day history of progressively worsening R sided weakness\n and decrease sensation. On she was diagnosed with a\n subsegmental posterior PE and was started on Lovenox 50mg .\n Per daughter's translation, pt. noticed sl numbness to RU/L\n extremity with weakness and R foot drop. Denies confusion, visual\n changes, N/V or L sided deficits.\n Chief complaint:\n 3d of R sided weakness/numbness\n PMHx:\n PMH:\n 1. Hypercholesterolemia\n 2. Pulmonary Emboli \n PSH: resection of a planum sphenoidale chordoid meningioma on\n \n Subdural hemorrhage (SDH)\n Assessment:\n Unequal pupils\n R side slightly weaker than L and slower to respond to commands on\n right side\n Decreased sensation on right side per daughter as translator\n last dose lovenox 0900 8/16 per daughter\n Action:\n neuro checks\n BP <140 without intervention\n Keppra given\n UA and T+S sent in ER with CXR completed\n repeat Ct done at 0445\n Response:\n Remains neurologically stable\n Plan:\n Cont q1 neuro checks\n SBP <140\n Keppra for seizure prophylaxis\n OR for evacuation as add on\n ? treatment for PE in future\n" }, { "category": "Physician ", "chartdate": "2185-09-06 00:00:00.000", "description": "Intensivist Note", "row_id": 590438, "text": "SICU\n HPI:\n 61 yo Ethiopian F s/p resection of a R Frontal meningioma on\n by Dr. who presents directly to the ED\n with 3 day history of progressively worsening R sided weakness\n and decrease sensation. On she was diagnosed with a\n subsegmental posterior PE and was started on Lovenox 50mg .\n Per daughter's translation, pt. noticed sl numbness to RU/L\n extremity with weakness and R foot drop. Denies confusion, visual\n changes, N/V or L sided deficits.\n Chief complaint:\n weakness\n PMHx:\n PMH:\n 1. Hypercholesterolemia\n 2. Pulmonary Emboli\n PSH: resection of a planum sphenoidale chordoid meningioma on\n \n :\n 1. Lovenox SQ 60mg - last dose @ 9am on \n 2. Calcium with D Daily\n 3. Docusate 100 mg Daily\n 4. Percocet 5/325 mg PO, PRN\n 5. Zocor 20 mg Daily\n Current medications:\n 24 Hour Events:\n OR SENT - At 03:25 PM\n OR RECEIVED - At 05:40 PM\n ARTERIAL LINE - START 05:52 PM\n Post operative day:\n POD#1 - s/p left crani (subdural hematoma evacuation)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Gentamicin - 02:03 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 12:00 AM\n Hydromorphone (Dilaudid) - 02:00 AM\n Other medications:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 78 (54 - 112) bpm\n BP: 134/70(91) {101/52(73) - 145/72(101)} mmHg\n RR: 20 (12 - 42) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.2 kg (admission): 66 kg\n Total In:\n 3,256 mL\n 556 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,256 mL\n 556 mL\n Blood products:\n Total out:\n 3,200 mL\n 1,190 mL\n Urine:\n 2,770 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n -634 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, by report from family, oriented and\n appropriate when speaking in Ethiopian\n Labs / Radiology\n 387 K/uL\n 11.3 g/dL\n 137 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 113 mEq/L\n 147 mEq/L\n 35.1 %\n 10.0 K/uL\n [image002.jpg]\n 04:54 AM\n 03:02 AM\n WBC\n 3.6\n 10.0\n Hct\n 32.4\n 35.1\n Plt\n 363\n 387\n Creatinine\n 0.7\n 0.6\n Glucose\n 92\n 137\n Other labs: PT / PTT / INR:12.5/22.2/1.1, Differential-Neuts:61.2 %,\n Lymph:30.0 %, Mono:6.5 %, Eos:1.9 %, Ca:9.6 mg/dL, Mg:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 61 yo F with h/o meningioma s/p resection and h/o\n PE on lovenox presenting with left SD hematoma of multiple durations\n and midline shift, now s/p evacuation of hematoma.\n Neurologic: SDH - Keppra 500mg for sz prophylaxis, SBP<140, Q1h\n neuro checks. Postop HCT shows expected postop changes, repeat in AM\n Cardiovascular: HD stable. SBP < 140\n Sinus Tach this AM\n Start\n Lopressor 25mg TID and change hydralazine to PRN\n Pulmonary: H/o PE - off lovenox. No acute issues. Satting well on NC.\n For IVC filter to prevent further PE\n Gastrointestinal / Abdomen: DAT in AM\n Nutrition: regular diet after IVC filter placement today\n Renal: No active issues. Good urine output\n Hematology: Stable hematocrit, off all anticoagulation, for IVC filter\n placement in AM (IR)\n Endocrine: No active issues.\n Infectious Disease: No active issues. RISS\n Lines / Tubes / Drains: PIV\n Wounds: dry dressings\n Imaging: Repeat Head CT\n Fluids: LR\n Consults: Neuro surgery\n Billing Diagnosis: SDH\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:43 PM\n Arterial Line - 05:52 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Zantac\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: SICU\n Total time spent: 32\n" }, { "category": "Echo", "chartdate": "2185-09-07 00:00:00.000", "description": "Report", "row_id": 75632, "text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary embolus. Right ventricular function.\nHeight: (in) 62\nWeight (lb): 115\nBSA (m2): 1.51 m2\nBP (mm Hg): 99/54\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 14:35\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. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal 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.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%). The estimated cardiac index\nis normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The estimated pulmonary artery systolic pressure is normal.\nThere is an anterior space which most likely represents a fat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional 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": "2185-09-05 00:00:00.000", "description": "Report", "row_id": 180386, "text": "Sinus bradycardia. Low QRS voltage in the limb leads. Compared to tracing #1\nthere is slight decrease in the voltage in the limb leads.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-09-04 00:00:00.000", "description": "Report", "row_id": 180387, "text": "Sinus rhythm. No significant diagnostic abnormalities. Compared to the previous\ntracing of there is no significant change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2185-09-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093657, "text": " 7:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: sdh\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with righ side wekness on comadin s/p brain tumor resection\n REASON FOR THIS EXAMINATION:\n sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc SUN 8:34 PM\n Left subdural hematoma overlying left cerebral convexity, larger from \n and more dense suggestive of interval bleeding. The maximal dimensions are\n approximately 20 mm. Assoc. mass effect with effacement of the left frontal\n . Subdural hematoma overyling the right frontal lobe appears similar,\n though superiorly, near the vertex, high attenuating extra- axial hemorrhage,\n new, may reflect a subdural hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old female with right-sided weakness on Coumadin, status\n post brain tumor resection. Evaluate subdural hematomas.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There are postoperative changes following a right frontal\n craniotomy. There is a predominantly hypodense right frontal and right\n temporal extra- axial collection, which is similar in size from , and may reflect evolving post-surgical blood products. External to the\n dura, there is an additional hypodense collection, measuring approximately 6\n mm in maximal dimensions, which also likely reflects residual post-operative\n changes and is not significantly changed. A tiny focus of hyperdensity in the\n right frontal lobe likely reflects residual intraparenchymal hemorrhage as\n seen on prior studies, decreased from .\n\n However, there is a new left acute-subacute subdural hematoma overlying the\n left frontal and parietal convexity with a fluid level, measuring up to 20 mm\n in width maximally. The subdural hematoma extends to overlie the left inferior\n frontal lobe, where there is hyperdense hemorrhage, compatible wtih acute\n blood products. A new right subdural hemorrhage is also evident overlying the\n right convexity near the vertex.\n\n There is associated local mass effect, with sulcal effacement, effacement of\n the left frontal and a rightward shift of normally midline structures of\n approximately 5 mm. No uncal herniation is appreciated. No major vascular\n territorial infarction is identified. A hypodensity in the right basal\n ganglia may be chronic.\n\n Visualized paranasal sinuses and mastoid air cells are normally aerated.\n Osseous structures reveal craniotomy defect in the right frontal bone.\n\n (Over)\n\n 7:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: sdh\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Enlarged left subdural hematoma, with acute-subacute components,\n compatible with interval bleeding from the prior study, with subsequent\n effacement of the frontal of the left lateral ventricle and 5 mm\n rightward midline shift.\n\n 2. New right subdural hematoma overlying the convexity near the vertex.\n\n 3. Evolving hemorrhagic products in the right frontal subdural space, from\n prior surgery.\n\n 4. Evolving small focus of intraparenchymal hemorrhage in the right frontal\n lobe, decreased from .\n\n Findings were posted to the ED dashboard at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2185-09-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1093660, "text": " 7:45 PM\n CHEST (PA & LAT) Clip # \n Reason: ?infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with weakness\n REASON FOR THIS EXAMINATION:\n ?infection\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, frontal and lateral views.\n\n CLINICAL INFORMATION: 61-year-old female with history of weakness.\n\n COMPARISON: .\n\n FINDINGS: Streaky opacities at the right base are slightly less prominent as\n compared to the prior exam, but again may represent atelectasis. Retrocardiac\n streaky opacity at the left lung base is without significant change and may\n also be secondary to atelectasis. No evidence of pleural effusion. The heart\n is moderately enlarged, stable. There is a calcified, tortuous aorta.\n\n IMPRESSION:\n 1. Streaky bibasilar opacities, right greater than left, less prominent than\n on the prior exam, but again may represent atelectasis.\n 2. No evidence of pleural effusion or pulmonary edema.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2185-09-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093690, "text": ", C. NSURG SICU-B 4:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 61 year old woman s/p R meningioma resection with L SDH\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p R meningioma resection with L SDH\n (Subacute/chronic/acute) with 5mm shift. PLEASE PERFORM @ 0500!!\n REASON FOR THIS EXAMINATION:\n 61 year old woman s/p R meningioma resection with L SDH\n (Subacute/chronic/acute) with 5mm shift. PLEASE PERFORM @ 0500!!\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Exam is little changed from , with large left and small right\n acute-subacute subdural hematomas, with unchanged rightward mass effect from\n the large left subdural hematoma. Post-surgical changes related to right\n frontal craniotomy again noted. Foci of intraparenchymal hemorrhage in the\n right frontal lobe are no longer conspicuous.\n\n" }, { "category": "Radiology", "chartdate": "2185-09-06 00:00:00.000", "description": "INTERUP IVC", "row_id": 1093928, "text": " 12:30 PM\n IVC GRAM/FILTER Clip # \n Reason: please place IVC filter***Ethiopian interpreter needed for c\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: OPTIRAY Amt: 45\n ********************************* CPT Codes ********************************\n * INTERUP IVC PERC PLCMT IVC FILTER *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with SDH, and PE\n REASON FOR THIS EXAMINATION:\n please place IVC filter***Ethiopian interpreter needed for consent\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old female with subdural hematoma and PE requiring IVC\n filter.\n\n OPERATORS: Drs. , and , attending\n interventional radiologist. Dr. was present and supervising the\n entire procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n fentanyl (total 50 mcg) and Versed (total 0.5 mg), further throughout the\n total intraservice time of 35 minutes during which the patient's hemodynamic\n parameters were continuously monitored.\n\n PROCEDURE: After the risks and benefits of the procedures were explained,\n informed consent was obtained. The patient was taken to the angiography suite\n and placed in supine on the table. The right groin was prepped and draped in\n standard sterile fashion. A preprocedure timeout and huddle were performed.\n Next, ultrasound guidance was used to access the right common femoral vein\n with a micropuncture needle. A guidewire was passed through the needle into\n the IVC. The needle was exchanged for micropuncture sheath. The inner\n dilator and wire were then removed and wire passed through the\n sheath into the superior IVC. The outer portion of the sheath was removed and\n exchanged for an Omniflush catheter which was extended into the IVC\n bifurcation. The wire was removed and a venogram performed demonstrating a\n conventional anatomy and a normal-appearing left common iliac vein. The IVC\n was of normal caliber with no aberrant renal veins or anomalous vessels within\n the infrarenal IVC. Left renal vein was slightly lower than the right. At\n the approximate level of the superior endplate of L2. Given these findings it\n was decided that an IVC filter could be placed in the infrarenal position.\n\n The IVC filter sheath and inner system was placed over the wire into the IVC\n and the G2 retreivable filter was deployed infrarenally without issue. The\n inner system was removed and a post- placement venogram was performed through\n the sheath demonstrating normal flow through the filter. The sheath was\n removed and hemostasis of the puncture site achieved with compression. The\n site was dressed. There were no immediate complications.\n\n IMPRESSION:\n (Over)\n\n 12:30 PM\n IVC GRAM/FILTER Clip # \n Reason: please place IVC filter***Ethiopian interpreter needed for c\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: OPTIRAY Amt: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Successful placement of G2 retrievable IVC filter in the infrarenal\n position. The filter can be retrieved at any time, if clinicaly indicated\n 2. Pre- and post-placement venograms of the inferior vena cava and proximal\n iliac veins demonstrating normal anatomy amenable to filter placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-09-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093689, "text": " 4:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 61 year old woman s/p R meningioma resection with L SDH\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p R meningioma resection with L SDH\n (Subacute/chronic/acute) with 5mm shift. PLEASE PERFORM @ 0500!!\n REASON FOR THIS EXAMINATION:\n 61 year old woman s/p R meningioma resection with L SDH\n (Subacute/chronic/acute) with 5mm shift. PLEASE PERFORM @ 0500!!\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc MON 6:27 AM\n PFI: Exam is little changed from , with large left and small right\n acute-subacute subdural hematomas, with unchanged rightward mass effect from\n the large left subdural hematoma. Post-surgical changes related to right\n frontal craniotomy again noted. Foci of intraparenchymal hemorrhage in the\n right frontal lobe are no longer conspicuous.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old female with right meningioma resection in , and\n now left subdural hematoma and 5-mm midline shift.\n\n COMPARISON: CT head, most recently performed on and .\n\n TECHNIQUE: MDCT axial imaging was performed through the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: Again postoperative changes are noted following right\n frontal craniotomy. Underlying right frontotemporal predominantly hypodense\n subdural and extradural collections, thought to reflect evolving post-surgical\n blood products, are unchanged. Areas of intraparenchymal hemorrhage in the\n right frontal lobe are no longer conspicuous.\n\n Allowing for differences in rotation, large left frontoparietal subdural\n collection with layering fluid-fluid level has not changed from one day prior,\n again consistent with acute- subacute subdural hematoma. Layering high density\n along the bilateral inferior frontal lobes is less on the left than seen one\n day prior. Also small acute-subacute subdural hematoma overlying the right\n superior convexity appears little changed.\n\n Again there is sulcal effacement, effacement of the left frontal , and\n approximately 5 mm rightward shift of normally midline structures which is not\n changed. There is asymmetric appearance to the prepontine cistern, which may\n be due to slight tilting of the patient's head. No definite uncal herniation\n is seen.\n\n The visualized paranasal sinuses and mastoid air cells remain aerated.\n\n IMPRESSION:\n 1. Large left and small right acute-subacute subdural hematomas are little\n changed from one day prior, allowing for slight differences in patient\n (Over)\n\n 4:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 61 year old woman s/p R meningioma resection with L SDH\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n positioning. Rightward mass effect from the large left subdural hematoma is\n also unchanged from one day prior.\n 2. Status post right frontal craniotomy with evolving hemorrhagic products\n underlying site of surgery unchanged. Right frontal intraparenchymal\n hemorrhage is no longer conspicuous.\n\n" }, { "category": "Radiology", "chartdate": "2185-09-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093847, "text": " 7:45 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: SDH. S/P PRIOR CRANI. EVAL POST-OP.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc MON 10:53 PM\n Decrease in size/density of left frontoparietal subdural hematoma following\n craniectomy and evacuation. Expected postoperative appearance includes\n pneumocephalus, small amount of hemorhage in resection bed, osseous defect.\n Small amount of new left temporoparietal SAH. Decreased mass effect and right\n shift of midline structures, decreased right parietal SDH, and stable right\n frontotemporal hypodense collection.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old female with craniectomy.\n\n COMPARISON: Non-contrast head CT approximately 15 hours ago.\n\n TECHNIQUE: Imaging was performed from the cranial vertex to the foramen\n magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There has been interval left frontoparietal\n craniectomy and evacuation of a large left subdural hematoma along the\n cerebral convexity, previously measuring 1.8 cm in maximal radial dimension.\n The collection is now decreased in density, and significantly smaller\n measuring 1.0 cm in maximal radial dimension (4:28). There is expected\n postoperative pneumocephalus, and a small amount of both linear hemorrhage at\n the evacuation site (4:24). However, there is also a small amount of\n apparently new subarachnoid hemorrhage (4:20).\n\n The degree of mass effect upon the frontal of the left lateral ventricle\n is somewhat decreased, the degree of right shift of midline structures is\n slightly improved, previously measuring 5 mm, and currently measuring 2 mm\n (4:24).\n\n The appearance of previous right frontal craniotomy, with underlying right\n frontal temporal hypodense collection is unchanged. In the right parietal\n lobe, the subdural collection previously measuring 1.7 cm in transverse\n dimension has decreased also, measuring 1.0 cm in transverse dimension (4:33).\n No new site of hemorrhage is identified. The visualized paranasal sinuses and\n soft tissues elsewhere appear normal.\n\n Note is made that the patient is in a somewhat oblique positioning within the\n scanner, which slightly impedes direct comparison with the prior study.\n Therefore, repeat when clinically feasible may be helpful.\n\n IMPRESSION:\n\n 1. Interval left frontoparietal craniectomy and subdural hematoma evacuation,\n with decrease in size and density of residual collection and expected\n postoperative change.\n\n 2. Associated decrease in degree of effacement of frontal of the left\n (Over)\n\n 7:45 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: SDH. S/P PRIOR CRANI. EVAL POST-OP.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lateral ventricle and right shift in midline structures.\n\n 3. Small amount of new subarachnoid hemorrhage in postoperative bed.\n\n 4. Decreased size of right parietal subdural collection.\n\n 5. Unchanged appearance of right frontotemporal hypodense subdural collection\n in previous post-surgical change.\n\n" }, { "category": "Radiology", "chartdate": "2185-09-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093848, "text": ", C. NSURG SICU-B 7:45 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: SDH. S/P PRIOR CRANI. EVAL POST-OP.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n PFI REPORT\n Decrease in size/density of left frontoparietal subdural hematoma following\n craniectomy and evacuation. Expected postoperative appearance includes\n pneumocephalus, small amount of hemorhage in resection bed, osseous defect.\n Small amount of new left temporoparietal SAH. Decreased mass effect and right\n shift of midline structures, decreased right parietal SDH, and stable right\n frontotemporal hypodense collection.\n\n" }, { "category": "Radiology", "chartdate": "2185-09-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093884, "text": " 8:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for post-operative hemorrhage. Must be compl\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with left SDH s/p prior crani and Lovenox for PE.\n REASON FOR THIS EXAMINATION:\n please evaluate for post-operative hemorrhage. Must be completed within 2hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa TUE 2:02 PM\n Improvement in subdural hematoma collection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old female with left subdural hematoma status post\n craniotomy.\n\n TECHNIQUE: Multidetector axial CT scan of the head was obtained without the\n administration of contrast.\n\n COMPARISON: CT scan dated and CT scan dated .\n\n FINDINGS: There has been interval evolution of the left frontal subdural\n hematoma. There is a decreased amount of pneumocephalus. The collection now\n measures 12 mm in maximal radial dimension (2A:13). The previously noted\n linear hemorrhage at the evacuation site is less prominent on this\n examination. The previously noted left frontoparietal subarachnoid hemorrhage\n appears grossly unchanged. The appearance of the previous right frontal\n craniotomy is unchanged. There is a hypodense collection in the right\n epidural as well as right subdural spaces consistent with prior surgery. A\n previously noted right parietal hematoma is currently measuring 29 mm in\n longest diameter versus 11 mm previously (2A:26). This could represent either\n a subdural or epidural hematoma. The ventricles are not enlarged. A\n hyperdense focus (2A:15) within the left sylvian fissure is likely due to\n layering of blood products in addition to different slice position on this\n examination; however, a small new bleed cannot be completely excluded. The\n paranasal sinuses and mastoid air cells are unremarkable. The patient is\n status post remote right craniotomy and status post left craniotomy.\n Otherwise, the osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Interval increase in size of right parietal hemorrhage.\n\n 2. Interval evolution of left subdural fluid collection.\n\n 3. New focus of hyperdensity in the left parietal region may represent\n interval layering of blood, however, new hemorrhage cannot be fully excluded.\n\n\n (Over)\n\n 8:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for post-operative hemorrhage. Must be compl\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2185-09-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1093885, "text": ", C. NSURG SICU-B 8:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for post-operative hemorrhage. Must be compl\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with left SDH s/p prior crani and Lovenox for PE.\n REASON FOR THIS EXAMINATION:\n please evaluate for post-operative hemorrhage. Must be completed within 2hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Improvement in subdural hematoma collection.\n\n" }, { "category": "Radiology", "chartdate": "2185-09-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1094033, "text": " 8:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for any increase in hemorrhage**please do at\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p SDH evacuation \n REASON FOR THIS EXAMINATION:\n Please evaluate for any increase in hemorrhage**please do at 8 am**\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa WED 5:01 PM\n PFI: Overall unchanged hemorrhage. Resolution of pneumocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old female status post subdural hematoma evacuation.\n Evaluation for change.\n\n TECHNIQUE: Multidetector axial CT scan of the head was obtained without the\n administration of contrast.\n\n COMPARISON: CT scan dated .\n\n FINDINGS: There has been interval resolution of pneumocephalus. The left\n subdural fluid collection is unchanged measuring approximately 12 mm in the\n maximal radial dimension (2:11). The linear hemorrhage at the evacuation site\n is similar in appearance. The previously noted left frontoparietal hematoma\n is unchanged. The hemorrhage at the right parietal vertex, allowing for\n different slice selection, is not significantly different from prior. There\n is no evidence of new hemorrhage, edema, mass effect or new infarction. The\n -white matter differentiation is preserved. The ventricles are normal in\n size and appearance. The paranasal sinuses and mastoid air cells are\n unremarkable. The patient is status post remote right craniotomy and status\n post left craniotomy. Otherwise the osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Interval resolution of pneumocephalus.\n 2. Stable foci of hemorrhage. No evidence of new hemorrhage.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-09-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1094034, "text": ", C. NSURG SICU-B 8:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for any increase in hemorrhage**please do at\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p SDH evacuation \n REASON FOR THIS EXAMINATION:\n Please evaluate for any increase in hemorrhage**please do at 8 am**\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Overall unchanged hemorrhage. Resolution of pneumocephalus.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2198-03-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555539, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt received on Propofol gtt, was not following commands, but was\n purposeful, reaching for ETT, PEARL 2mm brisk.\n Action:\n Sedation increased as needed for MRI at 08:00\n Response:\n Pt more sedate, able to perform MRI.\n Plan:\n Pt to OR at 09:30 for removal of mass, at this time not back from OR,\n will have head CT prior to returning to unit post op.\n" }, { "category": "Physician ", "chartdate": "2198-03-05 00:00:00.000", "description": "Intensivist Note", "row_id": 556006, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n s/p tumor resection\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Bisacodyl 5. CefazoLIN 6.\n Docusate Sodium 7. Famotidine\n 8. HydrALAzine 9. Insulin 10. Magnesium Sulfate 11. Ondansetron 12.\n Phenytoin 13. Potassium Chloride\n 14. Potassium Chloride 15. Potassium Chloride 16. Propofol 17. Senna\n 18. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EEG - At 03:52 PM\n FEVER - 101.2\nF - 11:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 10:37 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:11 PM\n Dilantin - 02:02 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.7\nC (99.9\n HR: 101 (94 - 114) bpm\n BP: 123/68(80) {114/51(66) - 155/95(100)} mmHg\n RR: 19 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 14 (11 - 17) mmHg\n Total In:\n 3,958 mL\n 969 mL\n PO:\n Tube feeding:\n 511 mL\n 438 mL\n IV Fluid:\n 1,194 mL\n 31 mL\n Blood products:\n 1,243 mL\n Total out:\n 3,839 mL\n 582 mL\n Urine:\n 3,100 mL\n 480 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 289 mL\n 102 mL\n Balance:\n 119 mL\n 387 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 478 (285 - 939) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 22\n PIP: 10 cmH2O\n SPO2: 99%\n ABG: ///25/\n Ve: 9.2 L/min\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, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Moves all extremities\n Labs / Radiology\n 102 K/uL\n 10.6 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 116 mEq/L\n 147 mEq/L\n 30.3 %\n 20.9 K/uL\n [image002.jpg]\n 03:53 PM\n 06:03 PM\n 02:05 AM\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n WBC\n 18.0\n 15.4\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n Hct\n 31\n 28.8\n 24.8\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n Plt\n 121\n 95\n 86\n 90\n 81\n 87\n 102\n Creatinine\n 1.4\n 1.3\n 1.2\n 1.0\n 0.9\n 0.8\n TCO2\n 20\n 23\n 24\n Glucose\n 140\n 177\n 138\n 136\n 196\n 122\n 138\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.3 g/dL,\n Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, sedated, wean propofol gtt, 24 hr\n video eeg Phenytoin 100 mg IV Q8, ventriculostomy drain, ct head shows\n evolving infarcts in right ACA\n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: ventilated on PS\n Gastrointestinal / Abdomen: colace/bisacodyl\n Nutrition: Tube feeding, free water 1 L through tube feeds, Replete\n with fiber Full strength\n Renal: UOP Free water 1 L through tube feeds\n Hematology: 2 uPRBC on and 2 uPRBC \n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd ; FU\n femoral line culture\n Lines / Tubes / Drains: ETT, 2 PIV, foley, ventriculostomy drain\n Wounds: head wound c/d/i\n Imaging: fu EEG\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:36 PM 70 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:02 AM\n ICP Catheter - 12:25 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2198-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 556117, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 91.6 None\n Ideal tidal volume: 366.4 / 549.6 / 732.8 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 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: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt successessfully EXTUBATED to a 40% cool nebulizer.!\n, RRT 17:54\n" }, { "category": "Physician ", "chartdate": "2198-03-03 00:00:00.000", "description": "Intensivist Note", "row_id": 555603, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n hypernatremia, brain mass\n PMHx:\n HTN\n Current medications:\n 1. 2. 1000 mL LR 3. 1000 mL LR 4. Acetaminophen 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. HydrALAzine 9. Insulin 10. Magnesium Sulfate 11. Ondansetron 12.\n Pantoprazole 13. Phenytoin\n 14. Potassium Chloride 15. Propofol 16. Senna 17. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n INTUBATION - At 06:00 AM\n INVASIVE VENTILATION - START 06:00 AM\n ARTERIAL LINE - START 06:45 AM\n\n admit from OR, slow correction of hypernatremia,\n tachycardia/hypotension responsive to multiple fluid boluses\n Post operative day:\n POD#1 emergent crani for tumor resection\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 10:00 PM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 06:00 AM\n Pantoprazole (Protonix) - 10:00 PM\n Other medications:\n Flowsheet Data as of 04:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 38.2\nC (100.8\n HR: 139 (76 - 139) bpm\n BP: 114/62(79) {104/57(73) - 148/79(99)} mmHg\n RR: 17 (10 - 31) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.2 kg (admission): 77.4 kg\n ICP: 8 (8 - 11) mmHg\n Total In:\n 8,877 mL\n 1,048 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,877 mL\n 1,048 mL\n Blood products:\n Total out:\n 3,984 mL\n 180 mL\n Urine:\n 850 mL\n 155 mL\n NG:\n Stool:\n Drains:\n 44 mL\n 25 mL\n Balance:\n 4,893 mL\n 868 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (600 - 650) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n Plateau: 12 cmH2O\n SPO2: 100%\n ABG: 7.46/32/164/21/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 410\n Physical Examination\n General Appearance: No acute distress\n HEENT: b/l conjunctival edema\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated, delayed responsive lower extremities to noxious\n stimuli, otherwise no spontaneous movement\n Labs / Radiology\n 95 K/uL\n 8.6 g/dL\n 138 mg/dL\n 1.3 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 131 mEq/L\n 157 mEq/L\n 24.8 %\n 15.4 K/uL\n [image002.jpg]\n 10:33 AM\n 11:55 AM\n 12:25 PM\n 01:44 PM\n 02:50 PM\n 02:56 PM\n 03:53 PM\n 06:03 PM\n 02:05 AM\n 02:19 AM\n WBC\n 17.3\n 18.0\n 15.4\n Hct\n 40.2\n 35\n 36\n 29\n 31.4\n 34\n 31\n 28.8\n 24.8\n Plt\n 187\n 119\n 121\n 95\n Creatinine\n 1.4\n 1.3\n TCO2\n 22\n 21\n 19\n 20\n 20\n 23\n Glucose\n 137\n 139\n 127\n 162\n 140\n 177\n 138\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Ca:7.9 mg/dL, Mg:2.2\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), TACHYCARDIA, OTHER, FEVER\n (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERNATREMIA\n (HIGH SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, sedated, propofol gtt, Phenytoin 100\n mg IV Q8H, MR within 36 hours, ventriculostomy drain, f/u ct head with\n right convexity SDH 7 mm and interval increased prominence right\n parasagittal frontal lobe edema\n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: ventilated\n Gastrointestinal/Abdominal: colace/bisacodyl\n Nutrition: NPO\n Renal: UOP improved s/p fluid boluses overnight, hypernatremic, LR at\n 125 cc/hr, once Na 150 switch to NS\n Hematology: s/p 3U PRBC in OR, stable\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines/Tubes/Drains: ETT, trauma line left femoral vein, 2 PIV, foley,\n ventriculostomy drain\n Wounds: head wound c/d/i\n Imaging: MRI/CT \n Fluids: LR 125 cc/hr\n Prophylaxis: protonix, boots\n Consults: neurosurgery, neurology\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:02 AM\n 20 Gauge - 03:02 AM\n Arterial Line - 06:45 AM\n Cordis/Introducer - 06:22 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2198-03-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 555909, "text": "Subjective: Per pt\ns parents, pt had lost ~20# over the past couple of\n months due to pt sleeping much more than usual.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 193 cm\n 77.4 kg\n 91 kg ( 05:00 AM)\n 20# wt loss\n 20.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 91.6 kg\n 85%\n 86.3kg\n 90%\n Diagnosis: Brain Tumor, hypernatremia, AMS\n PMH : HTN\n Food allergies and intolerances:\n Pertinent medications: RISS, Senna, Colace, Famotidine, Kcl repletions,\n others noted\n Labs:\n Value\n Date\n Glucose\n 196 mg/dL\n 06:15 AM\n Glucose Finger Stick\n 151\n 10:00 AM\n BUN\n 20 mg/dL\n 06:15 AM\n Creatinine\n 1.0 mg/dL\n 06:15 AM\n Sodium\n 145 mEq/L\n 06:15 AM\n Potassium\n 3.2 mEq/L\n 06:15 AM\n Chloride\n 116 mEq/L\n 06:15 AM\n TCO2\n 23 mEq/L\n 06:15 AM\n PO2 (arterial)\n 169 mm Hg\n 10:58 PM\n PCO2 (arterial)\n 27 mm Hg\n 10:58 PM\n pH (arterial)\n 7.55 units\n 10:58 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 10:58 PM\n Albumin\n 2.3 g/dL\n 06:15 AM\n Calcium non-ionized\n 8.0 mg/dL\n 06:15 AM\n Phosphorus\n 2.9 mg/dL\n 06:15 AM\n Ionized Calcium\n 1.19 mmol/L\n 02:19 AM\n Magnesium\n 2.0 mg/dL\n 06:15 AM\n ALT\n 84 IU/L\n 03:11 AM\n Alkaline Phosphate\n 49 IU/L\n 03:11 AM\n AST\n 44 IU/L\n 03:11 AM\n Phenytoin (Dilantin)\n 10.0 ug/mL\n 06:15 AM\n WBC\n 21.0 K/uL\n 06:15 AM\n Hgb\n 9.0 g/dL\n 06:15 AM\n Hematocrit\n 23.8 %\n 06:15 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 70cc/hr (1680kcals, 104g protein)\n GI: NGT in place, +BS\n Assessment of Nutritional Status\n Pt at risk of malnutrition due to: Brain tumor, possible inability to\n take po\ns, recent 10% wt loss, low %IBW\n Estimated Nutritional Needs based on Adm wt.\n Calories: -2709 (25-35 cal/kg)\n Protein: 108-124(1.4-1.6 g/kg)\n Fluid: 1cc/kcal\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 28 y.o. M brought to ED due to strange behavior, found to have a left\n frontal mass with right- shift of midline structures. Pt now s/p\n emergent crani, tumor resection with removal of L-frontotemporal region\n and ventriculostomy drain placement. Pt was receiving IVF and H20\n flushes for hypernatremia, but this is now resolved. Pt with NGT, to\n start on TF today. Current TF order will underfeed pt. Recommend\n feeding pt at lower end of his estimated kcal needs until pt is able to\n be weaned off ventilator.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec TF goal of Replete with Fiber @ 85cc/hr (2040kcals, 126g\n protein). Start at 15cc/hr, advance rate 10cc q4-6hrs as tolerated to\n goal.\n 2) Rec H20 FLUSHES of 100cc q6hrs.\n 3) Check residuals q4hrs, hold if >150.\n Following, please page with ?\ns #\n" }, { "category": "Social Work", "chartdate": "2198-03-06 00:00:00.000", "description": "Social Work Admission Note", "row_id": 556240, "text": "Met with pt\ns father who is requesting assistance in getting the pt\n from the Transportation Authority in . Father explains that pt\n was driving and abandoned the car in , family put out a missing\n persons report and the pt was found by police in another town.\n CT of the head shows pt to have a left frontal mass which explains some\n behaviors that the family has noticed over the past several days. Pt\n was working in the area and was recently laid off from his job\n with the government.\n Contact the Transportation Authority to inquire about a way of\n getting the car released with out a power of attorney form completed\n by the family. Instructed to contact a particular officer who is not\n available at this time. Will follow up.\n Full psychosocial evaluation pending.\n" }, { "category": "Physician ", "chartdate": "2198-03-06 00:00:00.000", "description": "Intensivist Note", "row_id": 556243, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n PMHx:\n PMH: htn, but not currently a problem per mother\n medications:\n 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Potassium Chloride 16. Potassium Chloride 17. Senna 18. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 12:58 PM\n INVASIVE VENTILATION - STOP 12:58 PM\n EXTUBATION - At 01:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:47 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 02:00 AM\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.1\nC (98.7\n HR: 100 (90 - 114) bpm\n BP: 143/32(62) {110/32(62) - 153/105(115)} mmHg\n RR: 17 (13 - 21) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 14 (12 - 19) mmHg\n Total In:\n 4,727 mL\n 1,461 mL\n PO:\n Tube feeding:\n 2,857 mL\n 617 mL\n IV Fluid:\n 370 mL\n 144 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,221 mL\n Urine:\n 2,765 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n 395 mL\n 121 mL\n Balance:\n 1,567 mL\n 240 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 657 (657 - 657) mL\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.46/40/130/29/5\n Ve: 12.8 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, L pupil larger\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: Absent, 2+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, expressive\n aphasia\n Labs / Radiology\n 183 K/uL\n 11.0 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 147 mEq/L\n 30.8 %\n 15.0 K/uL\n [image002.jpg]\n 02:05 AM\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n WBC\n 15.4\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n Hct\n 24.8\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n Plt\n 95\n 86\n 90\n 81\n 87\n 102\n 183\n Creatinine\n 1.3\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n TCO2\n 23\n 24\n 29\n Glucose\n 138\n 136\n 196\n 122\n 138\n 113\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.3 g/dL,\n Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: ASSESSMENT/PLAN: 28M w/ subacute/acute AMS.\n Hypernatremia to 168. s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg Phenytoin 150 mg IV\n Q8, ventriculostomy drain, ct head shows evolving infarcts in right\n ACA, and L temporal region\n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: IS, Stable\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Free water 1 L through tube feeds, Replete with fiber Full\n strength.\n Renal: : UOP adequate, treating hypernatremia with free water\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Infectious Disease: CefazoLIN 2 g IV Q8H Until\n drain is d/c'd ; FU femoral line culture\n Lines / Tubes / Drains: : ETT, 2 PIV, foley, ventriculostomy drain\n Wounds: head wound c/d/i\n Imaging\n Imaging: : F/U EEG\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:44 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 12:25 PM\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2198-03-06 00:00:00.000", "description": "Intensivist Note", "row_id": 556253, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n PMHx:\n PMH: htn, but not currently a problem per mother\n medications:\n 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Potassium Chloride 16. Potassium Chloride 17. Senna 18. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 12:58 PM\n INVASIVE VENTILATION - STOP 12:58 PM\n EXTUBATION - At 01:19 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:47 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Dilantin - 02:00 AM\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.1\nC (98.7\n HR: 100 (90 - 114) bpm\n BP: 143/32(62) {110/32(62) - 153/105(115)} mmHg\n RR: 17 (13 - 21) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 14 (12 - 19) mmHg\n Total In:\n 4,727 mL\n 1,461 mL\n PO:\n Tube feeding:\n 2,857 mL\n 617 mL\n IV Fluid:\n 370 mL\n 144 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,221 mL\n Urine:\n 2,765 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n 395 mL\n 121 mL\n Balance:\n 1,567 mL\n 240 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 657 (657 - 657) mL\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.46/40/130/29/5\n Ve: 12.8 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, L pupil larger\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: Absent, 2+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, expressive\n aphasia\n Labs / Radiology\n 183 K/uL\n 11.0 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 111 mEq/L\n 147 mEq/L\n 30.8 %\n 15.0 K/uL\n [image002.jpg]\n 02:05 AM\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n WBC\n 15.4\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n Hct\n 24.8\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n Plt\n 95\n 86\n 90\n 81\n 87\n 102\n 183\n Creatinine\n 1.3\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n TCO2\n 23\n 24\n 29\n Glucose\n 138\n 136\n 196\n 122\n 138\n 113\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.3 g/dL,\n Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: ASSESSMENT/PLAN: 28M w/ subacute/acute AMS.\n Hypernatremia to 168. s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg Phenytoin 150 mg IV\n Q8, ventriculostomy drain, ct head shows evolving infarcts in right\n ACA, and L temporal region\n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: IS, Stable\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Free water 1 L through tube feeds, Replete with fiber Full\n strength.\n Renal: : UOP adequate, treating hypernatremia with free water\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Infectious Disease: CefazoLIN 2 g IV Q8H Until\n drain is d/c'd ; FU femoral line culture\n Lines / Tubes / Drains: : ETT, 2 PIV, foley, ventriculostomy drain\n Wounds: head wound c/d/i\n Imaging\n Imaging: : F/U EEG\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:44 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 12:25 PM\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2198-03-04 00:00:00.000", "description": "Intensivist Note", "row_id": 555866, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 1000 mL D5W 3. Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. HydrALAzine 10. Insulin 11. Magnesium Sulfate 12.\n Ondansetron 13. Phenytoin 14. Phenytoin\n 15. Potassium Chloride 16. Potassium Chloride 17. Propofol 18. Senna\n 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:30 AM\n ARTERIAL LINE - STOP 02:26 PM\n CORDIS/INTRODUCER - STOP 10:08 PM\n SPUTUM CULTURE - At 11:07 PM\n FEVER - 101.2\nF - 10:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 09:10 PM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 08:01 AM\n Famotidine (Pepcid) - 08:51 PM\n Dilantin - 04:06 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.6\nC (99.7\n HR: 99 (99 - 151) bpm\n BP: 116/63(73) {97/46(60) - 155/89(89)} mmHg\n RR: 17 (14 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91 kg (admission): 77.4 kg\n ICP: 18 (8 - 19) mmHg\n Total In:\n 4,781 mL\n 1,333 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,542 mL\n 429 mL\n Blood products:\n 489 mL\n 493 mL\n Total out:\n 1,356 mL\n 936 mL\n Urine:\n 1,173 mL\n 600 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 183 mL\n 86 mL\n Balance:\n 3,425 mL\n 397 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 732 (732 - 732) mL\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 15 cmH2O\n Plateau: 12 cmH2O\n SPO2: 100%\n ABG: 7.55/27/169/23/3\n Ve: 10.9 L/min\n PaO2 / FiO2: 169\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, Non-distended, Non-tender\n Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, Moves Rue and RLE\n spontaneously; LUE withdraws\n Labs / Radiology\n 90 K/uL\n 8.3 g/dL\n 136 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 26 mg/dL\n 122 mEq/L\n 152 mEq/L\n 23.9 %\n 22.9 K/uL\n [image002.jpg]\n 01:44 PM\n 02:50 PM\n 02:56 PM\n 03:53 PM\n 06:03 PM\n 02:05 AM\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n WBC\n 17.3\n 18.0\n 15.4\n 19.0\n 22.9\n Hct\n 29\n 31.4\n 34\n 31\n 28.8\n 24.8\n 25.4\n 23.9\n Plt\n 119\n 121\n 95\n 86\n 90\n Creatinine\n 1.4\n 1.3\n 1.2\n TCO2\n 19\n 20\n 20\n 23\n 24\n Glucose\n 127\n 162\n 140\n 177\n 138\n 136\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Ca:7.5 mg/dL, Mg:2.2\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: Neurologic: s/p tumor resection, sedated, propofol gtt,\n Phenytoin 100 mg IV Q8H, , ventriculostomy drain, f/u ct head with\n right convexity SDH 7 mm and interval increased prominence right\n parasagittal frontal lobe edema. Hold Propofol. Check dilantin level\n Cardiovascular: Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV\n Q6H:PRN\n Pulmonary: Try PSV today\n Gastrointestinal / Abdomen: Start TF\n Renal: Foley, Adequate UO, Recheck sodium now and reassess free water\n deficit\n Hematology: 2 PRBC today\n Endocrine: RISS\n Infectious Disease: Infectious Disease: CefazoLIN 2 g IV Q8H Until\n drain is d/c'd\n Lines / Tubes / Drains: Lines/Tubes/Drains: ETT, trauma line left\n femoral vein, 2 PIV, foley, ventriculostomy drain\n Wounds: Dry dressings\n Imaging: None\n Fluids: D5 50ml/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: CVA, (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Glycemic Control:\n Lines:\n 20 Gauge - 03:02 AM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2198-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555998, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert at times, lethargic at times, arouse to voice or pain. Follows\n commands stick out tongue, open eyes, squeeze hands and move legs.\n Intubated, unable to assess orientation. Seizure activity focal noted x\n 1 < 1 minute. Ventricular drain at 15 cm above tragus and open,\n drainage blood tinged, but clearing. Immobilizers on wrists to prevent\n interference with vent and ventricular drain.\n Action:\n Neuro checks q 1 hour while awake q 2 hour overnight. Continues on 24\n hour EEG to be completed at 3 pm on .\n Response:\n More alert, increased movement of lower extremities, purposeful\n movement to self extubate when unrestrained.\n Plan:\n Continue frequent neuro checks, same orders for vent drain.\n Hypernatremia\n Assessment:\n Na 146\n Action:\n Receiving 250 ml free water q 4 hours via ngt.\n Response:\n Na 147\n Plan:\n Continue free water boluses and level monitoring.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp 101.2 oral\n Action:\n Tylenol via ngt x 1 at 2330\n Response:\n Temp to 99.5 oral\n Plan:\n Continue to monitor for temp and treat per orders.\n" }, { "category": "Nursing", "chartdate": "2198-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556232, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt does not speak at all, MAE right > left, pupils unequal 3mm rt and 4\n mm left, pt intermittently follows commands by raising finger when\n asked. Continuous EEG on.\n Action:\n Dr notified of unequal pupils, no new orers\n Response:\n Neuro status unchanged\n Plan:\n NVS q @HRs\n PT today if possible\n Speech and swallow\n Hypernatremia (high sodium)\n Assessment:\n NA 147 and K 3.1\n Action:\n Free water NGT q 6 on hold while pt receives 500ml D%W at 100ml/hr to\n replete K. KCL 60 meq NGT given.\n Response:\n none\n Plan:\n Recheck lytes today\n" }, { "category": "Nursing", "chartdate": "2198-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555845, "text": "Tachycardia, Other\n Assessment:\n St to 150, no ectopy, tmax 38.4 axillary, sbp 100-130\ns, hct 23\n Action:\n d/cd cordis , Tylenol 650 mg pr given, transfused with 2units prbc.,\n 2gms calcium gluconate iv given\n Response:\n Sr 90\ns to low 100\ns no ectopy. , transfusions completed without\n incident\n Plan:\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2198-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555853, "text": "Tachycardia, Other\n Assessment:\n St to 150, no ectopy, tmax 38.4 axillary, sbp 100-130\ns, hct 23\n Action:\n d/cd cordis ,tip of line sent for culture, sputum culture sent ,\n Tylenol 650 mg pr given, transfused with 2units prbc., 2gms calcium\n gluconate iv given\n Response:\n Sr 90\ns to low 100\ns no ectopy. , transfusions completed without\n incident\n Plan:\n Check hct in am, check k/ca in am, check culture results\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n u/o 40-60 cc/hr, d5w at 50cc/hr, sbp hovering in the 100\n Action:\n Transfused with 2prbc, iv hydration continues\n Response:\n u/o improving with hr down to low 100\n Plan:\n Continue to hydrate check hct this am\n Hypernatremia (high sodium)\n Assessment:\n Na 151 at 2200, d5w at 50cc/hr\n Action:\n Receiving 250 free water approx. q5-5hrs\n Response:\n Na trending down\n Plan:\n Check lyes this am\n Addendum :: patient with increasing focal seizure of right arm lasting\n 1-3minutes, per neurology patient down to ctscan. At approx. 1230 am.\n Ventricular drain draining approx. 20-30cc/hr blood tinged drainage .\n patient over breathing with ph at 7.55 and co2 at 26, sedated with\n 15mcg/kg/min of propofol, see decreased mniute ventilation , have not\n seen focal seizure since Propofol started. ?? patient need to continue\n decadron\n" }, { "category": "Nursing", "chartdate": "2198-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555856, "text": "Tachycardia, Other\n Assessment:\n St to 150, no ectopy, tmax 38.4 axillary, sbp 100-130\ns, hct 23\n Action:\n d/cd cordis ,tip of line sent for culture, sputum culture sent ,\n Tylenol 650 mg pr given, transfused with 2units prbc., 2gms calcium\n gluconate iv given\n Response:\n Sr 90\ns to low 100\ns no ectopy. , transfusions completed without\n incident\n Plan:\n Check hct in am, check k/ca in am, check culture results\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n u/o 40-60 cc/hr, d5w at 50cc/hr, sbp hovering in the 100\n Action:\n Transfused with 2prbc, iv hydration continues\n Response:\n u/o improving with hr down to low 100\n Plan:\n Continue to hydrate check hct this am\n Hypernatremia (high sodium)\n Assessment:\n Na 151 at 2200, d5w at 50cc/hr\n Action:\n Receiving 250 free water approx. q5-5hrs\n Response:\n Na trending down\n Plan:\n Check lyes this am\n Addendum :: patient with increasing focal seizure of right arm lasting\n 1-3minutes, per neurology patient down to ctscan. At approx. 1230 am.\n Ventricular drain draining approx. 20-30cc/hr blood tinged drainage .\n patient over breathing with ph at 7.55 and co2 at 26, sedated with\n 15mcg/kg/min of propofol, see decreased mniute ventilation , have not\n seen focal seizure since Propofol started. ?? patient need to continue\n decadron\n continue free h20\n" }, { "category": "Respiratory ", "chartdate": "2198-03-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555738, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\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: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\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 MRI\n 0930\n Bedside Procedures:\n Comments:\n Pt remains ventilator dependent at present; Post OP CT this ,AM to\n evaluate surgical sight.\n, RRT 16:32\n" }, { "category": "Nursing", "chartdate": "2198-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555739, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt with resection of large frontal mass, off sedation, some spontaneous\n movement to right arm, withdraws right leg, no movement to left side,\n Pupils unequal, but briskly react, NSurg aware.\n Appeared to have one seizure of less than 1 minute duration, rapid\n rhythmic twitching of right side only. NSurg in to assess. EEG\n performed, awaiting results\n Action:\n To MRI for follow up post op. Dilantin re-bloused and standing dose\n increased.\n Response:\n Unchanged exam\n Plan:\n Q1hr neuro checks, repeat CT of head.\n Hypernatremia (high sodium)\n Assessment:\n Na 155\n Action:\n D5W at 50cc/hr\n Response:\n Gradual decrease of Na level\n Plan:\n Continue slow hydration with free H2O, Q6hr sodiums\n" }, { "category": "Nursing", "chartdate": "2198-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556316, "text": "Altered mental status (not Delirium)\n Assessment:\n More alert today. Attempted to say name this am.\n Opens eyes spontaneously. Right pupil 3 brisk, left pupil 4 brisk.\n Follows commands by squeezing left hand slightly, slightly wiggles toes\n make a fist and gives high five on the right. Will move right hand\n freely up to face.\n No SZ activity seen today.\n Vent drain @15 above the tragus. Open, draining ~5-20ml\ns hr of blood\n tinged drainage. ICP\ns 13-18. waveform dampened\n Low grade temp t-max 100.2\n Action:\n Vent drain placed at 20 above the tragus per neurosurg. Dsg reinforced.\n Q2hr neuro checks.\n Dilantin bolus given for a level of 5.4\n Tylenol given for temp.\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n Head ct in am. ? clamp vent drain.\n" }, { "category": "Respiratory ", "chartdate": "2198-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555987, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 91.6 None\n Ideal tidal volume: 366.4 / 549.6 / 732.8 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: 25 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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / 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:\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 Comments: Patient continuously chews on tube. OPA placed halfway to\n protect ETT.\n" }, { "category": "Respiratory ", "chartdate": "2198-03-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555559, "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 Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned /\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 MRI\n 0730\n OR\n 0815\n Bedside Procedures:\n Comments:\n In OR most of the day for resection of brain tumor. Presently still\n there ? return soon. Prognosis = poor.\n, RRT 17:49\n" }, { "category": "Nursing", "chartdate": "2198-03-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555448, "text": "28 y/o M brought in to the ED by his family after he was noticed to\n have unusual behaviour over wks. Per report, pt has not been eating\n or drinking for 4 days and has been having delusions. On Wednesday, pt\n drove to and abandoned family car. He called his family\n who came to get him and brought him into the ED for evaluation. On\n arrival, pt was disoriented but denied any SI or HI.\n In the ED labs revealed a significant hypernatremia with Na 168 and\n Endocrine was consulted. They recommended slow correction with D5\n 1/2NS at 200cc/hr (he was correcting at 1meq/hr in ED). He underwent a\n head CT that revealed a left frontal mass with rightward shift of\n midline structures. Neurosurgery and neurology were consulted. Pt\n receivied Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent\n down for MRI. However, pt was noted to be altered and unable to follow\n commands and the MRI was not completed.\n On arrival to the SICU, Neuro & Neurosurg were called to re-evaluate.\n Altered mental status (not Delirium)\n Assessment:\n Obtunded and not following commands. Withdraws to pain and will\n respond to noxious stimuli. Noted to have some spontaneous purposeful\n movements. Occasional periods of apnea noted\n Perrla @3. opens eyes spontaneously occasionally.\n Repeat head ct complete.\n Action:\n Intubated for airway protection to have MRI.\n Q1 hr neuro checks. Noted to have ? Sz activity lasting less than a\n minute. Subsided on own. No further activity since. Micu resident\n MD aware.\n Response:\n Neuro remain unchanged.\n Sedated on propofol\n Plan:\n Continue Q1 hr neuro checks.\n MRI/EEG today.\n ? surgery at some point.\n" }, { "category": "Nursing", "chartdate": "2198-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555621, "text": "Altered mental status (not Delirium)\n Assessment:\n POD # 1 craniotomy with large tumor resection . Intubated, sedated, EVD\n in place.\n Action:\n Neuro exam. Unresponsive. ICP 8-11. Hourly drainage minimal from EVD.\n Response:\n Withdrawing to nail bed pressure in BLE on one exam. GCS 3.\n Plan:\n Q1h neuros, SBP < 140. Routine CT of head done for today. Dilantin IV\n TID.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tm 101.5\n Action:\n Tylenol PR\n Response:\n Tc 100.7\n Plan:\n Continue to follow temp curve\n Tachycardia, Other\n Assessment:\n HR 120-140s ST no ectopy, Pvvv 17-25\n Action:\n 2Ls in fluid boluses, Maintanence IVF increased.\n Response:\n HR down to 110-120s post fluid boluses and maintenance increase.\n Plan:\n Slow IV hydration secondary to hypernatremia\n Hypernatremia (high sodium)\n Assessment:\n Sodium 163\n Action:\n Slow IV hydration\n Response:\n Na 157\n Plan:\n Continue to monitor q4h Na\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n UO < 30 x 1 hr, tachycardic, Pvv > 10\n Action\n Fluid boluses x 3 overnight\n Response:\n Less tachycardic, UO trending up, PVV trending down\n Plan:\n Continue to monitor UO q1hr, Follow trends of PVV and HR.\n" }, { "category": "Nursing", "chartdate": "2198-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555914, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient sedated on propofol at being of shift, minimal response noted.\n Propofol stopped. Patient opening eyes spontaneously , will track with\n eyes. Will give weak hand grasp on left ue, right ue will demonstrate\n gross movement of limb, but have noted patient to move bilateral ue\n spontaneously, left > right. Patient will given minimal toe wiggle to\n command. Pupils left at times > right, but reactive to light. Ventric\n remains open at 15cm, draining blood tinged csf. Patient appears to\n continue to have some focal seizure activity.\n Action:\n Sedation to remain off, continue to monitor Neuro Q1 hrly, continue to\n monitor icp and drainage. Patient to have 24hr continueous EEg to\n monitor for seizure activity.\n Response:\n Patient more alert, follow simple commands at time of report, however\n inconsistently at times.\n Plan:\n Will monitor for seizure activity, continue to monitor neuro status.\n Report any changes to team.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient has low grade temp.\n Action:\n Pulmonary toileting maintained, labs monitored. Monitor vital signs,\n continue with iv antibiotics as ordered.\n Response:\n Continues to have low grade temps.\n Plan:\n To continue to monitor and treat accordingly. Await culture results\n Tachycardia, Other\n Assessment:\n Patient in st 98-110 bpm\n Action:\n Patient had blood transfusion per ordered. Monitor for agitation. Iv\n antibiotics given as ordered. Monitor labs electrolytes\n Response:\n Hr 90\ns-100\n Plan:\n Will continue to monitor and treat accordingly\n Hypernatremia (high sodium)\n Assessment:\n Patient last sodium level within parameters\n Action:\n Continue with free water as tolerated. Monitor labs in am\n Response:\n Levels within parameters\n Plan:\n Will continue with free water bolus 250cc Q6, monitor labs in am.\n" }, { "category": "Nursing", "chartdate": "2198-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556355, "text": "Altered mental status (not Delirium)\n Assessment:\n More alert today. Attempted to say name this am.\n Opens eyes spontaneously. Right pupil 3 brisk, left pupil 4 brisk.\n Follows commands by squeezing left hand slightly, slightly wiggles toe,\n can make a fist and gives high five on the right. Will move right hand\n freely up to face.\n No SZ activity seen today.\n Vent drain @15 above the tragus. Open, draining ~5-20ml\ns hr of blood\n tinged drainage. ICP\ns 13-18. waveform dampened\n Low grade temp t-max 100.2\n Action:\n Vent drain placed at 20 above the tragus per neurosurg. Dsg reinforced.\n Q2hr neuro checks.\n Dilantin bolus given for a level of 5.4\n Tylenol given for temp.\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n Head ct in am. ? clamp vent drain.\n" }, { "category": "Physician ", "chartdate": "2198-03-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 555412, "text": "Chief Complaint:\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n .\n In the ED, initial vs were: T 97.6 P 125 BP 140/85 RR 16 O2 Sats 99% on\n RA. Initial labs revealed a significant hypernatremia with Na 168 and\n Endocrine was consulted. They recommended slow correction with D5\n 1/2NS at 200cc/hr (he was correcting at 1meq/hr in ED). He underwent a\n head CT that revealed a left frontal mass with rightward shift of\n midline structures. Neurosurgery and neurology were consulted. Pt\n receivied Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent\n down for MRI. However, pt was noted to be altered and unable to follow\n commands and the MRI was not completed.\n .\n On arrival to the SICU, pt was obtunded and not following commands. He\n withdraws to pain and will respond to noxious stimuli. Pt was noted to\n have some spontaneous purposeful movements. Neuro & Neurosurg were\n called to re-evaluate.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n none\n Past medical history:\n Family history:\n Social History:\n Hypertension\n s/p patellar tendon repair\n multiple family members with various cancers, including prostate, lung\n ca & cerebral tumor (age >80)\n Denies smoking & illicit drug use, reports occaisional social\n drinking. Pt lives alone in and was recently laid off from\n work.\n Flowsheet Data as of 05:02 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 80 (75 - 85) bpm\n BP: 126/70(82) {126/67(82) - 135/73(86)} mmHg\n RR: 14 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 140 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -140 mL\n Respiratory\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n T: 99.9 BP: 126/68 P: 82 R: 13 Sats 97% on RA\n General: NAD, not responding to commands, responds to noxious stim\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, NABS, no rebound/guard\n Ext: Warm, dry, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: pupil response brisk bilaterally, withdraws to pain all four\n extremities. Purposeful movements appreciated.\n RUE & RLE +2 reflexes (left sided increased tone)\n LUE & LLE +3 reflexes (right sided less tone)\n Labs / Radiology\n 197 K/uL\n 14.4 g/dL\n 155 mg/dL\n 1.4 mg/dL\n 44 mg/dL\n 26 mEq/L\n 130 mEq/L\n 3.8 mEq/L\n 164 mEq/L\n 43.5 %\n 15.2 K/uL\n [image002.jpg]\n \n 2:33 A2/6/ 03:11 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 15.2\n Hct\n 43.5\n Plt\n 197\n Cr\n 1.4\n Glucose\n 155\n Other labs: PT / PTT / INR:15.9/28.4/1.4, ALT / AST:84/44, Alk Phos / T\n Bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Lactic Acid:1.8 mmol/L, Ca++:8.8 mg/dL, Mg++:2.7 mg/dL, PO4:3.2\n mg/dL\n Imaging: CT head : large ill defined low attenuation mass in the\n left frontal lobe with associated mass effect resulting in significant\n right shift of normally mildline structures, effacement of the\n left lateral ventricle, entrapment of the right lateral ventricle and\n loss of the supersellar cistern suggestive of some downward herniation.\n no hemmorhage. findings worrisome for primary brain\n neoplasm. recommend MRI for further evaluation.\n Assessment and Plan\n 28 y/o M with HTN who presents with MS changes, Hypernatremia and found\n to have intracranial mass.\n .\n # Mental Status changes: Etiology unclear, multiple possible\n etiologies. Pt remains significantly hypernatremic and Na correcting\n very slowly (0.5meq /hr). Exam not suggestive of herniation but\n worsened cerebral edema may be contributing. It is possible that pt is\n having non-convulsive seizures, though no e/o seizure activity to date.\n Pt not following commands, though having some purposeful movements\n -stat head CT (prelim essentially unchanged)\n -plan for elective intubation for MRI and hyperventilation\n -strict aspiration precautions\n -f/u TSH, dilantin level\n -f/u am EEG\n -f/u neuro & neuro recs\n -proceed with cautious & slow Na correction\n .\n # Intracranial Mass: Pt with left sided frontal mass and associated\n midline shift. Suspect primary brain neoplasm though unclear origin\n currently. Pt will need MRI for further elucidation and will likely\n need to be intubated for procedure. Pt will likely need further\n staging work up including CT chest/abd/pelv.\n - stat head CT\n - intubation with hyperventilation for cerebral edema\n - continue Decadron 4mg IV q 6hrs\n - f/u dilantin level and start Dilantin 100mg po TID\n - apprec Neurosurg/Neuro recs\n - q1hr neuro checks\n - NPO with aspiration precautions\n - social work consult\n .\n # Hypernatremia: Pt presented with severe hypernatremia, ARF and FENA\n <0.1. Suspect that there is a component of dehydration and also a free\n water deficit. Unclear if there is an underlying central process,\n awaiting urine & serum osms to eval for central diabetes insipidus.\n There is a risk of central pontine myelinolysis and worsening edema due\n to volume shifting with correction of hypernatremia. Will have to\n monitor lytes, volume and MS very carefully peri & post -intubation\n - apprec endocrine recs\n - f/u urine lytes and osms\n - f/u q2hr sodium (goal to correct at 0.5meq per hr)\n - very slow correction with D5 1/2NS at 100cc/hr\n - goal Na 150 per neurosurg\n .\n # ARF: Elevated BUN to creatinine ratio and FENA<0.1 likely all\n pre-renal. Trending down with hydration\n - continue to trend with gentle IVF\n - avoid nephrotoxins\n .\n # Hypertension: normotensive currently, will monitor for now\n .\n # FEN: NPO with IVF, place OG after intubation\n - nutrition consult\n - replete electrolytes\n .\n # Prophylaxis: Heparin sc tid\n .\n # Access: PIVx2\n .\n # Code: FULL\n .\n # Communication: family & patient\n ICU Care\n Nutrition: NPO on IVF\n Glycemic Control: none\n Lines:\n 18 Gauge - 03:02 AM\n 20 Gauge - 03:02 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: with family\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2198-03-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555609, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 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 ------ Protected Section ------\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 0300\n ------ Protected Section Addendum Entered By: , SRT\n on: 04:22 ------\n" }, { "category": "General", "chartdate": "2198-03-02 00:00:00.000", "description": "Generic Note", "row_id": 555429, "text": "TITLE: Overnight \n Pt seen and examined with housestaff. Please see resident H and P (Dr.\n for details. Briefly, this is a 28 yo woman who had been noted\n by family members to be acting strangely over last several days. In\n ED, Na noted to be 168. Head CT showed L-sided mass with midline\n shift. Neurology and neurosurgery consulted.\n A/P: Intracranial mass of unclear nature\n possible GBM vs met to\n brain. Pt becoming increasingly somenolent\n will check repeat CT scan\n for stability. Will also need MRI to further delineate process\n will\n likely need intonation for that. Q1 hour neuron checks. Treating\n hypernatremia with slow free H2O repletion, with goal in mid 150s to\n avoid further brain edema.\n ------ Protected Section ------\n Error: 28 yo MALE\n ------ Protected Section Addendum Entered By: , MD\n on: 06:27 ------\n" }, { "category": "Respiratory ", "chartdate": "2198-03-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555606, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 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" }, { "category": "Physician ", "chartdate": "2198-03-03 00:00:00.000", "description": "Intensivist Note", "row_id": 555673, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n hypernatremia, brain mass\n PMHx:\n HTN\n Current medications:\n 1. 2. 1000 mL LR 3. 1000 mL LR 4. Acetaminophen 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium 8. HydrALAzine 9. Insulin 10. Magnesium\n Sulfate 11. Ondansetron 12. Pantoprazole 13. Phenytoin 14. Potassium\n Chloride 15. Propofol 16. Senna 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 06:00 AM\n INVASIVE VENTILATION - START 06:00 AM\n ARTERIAL LINE - START 06:45 AM\n\n admit from OR, slow correction of hypernatremia,\n tachycardia/hypotension responsive to multiple fluid boluses\n Post operative day:\n POD#1 emergent crani for tumor resection\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 10:00 PM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 06:00 AM\n Pantoprazole (Protonix) - 10:00 PM\n Other medications:\n Flowsheet Data as of 04:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 38.2\nC (100.8\n HR: 139 (76 - 139) bpm\n BP: 114/62(79) {104/57(73) - 148/79(99)} mmHg\n RR: 17 (10 - 31) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.2 kg (admission): 77.4 kg\n ICP: 8 (8 - 11) mmHg\n Total In:\n 8,877 mL\n 1,048 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,877 mL\n 1,048 mL\n Blood products:\n Total out:\n 3,984 mL\n 180 mL\n Urine:\n 850 mL\n 155 mL\n NG:\n Stool:\n Drains:\n 44 mL\n 25 mL\n Balance:\n 4,893 mL\n 868 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (600 - 650) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n Plateau: 12 cmH2O\n SPO2: 100%\n ABG: 7.46/32/164/21/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 410\n Physical Examination\n General Appearance: No acute distress\n HEENT: b/l conjunctival edema\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated, delayed responsive lower extremities to noxious\n stimuli, otherwise no spontaneous movement\n Labs / Radiology\n 95 K/uL\n 8.6 g/dL\n 138 mg/dL\n 1.3 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 131 mEq/L\n 157 mEq/L\n 24.8 %\n 15.4 K/uL\n [image002.jpg]\n 10:33 AM\n 11:55 AM\n 12:25 PM\n 01:44 PM\n 02:50 PM\n 02:56 PM\n 03:53 PM\n 06:03 PM\n 02:05 AM\n 02:19 AM\n WBC\n 17.3\n 18.0\n 15.4\n Hct\n 40.2\n 35\n 36\n 29\n 31.4\n 34\n 31\n 28.8\n 24.8\n Plt\n 187\n 119\n 121\n 95\n Creatinine\n 1.4\n 1.3\n TCO2\n 22\n 21\n 19\n 20\n 20\n 23\n Glucose\n 137\n 139\n 127\n 162\n 140\n 177\n 138\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Ca:7.9 mg/dL, Mg:2.2\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), TACHYCARDIA, OTHER, FEVER\n (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), HYPERNATREMIA\n (HIGH SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, sedated, propofol gtt, Phenytoin\n rebolus and increase dose to 150 mg IV Q8H, MR within 36 hours,\n ventriculostomy drain, f/u ct head with right convexity SDH 7 mm and\n interval increased prominence right parasagittal frontal lobe edema\n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: Ventilated switch to PSV and assess after awake\n Gastrointestinal/Abdominal: colace/bisacodyl\n Nutrition: NPO\n Renal: UOP improved s/p fluid boluses overnight, hypernatremic, LR at\n 125 cc/hr, once Na 150 switch to NS\n Hematology: s/p 3U PRBC in OR, stable. Transfuse one unit now.\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines/Tubes/Drains: ETT, trauma line left femoral vein, 2 PIV, foley,\n ventriculostomy drain\n Wounds: head wound c/d/i\n Imaging: MRI/CT \n Fluids: LR 125 cc/hr\n Prophylaxis:H2 blocker, boots\n Consults: neurosurgery, neurology\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:02 AM\n 20 Gauge - 03:02 AM\n Arterial Line - 06:45 AM\n Cordis/Introducer - 06:22 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2198-03-02 00:00:00.000", "description": "Generic Note", "row_id": 555410, "text": "TITLE: Overnight \n Pt seen and examined with housestaff. Please see resident H and P (Dr.\n for details. Briefly, this is a 28 yo woman who had been noted\n by family members to be acting strangely over last several days. In\n ED, Na noted to be 168. Head CT showed L-sided mass with midline\n shift. Neurology and neurosurgery consulted.\n A/P: Intracranial mass of unclear nature\n possible GBM vs met to\n brain. Pt becoming increasingly somenolent\n will check repeat CT scan\n for stability. Will also need MRI to further delineate process\n will\n likely need intonation for that. Q1 hour neuron checks. Treating\n hypernatremia with slow free H2O repletion, with goal in mid 150s to\n avoid further brain edema.\n" }, { "category": "Nursing", "chartdate": "2198-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556707, "text": "Altered mental status (not Delirium)\n Assessment:\n More alert today.\n Opens eyes spontaneously. Right pupil 3 brisk, left pupil 4 brisk.\n Follows commands by squeezing left hand slightly, slightly wiggles toe,\n can make a fist and gives high five on the right. Will move right hand\n freely up to face. Left hand moves on bed but weaker.\n No SZ activity seen today.\n Vent drain @20 above the tragus. Clamped ICP\ns 13-18. waveform dampened\n Low grade temp t-max 100.0\n Action:\n Vent drain removed by MD. placed.\n Q2hr neuro checks.\n Dilantin bolus given for a level of 4.8\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n Head ct in am.\n Tylenol for temp.\n Awaiting pathology report.\n" }, { "category": "Physician ", "chartdate": "2198-03-07 00:00:00.000", "description": "Intensivist Note", "row_id": 556456, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n s/p craniotomy\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Phenytoin 16. Senna 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:00 AM\n Infusions:\n Other ICU medications:\n Dilantin - 06:00 PM\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 101 (85 - 107) bpm\n BP: 124/70(82) {120/22(51) - 153/96(118)} mmHg\n RR: 22 (14 - 23) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 12 (12 - 20) mmHg\n Total In:\n 2,956 mL\n 906 mL\n PO:\n Tube feeding:\n 1,686 mL\n 692 mL\n IV Fluid:\n 570 mL\n 214 mL\n Blood products:\n Total out:\n 4,023 mL\n 1,103 mL\n Urine:\n 3,765 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n 258 mL\n 73 mL\n Balance:\n -1,067 mL\n -197 mL\n Respiratory support\n SPO2: 98%\n ABG: ///27/\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, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, moves R> L\n Labs / Radiology\n 244 K/uL\n 11.4 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 110 mEq/L\n 147 mEq/L\n 33.1 %\n 15.3 K/uL\n [image002.jpg]\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n 02:41 AM\n WBC\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n 15.3\n Hct\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n 33.1\n Plt\n 86\n 90\n 81\n 87\n 102\n 183\n 244\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 23\n 24\n 29\n Glucose\n 136\n 196\n 122\n 138\n 113\n 106\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.3 g/dL,\n Ca:8.0 mg/dL, Mg:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg, Phenytoin 150 mg IV\n Q8, ventriculostomy drain to 20, ct head shows evolving infarcts in\n right ACA, mental status improved (following commands), CT head ,\n possible clamp of drain, dilantin load \n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: stable\n Gastrointestinal / Abdomen: bowel regimen. NGT.\n Nutrition: speech/swallow (Suggest pt continue to receive primary\n means of nutrition via the NG in place. Start taking small amounts of\n nectar thick liquids and pureed solids), Free water 1 L through tube\n feeds, Replete with fiber Full strength.\n Renal: UOP adequate, treating hypernatremia with free water\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines / Tubes / Drains: ETT, 2 PIV, foley, ventriculostomy drain\n Wounds:\n Imaging: EEG\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:12 PM 70 mL/hour\n Glycemic Control:\n Lines:\n ICP Catheter - 12:25 PM\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2198-03-07 00:00:00.000", "description": "Intensivist Note", "row_id": 556464, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n s/p craniotomy\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Phenytoin 16. Senna 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:00 AM\n Infusions:\n Other ICU medications:\n Dilantin - 06:00 PM\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.4\n HR: 101 (85 - 107) bpm\n BP: 124/70(82) {120/22(51) - 153/96(118)} mmHg\n RR: 22 (14 - 23) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 12 (12 - 20) mmHg\n Total In:\n 2,956 mL\n 906 mL\n PO:\n Tube feeding:\n 1,686 mL\n 692 mL\n IV Fluid:\n 570 mL\n 214 mL\n Blood products:\n Total out:\n 4,023 mL\n 1,103 mL\n Urine:\n 3,765 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n 258 mL\n 73 mL\n Balance:\n -1,067 mL\n -197 mL\n Respiratory support\n SPO2: 98%\n ABG: ///27/\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, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities, moves R> L\n Labs / Radiology\n 244 K/uL\n 11.4 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 110 mEq/L\n 147 mEq/L\n 33.1 %\n 15.3 K/uL\n [image002.jpg]\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n 02:41 AM\n WBC\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n 15.3\n Hct\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n 33.1\n Plt\n 86\n 90\n 81\n 87\n 102\n 183\n 244\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 23\n 24\n 29\n Glucose\n 136\n 196\n 122\n 138\n 113\n 106\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.3 g/dL,\n Ca:8.0 mg/dL, Mg:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg, Phenytoin 150 mg IV\n Q8, ventriculostomy drain to 20, ct head shows evolving infarcts in\n right ACA, mental status improved (following commands), CT head ,\n possible clamp of drain, dilantin load \n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: stable\n Gastrointestinal / Abdomen: bowel regimen. NGT.\n Nutrition: speech/swallow (Suggest pt continue to receive primary\n means of nutrition via the NG in place. Start taking small amounts of\n nectar thick liquids and pureed solids), Free water 1 L through tube\n feeds, Replete with fiber Full strength.\n Renal: UOP adequate, treating hypernatremia with free water\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines / Tubes / Drains: ETT, 2 PIV, foley, ventriculostomy drain\n Wounds:\n Imaging: EEG\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:12 PM 70 mL/hour\n Glycemic Control:\n Lines:\n ICP Catheter - 12:25 PM\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nutrition", "chartdate": "2198-03-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 556476, "text": "Current Wt: 85.8kg\n Pertinent medications: RISS, Heparin, Famotidine, Senna, Colace, others\n noted\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 02:41 AM\n Glucose Finger Stick\n 149\n 09:30 AM\n BUN\n 11 mg/dL\n 02:41 AM\n Creatinine\n 0.7 mg/dL\n 02:41 AM\n Sodium\n 147 mEq/L\n 02:41 AM\n Potassium\n 3.6 mEq/L\n 02:41 AM\n Chloride\n 110 mEq/L\n 02:41 AM\n TCO2\n 27 mEq/L\n 02:41 AM\n PO2 (arterial)\n 130 mm Hg\n 05:13 PM\n PCO2 (arterial)\n 40 mm Hg\n 05:13 PM\n pH (arterial)\n 7.46 units\n 05:13 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 05:13 PM\n Albumin\n 2.3 g/dL\n 06:15 AM\n Calcium non-ionized\n 8.0 mg/dL\n 02:41 AM\n Phosphorus\n 3.3 mg/dL\n 02:41 AM\n Ionized Calcium\n 1.15 mmol/L\n 05:13 PM\n Magnesium\n 2.2 mg/dL\n 02:41 AM\n ALT\n 84 IU/L\n 03:11 AM\n Alkaline Phosphate\n 49 IU/L\n 03:11 AM\n AST\n 44 IU/L\n 03:11 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 70cc/hr (1680kcals, 104g protein)\n Diet: Pureed solids, Nectar Thick Liquids\n GI: soft, +BS, Last BM 2days ago\n Assessment of Nutritional Status\n 28 y.o. M adm with left frontal mass, now s/p emergent crani, tumor\n resection with removal of L-frontotemporal region and ventriculostomy\n drain placement. Pt had a S/S evaluation , which recommended that\n pt could have pureed foods and nectar thick liquids for pleasure, but\n should continue to get TF as primary source of nutrition. Pt is\n tolerating TF, but current goal rate is likely underfeeding pt\n (provides only ~21kcals/adm wt). Rec increasing TF goal rate to better\n meet pt\ns needs. Pt with Na of 147 despite 250cc H20 flushes q6hrs;\n rec increasing to q4hrs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec increasing TF goal rate to Replete with fiber @ 85cc/hr\n (2040kcals, 126g protein).\n 2) Rec increasing H20 flushes to 250cc q4hrs.\n 3) Continue with bowel regimen.\n 4) Encourage small amounts of po intake as tolerated. Will\n monitor and adjust TF if needed.\n Following, Please page with ?\ns #\n" }, { "category": "Nursing", "chartdate": "2198-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556442, "text": "Altered mental status (not Delirium)\n Assessment:\n NVS stable, Pt alert at times and doses off where he needs to be\n stimulated to arouse. Pupils have been equal size 2-3mm each, Pt moves\n arms and follows commands inconsistently, Pt moves feet and legs\n spontaneously but not to command ICP catheter zeroed at 20cm above the\n tragus. ICP has been 15-17. Pt was not restrained prior to 7pm and\n found holding NGT at change of shift.\n Action:\n NGT replaced for meds and TFs\n Response:\n stable\n Plan:\n CT scan today\n NVS q 2 hrs\n" }, { "category": "Nursing", "chartdate": "2198-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556536, "text": "28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Altered mental status (not Delirium)\n Assessment:\n Both pupils reactive to light. L pupil sometimes larger then R- not\n new. Pt. opens eyes to voice, follows commands and denies pain by\n shaking head. Vent drain clamped since 12N. ICPs 17-19.\n Action:\n Neuro checks q2hrs.\n Response:\n No change in neuro status except sometimes more sleepy than others.\n Appears to be more responsive with family than staff. See metavision\n for details.\n Plan:\n Continue to monitor ICPs overnight. Page neurosurgery if ICPs >20 for\n more than 5min.\n Tachycardia, Other\n Assessment:\n HR 90s-110s ST, no ectopy noted. BP stable.\n Action:\n Q1hr vital signs.\n Response:\n VSS.\n Plan:\n Continue to monitor VS.\n Hypernatremia (high sodium)\n Assessment:\n Na 147- unchanged.\n Action:\n Free water boluses increased to 250cc q4hrs.\n Response:\n Tolerating TF and water boluses.\n Plan:\n Continue to monitor lytes.\n Mother, father and some friends into visit today.\n" }, { "category": "Nursing", "chartdate": "2198-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556534, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2198-03-04 00:00:00.000", "description": "Intensivist Note", "row_id": 555830, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 1000 mL D5W 3. Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. HydrALAzine 10. Insulin 11. Magnesium Sulfate 12.\n Ondansetron 13. Phenytoin 14. Phenytoin\n 15. Potassium Chloride 16. Potassium Chloride 17. Propofol 18. Senna\n 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:30 AM\n ARTERIAL LINE - STOP 02:26 PM\n CORDIS/INTRODUCER - STOP 10:08 PM\n SPUTUM CULTURE - At 11:07 PM\n FEVER - 101.2\nF - 10:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 09:10 PM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 08:01 AM\n Famotidine (Pepcid) - 08:51 PM\n Dilantin - 04:06 AM\n Other medications:\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.6\nC (99.7\n HR: 99 (99 - 151) bpm\n BP: 116/63(73) {97/46(60) - 155/89(89)} mmHg\n RR: 17 (14 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91 kg (admission): 77.4 kg\n ICP: 18 (8 - 19) mmHg\n Total In:\n 4,781 mL\n 1,333 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,542 mL\n 429 mL\n Blood products:\n 489 mL\n 493 mL\n Total out:\n 1,356 mL\n 936 mL\n Urine:\n 1,173 mL\n 600 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 183 mL\n 86 mL\n Balance:\n 3,425 mL\n 397 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 732 (732 - 732) mL\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 15 cmH2O\n Plateau: 12 cmH2O\n SPO2: 100%\n ABG: 7.55/27/169/23/3\n Ve: 10.9 L/min\n PaO2 / FiO2: 169\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, Non-distended, Non-tender\n Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, Moves Rue and RLE\n spontaneously; LUE withdraws\n Labs / Radiology\n 90 K/uL\n 8.3 g/dL\n 136 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 26 mg/dL\n 122 mEq/L\n 152 mEq/L\n 23.9 %\n 22.9 K/uL\n [image002.jpg]\n 01:44 PM\n 02:50 PM\n 02:56 PM\n 03:53 PM\n 06:03 PM\n 02:05 AM\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n WBC\n 17.3\n 18.0\n 15.4\n 19.0\n 22.9\n Hct\n 29\n 31.4\n 34\n 31\n 28.8\n 24.8\n 25.4\n 23.9\n Plt\n 119\n 121\n 95\n 86\n 90\n Creatinine\n 1.4\n 1.3\n 1.2\n TCO2\n 19\n 20\n 20\n 23\n 24\n Glucose\n 127\n 162\n 140\n 177\n 138\n 136\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Ca:7.5 mg/dL, Mg:2.2\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: Neurologic: s/p tumor resection, sedated, propofol gtt,\n Phenytoin 100 mg IV Q8H, MR within 36 hours, ventriculostomy drain, f/u\n ct head with right convexity SDH 7 mm and interval increased prominence\n right parasagittal frontal lobe edema\n Cardiovascular: Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV\n Q6H:PRN\n Pulmonary: ventilated . Assess neurologic status\n Gastrointestinal / Abdomen: Start TF\n Nutrition: Tube feeding, Start TF\n Renal: Foley, Adequate UO, Free water 21/2 L\n Hematology: 2PRBC\n Endocrine: RISS\n Infectious Disease: Infectious Disease: CefazoLIN 2 g IV Q8H Until\n drain is d/c'd\n Lines / Tubes / Drains: Lines/Tubes/Drains: ETT, trauma line left\n femoral vein, 2 PIV, foley, ventriculostomy drain\n Wounds: Dry dressings\n Imaging: None\n Fluids: D5 50ml/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: CVA, (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:02 AM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2198-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556133, "text": "S/P extubation today.\n Placed on 40% humidified face tent suctioned for thick yellow\n secretions prior to extubation.\n Sats 100%. Ls clear. Occ makes attempt to clear throat.\n Altered mental status (not Delirium)\n Assessment:\n Opens eyes spontaneously. Perrla @.\n Occasionally follows commands by squeezing left hand, slightly wiggles\n toes and make a fist. Will move right hand freely up to face.\n Continuous EEG in place. No SZ activity seen today.\n Vent drain @15 above the tragus. Open, draining ~15-20ml\ns hr of blood\n tinged drainage. ICP\ns 13-18. waveform dampened\n Low grade temp t-max 101.2\n Action:\n Q2hr neuro checks.\n Dilantin as ordered\n Resident aware of temp.\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n" }, { "category": "Nursing", "chartdate": "2198-03-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 556679, "text": "HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n Head CT revealed a left frontal mass with rightward shift of midline\n structures. Neurosurgery and neurology were consulted. Pt receivied\n Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent down for\n MRI.\n Pt initially on MICU service transferred to surgery and subsequently\n returned to SICU s/p emergent crani for tumor resection with removal of\n left frontotemporal region and a ventriculostomy drain placement.\n" }, { "category": "Respiratory ", "chartdate": "2198-03-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555827, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 Comments: Pt continuously \"chews\" on ETT.\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 CT\n 0000\n Transport uneventful\n Bedside Procedures:\n Comments:\n ------ Protected Section ------\n Comments: Pt was breathing with very high MV and overbreathing\n settings. Pt was given propofol after CT trip and MV decreased.\n ------ Protected Section Addendum Entered By: , SRT\n on: 05:21 ------\n" }, { "category": "Nursing", "chartdate": "2198-03-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 556683, "text": "HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n Head CT revealed a left frontal mass with rightward shift of midline\n structures. Neurosurgery and neurology were consulted. Pt receivied\n Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent down for\n MRI.\n Pt initially on MICU service transferred to surgery and subsequently\n returned to SICU s/p emergent crani for tumor resection with removal of\n left frontotemporal region and a ventriculostomy drain placement.\n Altered mental status (not Delirium)\n Assessment:\n More alert today.\n Opens eyes spontaneously. Right pupil 3 brisk, left pupil 4 brisk.\n Follows commands by squeezing left hand slightly, slightly wiggles toe,\n can make a fist and gives high five on the right. Will move right hand\n freely up to face. Left hand moves on bed but weaker.\n No SZ activity seen today.\n Vent drain @20 above the tragus. Clamped ICP\ns 13-18. waveform dampened\n Low grade temp t-max 100.0\n Action:\n Vent drain removed by MD. placed.\n Q2hr neuro checks.\n Dilantin bolus given for a level of 4.8\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n Head ct in am.\n Tylenol for temp.\n Awaiting pathology report.\n" }, { "category": "Respiratory ", "chartdate": "2198-03-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555824, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 Comments: Pt continuously \"chews\" on ETT.\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 CT\n 0000\n Transport uneventful\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2198-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556591, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt with removal of large frontal mass . Neuro status as per\n metavision.\n Action:\n Ventriculostomy drain clamped since yesterday afternoon.\n Response:\n ICP in high teens, occasionally over 20 but not sustained.\n Plan:\n Call team for ICP >20 for more than 5 minutes. For head CT today to\n see if drain can be pulled. ? Transfer to step down.\n" }, { "category": "Nursing", "chartdate": "2198-03-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 556678, "text": "HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n Head CT revealed a left frontal mass with rightward shift of midline\n structures. Neurosurgery and neurology were consulted. Pt receivied\n Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent down for\n MRI.\n Pt initially on MICU service, transferred to surgery and subsequently\n returned to SICU s/p emergent crani for tumor resection with removal of\n left frontotemporal region and a ventriculostomy drain placement.\n Altered mental status (not Delirium)\n Assessment:\n Alert\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2198-03-05 00:00:00.000", "description": "Intensivist Note", "row_id": 556043, "text": "SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n s/p tumor resection\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Bisacodyl 5. CefazoLIN 6.\n Docusate Sodium 7. Famotidine\n 8. HydrALAzine 9. Insulin 10. Magnesium Sulfate 11. Ondansetron 12.\n Phenytoin 13. Potassium Chloride\n 14. Potassium Chloride 15. Potassium Chloride 16. Propofol 17. Senna\n 18. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EEG - At 03:52 PM\n FEVER - 101.2\nF - 11:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 10:37 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:11 PM\n Dilantin - 02:02 AM\n Other medications:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.7\nC (99.9\n HR: 101 (94 - 114) bpm\n BP: 123/68(80) {114/51(66) - 155/95(100)} mmHg\n RR: 19 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 14 (11 - 17) mmHg\n Total In:\n 3,958 mL\n 969 mL\n PO:\n Tube feeding:\n 511 mL\n 438 mL\n IV Fluid:\n 1,194 mL\n 31 mL\n Blood products:\n 1,243 mL\n Total out:\n 3,839 mL\n 582 mL\n Urine:\n 3,100 mL\n 480 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 289 mL\n 102 mL\n Balance:\n 119 mL\n 387 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 478 (285 - 939) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 22\n PIP: 10 cmH2O\n SPO2: 99%\n ABG: ///25/\n Ve: 9.2 L/min\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, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Moves all extremities\n Labs / Radiology\n 102 K/uL\n 10.6 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 116 mEq/L\n 147 mEq/L\n 30.3 %\n 20.9 K/uL\n [image002.jpg]\n 03:53 PM\n 06:03 PM\n 02:05 AM\n 02:19 AM\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n WBC\n 18.0\n 15.4\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n Hct\n 31\n 28.8\n 24.8\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n Plt\n 121\n 95\n 86\n 90\n 81\n 87\n 102\n Creatinine\n 1.4\n 1.3\n 1.2\n 1.0\n 0.9\n 0.8\n TCO2\n 20\n 23\n 24\n Glucose\n 140\n 177\n 138\n 136\n 196\n 122\n 138\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.3 g/dL,\n Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, sedated, wean propofol gtt, 24 hr\n video eeg Phenytoin 100 mg IV Q8, ventriculostomy drain, ct head shows\n evolving infarcts in right ACA\n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: ventilated on PS; RSBI acceptable for extubation. Will give\n trial of extubation. Gas exchange adequate.\n Gastrointestinal / Abdomen: colace/bisacodyl\n Nutrition: Tube feeding, free water 1 L through tube feeds, Replete\n with fiber Full strength\n Renal: UOP Free water 1 L through tube feeds\n Hematology: 2 uPRBC on and 2 uPRBC \n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd ; FU\n femoral line culture\n Lines / Tubes / Drains: ETT, 2 PIV, foley, ventriculostomy drain\n Wounds: head wound c/d/i\n Imaging: fu EEG\n Fluids: KVO\n Consults: neurosurgery, neurology\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:36 PM 70 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:02 AM\n ICP Catheter - 12:25 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "General", "chartdate": "2198-03-06 00:00:00.000", "description": "Generic Note", "row_id": 556279, "text": "TITLE: Bedside Evaluation\n Pt seen for a bedside evaluation and he can start taking nectar\n thick liquids by tsp or cup (no straws) and pureed solids with strict\n supervision. Continue primary nutrition via the NG tube. Please see Web\n OMR or paper chart for additional details.\n , MS, CCC-SLP\n Pager#\n 11:46\n" }, { "category": "Nursing", "chartdate": "2198-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555915, "text": "28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On Wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt received Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Altered mental status (not Delirium)\n Assessment:\n Patient sedated on propofol at being of shift, minimal response noted.\n Propofol stopped. Patient opening eyes spontaneously, will track with\n eyes. Will give weak hand grasp on left ue, right ue will demonstrate\n gross movement of limb, but have noted patient to move bilateral ue\n spontaneously, left > right. Patient will given minimal toe wiggle to\n command. Pupils left at times > right, but reactive to light. Ventric\n remains open at 15cm, draining blood tinged csf. Patient appears to\n continue to have some focal seizure activity.\n Action:\n Sedation to remain off, continue to monitor Neuro Q1 hrly, continue to\n monitor icp and drainage. Patient to have 24hr continuous EEg to\n monitor for seizure activity.\n Response:\n Patient more alert, follow simple commands at time of report, however\n inconsistently at times.\n Plan:\n Will monitor for seizure activity, continue to monitor neuro status.\n Report any changes to team.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Patient has low grade temp.\n Action:\n Pulmonary toileting maintained, labs monitored. Monitor vital signs;\n continue with iv antibiotics as ordered.\n Response:\n Continues to have low grade temps.\n Plan:\n To continue to monitor and treat accordingly. Await culture results\n Tachycardia, Other\n Assessment:\n Patient in st 98-110 bpm\n Action:\n Patient had blood transfusion per ordered. Monitor for agitation. Iv\n antibiotics given as ordered. Monitor labs electrolytes\n Response:\n Hr 90\ns-100\n Plan:\n Will continue to monitor and treat accordingly\n Hypernatremia (high sodium)\n Assessment:\n Patient last sodium level within parameters\n Action:\n Continue with free water as tolerated. Monitor labs in am\n Response:\n Levels within parameters\n Plan:\n Will continue with free water bolus 250cc Q6, monitor labs in am.\n" }, { "category": "Respiratory ", "chartdate": "2198-03-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 555920, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 91.6 None\n Ideal tidal volume: 366.4 / 549.6 / 732.8 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: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\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 Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt remains on mechanical ventilation weaned to PSV 5/5 2 40%.\n Tolerating well at present There have been few if any secretions; he\n has had movement everywhere and If he wakes up more EXTUBATION is\n possible !\n, RRT 16:43\n" }, { "category": "Physician ", "chartdate": "2198-03-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 555392, "text": "Chief Complaint:\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n .\n In the ED, initial vs were: T 97.6 P 125 BP 140/85 RR 16 O2 Sats 99% on\n RA. Initial labs revealed a significant hypernatremia with Na 168 and\n Endocrine was consulted. They recommended slow correction with D5\n 1/2NS at 200cc/hr (he was correcting at 1meq/hr in ED). He underwent a\n head CT that revealed a left frontal mass with rightward shift of\n midline structures. Neurosurgery and neurology were consulted. Pt\n receivied Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent\n down for MRI. However, pt was noted to be altered and unable to follow\n commands and the MRI was not completed.\n .\n On arrival to the SICU, pt was obtunded and not following commands. He\n withdraws to pain and will respond to noxious stimuli. Pt was noted to\n have some spontaneous purposeful movements. Neuro & Neurosurg were\n called to re-evaluate.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n none\n Past medical history:\n Family history:\n Social History:\n Hypertension\n s/p patellar tendon repair\n multiple family members with various cancers, including prostate, lung\n ca & cerebral tumor (age >80)\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Denies smoking & illicit drug use, reports occaisional social\n drinking. Pt lives alone in and was recently laid off from\n work.\n Review of systems:\n Flowsheet Data as of 05:02 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 80 (75 - 85) bpm\n BP: 126/70(82) {126/67(82) - 135/73(86)} mmHg\n RR: 14 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 140 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -140 mL\n Respiratory\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 197 K/uL\n 14.4 g/dL\n 155 mg/dL\n 1.4 mg/dL\n 44 mg/dL\n 26 mEq/L\n 130 mEq/L\n 3.8 mEq/L\n 164 mEq/L\n 43.5 %\n 15.2 K/uL\n [image002.jpg]\n \n 2:33 A2/6/ 03:11 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 15.2\n Hct\n 43.5\n Plt\n 197\n Cr\n 1.4\n Glucose\n 155\n Other labs: PT / PTT / INR:15.9/28.4/1.4, ALT / AST:84/44, Alk Phos / T\n Bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Lactic Acid:1.8 mmol/L, Ca++:8.8 mg/dL, Mg++:2.7 mg/dL, PO4:3.2\n mg/dL\n Imaging: CT head : large ill defined low attenuation mass in the\n left frontal lobe with associated mass effect resulting in significant\n right shift of normally mildline structures, effacement of the\n left lateral ventricle, entrapment of the right lateral ventricle and\n loss of the supersellar cistern suggestive of some downward herniation.\n no hemmorhage. findings worrisome for primary brain\n neoplasm. recommend MRI for further evaluation.\n Assessment and Plan\n 28 y/o M with HTN who presents with MS changes, Hypernatremia and found\n to have intracranial mass.\n .\n # Mental Status changes: Etiology unclear, multiple possible\n etiologies. Pt remains significantly hypernatremic and Na correcting\n very slowly (0.5meq /hr). Exam not suggestive of herniation but\n worsened cerebral edema may be contributing. It is possible that pt is\n having non-convulsive seizures, though no e/o seizure activity to date.\n Pt not following commands, though having some purposeful movements\n -stat head CT\n -strict aspiration precautions\n -f/u TSH, dilantin level\n -f/u am EEG\n -f/u neuro & neuro recs\n -proceed with very slow Na correction\n -proceed with MRI (may need intubation)\n .\n # Intracranial Mass: Pt with left sided frontal mass and associated\n midline shift. Suspect primary brain neoplasm though unclear\n currently. Pt will need MRI for further elucidation and may need to be\n intubated for procedure.\n - stat head CT\n - continue Decadron 4mg IV q 6hrs\n - f/u dilantin level and start Dilantin 100mg po TID\n - apprec Neurosurg/Neuro recs\n - q1hr neuro checks\n - NPO with aspiration precautions\n - social work consult\n .\n # Hypernatremia:\n - f/u stat labs\n - f/u q2hr Na\n - slow correction with D5 1/2NS at 100cc/hr\n - goal Na 150 per neurosurg\n .\n # Hypertension: normotensive currently, will monitor for now\n .\n # FEN: NPO with IVF\n - replete electrolytes\n .\n # Prophylaxis: Heparin sc tid\n .\n # Access: PIVx2\n .\n # Code: FULL\n .\n # Communication: family & patient\n ICU Care\n Nutrition: NPO on IVF\n Glycemic Control: none\n Lines:\n 18 Gauge - 03:02 AM\n 20 Gauge - 03:02 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: with family\n Code status: Full code\n Disposition: ICU\n" }, { "category": "General", "chartdate": "2198-03-08 00:00:00.000", "description": "Generic Note", "row_id": 556636, "text": "TITLE:\n SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n confusion\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Senna 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n : admit from OR\n : 2 units of PRBC\n : extubated, tube feeds started, cont EEG\n : speech/swallow study\n : EVD clamped, CT improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Dilantin - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:19 AM\n Other medications:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.8\n HR: 101 (87 - 112) bpm\n BP: 112/86(92) {94/62(75) - 142/86(94)} mmHg\n RR: 23 (15 - 28) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 15 (3 - 19) mmHg\n Total In:\n 3,256 mL\n 1,152 mL\n PO:\n Tube feeding:\n 1,690 mL\n 552 mL\n IV Fluid:\n 505 mL\n 100 mL\n Blood products:\n Total out:\n 3,400 mL\n 635 mL\n Urine:\n 3,310 mL\n 635 mL\n NG:\n Stool:\n Drains:\n 90 mL\n Balance:\n -144 mL\n 517 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n NAD, following commands, tracks, still mostly non-verbal\n RRR\n CTA b/l\n soft, NT, ND\n no edema\n Labs / Radiology\n 320 K/uL\n 11.8 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 145 mEq/L\n 33.1 %\n 20.5 K/uL\n [image002.jpg]\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n 02:41 AM\n 03:15 AM\n WBC\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n 15.3\n 20.5\n Hct\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n 33.1\n 33.1\n Plt\n 86\n 90\n 81\n 87\n 102\n 183\n 244\n 320\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 24\n 29\n Glucose\n 136\n 196\n 122\n 138\n 113\n 106\n 111\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:3.1 g/dL,\n Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg, Phenytoin 150 mg IV\n Q8, ventriculostomy drain to 20, ct head shows evolving infarcts in\n right ACA, mental status improved (following commands), CT head \n evolving aca and mca infarcts, clamped drain, dilantin load \n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: stable\n Gastrointestinal / Abdomen: bowel regimen. NGT.\n Nutrition: speech/swallow (Suggest pt continue to receive primary\n means of nutrition via the NG in place. Start taking small amounts of\n nectar thick liquids and pureed solids), Free water 1 L through tube\n feeds, Replete with fiber Full strength.\n Renal: UOP adequate, treating hypernatremia with free water\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: Other: brain tumor\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:35 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 12:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2198-03-08 00:00:00.000", "description": "ICU intensivist note", "row_id": 556637, "text": "TITLE:\n SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n confusion\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Senna 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n : admit from OR\n : 2 units of PRBC\n : extubated, tube feeds started, cont EEG\n : speech/swallow study\n : EVD clamped, CT improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Dilantin - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:19 AM\n Other medications:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.8\n HR: 101 (87 - 112) bpm\n BP: 112/86(92) {94/62(75) - 142/86(94)} mmHg\n RR: 23 (15 - 28) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 15 (3 - 19) mmHg\n Total In:\n 3,256 mL\n 1,152 mL\n PO:\n Tube feeding:\n 1,690 mL\n 552 mL\n IV Fluid:\n 505 mL\n 100 mL\n Blood products:\n Total out:\n 3,400 mL\n 635 mL\n Urine:\n 3,310 mL\n 635 mL\n NG:\n Stool:\n Drains:\n 90 mL\n Balance:\n -144 mL\n 517 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n NAD, following commands, tracks, still mostly non-verbal\n RRR\n CTA b/l\n soft, NT, ND\n no edema\n Labs / Radiology\n 320 K/uL\n 11.8 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 145 mEq/L\n 33.1 %\n 20.5 K/uL\n [image002.jpg]\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n 02:41 AM\n 03:15 AM\n WBC\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n 15.3\n 20.5\n Hct\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n 33.1\n 33.1\n Plt\n 86\n 90\n 81\n 87\n 102\n 183\n 244\n 320\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 24\n 29\n Glucose\n 136\n 196\n 122\n 138\n 113\n 106\n 111\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:3.1 g/dL,\n Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg, Phenytoin 150 mg IV\n Q8, ventriculostomy drain to 20, ct head shows evolving infarcts in\n right ACA, mental status improved (following commands), CT head \n evolving aca and mca infarcts, clamped drain, dilantin load \n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: stable\n Gastrointestinal / Abdomen: bowel regimen. NGT.\n Nutrition: speech/swallow (Suggest pt continue to receive primary\n means of nutrition via the NG in place. Start taking small amounts of\n nectar thick liquids and pureed solids), Free water 1 L through tube\n feeds, Replete with fiber Full strength.\n Renal: UOP adequate, treating hypernatremia with free water\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: Other: brain tumor\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:35 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 12:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2198-03-08 00:00:00.000", "description": "ICU intensivist note", "row_id": 556643, "text": "TITLE:\n SICU\n HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n In the ED hemodynamically stable. Na 168 and Endocrine was consulted.\n They recommended slow correction with D5 1/2NS at 200cc/hr (he was\n correcting at 1meq/hr in ED). Head CT that revealed a left frontal mass\n with rightward shift of midline structures. Neurosurgery and neurology\n were consulted. Pt receivied Decadron 10mg IV x 1, Dilantin 1 gram load\n and pt was sent down for MRI. However, pt was noted to be altered and\n unable to follow commands and the MRI was not completed.\n Pt initially on MICU service. Pt transferred to surgery and\n subsequently returned to SICU s/p s/p emergent crani for tumor\n resection with removal of left frontotemporal region and a\n ventriculostomy drain was placed.\n Chief complaint:\n confusion\n PMHx:\n htn, but not currently a problem per mother\n medications:\n 1. 2. 500 mL D5W 3. Acetaminophen 4. Artificial Tears 5. Bisacodyl 6.\n CefazoLIN 7. Docusate Sodium\n 8. Famotidine 9. Heparin 10. HydrALAzine 11. Insulin 12. Magnesium\n Sulfate 13. Ondansetron 14. Phenytoin\n 15. Senna 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n : admit from OR\n : 2 units of PRBC\n : extubated, tube feeds started, cont EEG\n : speech/swallow study\n : EVD clamped, CT improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Dilantin - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:19 AM\n Other medications:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.8\n HR: 101 (87 - 112) bpm\n BP: 112/86(92) {94/62(75) - 142/86(94)} mmHg\n RR: 23 (15 - 28) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 77.4 kg\n Height: 76 Inch\n ICP: 15 (3 - 19) mmHg\n Total In:\n 3,256 mL\n 1,152 mL\n PO:\n Tube feeding:\n 1,690 mL\n 552 mL\n IV Fluid:\n 505 mL\n 100 mL\n Blood products:\n Total out:\n 3,400 mL\n 635 mL\n Urine:\n 3,310 mL\n 635 mL\n NG:\n Stool:\n Drains:\n 90 mL\n Balance:\n -144 mL\n 517 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n NAD, following commands, tracks, still mostly non-verbal\n RRR\n CTA b/l\n soft, NT, ND\n no edema\n Labs / Radiology\n 320 K/uL\n 11.8 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 145 mEq/L\n 33.1 %\n 20.5 K/uL\n [image002.jpg]\n 10:58 AM\n 08:58 PM\n 10:58 PM\n 06:15 AM\n 08:13 PM\n 02:41 AM\n 05:13 PM\n 02:27 AM\n 02:41 AM\n 03:15 AM\n WBC\n 19.0\n 22.9\n 21.0\n 22.3\n 20.9\n 15.0\n 15.3\n 20.5\n Hct\n 25.4\n 23.9\n 23.8\n 28.0\n 30.3\n 30.8\n 33.1\n 33.1\n Plt\n 86\n 90\n 81\n 87\n 102\n 183\n 244\n 320\n Creatinine\n 1.2\n 1.0\n 0.9\n 0.8\n 0.8\n 0.7\n 0.7\n TCO2\n 24\n 29\n Glucose\n 136\n 196\n 122\n 138\n 113\n 106\n 111\n Other labs: PT / PTT / INR:14.6/27.4/1.3, ALT / AST:84/44, Alk-Phos / T\n bili:49/, Differential-Neuts:90.7 %, Lymph:6.5 %, Mono:2.3 %, Eos:0.2\n %, Fibrinogen:185 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:3.1 g/dL,\n Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), FEVER (HYPERTHERMIA, PYREXIA, NOT\n FEVER OF UNKNOWN ORIGIN), TACHYCARDIA, OTHER, HYPERNATREMIA (HIGH\n SODIUM), HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n Assessment and Plan: 28M w/ subacute/acute AMS. Hypernatremia to 168.\n s/p emergent crani for tumor resection .\n Neurologic: s/p tumor resection, 24 hr video eeg, Phenytoin 150 mg IV\n Q8, ventriculostomy drain to 20, ct head shows evolving infarcts in\n right ACA, mental status improved (following commands), CT head \n evolving aca and mca infarcts, clamped drain, dilantin load \n Cardiovascular: Goal SBP <140, HydrALAzine 10 mg IV Q6H:PRN\n Pulmonary: stable\n Gastrointestinal / Abdomen: bowel regimen. NGT.\n Nutrition: speech/swallow (Suggest pt continue to receive primary\n means of nutrition via the NG in place. Start taking small amounts of\n nectar thick liquids and pureed solids), Free water 1 L through tube\n feeds, Replete with fiber Full strength.\n Renal: UOP adequate, treating hypernatremia with free water\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: CefazoLIN 2 g IV Q8H Until drain is d/c'd\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: Other: brain tumor\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:35 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 12:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2198-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556123, "text": "S/P extubation today.\n Placed on 40% humidified face tent suctioned for thick yellow\n secretions prior to extubation.\n Sats 100%. Ls clear. Occ makes attempt to clear throat.\n Altered mental status (not Delirium)\n Assessment:\n Opens eyes spontaneously. Perrla @.\n Occasionally follows commands by squeezing left hand, slightly wiggles\n toes and make a fist. Will move right hand freely up to face.\n Continuous EEG in place. No SZ activity seen today.\n Vent drain @15 above the tragus. Open, draining ~15-20ml\ns hr of blood\n tinged drainage. ICP\ns 13-18. waveform dampened\n Low grade temp t-max 101.2\n Action:\n Q2hr neuro checks.\n Dilantin as ordered\n Resident aware of temp.\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n" }, { "category": "Nursing", "chartdate": "2198-03-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 556723, "text": "HPI:\n 28 y/o M with PMHx of HTN was brought in to the ED by his family after\n he was noticed to have unusual behaviour over wks. Per report, pt\n has not been eating or drinking for 4 days and has been having\n delusions. On wednesday, pt drove to and abandoned family\n car. He called his family who came to get him and brought him into the\n ED for evaluation. On arrival, pt was disoriented but denied any SI or\n HI.\n Head CT revealed a left frontal mass with rightward shift of midline\n structures. Neurosurgery and neurology were consulted. Pt receivied\n Decadron 10mg IV x 1, Dilantin 1 gram load and pt was sent down for\n MRI.\n Pt initially on MICU service transferred to surgery and subsequently\n returned to SICU s/p emergent crani for tumor resection with removal of\n left frontotemporal region and a ventriculostomy drain placement.\n Altered mental status (not Delirium)\n Assessment:\n More alert today.\n Opens eyes spontaneously. Right pupil 3 brisk, left pupil 4 brisk.\n Follows commands by squeezing left hand slightly, slightly wiggles toe,\n can make a fist and gives high five on the right. Will move right hand\n freely up to face. Left hand moves on bed but weaker.\n No SZ activity seen today.\n Vent drain @20 above the tragus. Clamped ICP\ns 13-18. waveform dampened\n Low grade temp t-max 100.0\n Action:\n Vent drain removed by MD. placed.\n Q2hr neuro checks.\n Dilantin bolus given for a level of 4.8\n Response:\n Neuro status remains unchanged.\n Plan:\n Continue Q2 hr neuro checks.\n Monitor for signs of sz activity.\n Head ct in am.\n Tylenol for temp.\n Awaiting pathology report.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Code status:\n Height:\n 76 Inch\n Admission weight:\n 77.4 kg\n Daily weight:\n 91 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: Patellar tendon repair\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:72\n Temperature:\n 99.9\n Arterial BP:\n S:116\n D:66\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 40% %\n 24h total in:\n 2,185 mL\n 24h total out:\n 2,115 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:15 AM\n Potassium:\n 3.7 mEq/L\n 03:15 AM\n Chloride:\n 109 mEq/L\n 03:15 AM\n CO2:\n 27 mEq/L\n 03:15 AM\n BUN:\n 14 mg/dL\n 03:15 AM\n Creatinine:\n 0.7 mg/dL\n 03:15 AM\n Glucose:\n 111 mg/dL\n 03:15 AM\n Hematocrit:\n 33.1 %\n 03:15 AM\n Finger Stick Glucose:\n 126\n 04:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 1119\n Date & time of Transfer: 21:00 PM\n" }, { "category": "Radiology", "chartdate": "2198-03-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1064072, "text": " 2:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pt bleeding from head incision. ? bleeding in head? infectio\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with craniectomy- piece of skull missing.\n REASON FOR THIS EXAMINATION:\n pt bleeding from head incision. ? bleeding in head? infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe SUN 6:51 AM\n PFI: Significantly increased low density fluid collection (similar to CSF)\n around the left surgical site and deep to the superficial scalp tissues.\n Right-sided subdural hematoma, which now appears chronic, is also increased\n measuring up to 9 mm from the inner table resulting in significantly increased\n leftward subfalcine herniation of approximately 16 mm and increased mass\n effect noted on the right lateral ventricle. No new regions of intracranial\n hemorrhage are identified with mild residual blood noted along the surgical\n site and near residual tumor. Involutional changes of prior ACA and inferior\n division left MCA infarcts continue.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post surgical resection with bleeding from head incision.\n\n Comparison is made to and CT exams and , MRI.\n\n NON-CONTRAST HEAD CT.\n\n No new regions of acute intracranial hemorrhage are identified with mild\n residual hyperdense blood products noted along the left frontoparietal\n craniectomy site and around the residual tumor at the floor of the anterior\n cranial fossa. Low attenuation right-sided subdural hematoma does appear to\n have increased in size, now approximately 9 mm from the inner table resulting\n in more mass effect on the adjacent sulci and new 16 mm leftward subfalcine\n herniation. The degree of mass effect on the basilar cisterns is stable with\n continued effacement of the right and left ambient cisterns likely relating to\n some degree of uncal herniation. The size of the ventricles is slightly\n increased status post removal of ventriculostomy catheter with increased mass\n effect noted on the right ventricular system. Degree of hypoattenuation\n within the paramedian frontal lobes appears increased from most recent exam\n which likely represents a continued evolution of known infarcts. Similar\n changes are also noted involving the left frontal lobe from prior inferior\n left MCA division infarct. Paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Significant accumulation of low-density fluid collection within the\n subcutaneous tissues abutting the craniectomy site. No new regions of\n intracranial hemorrhage are identified.\n 2. Low attenuating subacute to chronic right subdural hematoma does appear to\n have increased in size from prior exam as described above resulting in\n increased mass effect on the right and new marked worsening of leftward\n (Over)\n\n 2:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pt bleeding from head incision. ? bleeding in head? infectio\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n subfalcine herniation.\n 3. Continued involutional changes from prior ACA infarct and left MCA\n infarct.\n\n These findings were discussed with caring clinical team member \n shortly after exam acquisition at 3:30 a.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1064073, "text": ", NSURG FA11 2:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pt bleeding from head incision. ? bleeding in head? infectio\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with craniectomy- piece of skull missing.\n REASON FOR THIS EXAMINATION:\n pt bleeding from head incision. ? bleeding in head? infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Significantly increased low density fluid collection (similar to CSF)\n around the left surgical site and deep to the superficial scalp tissues.\n Right-sided subdural hematoma, which now appears chronic, is also increased\n measuring up to 9 mm from the inner table resulting in significantly increased\n leftward subfalcine herniation of approximately 16 mm and increased mass\n effect noted on the right lateral ventricle. No new regions of intracranial\n hemorrhage are identified with mild residual blood noted along the surgical\n site and near residual tumor. Involutional changes of prior ACA and inferior\n division left MCA infarcts continue.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061649, "text": " 9:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with difficulty extubating\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Difficulty extubating.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 4.4 cm above the carina. The NG tube tip passes below the\n diaphragm with its tip being obscured by the shielding. Cardiomediastinal\n silhouette is stable. Questionable right lower lobe opacity is seen although\n it might be projectional due to suboptimal technique of the study. Repeated\n radiograph is recommended including the entire right chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1061287, "text": " 4:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: INterval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p craniotomy\n REASON FOR THIS EXAMINATION:\n INterval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 8:17 PM\n PFI: Expected post-surgical change with interval decrease in mass effect.\n Persistent entrapment of the right temporal . Small post-surgical area of\n hemorrhage in the left inferior frontal lobe.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old male status post craniotomy. Evaluate for interval\n change.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: CT from earlier today at 5 a.m.\n\n FINDINGS: The patient is status post right frontotemporal craniectomy with a\n large postoperative cavity in the left frontal to temporal lobe. There is a\n small amount of hemorrhage in the inferior left frontal lobe as well as an\n expected amount of pneumocephalus. There has been interval decrease in\n rightward shift of normally midline structures, which is approximately 5 mm on\n the current study. There is persistent mass effect on the left lateral\n ventricle and trapping of the right temporal . There is interval decrease\n in the subfalcine herniation and effacement of the suprasellar cistern. There\n is suspected postoperative scalp hematoma.There has been interval development\n of intraventricular hemorrhage, likely related to surgery. There is an\n expected postoperative scalp hematoma. There is mild mucosal thickening in the\n paranasal sinuses. The mastoid air cells are well aerated.\n\n IMPRESSION: Status post left frontotemporal craniectomy with expected post-\n surgical change. Interval decrease in mass effect with persistent entrapment\n of the right lateral ventricle. Interval development of intraventricular\n hemorrhage and inferior left frontal lobe hemorrhage, likely related to\n surgery. Please note, this study does not evaluate for residual neoplasm.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-03 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1061367, "text": " 8:35 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please eval for mass residual ****Please do within 36 hrs **\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with mass resection\n REASON FOR THIS EXAMINATION:\n please eval for mass residual ****Please do within 36 hrs ******\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 11:54 AM\n Status post resection of a frontal lobe mass. New right anterior cerebral\n artery and left temporal lobe infarcts are identified. Blood products are\n seen at the surgical site. Enhancement has considerably decreased but\n residual enhancement is difficult to assess in absence of T1 spin echo images.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with status post resection of a mass.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. MP-RAGE sagittal images were\n acquired following gadolinium. Comparison was made with the previous MRI of\n .\n\n FINDINGS: Since the previous study the patient has undergone resection of a\n large bifrontal mass. Left frontal craniotomy is identified. Blood products\n are seen in the region of resection. On the diffusion images there are no new\n infarcts identified in the right anterior cerebral artery territory along the\n midline and also in the left temporal region in the left middle cerebral\n artery territory including involvement of the left temporal lobe. At the site\n of surgical resection blood products are seen with surgical cavity. Residual\n enhancement is difficult to judge secondary to absence of spin echo T1 post-\n gadolinium images. Some enhancement is seen at the margin which appears\n meningeal enhancement. Further followup can help for assessment of residual\n lesion. Mass along the right side of the midline and involving the corpus\n callosum appears unchanged. Since the previous study there is now blood\n products seen in the ventricles and a right ventricular drain is identified\n extending to the right lateral ventricle. The ventricular size has decreased.\n\n IMPRESSION: Status post resection of a frontal lobe mass. Residual mass is\n identified to the right of midline. There is new infarct seen in the right\n anterior cerebral artery region along the midline frontal lobe and also in the\n left temporal region. Blood products are seen at the surgical site. Residual\n enhancement is difficult to assess in absence of post- gadolinium T1 images\n but appears much decreased since the previous study.\n\n\n (Over)\n\n 8:35 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please eval for mass residual ****Please do within 36 hrs **\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2198-03-03 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1061368, "text": ", MED SICU-A 8:35 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please eval for mass residual ****Please do within 36 hrs **\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with mass resection\n REASON FOR THIS EXAMINATION:\n please eval for mass residual ****Please do within 36 hrs ******\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Status post resection of a frontal lobe mass. New right anterior cerebral\n artery and left temporal lobe infarcts are identified. Blood products are\n seen at the surgical site. Enhancement has considerably decreased but\n residual enhancement is difficult to assess in absence of T1 spin echo images.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1061108, "text": " 7:31 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with new brain tumor\n REASON FOR THIS EXAMINATION:\n please evaluate\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 12:10 PM\n Large bifrontal mass with involvement of corpus callosum identified\n demonstrating subtle areas of blood products. Obstruction to the right\n lateral ventricle with periventricular edema is seen.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with new brain tumor.\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 were obtained following gadolinium. Correlation was made with CT of\n .\n\n FINDINGS: There is a large frontal irregularly enhancing mass identified\n extending across the midline to the opposite cerebral hemisphere and\n involvement of the corpus callosum and subependymal region of both lateral\n ventricles. There is midline shift seen. There is dilatation of the right\n lateral ventricle with mild periventricular edema. The basal cisterns remain\n patent. No other areas of abnormal enhancement are seen within the brain or\n extra-axial region.\n\n IMPRESSION: Large bifrontal mass involving the corpus callosum with dilated\n right lateral ventricle secondary to obstruction. The appearances are\n suggestive of a neoplasm such as glioma or less likely lymphoma. Mild soft\n tissue changes are seen in the right frontal and left maxillary sinuses. The\n mass measures approximately 7 cm in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1061109, "text": ", F. MED SICU-A 7:31 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with new brain tumor\n REASON FOR THIS EXAMINATION:\n please evaluate\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Large bifrontal mass with involvement of corpus callosum identified\n demonstrating subtle areas of blood products. Obstruction to the right\n lateral ventricle with periventricular edema is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1064193, "text": " 1:30 AM\n CHEST (PA & LAT) Clip # \n Reason: pna?\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with fever\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr MON 1:07 PM\n Normal chest radiograph.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man with fever.\n\n No comparison is available.\n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: The cardiomediastinal silhouette and\n hilar contours are normal. The lungs are clear with no focal consolidation,\n pleural effusion or pneumothorax. The overlying soft tissue and osseous\n structures appear unremarkable.\n\n IMPRESSION: Normal chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1064299, "text": " 1:02 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: evaluate for dvt / prolonged bedrest wh low grade temps x 2\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bifrontal mass resection\n REASON FOR THIS EXAMINATION:\n evaluate for dvt / prolonged bedrest wh low grade temps x 2 days without\n obvious source\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TPKb MON 8:06 PM\n No evidence of left or right lower extremity deep venous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 28-year-old man with bifrontal mass resection with low-\n grade temperatures for two days without obvious source.\n\n COMPARISON: .\n\n FINDINGS: There is normal augmentation, compression and respiratory\n variability in the left and right common femoral vein. There is normal\n compressibility and augmentation in the left and right superficial femoral and\n popliteal veins. There is normal color flow and compressibility in the left\n and right posterior tibial and peroneal veins.\n\n IMPRESSION:\n\n 1. No evidence of left or right lower extremity deep venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1064300, "text": ", NSURG FA11 1:02 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: evaluate for dvt / prolonged bedrest wh low grade temps x 2\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bifrontal mass resection\n REASON FOR THIS EXAMINATION:\n evaluate for dvt / prolonged bedrest wh low grade temps x 2 days without\n obvious source\n ______________________________________________________________________________\n PFI REPORT\n No evidence of left or right lower extremity deep venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1064194, "text": ", NSURG FA11 1:30 AM\n CHEST (PA & LAT) Clip # \n Reason: pna?\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with fever\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n PFI REPORT\n Normal chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061393, "text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check position og NG\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with Brain mass s/p excision\n REASON FOR THIS EXAMINATION:\n check position og NG\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON , 11:03\n\n INDICATION: NGT placement.\n\n Compared to the prior film an NG tube has been placed and its tip cannot be\n localized as the tube extends beyond the confines of the film; it is clearly\n below the left hemidiaphragm. The lungs remain clear.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1061288, "text": ", MED SICU-A 4:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: INterval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p craniotomy\n REASON FOR THIS EXAMINATION:\n INterval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Expected post-surgical change with interval decrease in mass effect.\n Persistent entrapment of the right temporal . Small post-surgical area of\n hemorrhage in the left inferior frontal lobe.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1064432, "text": " 5:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess change in subgaleal collection ****Please do b\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p tumor rsection\n REASON FOR THIS EXAMINATION:\n please assess change in subgaleal collection ****Please do by 6a********\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe TUE 6:52 AM\n 2 new small regions of IPH in the inferior rt frontal lobe. Subgaleal\n collection minimally enlarged (approx 3mm bigger) study otherwise stable\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for interval changes of subgaleal collection.\n\n TECHNIQUE: NON CONTRAST CT HEAD\n\n COMPARISON; CT HEAD DONE ON \n\n FINDINGS:\n\n The low attenuation left subgaleal collection is minimally increased in size,\n for example, when measured at the same level, previously measured\n approximately 27 mm and currently measures approximately 30 mm. Additionally,\n new on today's exam are scattered small regions of intraparenchymal hemorrhage\n within the inferior right frontal lobe measuring 5 x 10 mm and 11 x 11 mm.\n Additional regions of linear hyperdensity along the left cerebral convexity\n and at the base of the anterior cranial fossa are not significantly changed.\n Effacement of ambient cisterns on both sides relating to uncal herniation is\n unchanged. Regions of hypoattenuation from prior infarcts involving the\n inferior frontal lobes and left temporal lobe is also stable as is the degree\n of leftward subfalcine herniation which measures approximately 15 mm on\n today's exam. Chronic appearing right-sided subdural hematoma is also not\n significantly changed from prior exam. Bony structures and paranasal sinuses\n are stable in appearance.\n\n IMPRESSION:\n\n 2 new foci of acute intraparenchymal hemorrhage in the rt. frontal lobe. Other\n findings unchanged compred to the most recent CT as described above with\n subfalcine and uncal henriation. Close follow up as clinically indicated.\n\n These findings were discussed with the neurosurgical resident who has\n signed into Dr. pager at approximately 7:00 a.m. on date of exam.\n\n\n\n\n\n (Over)\n\n 5:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess change in subgaleal collection ****Please do b\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2198-03-29 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1066257, "text": " 4:09 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with brain cancer s/p resection and complicated by CVA\n REASON FOR THIS EXAMINATION:\n assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT FRI 11:35 AM\n IMPRESSION: Overall complex appearance, representing a combination of\n residual and progressive high-grade infiltrating neoplasm with marked\n associated vasogenic edema, post-surgical change and superimposed\n post-operative extensive acute infarction, with:\n\n 1. Enlarging left frontotemporoparietal scalp subgaleal hemorrhagic\n collection.\n\n 2. Allowing for differences in modality and scan angulation probable\n worsening further brain herniation through the large surgical defect.\n\n 3. Severe mass effect with 15 mm subfalcine herniation, also probably\n slightly worse, and similar effacement of the right and trapping of the left\n lateral ventricle. No further uncal herniation or effacement of the basilar\n cisterns to indicate further downward transtentorial herniation.\n\n 3. Relatively small more acutely hemorrhagic focus in the right frontal lobe,\n with no additional, as on the recent CT, with no additional hemorrhagic focus\n identified, and no further acute infarction.\n ______________________________________________________________________________\n FINAL REPORT\n MR EXAMINATION OF THE BRAIN WITH CONTRAST \n\n HISTORY: 28-year-old man with \"brain cancer\" status post resection,\n complicated by CVA; assess for interval change.\n\n TECHNIQUE: Routine enhanced MR examination, including T1-weighted axial\n SE and sagittal MP-RAGE sequences, post-gadolinium, the latter with coronal\n and axial reformations. Note that, according to the technologist's note, \"the\n patient was very confused and moving his head. Best exam possible\"; in\n particular, the axial and sagittal T1-weighted SE and axial FLAIR FSE\n sequences were significantly motion-degraded and were repeated.\n\n FINDINGS: The study is compared with a series of recent examinations,\n including the pre- and post-operative enhanced MR examinations of and ,\n and the most recent NECT of . The patient is status post extensive\n left frontotemporoparietal craniectomy and, as on recent examinations, there\n is a very large left scalp subgaleal complex fluid collection with large\n amount of layering debris and blood products. Allowing for difference in\n modality and scan angulation, this crescentic collection appears larger, now\n (Over)\n\n 4:09 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n measuring maximally 15.4 (AP) x 4.2 cm (TRV), versus 12.7 x 2.8, respectively,\n on the most recent study.\n\n Allowing for technical differences and the limitations above, there may also\n be further herniation of the underlying brain through the large skull defect.\n The further mass effect is largely due to the extensive enhancing process\n involving the medial aspect of both frontal lobes at the margins of the\n resection cavity, extending to the much of the anterior left temporal lobe.\n This borders the anterior lobectomy cavity, involving the entirety of the\n splenium of the corpus callosum and subjacent deep matter and extends\n along the septum pellucidum, with associated extensive vasogenic edema. It is\n difficult to weigh the contribution of the superimposed extensive right ACA\n territorial and left temporoparietal infarction, likely exhibiting central\n enhancement, given its time-course. The combination of these factors results\n in marked, 15 mm leftward shift of the septum pellucidum, effacement of the\n right and dilatation of the components of the left lateral ventricle, likely\n related to trapping at the level of the foramen of . However, there is\n no further uncal or downward transtentorial herniation, with the basal\n cisterns preserved.\n\n Allowing for the postoperative changes, above, there is no new focus of\n restricted diffusion to indicate additional acute infarction with single\n rounded 12.5 mm focus of bright diffusion signal in the mid-right frontal\n region demonstrating a \"blooming\" rim on GRE sequence, corresponding to the\n round hemorrhagic focus in this region, as on the recent CT. Other than this\n site, as well as small amount of blood products along previous ventriculostomy\n tract, no new hemorrhage is identified. Incidentally noted is extensive fluid-\n opacification of the mastoid air cells, bilaterally, likely related to\n protracted intubation and supine positioning.\n\n IMPRESSION: Overall complex appearance, representing a combination of\n residual and progressive high-grade infiltrating neoplasm with marked\n associated vasogenic edema, post-surgical change and superimposed post-\n operative extensive acute infarction, with:\n\n 1. Enlarging left frontotemporoparietal scalp subgaleal hemorrhagic\n collection.\n\n 2. Allowing for differences in modality and scan angulation, probable\n worsening further brain herniation through the large surgical defect.\n\n 3. Severe mass effect with 15 mm subfalcine herniation, also probably\n slightly worse, and similar effacement of the right and trapping of the left\n lateral ventricle. No further uncal herniation or effacement of the basilar\n cisterns to indicate further downward transtentorial herniation.\n (Over)\n\n 4:09 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Relatively small more acutely hemorrhagic focus in the right frontal lobe,\n as on the recent CT, with no additional hemorrhagic focus identified, and no\n further acute infarction.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-29 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1066258, "text": ", NSURG 7S 4:09 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with brain cancer s/p resection and complicated by CVA\n REASON FOR THIS EXAMINATION:\n assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION: Overall complex appearance, representing a combination of\n residual and progressive high-grade infiltrating neoplasm with marked\n associated vasogenic edema, post-surgical change and superimposed\n post-operative extensive acute infarction, with:\n\n 1. Enlarging left frontotemporoparietal scalp subgaleal hemorrhagic\n collection.\n\n 2. Allowing for differences in modality and scan angulation probable\n worsening further brain herniation through the large surgical defect.\n\n 3. Severe mass effect with 15 mm subfalcine herniation, also probably\n slightly worse, and similar effacement of the right and trapping of the left\n lateral ventricle. No further uncal herniation or effacement of the basilar\n cisterns to indicate further downward transtentorial herniation.\n\n 3. Relatively small more acutely hemorrhagic focus in the right frontal lobe,\n with no additional, as on the recent CT, with no additional hemorrhagic focus\n identified, and no further acute infarction.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1066422, "text": " 12:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pt s/p 43cm left sided PICC placement..verify placement\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with s/p 43cm Left PiCC placement\n REASON FOR THIS EXAMINATION:\n pt s/p 43cm left sided PICC placement..verify placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man with left PICC placement.\n\n Comparison is made to the prior study of .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST. The distal tip of left PICC\n projects in the distal SVC. The cardiomediastinal silhouette and hilar\n contours are normal. The lungs are clear with no focal consolidation, pleural\n effusion or pneumothorax. The overlying soft tissue and osseous structures\n appear unremarkable.\n\n IMPRESSION: Standard position of the left PICC with no complication.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-11 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1062970, "text": " 5:15 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: requested by dr / pt with low grade temps\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bifrontal mass resection / immobility\n REASON FOR THIS EXAMINATION:\n requested by dr / pt with low grade temps\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRSg SUN 7:38 PM\n PFI: No DVT in bilateral lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man with bifrontal mass restriction now with\n inability.\n\n COMPARISON: None available.\n\n TECHNIQUE: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: -scale and color\n ultrasonographic images demonstrate wall-to-wall flow with normal response to\n respiration and Valsalva in the common femoral veins bilaterally. The\n bilateral common femoral, superficial femoral, popliteal, and greater\n saphenous veins demonstrate compression and flow is demonstrated in calf\n veins.\n\n IMPRESSION: No DVT of the lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-11 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1062971, "text": ", NSURG FA11 5:15 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: requested by dr / pt with low grade temps\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bifrontal mass resection / immobility\n REASON FOR THIS EXAMINATION:\n requested by dr / pt with low grade temps\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT in bilateral lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1064901, "text": " 10:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p frontal mass resection\n REASON FOR THIS EXAMINATION:\n ? interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:46 PM\n The subgaleal collection is unchanged but the intrinsic densities have\n slightly altered. Mass effect on the frontal lobe and small petechial\n hemorrhages in the inferior right frontal lobe are unchanged. No new\n hemorrhage seen. Small area of air in the inferior left frontal lobe is new\n since the previous study and could be secondary to interval intervention.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient is status post frontal mass resection and\n craniectomy.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Comparison was made with the previous CT of .\n\n FINDINGS: Again left-sided craniectomy is identified in the frontal region\n with subgaleal fluid collection. The thickness and the extent of the\n subgaleal fluid collection has not significantly changed since the previous\n study. However, the intrinsic densities have changed with isodense material\n seen posteriorly on the current study. This could be secondary to\n redistribution of chronic blood products within the collection. No acute\n blood products are identified. There is now a small amount of air seen in the\n inferior left frontal lobe which is new since the previous study and could be\n related to interval intervention. A small hyperdense area indicating\n petechial hemorrhage is seen in the inferior right frontal lobe. Bifrontal\n hypodensities are again identified and the mass effect is noted on the lateral\n and third ventricles. These findings are unchanged. Partial obliteration of\n the basal cisterns is also unchanged. Small right-sided hypodense subdural is\n also unchanged.\n\n IMPRESSION:\n 1. The extent and the size of left-sided subgaleal collection is unchanged\n but the intrinsic density posteriorly is changed as described above.\n 2. Hypodensities in both frontal lobes and small foci of hemorrhage in the\n inferior right frontal lobe are unchanged.\n 3. New area of air is identified in the inferior left frontal lobe which is\n new which is better visualized on the current study and could be secondary to\n intervention.\n 4. Otherwise unchanged study with mass effect in the basal cisterns and the\n ventricles unchanged.\n\n (Over)\n\n 10:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2198-03-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1064902, "text": ", NSURG FA11 10:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p frontal mass resection\n REASON FOR THIS EXAMINATION:\n ? interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n The subgaleal collection is unchanged but the intrinsic densities have\n slightly altered. Mass effect on the frontal lobe and small petechial\n hemorrhages in the inferior right frontal lobe are unchanged. No new\n hemorrhage seen. Small area of air in the inferior left frontal lobe is new\n since the previous study and could be secondary to interval intervention.\n\n" }, { "category": "ECG", "chartdate": "2198-03-01 00:00:00.000", "description": "Report", "row_id": 242882, "text": "Normal sinus rhythm. Within normal limits. No previous tracing available for\ncomparison.\n\n" }, { "category": "ECG", "chartdate": "2198-03-04 00:00:00.000", "description": "Report", "row_id": 242881, "text": "Sinus tachycardia. Diffuse repolarization changes which are non-specific.\nCompared to the previous tracing of there is no significant diagnostic\nchange.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062112, "text": ", NSURG SICU-A 8:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval exam\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with s/p intracranial mass resection\n REASON FOR THIS EXAMINATION:\n interval exam\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Evidence of new hemorrhage or major vascular territory infarction.\n Evolving bilateral ACA, left MCA distribution infarcts.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1061094, "text": " 10:07 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with altered mental status. Evaluate for\n cardiopulmonary process.\n\n PA and lateral chest radiograph shows clear lungs. The heart, mediastinum,\n hila, and pulmonary vascularity are normal. There is no pleural effusion or\n pneumothorax.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062111, "text": " 8:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval exam\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with s/p intracranial mass resection\n REASON FOR THIS EXAMINATION:\n interval exam\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 7:15 PM\n PFI: Evidence of new hemorrhage or major vascular territory infarction.\n Evolving bilateral ACA, left MCA distribution infarcts.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old male status post cranial mass resection. Evaluate\n for interval change.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: Multiple studies including most recent of .\n\n FINDINGS: The patient is status post frontoparietal craniectomy and right\n transfrontal ventriculostomy terminating in the anterior recess of the third\n ventricle, with near-complete resolution of intraventricular hemorrhage. There\n is persistent but slightly less prominent perilesional parenchymal hemorrhage.\n The presence of residual tumor is better assessed on the post- surgical MR of\n .\n\n Evolving hypoattenuation in the bilateral parasagittal frontal lobes and is\n consistent with bilateral ACA infarction. There is expected evolution of the\n left temporal infarct in the inferior division, MCA distribution, with\n persistent extra- axial low attenuation fluid at the floor of the middle\n cranial fossa, likely related to resection as demonstrated on the immediately\n post-operative MR. The right frontal subdural hematoma is essentially\n unchanged.\n\n Postoperative changes of the subgaleal soft tissues are stable. A small\n amount of fluid in the sphenoid sinus, a mucus-retention cyst in the left\n maxillary sinus and opacification of the right frontal sinus and right mastoid\n air cells are again noted.\n\n IMPRESSION:\n 1. Status post resection of mass in the left frontotemporoparietal region\n with perilesional parenchymal hemorrhage and edema. Evaluation for residual\n tumor is limited on the noncontrast CT, but better evaluated on the MR of\n .\n\n 2. Expected evolution of infarcts in the bilateral ACA and inferior division,\n left MCA distribution.\n\n (Over)\n\n 8:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval exam\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Stable position of right transfrontal ventriculostomy catheter with near\n complete interval resolution of intraventricular hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1061121, "text": " 4:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls evaluate for mass effect, herniation\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with new brain mass and hypernatremia, acute MS changes\n REASON FOR THIS EXAMINATION:\n pls evaluate for mass effect, herniation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 28-year-old male with new brain mass and hypernatremia.\n Evaluate mass effect, herniation.\n\n NON-CONTRAST HEAD CT: Compared to prior exam from at 22:46,\n large ill-defined hypoattenuating mass in the left frontotemporal lobe is not\n significantly changed. Mass effect from this lesion results in significant\n rightward shift of normally midline structures. There is associated\n effacement of the left lateral ventricle, entrapment of the right lateral\n ventricle, and obliteration of the suprasellar cistern, which suggest downward\n herniation, the extent of which is unchanged as well. There is some\n suggestion of increasing edema in the left frontal lobe; however, this may be\n technical. There is no hemorrhage or evidence of major vascular territorial\n infarct. Maxillary mucosal thickening is mild. The mastoid air cells are\n normally aerated.\n\n IMPRESSION: Compared to prior exam from at 22:46, there is\n no significant change in large ill-defined low attenuation mass centered in\n the left frontotemporal lobe. The degree of rightward shift of normally\n midline structures, entrapment of the right lateral ventricle and effacement\n of the suprasellar cistern is unchanged as well. Further evaluation with MRI\n is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-04 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 1061466, "text": " 12:30 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: ?seizures r side\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with Frontal mass excision and post op ACA and temporal lobe\n ischemia\n REASON FOR THIS EXAMINATION:\n ?seizures r side\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with frontal mass excision with postoperative\n ACA and temporal lobe ischemia.\n\n COMPARISON: CT head and MR .\n\n TECHNIQUE: Non-contrast axial images of the head are obtained at 5 mm section\n thickness.\n\n FINDINGS: Compared to a day prior, there has been little interval change. The\n patient is status post left frontoparietal craniectomy with persistent\n extensive pneumocephalus, hemorrhage and edema in the resection bed. Evolving\n hypoattenuation in the right parasagittal frontal lobe is again consistent\n with worsening infarction/edema. A right frontal ventriculostomy catheter\n terminates near the third ventricle with unchanged caliber of the ventricular\n system. Blood is again identified in the lateral third and fourth ventricles,\n similar to prior. A layering right subdural hematoma demonstrates slight\n decrease in size, measuring approximately 3 mm in greatest axial dimension\n compared to 6 mm previously. Evolving hypodensity in the left temporal region\n is also consistent with infarction. A small amount of fluid layers in the\n sphenoid sinus with a small left maxillary mucus retention cyst again\n observed. A right frontal air cell is opacified. Multiple right mastoid air\n cells are again opacified.\n\n IMPRESSION:\n 1. Postoperative change underlying left frontoparietal craniotomy with\n persistent pneumocephalus and blood and edema in the surgical bed, unchanged.\n Since the last exam, there has been an interval decrease in size of a right\n convexity subdural hematoma.\n 2. Evolving infarcts in the right ACA distribution and left temporal lobe. No\n new large territorial infarct identified.\n 3. Right ventriculostomy catheter with unchanged caliber of the ventricular\n system with persistent ventricular blood as described.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1061092, "text": " 9:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute intracranial process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for acute intracranial process\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 11:16 PM\n large ill defined low attenuation mass in the left frontal lobe with\n associated mass effect resulting in significant right shift of normally\n mildline structures, effacement of the left lateral ventricle, entrapment of\n the right lateral ventricle and loss of the supersellar cistern suggestive of\n some downward herniation. no hemmorhage. findings worrisome for primary brain\n neoplasm. recommend MRI for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with altered mental status. Evaluate for acute\n intracranial process.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: Large ill-defined hypoattenuating mass in the left\n frontotemporal lobe measures approximately 5.1 x 3.6 cm. Mass effect from this\n lesion results in significant rightward shift of normally midline structures.\n There is associated effacement of the left lateral ventricle, entrapment of\n the right lateral ventricle and encroachment on the suprasellar cistern\n suggesting early downward herniation. Given patient's age, these findings are\n worrisome for a primary brain neoplasm. There is no hemorrhage or evidence of\n major vascular territorial infarct. Maxillary mucosal thickening is mild. The\n mastoid air cells are normally aerated.\n\n IMPRESSION: Large ill-defined low attenuation mass centered in the left\n frontotemporal lobe with resulting rightward shift of midline structures,\n entrapment of the right lateral ventricle and obliteration of the suprasellar\n cistern suggestive of downward herniation. Differential consideration for\n this mass favor primary neoplasm of the brain. Recommend further evaluation\n with MRI.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1061330, "text": " 2:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: post op changes\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p crani for mass resection\n REASON FOR THIS EXAMINATION:\n post op changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male status post craniotomy for mass resection.\n Evaluate postoperative changes.\n\n NON-CONTRAST HEAD CT: Compared to prior exam from at 16:57,\n there has been interval development of a right convexity subdural hematoma\n measuring 7 mm in thickness. In the interim, a ventriculostomy catheter via a\n right frontal approach has been placed terminating at the roof of the third\n ventricle with subsequent decompression of the previously dilated right\n lateral ventricle. The configuration and size of the left lateral ventricle\n is unchanged from the prior study; however, slightly increased in dilatation\n compared to initial CT. Blood is identified in the lateral, third and fourth\n ventricles similar to the prior exam. There are postoperative changes\n underlying the region of left frontoparietal craniotomy with extensive\n pneumocephalus and blood within the operative bed, not significantly changed.\n Note is made of increased prominence of foci of low attenuation in the right\n parasagittal frontal lobe compared to prior exam worrisome for\n edema/infarction. The sinuses show mucosal thickening and scattered air-fluid\n levels ttributable to the presence of ET tube. Left periorbital and\n subcutaneous tissue emphysema is related to recent surgery.\n\n IMPRESSION:\n\n 1. Postoperative changes underlying the region of left frontoparietal\n craniotomy with extensive pneumocephalus and blood within the surgical bed,\n unchanged from . Since the last exam, there is interval\n development of a right convexity subdural hematoma.\n\n 2. Increased conspicuity of area of low attenuation in the right parasagittal\n inferior frontal lobe, which suggest increasing edema/infarct.\n\n 3. Status post placement of a ventriculostomy catheter with decompression of\n previously trapped right lateral ventricle. Stable appearance of mildly\n dilated left lateral ventricle.\n\n\n\n (Over)\n\n 2:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: post op changes\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061134, "text": " 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate for ETT tube placement\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with mental status changes, hypernatremia and intracranial mass\n now s/p intubation\n REASON FOR THIS EXAMINATION:\n pls evaluate for ETT tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 11:07 AM\n Too high position of the ET tube tip that should be advanced for about 3.5/4\n cm.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypernatremia and intracranial mass.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip has been inserted with its tip approximately 8.9 cm above the\n carina and should be advanced for 3.5 cm, tip being above the clavicular\n heads. Cardiomediastinal silhouette is unremarkable and the lungs are clear.\n\n The findings wre discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2198-03-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1061135, "text": ", F. MED SICU-A 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate for ETT tube placement\n Admitting Diagnosis: BRAIN TUMOR;HYPERNATREMIA;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with mental status changes, hypernatremia and intracranial mass\n now s/p intubation\n REASON FOR THIS EXAMINATION:\n pls evaluate for ETT tube placement\n ______________________________________________________________________________\n PFI REPORT\n Too high position of the ET tube tip that should be advanced for about 3.5/4\n cm.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-07-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1019087, "text": " 9:12 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval left apical ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n re-eval left apical ptx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 53-year-old male with left apical pneumothorax.\n\n AP & lateral chest radiograph compared to shows small left\n apical pneumothorax minimally decreased in size compared to prior exam. The\n remainder of the exam is essentially unchanged. Again seen is stable moderate\n cardiomegaly and normal postoperative widening of the mediastinum which is\n decreased in size compared to the immediate postoperative radiographs. Small\n left pleural effusion and retrocardiac atelectasis is stable. Tip of a right\n internal jugular central venous line overlies the distal SVC. Note is made of\n normal retrosternal fluid collection with tiny locule of air, unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-14 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1018646, "text": " 12:39 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: re-eval effusion s/p CT placed left\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n re-eval effusion s/p CT placed left\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 12:49.\n\n COMPARISON: , 7:24.\n\n INDICATION: Status post coronary artery bypass surgery.\n\n New left chest tube is present, with slight angulation of the tube at the\n distal side port. Left pleural effusion has slightly decreased in size with\n residual moderate effusion remaining, and no visible pneumothorax.\n Endotracheal tube remains slightly high, terminating about 6.8 cm above the\n carina. Swan-Ganz catheter, and nasogastric tube remain in place. Marked\n widening of cardiomediastinal contours appear unchanged. Left lower lobe\n atelectasis is also similar in appearance to the previous exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018513, "text": " 1:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx eval mediastinum\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n ? ptx eval mediastinum\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz FRI 5:04 PM\n Rule out _____ mediastinum. The mediastinum is still enlarged secondary to\n post-surgical changes, cannot exclude hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: at 12:27.\n\n HISTORY: 53-year-old man status post CABG, evaluate for mediastinum.\n\n FINDINGS:\n\n There is essentially no change in the position of any of the lines, tubes, and\n catheters, already in place. The mediastinum is still persistently widened\n secondary to acute post-surgical changes, which can also include hematoma. A\n small-to-moderate left pleural effusion is stable. There is no right pleural\n effusion. Small left lower lobe atelectasis and adjacent effusion is also\n seen.\n\n IMPRESSION:\n 1. Widened mediastinum secondary to post-surgical changes. Hematoma cannot\n be excluded and short-term followup examination is recommended.\n\n 2. Lines, tubes, and catheters are in satisfactory location.\n\n 3. Persistent small-to-moderate left pleural effusion with adjacent small\n left basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018514, "text": ", CSURG CSRU 1:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx eval mediastinum\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n ? ptx eval mediastinum\n ______________________________________________________________________________\n PFI REPORT\n Rule out _____ mediastinum. The mediastinum is still enlarged secondary to\n post-surgical changes, cannot exclude hematoma.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018617, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p off-pump CABGx2 \n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: \n\n INDICATION: Status post coronary artery bypass surgery.\n\n Endotracheal tube is in a high position, terminating about 8.3 cm above the\n carina, as communicated by phone to Dr. on . Other\n indwelling devices are in standard position. Persistent widening of\n cardiomediastinal contours, and persistent moderate left pleural effusion are\n demonstrated as well as worsening left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-12 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1018358, "text": " 4:34 PM\n CAROTID SERIES COMPLETE; VENOUS DUP EXT UNI (MAP/DVT) LEFT Clip # \n Reason: pre-op eval\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CAD, s/p cath, planned CABG\n REASON FOR THIS EXAMINATION:\n pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with CAD, being evaluated for CABG.\n\n RADIOLOGISTS: The exam was read by Dr. and Dr. .\n\n TECHNIQUE AND FINDINGS: Extracranial evaluation of bilateral carotids was\n performed with B-mode, color and spectral Doppler ultrasound modes.\n\n On the right, peak systolic velocities are 43, 70 and 85 cm/sec in the\n internal, common, and external carotid arteries respectively. The right ICA\n to CCA ratio is 0.61.\n\n On the left, peak systolic velocities are 62, 95 and 76 cm/sec in the\n internal, common and external carotid arteries respectively. The left ICA to\n CCA ratio is 0.65.\n\n Both vertebral arteries presented antegrade flow.\n\n COMPARISON: None available.\n\n IMPRESSION: There is no evidence of stenosis within the internal carotid\n arteries bilaterally.\n\n\n VENOUS MAPPING\n\n INDICATION: 53-year-old man with CAD, being evaluated for CABG.\n\n RADIOLOGISTS: The study was read by Dr. and Dr. .\n\n TECHNIQUE: Vein mapping of the superficial veins in the left lower extremity\n was performed with B-mode ultrasound. Right GSV previously harvested.\n\n FINDINGS: The left greater saphenous vein was patent and compressible with\n diameters ranging between 0.58 cm and 0.38 cm.\n\n COMPARISON: None available.\n\n IMPRESSION: Patent left greater saphenous vein with diameters described\n above.\n\n (Over)\n\n 4:34 PM\n CAROTID SERIES COMPLETE; VENOUS DUP EXT UNI (MAP/DVT) LEFT Clip # \n Reason: pre-op eval\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2170-07-12 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1018366, "text": " 5:29 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\\CATH\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CAD, s/p cath, planned for CABG\n REASON FOR THIS EXAMINATION:\n Pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE PA AND LATERAL CHEST, AT 17:30 HOURS\n\n HISTORY: Preoperative for CABG.\n\n COMPARISON: .\n\n FINDINGS: The lungs are clear without consolidation or edema. The\n mediastinum is unremarkable. The cardiac silhouette is within normal limits\n for size. No effusion or pneumothorax is noted. There are bridging\n osteophytes across multiple segments of the lower thoracic spine.\n\n IMPRESSION: No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018745, "text": " 11:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man ws/p change of Cordis to triple lumen catheter\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Triple lumen catheter.\n\n Right internal jugular vascular catheter terminates within the lower SVC\n adjacent to the junction with the right atrium. No pneumothorax is\n identified. Endotracheal tube and Swan-Ganz catheter have been removed with\n residual left chest tube remaining in place. Persistent moderate left\n effusion with adjacent atelectasis and postoperative widening of\n cardiomediastinal contours.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018858, "text": " 8:34 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz MON 3:14 PM\n PFI: Persistent moderate left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 53-year-old man status post CABG with effusion.\n\n FINDINGS:\n\n The moderate left pleural effusion is stable. Persistent mild-to-moderate\n cardiomegaly with mediastinal widening secondary to recent CABG procedure has\n not essentially changed. No change in the status of the left chest drainage\n catheter which terminates in the superior portion of the left hemithorax. A\n right internal jugular line terminates in the distal SVC. The right lung is\n clear. No right pleural effusion is seen. The sternotomy wires are\n unremarkable.\n\n IMPRESSION:\n 1. Stable moderate left pleural effusion.\n 2. Stable mild-to-moderate cardiomegaly, with post-surgical changes at the\n upper mediastinum.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1018950, "text": " 1:38 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz MON 4:07 PM\n Rule out pneumothorax after removal of chest drainage tube. New left apical\n pneumothorax is seen along with decrease in size of left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest PA and lateral on .\n\n COMPARISON: , at 08:35.\n\n HISTORY: 53-year-old man status post CABG, rule out pneumothorax after the\n chest tube has been removed.\n\n FINDINGS:\n\n In the interim, the left chest tube has been removed with a new apical left\n pneumothorax and decrease in the size of the small left pleural effusion.\n Persistent moderate cardiomegaly is stable. The right lung is clear. Multiple\n sternotomy wires are seen none of which are broken or displaced. No change in\n the status of the right internal jugular line which terminates in the distal\n SVC.\n\n IMPRESSION:\n 1. New left apical pneumothorax after the removal of left chest tube drainage\n catheter which has resulted in decrease of a small left pleural effusion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018859, "text": ", CSURG FA6A 8:34 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n effusion\n ______________________________________________________________________________\n PFI REPORT\n PFI: Persistent moderate left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1018951, "text": ", CSURG FA6A 1:38 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n PFI REPORT\n Rule out pneumothorax after removal of chest drainage tube. New left apical\n pneumothorax is seen along with decrease in size of left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1018486, "text": " 12:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with off pump CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. Page \n with issues. Pt will be in CSRU in 30 mins\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB FRI 12:57 PM\n Proximal endotracheal tube position, 7 cm above carina. Mediastinal widening,\n likely postoperative, but followup non-rotated radiograph recommended as well\n as clinical correlation to exclude mediastinal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, \n\n Compared to previous study of .\n\n INDICATION: Status post CABG.\n\n There has been interval median sternotomy and coronary artery bypass surgery.\n Endotracheal tube terminates 7 cm above the carina; Swan-Ganz catheter,\n nasogastric tube, mediastinal drains, and left chest tube are in standard\n position. Apparent widening of mediastinum may be due to a combination of\n postoperative changes and accentuation by rotation, low volumes, and supine\n technique, but followup radiograph in non-rotated position as well as clinical\n correlation suggested to exclude a hematoma as communicated to \n by phone on . Bibasilar atelectasis and small-to-moderate left\n pleural effusion are evident. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1018487, "text": ", CSURG CSRU 12:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with off pump CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. Page \n with issues. Pt will be in CSRU in 30 mins\n ______________________________________________________________________________\n PFI REPORT\n Proximal endotracheal tube position, 7 cm above carina. Mediastinal widening,\n likely postoperative, but followup non-rotated radiograph recommended as well\n as clinical correlation to exclude mediastinal hematoma.\n\n\n" }, { "category": "Echo", "chartdate": "2170-07-13 00:00:00.000", "description": "Report", "row_id": 82351, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension.\nStatus: Inpatient\nDate/Time: at 10:54\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast is seen in the LAA.\nNo thrombus 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: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Normal LV cavity size.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. aortic valve\nleaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. \nmitral valve leaflets. No mass or vegetation on mitral valve. Mild mitral\nannular calcification. No MS. Physiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: 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 patient received antibiotic\nprophylaxis. The TEE probe was passed with assistance from the anesthesioology\nstaff using a laryngoscope. No TEE related complications. Suboptimal image\nquality. Results were personally reviewed with the MD caring for the patient.\n\nConclusions:\nOff_Pump CABG:1. The left atrium is normal in size. No spontaneous echo\ncontrast is seen in the left atrial appendage. No thrombus is seen in the left\natrial appendage.\n2. No atrial septal defect is seen by 2D or color Doppler.\n3. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal.\n4. Right ventricular chamber size and free wall motion are normal.\n5. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n6. There are three aortic valve leaflets. The aortic valve leaflets (3) are\n . There is no aortic valve stenosis. No aortic regurgitation\nis seen.\n7. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The mitral valve leaflets are . No mass or\nvegetation is seen on the mitral valve. Physiologic mitral regurgitation is\nseen (within normal limits).\nDr. was notified in person of the results.\n8. Transient RWMA seen with LAD, OM occlusion with acceptable bp, SvO2, and CO\nthroughout.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-13 00:00:00.000", "description": "Report", "row_id": 1645542, "text": "56 yr old male S/P CABG remains on mechanical ventilation with plan to extubate soon.Transfused for low hct,neo and epi provided by clinicia earlier for bradycardia and hypotension.Will sleep on vent over night with plan to extubate tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-13 00:00:00.000", "description": "Report", "row_id": 1645543, "text": "OP DAY - OFF PUMP CABG X 2\nADMIT TO CVICU A WITH 140CC CT DRAINAGE IN CT COLLECTION UNIT & SBP 123 AND PAS 59/32 CVP 18 ON NEOSYNEPHRINE. CONTINUED WITH HIGH CT DRAINAGE REQUIRING VOLUME AND TITRATION OF VASOCONSTRICTORS. ACT 150. PLATELET TRANSFUSION STARTED AS ORDERED BY ANESTHESIOLOGIST AT BEDSIDE (HISTORY OF RECENT PLAVIX USE). PROTAMINE STARTED AROUND THE SAME TIME. CALLED TO ASSESS PATIENT FOR HYPOTENSION, LOW FALLING SVO2, POOR CI. MACULAR PINK BODY RASH NOTED. NO WHEEZING. PROTAMINE STOPPED (11MG INFUSED). PLATELETS ALREADY IN. BLODD BANK SAMPLE OBTAINED AND SENT WITH PLATELET BAG AND POSSIBLE TRANSFUSION REACTION DATA. BENADRYL 50MG IV, FAMOTIDINE IV GIVEN. EPINEPHRINE STARTED. RASH LATER RESOLVED. ADDITIONAL BENADRYL GIVEN PRIOR TO PRBC GIVEN LATER THIS SHIFT.\n\nCONTINUED WITH LOW CO BY FICK AND LOW SVO2. PA CATHETER REPOSITIONED BY NP WHEN LOW NUMBERS PERSISTED DESPITE VOLUME REPLACEMENT. CONTINUED HYPOTENSION REQUIRING NOREPINEPHRINE. MILRINONE 0.375MCG/KG/MIN STARTED FOR CONTINUED LOW CO BUT ONLY ON FOR ABOUT 3MINUTES. TEE JUST AFTER MILRINONE STARTED NOTED \"HYPERTROPHIC VENTRICLE WITH UNDER FILLED HEART\" ACCORDING TO DR. (INTENSIVIST). LR BOLUSES RESUMED AND MILRINONE STOPPED. PT EVENTUALLY RECEIVED 6LITERS OF LR, 2UPRBC (HCT TO 26) AND 250CC 5%ALBUMIN. CO IMPROVED. NEOSYNEPHRINE, THEN EPINEPHRINE AND LATER NOREPINEPHRINE WEANED OFF AS DISCUSSED BY DR. .\n\nCURRENTLY NSR 79. SVO2 74% WITH SQI 1 /CCO 5.4 (BUT HIGHER BY FICK). BREATHSOUNDS CLEAR BILATERALLY. TWO CXRs EARLIER REPORTED TO SHOW A WIDENED MEDIASTINUM, AND L ATELECTASIS. CT DRAINAGE ORIGINALLY THICK AND WITH CLOT AND CURRENTLY THIN AND WATERY SEROSANGUINOUS. REMAINS INTUBATED WITH NO PLANS TO VENT WEANT TONIGHT. PEEP REMAINS AT 8 ATELECTASIS. PT WILL NEED CLOSE OBSERVATION AFTER EXTUBATION WITH H/O S L E E P A P N E A. PLAN TO VENT WEAN AS TOLERATED IN AM.\n\nOGT DRAINING BILIOUS. ABD LARGE AND FIRM. ABSENT BOWEL SOUNDS.\n\nAWOKE AND NODDED HEAD TO QUESTIONS. MAE. REMAINS ON PROPOFOL. MORPHINE GIVEN FOR PROBABLE INCSIONAL PAIN. PT ON PRE-OP FOR R SHOULDER PAIN. PT LEGALLY BLIND. WILL NEED F A L L P R E V E N T I O N CARE.\n\nHOURLY URINE OUTPUT IMPROVED WITH IMPROVED HEMODYNAMICS. PRE-OP NURSING ASSESSMENT NOTES THAT PT IS SOMETIMES INCONTINENT OF URINE AND USES DIAPERS/PADS.\n\nSKIN INTACT. NO RASH PRESENT AT THIS TIME. NO INFORMATION FROM BLOOD BANK REGARDING POSSIBLE PLATELET TRANSFUSION REACTION. CANNOT R/O POSSIBLE REACTION TO P R O T A M I N E.\n\nIDDM. GLUCOSE TO THE 180S. SEE GLUCOSE AND INSULIN GTT.\n\nNO CONTACT WITH NEXT OF (BROTHER) THIS SHIFT.\n\nH/O DVT. ELASTIC STOCKING PLACED ON R LEG. ACE WRAP REMAINS ON L LEG.\n\nPLAN TO CONTINUE TO MONITOR CLOSESLY.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-14 00:00:00.000", "description": "Report", "row_id": 1645544, "text": "11p-7a\n\nPOD 1cabg x2.\nNeuro: sedated on propofol. Light at times, does follow commands.\nPupils equal, on the sluggish side. Nods to pain, morphine given with effect Q3 hr overnight. Becomes anxious when waking, reaching for tube.\n\nCV: SR 70's. Able to turn levo off. SBP 90's - 110. Becomes hypertensive when waking. CVP 11-14- just monitor per team.\nCO >6. Index >3. +palp pp.\n\nResp: Remains orally intubated SIMV 60%. 8peep for atelectasis on cxr on eves/ 5 PS. Sats 100%. ABG wnl. Lungs clear.\nNeeds follow up cxr this am for widened mediastinum on last cxr.\nChest tubes draining 0-50cc/hr serosang drainage. Not much effort to breathe with rsbi per RT.\n\nGI/GU: abdomen softly distended. no bs yet. meds via ogt, tube replaced at midnight due to coiled in mouth. ogt to clws, bilious drainage. UOP qs.\nInsulin gtt cont at 4 units/hr. Will start glargine this am.\n\nSkin: see flowsheet.\n\nSocial: no calls.\n\nPlan: Cont to monitor hemodyanamics closely. Attempt to wean vent to extubate. Pt may need something for anxiety while weaning vent off propofol. Monitor chest drainiage. Pain control. Hopefully d/c insulin. ?? start heparin for hx dvt??\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-14 00:00:00.000", "description": "Report", "row_id": 1645545, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes made overnight. BS's diminished. RSBI=102 this am. See flowsheet for further data. Will reattempt wean later this am.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-14 00:00:00.000", "description": "Report", "row_id": 1645546, "text": "NEURO: APPEARS INTACT, FOLLOWING COMMANDS, MAE.\n\nCARDIAC: HEART RATE NSR-ST WITHOUT ECTOPY. K+/+CA REPLEATED. CO/CI ACCEPTABLE. USING IV NTG TO KEEP S B/P LESS THAN 120, PRESENTLY OFF. CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. LT CHEST TUBE PLACED, TRANSIENT LEAK WITH MINIMAL DRAINAGE. PATIENT SEDATED WITH IV MORPHINE AND INCREASED PROPOFOL-APPEARED TO TOLERATE WELL. DOPPLERABLE PULSES. LT LEG WRAP REWRAPPPED.\n\nRESP: CS DIMINISSHED IN BASES, SUCTIONED FOR THICK TAN PRIOR TO EXTUBATION AT 1445. PHH 50% WITH O2 SAT 92-94%. WILL INTRIDUCE TO SPIROCARE.\n\nGI: OG TUBE PULLED WITH EXTUBATION. (-) BOWEL SOUNDS.\n\nGU: FOILEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\n\nENDO: INSULIN GTT INFUSING, FOLLOWING PROTOCOL.\n\nPAIN: PATIENT MEDICATED WITH IV MORHINE AND SQ FOR SHOULDER PAIN, PATIENT ASKING FOR OXYCONDIN. RELUCTANT TO GIVE PO MEDS AT THIS TIME DUE TO 6 IN GASTRIC DRAINAGE PRIOR TO EXTUBATION.\n\nFAMILY: AND MOTHER IN TO VISIT, PLANS EXPLAINED.\n\nPLAN: INSTRUCT IN SPIROCARE. ENCOURAGE PATIENT TO TURN/COUGH/DEEP BREATH. MEDICATE AS NEEDED. REPLEATE LAB WORK AS NEEDED. FOLLOW INSULIN PROTOCOL. ? DC CCO SWAN IM AM. ? DC LT CHEST TUBE IN AM. OOB IN AM. FOLLOW HEMODYNAMICS.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-14 00:00:00.000", "description": "Report", "row_id": 1645547, "text": "Patient extubated and now is on 50% open face mask.Chest tube inserted (L) side due to pleural effusion.Patient alert,following commands will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-15 00:00:00.000", "description": "Report", "row_id": 1645548, "text": "CVICU NPN\nO: ROS\n\nNeuro: A&Ox3, MAE and follows commands consistently. Very uncomfortable in bed due to back and shoulder pain. Treated w/ percocet w/ gd effect. OOB - Chair w/ min assist of 2. Steady gait. Able to stand independently with supervision x5minutes. Pt remained in chair and slept off and on. Brief period of panic after bathing and moving. Calmed with reassurance.\n\nCV: Hr 70's -80's nsr no ectopy. Stable BP w/ MAP 60-78. Palpable pedal pulses.\n\nResp: Stable 02sats on 4lnp. SRR 20-28. LS clear, diminished. Scattered crackles resolving w/ diuresis. Exertional wheezing resolves w/ rest. Strong productive cough independently for thick, yellow secretions.\n\nRenal: Diuresisng welll w/ iv lasix. Body balance neg 1480 at mn and neg 300 since mn. Lytes wnl.\n\nGI: Tol liquids well. No stool, hypoactive bowel sounds. Denies nausea. Cont on colace and zantac.\n\nEndo: Insulin gtt titrated to BS <120. Weaning and will change to SS insulin.\n\nHeme: Hct 25.4 (32). Stable CT output with no evidence of bleeding.\n\n\nID: Tmax 99.1, WBC 13.8. Cont on iv vanco postop.\n\nSkin: Intact. Sternal and mediastinal dsgs changed and D&I. Backside intact. +edema.\n\nSH: No family contact .\n\nA: Hemodynamically stable s/p cabg.\n\nP: Cont to monitor and support systems. Pulm toilet. Pain control.\nIncrease activity. Advance DAT. Wean insulin gtt. Pt is ready for transfer. Cont pt and family support.\n" }, { "category": "ECG", "chartdate": "2170-07-13 00:00:00.000", "description": "Report", "row_id": 206550, "text": "Probable junctional bradycardia. Left axis deviation. Left anterior\nfascicular block. There is a late transition which is probably normal.\nCompared to the previous tracing junctional bradycardia is new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2170-07-12 00:00:00.000", "description": "Report", "row_id": 206551, "text": "Sinus rhythm with a competing ectopic atrial rhythm. Left axis deviation.\nLeft anterior fascicular block. There is a late transition which is probably\nnormal. Compared to the previous tracing sinus rhythm is now competing with\nan ectopic atrial rhythm.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2170-07-12 00:00:00.000", "description": "Report", "row_id": 206552, "text": "Probable ectopic atrial rhythm. Left axis deviation. Left anterior fascicular\nblock. There is a late transition which is probably normal. Compared to the\nprevious tracing sinus rhythm is no longer present.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2137-01-29 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 778072, "text": " 10:57 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, increased bradycardia, on NC\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Infant with prematurity, increased bradycardia. Evaluate lung\n fields.\n\n CHEST AP SUPINE: NG tube terminates in the stomach. The lungs are clear.\n Heart size and vascularity are normal. The abdominal gas pattern is normal.\n\n IMPRESSION: Normal examination.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-05 00:00:00.000", "description": "Report", "row_id": 1794233, "text": "1 Sepsis\n Infant continues on antibiotics as ordered, IV site soft\nflushes well. Continue antibiotics as plan.Infant stable\nshowing no s/s of sepsis at this time.\n3 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0 distention, tol.\nfeeds well by gavage, minimal asp. moderate spits with each\nfeed, fed over 1hour and 45minutes. Voiding, stooling. Wt.\nup 25gms to 1.850. Continue present plans.\n5 \n No contact from so far tonight. Plan to keep\nfamily updated.\n7 A/Bs\n No spells so far tonight, continue to monitor and record\nany spells.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-05 00:00:00.000", "description": "Report", "row_id": 1794234, "text": "NURSING TRANSFER NOTE\n\n\n#1 O:BABY CONTINUES ON IV AMPI AND GENT. A: DAY 9 OF 14 DAY\nCOURSE. P: COMPLETE 14 DAYS OF ANTIBIOTICS.\n#3 O: TOTAL FLUIDS 150CC/KG/DAY OF BREASTMILK/PE26. FEEDS\nGIVEN EVERY 4 HOURS OVER 1 1/2 HOURS DUE TO SPITTING. BABY\nHAS NOT BREAST FED AS MOTHER IS NOT FEELING WELL. ABDOMEN\nSOFT, BOWEL SOUNDS ACTIVE, NO LOOPS, GIRTH STABLE AT 24 TO\n26CM, VOIDING WELL, STOOLS GUIAC NEGATIVE. A: HAVING ABOUT\n2 SPITS A DAY, FEEDS GIVEN SLOWLY BY GAVAGE. P:START\nBREASTFEEDING WHEN MOTHER FEELING UP TO IT.\n#4 O: TEMP STABLE TONIGHT IN OFF ISOLETTE. BABY IS \nAND ACTIVE DURING CARES, NO INTERESTED IN PACIFIER. BABY\nSETTLES TO SLEEP WELL AND SLEEPS WELL BETWEEN CARES. A:\nAPPROPRIATE FOR AGE. P: CONTINUE TO SUPPORT DEVELOPMENT.\n#5 O: MOTHER IS AT HOME BUT NOT FEELING WELL AND REQUESTED\nBABY'S TRANSFERED TO HOSPITAL, PERMISSION TO\nTRANFER SIGNED. A: INVOLVED FAMILY. P: TRANSFER BABY TO\n HOSPITAL.\n#7 O: NO SPELLS NOTED TO TIME OF REPORT.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-05 00:00:00.000", "description": "Report", "row_id": 1794235, "text": "Neonatology Attending\nDOL 9\n\nRemains in room air with no apneas/bradycardias since , on caffeine.\n\nMurmur intermittently BP 74/37 (54).\n\nWt 1850 (+25) on TFI 150 cc/kg/day BM26/PE26, tolerating over 105 minutes for reflux. Voiding and stooling normally.\n\nOn ampicillin and gentamicin day 9 of planned 14 day course.\n\nA&P\nPreterm infant with respiratory and feeding immaturity, resolving sepsis. We will transfer to for further care. Otherwise continue current management as detailed above.\n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794197, "text": "Admission Note\n32-4/7 week GA male twin admitted for prematurity\n\nMaternal Hx - 28 year-old G1P0->2 woman with PMHx notable for tobacco use (1 pack per week, ?ending prior to pregnancy) and alcohol use (1-2 drinks/week in pregnancy). Prenatal screens: O positive, antibody negative, rubella immune, HBsAg negative, RPR non-reactive, GBS unknown.\n\nPregnancy Hx - LMP for and EGA 32-4/7 weeks. Spontaneous twin gestation, diagnosed at 19 weeks. Serial ultrasounds normal and consistent with dates. Antepartum course reportedly unremarkable until when SROM, treated with betamethasone, clindamycin and MgSO4 tocolysis. Proceeded to cesarean section for preterm labor with PPROM, and breech presentation of first twin.\n\nNeonatal course - Infant apneic and hypotonic at delivery, but responsive to tactile stim, oral and nasal bulb suctioning, brief bag-mask ventilation (1 minute) and free flow oxygen Subsequently pink with mild retractions in free-flow oxygen. Transferred uneventfully to NICU. Apgars 7 at one minute (-2 color, -1 tone), 8 at five minutes (-1 color, -1 tone).\n\nPE\nBW 1750g (50th %ile) OFC 30cm (50th %ile) LN 39.5cm (10-25th %ile)\nhr 192 rr 54 BP 54/32 (44) T 99.8 BP 54/32 (44) SaO2 100% in room air\nHEENT AFSF: non-dysmorphic; palate intact; neck/mouth normal; no nasal flaring\nCHEST mild retractions; minimal grunting respirations; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal male genitalia; testes undescended bilaterally\nCNS active, responsive to stim; tone AGA; moving all limbs symmetrically; gag/grasp normal\nINTEG bruising over right buttocks\nMSK normal spine/limbs/hips/clavicles\n\nImpression\n32-4/7 week GA male with\n1. Mild respiratory distress - Differential includes retained fetal lung fluid and mild surfactant deficiency. Pneumonia cannot be excluded clinically at this point, although the infant appears very active.\n2. Sepsis risk - Based on unknown maternal GBS colonization status, PPROM, preterm labor.\n\nPlan\nInfant has been admitted to NICU for cardiorespiratory monitoring. If respiratory distress worsens or if oxygen requirement > 30% FiO2, chest radiograph and blood gas will be checked and consideration will be given to intubation for surfactant administration. Will maintain SaO2 89-94%.\n\nCardiac examination is unremarkable. We will maintain vigilance for PDA and maintain mean BP > 35 mmHg.\n\nInfant will remain NPO until cardiorespiratory stability has been established. PIV D10W will be provided in the interim. D-stick pending.\n\nA CBC and blood culture will be drawn and broad spectrum antibiotic therapy started for anticipated course of 48 hours pending WBC and culture results as well as presence of clinical signs and symptoms of infection.\n\nParents updated regarding current status, diagnostic considerations and our management plan.\n\nPOBx: Dr. \nDelivering OB: Dr. \nPMD: Dr. \n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794198, "text": "Admission Note\n(Continued)\n()\n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794199, "text": "Admission Note\nNursing Admit Note: Baby boy, twin A, admitted to NICU at 0300. Born to a 28yo G1 P0 with PROM tx with MgSO4, Beta, and clindamycin. C/S for twin A being breech. Baby emerged apneic and hypotonic but responsive to tactile stim and brief bag/mask ventilation. Apgars 7, 8. LS clear and equal. +IC/Sc retractions. In room air,sats 98-100%. Bulb sxn'd at birth for moderate amt of secretions. RR 70's. Mild nasal flaring with cares. No murmur noted. Color pink with poor perfusion to hands and feet, improving since admit time. Brisk cap refill. BP stable, see flow sheet. Abd soft and flat with hypoactive bowel sounds. NPO, TF 80cc/kg/day D10 via PIV in right hand. Initial d/stick 109. BW 1750gm. Testes undescended bilaterally. Awake and active with cares. Temp slightly unstable, adjusting warmer as needed, seef flow sheet. Void and stool in DR. noted to lower back. Parents up to visit briefly. CBC and blood cx sent, Amp and Gent started. CBC benign. Will monitor for any s/s resp distress, monitor BP's and d/sticks.\n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794200, "text": "1 Infant with Potential Sepsis\n2 Respiratory\n3 Fluid and Nutrition\n4 Growth and Dev.\n5 Parents\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Respiratory; added\n Start date: \n 3 Fluid and Nutrition; added\n Start date: \n 4 Growth and Dev.; added\n Start date: \n 5 Parents; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794201, "text": "Neonatology\nContinues to do well since birth. RA. No spells. Mild transitional distress. BP in good arneg.\n\nREmains nPO on IVF. WIll wait for resolution of transitional symptoms for start of feeds . BS in good range ABdomen benign. Feeds to be considered later in day or in am.\n\nOn abx. CBC notale for significant shift with neutropenia.. WIll recheck CBC in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794202, "text": "Nursing NICU Note\n\n\n#1. Sepsis O: Pt. is alert and active w/ cares. Temps\nstable. He is on IV Amp+Gent. CBC and blood cult sent. A:\n Potential for sepsis. P: Continue to monitor for s/s of\ninfection. Continue w/ 48hr R/O.\n\n#2. Respiratory O: Pt. remains in RA, O2 sats >95%. LS\nclear/=. RR 30-70's. No increase work of breathing noted.\nHe has v. mild SC retractions. No A&B's noted. A: Pt. is\nstable in RA. P: Continue to monitor respiratory status.\nMonitor for A&B's.\n\n#3. FEN O: Pt. is NPO. TF 80cc/kg/d of D10W =5.8cc/hr is\ninfuseing via L.hand PIV without incident. Abdomen is\nsoft/flat, hypoative BS noted. He is voiding/ no stool this\nshift thus far. A: Pt. is tolerating current nutrtional\nplan. P: Continue w/ current feeding plan. Monitor for\ns/s of intolerance. Plan to start NG feeds of PE20 @\n20cc/kg tonight if pt. remains stable.\n\n#4. Growth/Development O: Pt. is on an open warmer, temps\nsl. warm, stable. He is alert and active w/ cares, sleeps\nwell in between. Fontanelle soft/flat. +cry, +suck noted.\nA: AGA P: Continue to provide environment appropriate for\ngrowth and development. Plan to place pt. into an air\nisolette later tonight.\n\n#5. Parents O: Mom called this afternoon and was updaed\non pt's current status and daily plan of care. Parents have\nnot been up to the unit to visit yet. P: Parents plan to\nvisit later this afternoon. Continue to update, support and\neducate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-27 00:00:00.000", "description": "Report", "row_id": 1794203, "text": "Nursing Progress Note (6PM-11PM)\n\n\n#1 Sepsis: Alert and active with good tone. No temp\ninstability noted. No acute S/S of sepsis. P/ COnt\nantibiotics as ordered. CBC with lytes and bili in AM\n#2 RESP: Remains on RA with good sat. Clear equal BS. mild\nretraction. No spells.No murmur.Warm and well perfused.Good\npulses. MBP 39.P/ COnt to assess CVR status\n#3 FEN: Remains on TF80cc/k/d of D10W infusing well via\nleft hand PIV.Intact and patent with good blood return.\nBenign soft abdomen. voiding QS. No BM. P/ will start\nenteral feeding tonight at 20cc/k/d. Cont to minitor\n#4 G/D: transferred to Rm 957 without incident.\nMaintaining stable temp on Air isolette. Sleeps in between\ncares. Calms with pacifier and bounderies.P/ COnt to support\nG/D\n#5 Parents: Family aware of transfer. No contact since the\nvisit this PM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-28 00:00:00.000", "description": "Report", "row_id": 1794204, "text": "NPN 2300-0730\n\n\n1. On amp and gent for 48hr R/O. CBC benign thus far.\nRepeat blood culture and CBC pending. VSS-see flowsheet.\nDstick 109. Alert and active with cares. No apparent s/sx\nof infection. Will continue to monitor for s/sx of sepsis.\n\n2. In RA with sats 96-98%. Lungs clear, RR 30-50's with\nmild SC retractions. No A&B's thus far. Stable in RA.\nCont to monitor resp status.\n\n3. Wt up 45gm to 1795gm. TF 80/k/d D10W via PIV. Abd\nbenign. 12hr U/O 2.3cc/k/hr, no stool thus far. Dstick\n109. See lab flowsheet for lytes and bili; to be reported\nto NP . Enteral feeds to be initiated this am\nat 20/k/d of PE20 via NGT. Will continue to monitor fluid\nand electrolyte status.\n\n4. Temp stable nested in air isolette. Awake and irritable\nwith cares, settles quickly after cares. MAE. Suckles on\npacifier at times. Cont to promote G&D.\n\n5. No contact thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-28 00:00:00.000", "description": "Report", "row_id": 1794205, "text": "NPN 2300-0730 addendum\n\n6 Hyperbili\n\n6. Bili this am 6.6/0.3/6.3. Color ruddy, no stool thus\nfar. Feeds started this am. Bili blanket started with eye\nshields on. Cont to monitor bili as per team.\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbili; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-28 00:00:00.000", "description": "Report", "row_id": 1794206, "text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1795, bili=6.6. TF=80 cc/kg/d.\nA/P: Infant with mature surfactant synthesis. Cont amp and gent for 48h r/o. Start PO/PG feeds. Start phototherapy.\n" }, { "category": "Nursing/other", "chartdate": "2137-01-29 00:00:00.000", "description": "Report", "row_id": 1794209, "text": "Newborn Med Attending\n\nCont in and out of low flow O2 for HR drifts. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1770 down 25, on 150 cc/kg/d PE20. Bili=8.3.\nA/P: Infant with occ spells, working up on PO fees. Cont phototherapy. D/C amp and gent if cx - at 48h.\n" }, { "category": "Nursing/other", "chartdate": "2137-01-28 00:00:00.000", "description": "Report", "row_id": 1794207, "text": "Nursing NICU Note\n\n\n#1. Sepsis O: Pt. is alert and active w/ cares. Temps\nstable. He is on IV Amp + Gent. LP done this afternoon,\nresults pending. CBC sent this am -, blood cult pending. A:\n Potential for sepsis. P: Continue to monitor for s/s of\ninfection. Continue w/ IVAB.\n\n#2. Respiratory O: Pt. remains in Ra, O2 sat 96-99%. LS\nclear/=. RR 30-50's. No increase work of breathing noted.\nHe has had brady x1 today. A: Pt. is stable in RA. P:\nContinue to monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 80cc/kg/d. Enteral feeds advanced today to\n35cc/kg of PE 20/BM =10cc Q 4hrs, gavaged over 20 min,\ntolerated well. IVF of D10W @ 45cc/kg =3.4cc/hr is\ninfuseing via L. hand PIV without incident. Abdomen is\nsoft, pink, +BS, no loops/spits. Abdominal girth is\n21.5-22.5cm. He is voiding/ passed sm mec stool x1. A:\nPt. is tolerating current nutritional plan. P: Continue to\nadvance feeds by 15cc/kg () as pt. tolerates.\nStart IVF of D10W 2+1 tonight. Monitor for s/s of\nintolerance.\n\n#4. Growth/Development O: Pt. remains in an air isolette\nw/ stable temps. He is alert and active w/ cares, sleeps\nwell in between. Fontanelle soft/flat. He loves to use his\npacifier. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n#5. Parents O: Parents in to visit this afternoon and\nwere updated at bedside on pt's current status and daily\nplan of care. A: Parents loving and involved. P:\nContinue to update, support and educate.\n\n#6 Hyperbili O: Pt. remains under single blanket.\n today 6.6/0.3/6.3. He is ruddy, well perfused. A:\nAlteration in . P: COntinue w/ blanket. Check\n in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-29 00:00:00.000", "description": "Report", "row_id": 1794208, "text": "npn 1900-0700\n\n\n#1 r/o sepsis\no: pt remains on double abx via iv. temps stable for better\nhalf of night, one low temp 97.1ax ?evironmental reasons.\nalert and awake with cares. irritable at times. bc and\nprelim. lp neg to date. a: stable P: cotninue to monitor for\nchanges and support.\n#2 resp\nO: pt placed in nc 21% with flow 200cc for multiple hr drops\nto low 80's. o2 sat maintaining and never dropping below\n98%. lsc and equal. no retractions noted. rr 30-60's. a:\nneed for flow in r/a for multiple hr drops. hr drops\nresolved since placed on nc. p: continue to monitor for\nchanges and support.\n#3 fen\nO: tf 150cc/kg of pe20 gavaged q4hours. wt. 1.770kg\n(-25gms). abd benign. voiding 2.8cc/kg in past 24 hours. no\nstools thus far this shift. ag stable 22-24cm. dstic 62.\nlytes drawn and wnl. no aspirates. spitting after each\nfeeding small to large amts. p: continue to monitor and\nsupport\n#4 g&d\no: pt in air controlled isolette swaddled with one low temp\nof 97.1 tonight. ?environmental due to aggressive weaning of\nisolette. alert and irritable with cares, calms well with\nbinki. maew. fontanelles soft and flat. a: stable p:\ncontinue to monitor for changes and support.\n#5 parents\nmom for update earlier in shift. appropriate on phone\nand asking well thought questions. concerned. a; involved\nand loving family. p: continue to monitor for changes and\nsupport.\n#6 hyperbili\no: pt with bili blanket intact. repeat bili drawn this am,\ntotal 8.3 with direct 0.4. ruddy color, sclera white.\nvoiding qs, no stools this shift. a: bili up since\nyesterday. p: continue to monitor for changes and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-29 00:00:00.000", "description": "Report", "row_id": 1794210, "text": "NURSING PROGRESS NOTES.\n\n\n#1 O: BABY REMAINS ON IV AMPICILLIN AND GENTAMICIN. TEMP\nINSTABILITY AND D/STIX OF 48 POSSIBLY RELATED TO SEPSIS.\nBABY ALSO SEEMS SOMEWHAT LESS ACTIVE THIS AFTERNOON. NNP \n AWARE. A: CONTINUES ON ANTIBIOTICS. P: CONTINUE\nTO FOLLOW CULTURE RESULTS AND FOR SIGNS OF SEPSIS.\n#2 O: BABY HAD A CLUSTER OF BRADY'S WITH DESATS AND APNEA\nTHIS MORNING AND 1 MORE EPISODE AT NOON. CHEST X-RAY DONE\nAND BABY STARTED ON CAFFEINE. BABY ALSO REMAINS IN NASAL\nCANNULA OXYGEN, 200CC FLOW, 21%. A: REQUIRES CAFFEINE. P:\nCONTINUE TO MONITOR AND PROVIDE SUPPORT AS REQUIRED.\n#3 O: TOTAL FLUIDS 80CC/KG/DAY UNTIL 1630 WHEN D/STIX WAS\n48. TOTAL FLUIDS THEN INCREASED TO 100CC/KG/DAY. FEEDS OF\nBMPE20 ADVANCED TO 60CC/KG/DAY AT 1200. FEEDS GIVEN EVERY 4\nHOURS OVER 45 MIN DUE TO A HISTORY OF SPITTING LAST NIGHT.\n1 SMALL SPIT NOTED THIS MORNING. ABDOMEN SOFT, BOWEL SOUNDS\nACTIVE, NO LOOPS, GIRTH DECREASING OVER THE DAY. VOIDING\n2.9CC/KG/HR, LAST STOOL AT 4PM YESTERDAY. IV FLUIDS OF D10\nWITH LYTES INCREASED TO 40CC/KG/DAY AT 1630. IV INFUSING\nWELL VIA PERIPHERAL IV. A: TOLERATING SLOW INCREASE IN\nGAVAGE FEEDS. P: CONTINUE TO ADVANCE FEEDS 10CC/KG AS\nTOLERATED.\n#4 O: TEMP UNSTABLE TODAY AND RANGED FROM 97.9 TO 100.5.\nBABY IS AND ACTIVE DURING CARES AND HAS SLEPT\nCOMFORTABLY BETWEEN CARES. BABY SUCKS PACIFIER WHEN OFFERED.\n A: APPROPRIATE FOR AGE. P: CONTINUE TO SUPPORT\nDEVELOPMENT.\n#5 O: MOTHER IN TO VISIT AND CHANGE BABY THIS MORNING.\nMOTHER WAS UPDATED BY MD IN HER ROOM. FAMILY MEETING BOOKED\nFOR 1130 TOMORROW. A: INVOLVED FAMILY. P: CONTINUE TO KEEP\nINFORMED.\n#6 O: BABY CHANGED FROM BILI BLANKET AS BILI HAD GONE UP TO\nDOUBLE PHOTOTHERAPY. EYES CLEAN AND COVERED. A: INCREASING\nBILI TODAY. P: DOUBLE PHOTOTHERAPY. CHECK BILI IN AM.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-31 00:00:00.000", "description": "Report", "row_id": 1794214, "text": "NICU NSG NOTE\n\n\n#1. Sepsis. O/ Conts on ampi and gent as ordered. Temps\nstable in air isolette. and active. Gent levels due\nwith next dose. A/ Day fo abx treatment. P/ Cont to\nmonitor for s/s sepsis. Cont abx as ordered. Gent levels as\nordered.\n\n#2. Resp. O/ Conts in RA with sats >95%. LS clear and equal.\nMild retx. No spells thus far this shift. On caffeine. RR\n20-60'd. A/ Stable. P/ Cont to monitor.\n\n#3. FEN. O/ Conts on TF 120cc/k/d. Enteral feeds increased\nto 90cc/k/d at mn. Receiving q4h volumes PE/BM via gavage\nover 1h. Max asp 7cc, nonbilious, partially digested\nformula. Abd soft. No loops. AG stable at 25cm. Mec stool\nx1. IV at 30cc/k/d. UO for 24h 3.3cc/k/h. Wt down 5gm. A/\nTolerating feeding advancement thus far. P/ Cont to monitor\nfor feeding intolerances. Monitor wts, I&O's.\n\n#4. G&D. O/ Awake and with cares. Sleeping quietly in\nbetween. Temps stable in air isolette. MAE. Nested on\nsheepskin. A/ AGA. P/ Cont to support developmental needs of\ninfant.\n\n#5. Parenting. O/ Mom in this eve for cares. Kangaroo'd\ninfnat x1h. Updated on status/plan. Mom conts to express\ninterest in transfer to , when stable. A/\nUpdated and involved. P/ Cont to proivde info and support to\nfamily.\n\n#6. Hyperbili. O/ Conts on single phototherapy with eye\nshields in place. Bili ordered for am. A/ Hyperbili of\nprematurity. P/ Cont phototherapy as ordered. Bili level as\nordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-30 00:00:00.000", "description": "Report", "row_id": 1794211, "text": "NPN:\n\nRESP: NC- 21%, 200cc. Sats 98-100%. RR=30's with SC retraction. BBS =/clear. A&B cluster early yesterday a.m; none since Caffeine loading dose given at 1530 yesterday. Maintenance Caffeine to begin today.\n\nCV: No audible murmur. HR=120-140. BP=68/47 (57). Color pink w/jaundice. Perfusion good.\n\nFEN: Wt=1690g (-80g). TF=100cc/kg/d. Enteral fdgs @ 70cc/kg/d; tolerating 20cc BM/PE-20 q 4 h via NG over 45 minutes w/o spits. IV of D-10-W w/NaCl 2mEq, KCl 1 mEq/100cc at 30cc/kg/d. Enteral feeds to be increased 10cc/kg as tolerated. Abd benign. U/O=3.4cc/kg/h yesterday. Mec stool x 1.\n\nID: Blood cx of neg to date. LP gram stain of neg to date. Remains on Amp & Gent (day ).\n\nG&D: Temp stable (98-99.2) in air-controlled isolette; isolette temp weaned slightly. Active and fussy w/cares. Settled quickly once contained. Tone good. Rested well. Nested in sheepskin. PKU done.\n\nBILI: Dbl Phx. Bili this a.m - 5.4/ 0.3/ 5.1 (down from 8.3).\n\nSOCIAL: Parents and Grandmother in for fdg. Father took temp and changed diaper. Mother held during gavage fdg. Family meeting planned for today, 1130.\n" }, { "category": "Nursing/other", "chartdate": "2137-01-30 00:00:00.000", "description": "Report", "row_id": 1794212, "text": "Neonatology\nDoing well. Remains in NCO2 at 200 cc. Loaded with caffeine yesterday for increased spells. Much improved today. Comfortable appearing.\nCV stable\n\nWT 1690 down 80. TF at 100 cc/k/d. BS 48 yesterday. Now higher. Feeds at 70 cc/k/d. Advancing without difficulty. Will advance TF to 120 cc/k/d.\n\nBili in range under phototherapy.\n\nRepeat BC NGSF. CSf w/o pleocytosis. Will continue double rx for 5 days then change to ampicillin. Gent levels to be checked.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-30 00:00:00.000", "description": "Report", "row_id": 1794213, "text": "NURSING PROGRESS NOTES.\n\n\n#1 O: BABY CONTINUES ON IV ANTIBIOTICS. TEMP STABLE AND\nBABY AND ACTIVE WITH CARES. A: TEMP STABLE TODAY AND\nBABY MORE ACTIVE THAN YESTERDAY. DAY 4 OF ANTIBIOTIC COURSE\nTODAY. P: DECIDE ON LENGTH OF COURSE. CHECK GENT LEVELS\nTONIGHT.\n#2 O: BREATH SOUNDS CLEAR AND EQUAL. MILD RETRACTIONS.\nBABY HAD 1 WITH APNEA REQUIRING MILD STIM. NASAL\nCANNULA DISCONTINUED AT 11AM. BABY REMAINS ON CAFFEINE. A:\nWEANED OFF OXYGEN TODAY. P: CONTINUE TO MONITOR AND PROVIDE\nSUPPORT AS REQUIRED.\n#3 O: TOTAL FLUIDS INCREASED TO 120CC/KG/DAY. FEEDS\nADVANCED TO 80CC/KG/DAY AT NOON. FEEDS GIVEN EVERY 4 HOURS\nOVER 1 HOUR. NO SPITS, 1 X 3CC ASPIRATE. ABDOMEN SOFT,\nBOWEL SOUNDS ACTIVE, NO LOOPS, GIRTH STABLE, VOIDING\n3.2CC/KG/HR OVER LAST 8 HOURS, PASSING MECONIUM. IV FLUIDS\nOF D10W WITH LYTES INFUSING WELL VIA PERIPHERAL IV. A:\nADVANCING SLOWLY ON FEEDS. P: CONTINUE TO ADVANCE FEEDS\n10CC/KG/ AS TOLERATED.\n#4 O: TEMP STABLE IN ISOLETTE TODAY. BABY IS AND\nACTIVE DURING CARES AND HAS SETTLED WELL AND SLEPT BETWEEN\nCARES. PACIFIER TAKEN WELL WHENEVER OFFERED. A:\nAPPROPRIATE FOR AGE. P: CONTINUE TO SUPPORT DEVELOPMENT.\n#5 O: MOTHER IN THIS MORNING WITH GRANDMOTHER TO VISIT AND\nHOLD BABIES TOGETHER. PARENTS IN FOR FAMILY MEETING THIS\nAFTERNOON. DAD DID BABY CARES. DAD WITH TEMP\nTAKING AND DIAPER CHANGING IN ISOLETTE. PARENTS WOULD LIKE\n TRANSFERED TO WHEN THEY ARE READY. A:\nINVOLVED FAMILY. P: CONTINUE TO KEEP INFORMED.\n#6 O: BABY DECREASED TO SINGLE PHOTOTHERAPY TODAY. A:\nIMPROVING BILI. P: CONTINUE PHOTOTHERAPY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-04 00:00:00.000", "description": "Report", "row_id": 1794231, "text": "NURSING PROGRESS NOTES.\n\n\n#1 O: BABY REMAINS ON IV ANTIBIOTICS. IV FLUSHES WELL. A:\nDAY 8 OF 14 TODAY. P: COMPLETE ANTIBIOTIC COURSE.\n#3 O: TOTAL FLUIDS 150CC/KG/DAY OF BM/PE24, INCREASING TO 26\nCALORIES TODAY. FEEDS GIVEN OVER 1 1/2 HOURS TODAY. NO\nSPITS OR LARGE ASPIRATES. ABDOMEN SOFT, BOWEL SOUNDS\nACTIVE, NO LOOPS, GIRTH STABLE, VOIDING AND STOOLING GUIAC\nNEGATIVE STOOLS. A: TOLERATING FEEDS OVER 1 1/2 HOURS. P:\nCONSIDER BREASTFEEDING/BOTTLEFEEDING WHEN PARENTS VISIT.\n#4 O: TEMP STABLE IN ISOLETTE ON AIR MODE. BABY WAKES\nDURING CARES AND IS AND ACTIVE. HE SLEEPS WELL\nBETWEEN CARES. A: APPROPRIATE FOR AGE. P: CONTINUE TO\nSUPPORT DEVELOPMENT.\n#5 O: PARENTS CALLED AND WERE UPDATED. MOTHER STILL NOT\nFEELING WELL. WOULD LIKE BABIES TRANSFERED WHEN POSSIBLE.\nA: INVOLVED FAMILY. P: CONTINUE TO KEEP INFORMED.\n#7 O: NO SPELLS NOTED TO TIME OF REPORT.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-01-31 00:00:00.000", "description": "Report", "row_id": 1794215, "text": "NPN 0700-1900\n\n\nSepsis: VSS. Cont on amp and gent. D5/14. no s/s of sepsis.\n\nRESP: Cont in RA. O2sat 97-100%. RR 30-50's with mild SCR.\nNo spells thus far. Cont on caffeine.\n\nFEN: bw=1750g. TF incr to 140cc/kg/d. Currently receiving\nIVF D10W with 2mEqNaCl and 1mEqKCl at 35cc/kg/d via PIV, and\nenteral feeds of BM/PE 20 at 105cc/kg/d, advancing 15cc/kg\n at 12/24. Tolerating well. Belly is soft and round, +BS,\nAG stable. No loops, min asp. Voiding, UO=4.2cc/kg/hr X8hr,\nno stool thus far.\n\nG&D: AFSF. MAEW. Temp stable, swaddled in air-controlled\nisolette. and active with cares, at times slightly\nirritable. Settles with paci.\n\nParents: Mom in X2. Providing cares and breastmilk. Held\ninfant X30min. Asking questions, updated at bedside.\n\nHyperbili: Phototherapy dc'd at 1200. Plan to check bili in\nAM.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-01 00:00:00.000", "description": "Report", "row_id": 1794218, "text": "Neonatology\nDOing well. RA. No spells. Comfortable\n\nWT 1720 up 35. Still requiring gavage. Tolerating feeds at 120 cc/k/d out of TF of 140. TF to be advanced to 150 and will continue feed advancement. Abdomen bneign\n\nRebound bili 4 range today. Continues off photorx.\n\n\nPlan to dc gent after 5 days of double coverage.\n\nPlan to arrange transfer to when beds available and CV access obtained for sib.\n" }, { "category": "Nursing/other", "chartdate": "2137-02-01 00:00:00.000", "description": "Report", "row_id": 1794219, "text": "Nursing Progress Note\n\n\nSEPSIS O/A: Day 5 of Antibiotic therapy (Ampi & Gent).\nRepeat blood cultures negative to date. PICC line consent\nsigned. P: Cont to monitor for s/s of sepsis.\n\nRESP O/A: Infant remains in RA; O2 sats 98-100%. RR 30-40s;\nLS clear/=. Mild sc/ic retractions noted. No spells thus far\ntoday; continues on caffeine. P: Cont to monitor resp\nstatus.\n\nFEN O/A: TF increased from 140 to 150cc/k/d. IVF off @ 1200,\nEnteral feeds currently @ 135cc/k of BM20/PE20 pg. Plan to\nincrease by 15cc/k @ 12 & 00 (Will be @ full feeds\ntonight @ 00). Infant currently recieves 39cc q4h gavaged\nover 1h 15 min. DS 88. One spit noted today, max aspirate\nof 3cc. Abdomen is soft & full, pos BS. Voiding/ trace\nstooling. P: Cont to monitor feeding tolerance while working\nup to full feeds.\n\nG&D O/A: is swaddled & nested in sheepskin; maintaining\nstable temps in an air isolette. Sleeps well between feeds,\nA/A @ care times; wide-eyed & looks around. Loves pacifier.\nP: Cont to support developmental needs.\n\nPAR O/A: Mom in to visit x2 today before being discharged\nhome. Very loving towards . Asking appropriate questions\nr/t infant's current status & plan for the day. P: Cont to\nsupport NICU family.\n\nBILI O/A: Infant's color remains ruddy. Phototherapy is\ncurrently off for rebeound of 3.9/0.2/3.7 this morning. P:\nCont to monitor for s/s of hyperbili.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-01 00:00:00.000", "description": "Report", "row_id": 1794216, "text": "NPN 1900-0700\n\n\n#1Potential sepsis. O: Temp. stable swaddled in air control\nisolette, well perfused. Pt. on ampicillin and gentamycin.\nA: No increasing signs of sepsis. P:Continue antibiotics as\nordered, monitor for increasing signs of sepsis.\n\n#2Resp. O: RR 30s to 50s, sat 96 and greater, no spells, no\nnoted drifts, BS clear and equal. On caffeine. A: No apnea\nnoted. P:Continue to monitor resp. status.\n\n#3FEN. O: Wt. 1720 gms, up 35 gms. BW 1750gms. On TF of\n140cc/k/hr, increased to 120cc/k/day enterally at 2400.On\nIVF of D10 with lytes at 20cc/k/hr. No spits with feeds\ngiven over 75 minutes, minimal aspirates. Abd. soft, stable\ngirth, no loops, active bowel sounds. Meconium stool x1.\nUrine output 3.2cc/k/hr last 24 hour period, 2.6cc/k/hr last\n8 hours. A:Advancing feeds, appears to be tolerating. P:\nContinue to advance feeds by 15cc/k/day, monitor for\ntolerance of feeds.\n\n#4G/D. O: Temp. stable swaddled in air control isolettte.\nPt. and active with cares, sleeping between cares,\ntakes pacifier. A: AGA. P: Support developmental needs.\n\n#5Parents. O: parents here for evening cares, participating\nin cares, asking appropriate questions,NNP in with parents\nto discuss and obtain consent for PIC line placement.\nA:Involved parents. P: Continue to update and support\nparents.\n\n#6Bili. O: Pt. not under phototherapy, slightly ruddy.\nP:Check bili this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-01 00:00:00.000", "description": "Report", "row_id": 1794217, "text": "Clinical Nutrition\nO:\n32 wk Gestational age BB, AGA, now on DOL 5.\nBirth wt: 1750 g (~50th %ile); current wt: 1720 g (down ~2% from birth wt.)\nHC: 30 cm (~25th to 50th %ile)\nLN: 39.5 cm (~10th to 25th %ile)\nLabs noted.\nNutrition: 140 cc/kg/d TF. EN @ 120 cc/kg/d BM/PE 20, advancing 15 cc/kg/. Feeds given over 75 min. due to spits. Remainder of fluids as D10 w/ 2 Na and 1 K. Projected intake for next 24 hrs from feeds ~93 kcal/kg/d, ~1.5 to 2.8 g pro/kg/d.\nGI: 1 lg spit, max aspirate 3 cc of partially digested feeds. Small meconium stool.\n\nA/Goals:\nTolerating feeds without GI problems except spits as noted above; extending time of feeds to compensate. Tolerating IVF wean without dstix issues. Labs noted. Initial goal for feeds is ~150 cc/kg/d of PE/BM 24, providing ~120 kcal/kg/d and ~3.3 to 3.6 g pro/kg/d. Further advances in feeds as per growth and tolerance. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 g/kg/d for wt gain, ~1 cm/wk for LN gain, and ~0.5 to 1.0 cm/wk for HC gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2137-02-02 00:00:00.000", "description": "Report", "row_id": 1794222, "text": "Neonatology Attending\n\nDay 6\n\nRemains in RA. No murmur. Weight 1770 gms (+50). TF at 150 cc/kg/d. Passing heme negative stools. Had one spit overnight. Gavaged over 1.25 hours. Benign abdomen. Day ampicillin and gentamicin. Stable temperature in air-controlled incubator.\n\nAdequate breathing control so far. Monitoring closely. Advancing to 22 cal/oz feeds. Continuing antibiotic course. Will need PICC access.\n" }, { "category": "Nursing/other", "chartdate": "2137-02-04 00:00:00.000", "description": "Report", "row_id": 1794232, "text": "Nursing NICU Note\n\n\n#1. Sepsis O: Pt. is and active . Temps stable. He\nis on Day #8 of 14 days IV AMp+Gent. LP -, re-peat blood\ncult -. A: Potential for sepsis. P: Continue to monitor\nfor s/s of infection. Continue w/ schedule of IVAB.\n\n#3. FEN O: TF 150cc/kg/d of BM/PE 26 =45cc Q 4hrs,\ngavagged over 1 1/2 hrs (for hx of spits), tolerated well.\nAbdomen is soft, +BS, no loops, no spits. Abdominal girth\nis 25-25cm. He is voiding/ no stool this shift thus far.\nA: Pt. is tolerating current nutritional plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance. Monitor for spitting and decrease gavage times\naccordingly.\n\n#4. Growth/Development O: Pt. remains in an air isolette,\nswaddled w/ stable temps. He is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat, sutures\noverriding. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n#5. Parents O: Parents in to visit for cares. They\nwere updated on pt's current status and daily plan of care.\n Parents are active participants in cares. A: Parents\nloving and involved. P: Continue to update, support and\neducate.\n\n#7. A&B's O: Pt. has had no A&B's this shift. He is on\nCaffeine. A: Potential for A&B's. P: Continue to\nmonitor.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-02 00:00:00.000", "description": "Report", "row_id": 1794220, "text": "NICU NSG NOTE\n\n\n#1. Sepsis. O/ Conts on abx as ordered. Temps 97.7-98.6 ax.\nIsolette adjusted for 97.7, with good results. and\nactive. BC ngtd. A/ Day abx for + initial BC. P/ Cont\nabx as ordered. Monitor for s/s sepsis.\n\n#2. Resp. O/ RA. LS clear and equal. RR 20-50's. SubC\nretractions. On caffeine. No spells. A/ Stable. P/ Cont to\nmonitor.\n\n#3. FEN. O/ Conts on 150cc/k/d PE20. Receiving q4h volumes\nvia gavge over 75mins. Max asp 3.6cc. Sm spit x1. Voiding\nand stooling. No loops. + BS. AG 25-25.5. Wt up 50gm. A/\nTolerating feeds. Abd exam benign. P/ Cont to monitor for\nfeeding intolerances. Monitor wts.\n\n#4. G&D. O/ Awake and with cares. Temps stable in air\nisolette. MAE. Brings hands to mouth. Nested and swaddled on\nsheepskin. A/ AGA. P/ Cont to support developmental needs of\ninfant.\n\n#5. Parenting. O/ Mom called x1 for update. Stated she will\nbe in today. A/ Updated and involved. P/ Cont to provide\ninfo and support to family.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-02 00:00:00.000", "description": "Report", "row_id": 1794221, "text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in air mode isolette. In room air, BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating advancing feeds well. Without rashes. Nonciced male, testes down bilaterally. Good tone, AFSF, PFSF, +suck, +, +pantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2137-02-03 00:00:00.000", "description": "Report", "row_id": 1794227, "text": "Neonatology Attending\nDOL 7\n\n is in room air with no apneas/bradycardias, on caffeine.\n\nNo murmur. BP 74/40 (54).\n\nWt 1770 (unchanged) on TFI 150 cc/kg/day BM22/PE22, tolerating well. Abdomen benign. Voiding and stooling normally.\n\nOn ampicillin and gentamicin, day 7 of 14 for E. coli bacteremia.\n\nA&P\nPreterm infant with respiratory and feeding immaturity, resolving sepsis. We will advance caloric density to 24 kcal/oz. We will attempt a PICC today.\n" }, { "category": "Nursing/other", "chartdate": "2137-02-03 00:00:00.000", "description": "Report", "row_id": 1794228, "text": "Nursing Progress Note\n\n\nSEPSIS O/A: Day ; Ampi/Gent antibiotic therapy. P: Cont\nto monitor for potential s/s of sepsis.\n\nFEN O/A: TF @ 150cc/k/d. Calories increased from PE/BM22 to\nPE/BM24. Recieves 44cc q4h pg. Tolerating feeds gavaged over\n1h 20 min; no spits. Abdomen benign, girths stable. Started\non Fe supps today. P: Cont to monitor feeding tolerance.\n\nG&D O/A: Temps stable in an Air isolette. is swaddled &\nnested in sheepskin. Sleeps well between feedings; quietly\nA/A with cares. Loves pacifier. P: Support developmental\nneeds.\n\nPAR O/A: Mom called today for an update. Asking appropriate\nquestions r/ status & plan for the day. P: Cont to\nsupport first time parents.\n\nAs/Bs O/A: No periods of apnea or bradycardia noted thus far\ntoday. P: Cont to monitor for spells.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-02 00:00:00.000", "description": "Report", "row_id": 1794223, "text": "Nursing Progress Note\n\n\nSEPSIS O/A: Continues on antibiotic treatment of Ampi &\nGent. Currently on day 6 of 14. P: Cont to monitor for s/s\nof sepsis.\n\nFEN O/A: TF @ 150cc/k/d. Increased calories from BM/PE 20 to\nBM/PE 22. Tolerating feeds gavaged over 1hour & 20 minutes;\nno spits. Max aspirate 2cc. Abdomen benign, pos BS.\nVoiding/no stool. P: Cont to monitor feeding tolerance.\n\nG&D O/A: Temps stable in an Air isolette. has been\nsleeping well between feedings; quietly & active with\ncares. Sucks on pacifier for comfort. P: Cont to support\ndevelopmental needs.\n\nPAR O/A: Mom called for an update this afternoon. Will be in\nto kangaroo @ the evening cares. P: Cont to support NICU\nfamily.\n\nAs/Bs O/A: Two spells noted thus far today. HR 68-72s, O2\nsats 86%, apnea noted; mild stim needed for resolve.\nContinues on caffeine. P: Cont to monitor for s/s of\nincreased spells.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-02 00:00:00.000", "description": "Report", "row_id": 1794224, "text": "NPN Adendum\nAs/Bs O/A: Correction: No spells noted for today. Maintaining O2 sats 97-100% in RA.\n" }, { "category": "Nursing/other", "chartdate": "2137-02-03 00:00:00.000", "description": "Report", "row_id": 1794225, "text": "NPN 1900-0700\n\n\n#1Potential sepsis. O:Pt. pink, well perfused, with\ncares. BP 74/40, MAP 54. Temp. stable.Remains on ampicillin\nand gentamycin. A:No increasing signs of sepsis noted. P:\nContinue to observe for increased signs of sepsis, continue\nantibiotics.\n\n#3FEN. Wt. 1770gms, no change. On TF of 150cc/k/d of\nBM22/PE22, now receiving 44cc gavaged over 1 hour, 20\nminutes. No spits, minimal aspirates. No loops, active bowel\nsounds, stable girth. Voiding and stooling. A:appears to be\ntolerating NGT feeds. P: continue to monitor for tolerance\nof feeds.\n\n#4G/D. O: Temp. stable swaddled in air control isolette.\n and active with cares, font. flat, MAE. Pt. sleeping\nbetween cares. Takes pacifier. A: AGA. P: support\ndevelopmental needs.\n\n#5Parents. O: Parents here for evening cares, participating\nwith cares. Mom held infant tonight. Parents asking\nappropriate questions, updated. A: Involved parents. P:\ncontinue to update and support parents.\n\n#7A's/B's.O:RR 30s to 50s, mild SC retractions present. BS\nclear and equal. No spells tonight. A: No bradys so far\ntonight. P: Continue to monitor, continue caffeine.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-03 00:00:00.000", "description": "Report", "row_id": 1794226, "text": "Neonatology Attending\nAddendum-Physical Examination\n\nHEENT AFSF; no nasal flaring\nCHEST no retractions; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; bs active; normal male genitalia\nCNS active, , resp to stim; tone AGA; moving all extremities\nINTEG normal\n" }, { "category": "Nursing/other", "chartdate": "2137-02-04 00:00:00.000", "description": "Report", "row_id": 1794229, "text": "Nursing Progress Note\n\n\n1.O: IV antibiotics to be given at 0400 and 0430. IV in hand\nwith prn adapter flushes well. Temp stable in a heated\nisolette. Active and with cares. To receive IV\nantibiotics for 14 days.\n A: Sepsis being treated.\n P: Continue with antibiotics for 14 days. Question if\nanother PIC attempt to be done today.\n3.O: Weight 1825 gms up 55 gms. Total fluids 150cc/kg/day.\nOn BM 24 cal or PE 24 45cc's q4h over 1 hour and 20 minutes.\nHad a few spits while gavaging with PE24 and Dad holding\ninfant. No spits during the next feeding. Abdomen soft,\npositive bowel sounds, no loops. Voiding and stooling.\nStools heme neg.\n A: Still having occaisional spits.\n P: Continue to gavage slowly. Monitor abdomen and weight\ngain.\n\n4.O: In a heated isolette swaddled and nested on sheepskin.\nActive and for cares. Sucking on pacifier\nintermittently.\n A: Gestationally appropriate.\n P: Continue with interventions.\n5.O: Mom called to find out how they were doing. Dad came in\nfor the 8 PM feeding. He took the temp, changed the diaper\nand did cord care. He asked a few questions. Da held \n the feeding and held at the same time.\n A: Loving parents. He handles the infants lovingly and\nappropriately.\n P: Inform and support.\n7.O: Resting HR 140's-150's. A soft murmur was heard. No A's\n& B's noted thus far this shift.\n A: Remains on caffeine.\n P: Document all spells.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-02-04 00:00:00.000", "description": "Report", "row_id": 1794230, "text": "Neonatology Attending\nDOL 8\n\nRemains in room air with no distress and no cardiorespiratory events, on caffeine.\n\nMurmur persists. BP 83/55 (63).\n\nWt 1825 (+55) on TFI 150 cc/kg/day BM24/PE24 over 90 minutes for reflux. Abdomen benign. Voiding and stooling normally.\n\nOn ampicillin and gentamicin day 8 of planned 14-day course.\n\nA&P\nModerately preterm infant with respiratory and feeding immaturity, E.coli bacteremia.\n\nWe will assess murmur clinically.\n\nContinue with current antibiotic regimen.\n" } ]

[ { "category": "Radiology", "chartdate": "2164-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 995058, "text": " 1:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for airspace disease\n Admitting Diagnosis: STEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with low grade fevers and left lower lobe crackles\n REASON FOR THIS EXAMINATION:\n evaluate for airspace disease\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Low-grade fever and left lower lobe crackles, evaluate for\n pneumonia.\n\n CHEST AP:\n\n Cardiac size is normal. Atelectasis at both bases is present. Some pulmonary\n plethora is seen and a degree of some failure is probably present.\n\n IMPRESSION: Bilateral atelectasis, probable early failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-22 00:00:00.000", "description": "MR CARDIAC W/FLOW/VEL P/P CONTRAST", "row_id": 995438, "text": " 1:10 PM\n MR CARDIAC W/FLOW/ /P CONTRAST Clip # \n Reason: Evidence of pericarditis, pericardial effusion\n Admitting Diagnosis: STEMI\n Contrast: MAGNEVIST Amt: 25CC .2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58y/o F admitted with late presenting STEMI s/p stent to LAD, now with chest\n pain consistent with pericardial etiology. Akinetic wall distal half on\n anterior wall and septum s/p MI\n REASON FOR THIS EXAMINATION:\n Evidence of pericarditis, pericardial effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n Patient Name: , \n\n MR#: Status: Outpatient\n Study Date: \n Indication: 58-year-old woman with a history of anterior myocardial infarction\n and LAD stent placement and persistent chest pain referred for evaluation of\n pericarditis.\n\n Requesting Physician: . and \n\n Height (in): 64\n Weight (lbs): 143\n Body Surface Area (m2): 1.71\n\n Hemodynamic Measurements\n\n Measurement Result\n Systemic Blood Pressure (mmHg) 95/49\n Heart Rate (bpm) 88\n\n Rhythm: Sinus\n\n CMR Measurements\n\n Measurement Result Female Normal\n Range\n LV End-Diastolic Dimension (mm) *58 <55\n LV End-Diastolic Dimension Index\n (mm/m2) *34 <33\n LV End-Systolic Dimension (mm) 46\n LV End-Diastolic Volume (ml) *155 <143\n LV End-Diastolic Volume Index (ml/m2) *91 <78\n LV End-Systolic Volume (ml) 104\n LV Stroke Volume (ml) 51\n LV Ejection Fraction (%) **33 >56\n LV Anteroseptal Wall Thickness (mm) 8 <10\n LV Inferolateral Wall Thickness (mm) 7 <9\n (Over)\n\n 1:10 PM\n MR CARDIAC W/FLOW/ /P CONTRAST Clip # \n Reason: Evidence of pericarditis, pericardial effusion\n Admitting Diagnosis: STEMI\n Contrast: MAGNEVIST Amt: 25CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n LV Mass (g) 108\n LV Mass Index (g/m2) *63 <60\n\n RV End-Diastolic Volume (ml) 97\n RV End-Diastolic Volume Index (ml/m2) 57 <103\n RV End-Systolic Volume (ml) 48\n RV Stroke Volume (ml) 49\n RV Ejection Fraction (%) 51 >49\n\n QFlow Net Aortic Forward Stroke\n Volume (QS net, ml) 47\n QFlow Net Pulmonary Artery Forward\n Stroke Volume (Qp net, ml) 55\n QP/QS 1.2 0.8-1.2\n QFlow Aortic Cardiac Output (l/min) 4.2\n QFlow Aortic Cardiac Index (l/min/m2) 2.5 >2.0\n QFlow Aortic Valve Regurgitant Volume\n (ml) 1\n QFlow Aortic Valve Regurgitant Fraction\n (%) 2 <5\n Mitral Valve Regurgitant Volume (ml) 4\n Mitral Valve Regurgitant Fraction (%) *8 <5\n Effective Forward LVEF (%) **30 >56\n Pulmonic Valve Regurgitant Volume (ml) 0\n Pulmonic Valve Regurgitant Fraction (%) 0 <5\n Tricuspid Valve Regurgitant Volume (ml) 0\n Tricuspid Valve Regurgitant Fraction (%) 0 <5\n\n Aortic Valve Area (2-D) (cm2) 3.3 >3.0\n Aortic Valve Area Index (cm2/m2) 1.9\n\n Ascending Aorta diameter (mm) 30 <35\n Ascending Aorta diameter Index (mm/m2) 18 <21\n Transverse Aorta diameter (mm) 24 <31\n Descending Aorta diameter (mm) 22 <25\n Descending Aorta Index (mm/m2) 13 <15\n Main Pulmonary Artery diameter (mm) 26 <27\n Main Pulmonary Artery diameter Index\n (mm/m2) *15 <15\n Left Atrium (Parasternal Long Axis)\n (mm) *41 <40\n Left Atrium (4-Chamber) (mm) *56 <52\n Right Atrium (4-Chamber) (mm) 43 <50\n Pericardial Thickness (mm) 3 <4\n Coronary Sinus diameter (mm) 11 <15\n (Over)\n\n 1:10 PM\n MR CARDIAC W/FLOW/ /P CONTRAST Clip # \n Reason: Evidence of pericarditis, pericardial effusion\n Admitting Diagnosis: STEMI\n Contrast: MAGNEVIST Amt: 25CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n * = Mildly abnormal, ** =moderately abnormal, *** = severely abnormal\n\n CMR Technical Information:\n CMR Technologists: , RT\n Nursing support: , RN\n\n eGFR: >75ml/min\n Total Gd-DTPA (Magnevist ) contrast: 25 ml (0.2mmol/kg)\n Injection site: Left hand antecubital vein\n\n Complications: None.\n\n 1) Structure: Axial dual-inversion T1-weighted images of the myocardium were\n obtained without spectral fat saturation pre-pulses in 5 mm contiguous slices.\n 2) Function: Breath-hold cine SSFP images were acquired in the left\n ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8\n mm slices with 2 mm gaps), sagittal and coronal orientations of the left\n ventricular outflow tract, and aortic valve short axis orientations. Breath-\n hold real time SSFP images were acquired in the left ventricular 2-chamber, 4-\n chamber, and mid-papillary short axis slices.\n 3) Flow: Phase-contrast cine images were obtained transverse to the aorta\n (axial plane) and main pulmonary artery (oblique plane).\n 4) Myocardial Viability/Fibrosis: Late gadolinium enhancement (LGE) images\n were obtained using a segmented inversion-recovery TFE acquisition with\n spectral fat saturation pre-pulses. Short-axis (8 mm slices with 2 mm gaps),\n 4-chamber and 2-chamber long-axis images were obtained 15 minutes after\n injection of a total of 0.2 mmol/kg gadopentetate dimeglumine (25ml Magnevist\n solution). Navigator gated high resolution late gadolinium images were also\n obtained using a segmented inversion-recovery TFE acquisition with spectral\n fat saturation pre-pulses in short-axis (4 mm slices) 20 minutes after\n injection of a total of 0.2 mmol/kg gadopentetate dimeglumine (25ml Magnevist\n solution).\n\n Findings:\n Structure and Function\n There was normal epicardial fat distribution. The pericardial thickness was\n normal. There were small bilateral pleural effusions (right greater than left)\n with associated atelectasis. There was no pericardial effusion. The origin of\n the left main coronary artery was identified in its customary position. The\n right coronary artery origin was not well visualized. The indexed diameters of\n the ascending and descending thoracic aorta were normal. The main pulmonary\n artery diameter index was mildly increased. The left atrial AP dimension was\n mildly increased. The right and left atrial lengths in the 4-chamber view\n were normal and mildly increased, respectively. The coronary sinus diameter\n was normal.\n (Over)\n\n 1:10 PM\n MR CARDIAC W/FLOW/ /P CONTRAST Clip # \n Reason: Evidence of pericarditis, pericardial effusion\n Admitting Diagnosis: STEMI\n Contrast: MAGNEVIST Amt: 25CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The left ventricular end-diastolic dimension index was mildly increased. The\n end-diastolic volume index was mildly increased. The calculated left\n ventricular ejection fraction was moderately decreased at 33% with severe\n hypokinesis of the mid septum and anterior wall and near akinesis of the\n distal septum, anterior wall, lateral wall, and inferior wall as well as the\n apex. The left ventricular apex appeared thinned and an associated 9 x 7 mm\n low signal mass was present in the blood pool adjacent to the apex, consistent\n with a thrombus. The anteroseptal and inferolateral wall thicknesses were\n normal. The left ventricular mass index was mildly increased. The right\n ventricular end-diastolic volume index was normal. The calculated right\n ventricular ejection fraction was normal at 51%, with normal free wall\n motion.\n The aortic valve was tri-leaflet with normal valve area.\n\n Quantitative Flow\n There was no significant intra-cardiac shunt. Aortic flow demonstrated no\n significant aortic regurgitation. The calculated mitral valve regurgitant\n fraction was consistent with mild mitral regurgitation. The resultant\n effective forward LVEF was moderately decreased at 30%. The right ventricular\n stroke volume and pulmonic flow demonstrated no significant pulmonic or\n tricuspid regurgitation.\n\n Myocardial Perfusion and Fibrosis\n There were areas of transmural focal hyperenhancement in the septum, anterior\n wall, apex, and distal inferior wall, consistent with myocardial\n scarring/infarction. This degree of hyperenhancement is consistent with poor\n (<20%) likelihood of functional recovery after revascularization of these\n segments.There was less than 50% transmural hyperenhancement in the\n inferoseptum and inferior wall. This degree of hyperhencement is consistent\n with intermediate (~50%) likelihood of functional recovery after\n revascularization of these segments.\n\n Impression:\n 1. Left ventricular apical thrombus.\n 2. Mildly increased left ventricular cavity size. Moderate regional left\n ventricular systolic dysfunction with severe hypokinesis of the mid septum and\n anterior wall and near akinesis of the distal septum, anterior wall, lateral\n wall, and inferior wall as well as the apex. The LVEF was moderately\n decreased at 33%. The effective forward LVEF was moderately decreased at 30%.\n There was MR evidence of myocardial scarring/infarction in the septum,\n anterior wall, apex, and distal inferior wall, consistent with myocardial\n scarring/infarction, consistent with poor (<20%) likelihood of functional\n recovery after revascularization of these segments. There was MR evidence of\n scarring/infarction in the inferoseptum and inferior wall, consistent with\n intermediate (~50%) likelihood of functional recovery after revascularization\n (Over)\n\n 1:10 PM\n MR CARDIAC W/FLOW/ /P CONTRAST Clip # \n Reason: Evidence of pericarditis, pericardial effusion\n Admitting Diagnosis: STEMI\n Contrast: MAGNEVIST Amt: 25CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of these segments.\n 3. Normal right ventricular cavity size and systolic function. The RVEF was\n normal at 51%.\n 4. Mild mitral regurgitation.\n 5. The indexed diameters of the ascending and descending thoracic aorta were\n normal. The main pulmonary artery diameter index was mildly increased.\n 6. Mild left atrial enlargement.\n 7. A note is made of small bilateral pleural effusions with associated\n atelectasis.\n\n The team caring for the patient was notified of the study results. The\n patient was already receiving therapeutic anticoagulation.\n\n The images were reviewed by . , , ,\n and .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-02-18 00:00:00.000", "description": "Report", "row_id": 1628748, "text": "CCU NRSG ADMIT NOTE\n58yo with pmhx of hypothyroidism, ^ chol. Had chest pain since initially radiating down L arm, this pain lessened and cont through but increased on therefore she went to EW. There they noted ST elevations anteriorally. She was tx'd with heparin, plavix, asa, slntg and ivntg, also iv ativan/morphine. She was transferred to cath lab for emergent cath. Cath revealed LAD with prox 90% with thrombus, mild diffuse mid and distal dz. LCX with origin OM! 50%, RCA ostial 50%. Stent was placed in LAD with good result. Integrillin was bolused and started gtt. She had ^^ filling pressures and lasix 20mg iv was given with approx 2 liters out. She was transferred to CCU for further management with sheaths intact.\n ID: Afebrile.\n CV: C/O chest pain on arrival ( of note had chest pain post procedure), EKG done and appears to be improved from post procedure. It also appears that cath labs V3 and V4 were wrongly placed. Hr 80's Sr having small runs of VT that are self limiting. K+ was 3.7 and replaced with 40meq kcl. Lopressor 5mg iv given and also given 12.5mg po lopressor, but she had a large emesis approx 30mins after rec'ing dose. Integrillin conts at 2mcg/kg/min. R groin sheaths removed at 2230 without incident. There is a small eccymotic area that is outlined but hct is stable. Distal pulses are palpable. Arrived on ivntg which was dc'd after lopressor given. 1/2 NS at 100cc/hr for 1 liter has been completed.\n Resp: O2 titrated down to 2lnp with sats in the upper 90's. Lasix 10mg ordered but held due to large urine output from cath lab. Lungs are clear throughout. No cough/sputum.\n GI/GU: Abd soft with (+) bowel sounds. Had large emesis of undigested food. No bm. No further emesis but she has c/o on/off nausea. Had excellent effect from cath lab lasix. Decrease in uo at 6am therefore rec'd 250cc ns bolus at 7am.\n MS: Lethargic during night presumably from previous morphine and fentanyl. Her neuro exam was (-). No drift/droop, oriented x 3, moving all extrems equally strong. Speech slightly slurred on admit clearing somewhat but remains groggy sounding.\nA: s/p STEMI\n hemodynamically stable\n low urine output after diuresis rec'd 250 cc bolus\nP: follow groin site\n asses uo after bolus finished\n d/c integrillin at 2pm\n cont to assess neuro\n needs smoking cessation info\n\n" }, { "category": "Nursing/other", "chartdate": "2164-02-18 00:00:00.000", "description": "Report", "row_id": 1628749, "text": "CCU progress note 7a-7p\n\nEVENTS: s/p lg STEMI. pt had chest pain this morning at 8am - EKG done - NTG s/l x 3 given w/ decrease in pain eventually to 0. ECHO done. Family in to visit this afternoon. At 330pm pt stated she had been having dull ache in chest again - - total of 2 s/l NTG given w/ good effect of 0/10 CP. c/o nausea at this time - given zofran w/ cessation of nausea.\n\nNEURO: A+Ox3 - answers appropriately. but pt remains very lethargic, with questionable residual effects from ativan given night before. family in to see pt. no neuro defecits noted. sleeping in naps and most of day. \"I'm very tired, I need to rest\". Husband at bedside all evening. Both daughters in to visit earlier in afternoon. cardiac teaching - HPI reviewed w/ family/pt.\n\nID: low grade temp 100.6 max. Given tylenol at 4pm for temp of 100 - ?post MI temp. no abx.\n\nRESP: LS dim bases. O2 increased to 3L n/c - sats dropped to 93% w/ 2nd episode of CP. sats now 96-98%. no SOB noted.\n\nCARDIAC: SR 80-90s. SBP 110-120s. Pain episode this morning \"ache\" sternal pain - given NTG x 3 s/l. EKG. Lopressor 25mg po given this morning, then w/ 2nd episode of CP \"dull ache\" w/ 2 s/l NTG this afternoon. Pt stated she didn't want to tell staff about pain since she thought it would go away again - reinforced that pt needs to notify staff with any pain/discomfort so we can make the pain go away! HR up to mid 90s this afternoon, given lopressor 25mg po and CCu team increased dose to Lopressor 25mg po TID. 2 PIV for access. CK trending down : 4am peak CPK MB 313 - 12pm CPK 1539 MB 168. pneumoboots on. no anticoagulants ordered. on asa, plavix. Integrillin to be continued for 36hrs @ 2mcg/kg/min. R groin site D+I - ecchymotic area marked, soft, no increase noted. palpable pedal pulses.\n\nGI/GU: foley patent. good u/o. abd soft +Bs. episode of nausea after CP this evening - given zofran w/ good effect. pt not eating today, not hungry. taking sips of gingerale and ice water. able to keep down medications today.\n\nPLAN: monitor for chest pain - reinforce that she has to tell staff when she is having pain!!! con't cardiac meds. cycle CKs next due 8pm. supportive care, emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2164-02-19 00:00:00.000", "description": "Report", "row_id": 1628750, "text": "CCU NPN\n58yo with anterior STEMI s/p cath which revealed 90% prox LAD lesion that was stented. CPK's ^ to now decreasing. Had chest pain after procedure with no EKG changes. Also had increase in residual chest pain x 2 that was tx'd with slntg with pain resolution.\nID: Low grade temp, rec'ing tylenol. WBC slightly ^.\nCV: She has not c/o chest pain tonight, stating that her chest feels fine. Hr remains elevated in the 90's no vea noted. Bp mostly 90's with maps in the low to mid 60's. Held lopressor at midnight due to low bp. Intern aware. Preliminary echo result show an EF on 30% with severe hypokinesis near akinesis of the distal of anterior wall and septum, distal inferior wall and apex. The basal anterior septum is also severely hypokinetic. Her R groin eccymosis appear to be ^ in size from outlined area, also is having ^^ lower back pain, team aware and in to evaluate. Hct checked and is currently stable. She rec'd oxycodone with good relief of back pain. Distal pulses are palpable. Integrilin at 2mcg/kg/min.\nResp: O2 at 2lnp with sats in the upper 90's, attempted to wean O2 to off but sats decrease down to low 90's. Lungs are clear but diminished in bases. Encouraged to take deep breaths and cough.\nGI/GU: Conts to have bouts of nausea,but no emesis, wanting to keep bucket nearby. Taking sips of water. Foley drng clear yellow urine approx 20-30cc/hr. She was basically even for yesterday and (-) approx 2 liters on admit day due to lasix given in cath lab.\nMS: She is more alert tonight. Oriented x 3, no neuro deficits noted.\nA: Low bp requiring hold of lopressor\n ^ in size of eccymosis and back pain > hct stable\n EF approx 30%\nP: cont to follow groin site ? recheck hct at noon\n integrilin to be dc'd at 8am\n follow for further chest pain\n\n" }, { "category": "Nursing/other", "chartdate": "2164-02-20 00:00:00.000", "description": "Report", "row_id": 1628755, "text": "CCU Nursing Progress note 7am-7pm\nS: The pain hurts when I cough.\n\nO: CV - Pt c/o pleuritic cp. Decreases when sitting upright and leaning forward. Pain down to 1/10 post 600mg po Motrin. Pt encouraged to c/db as she is a smoker.\nHR 90's nsr w/ no vea. BP 86-98/50-60's. Able to tolerate staggering doses of 6.25mg po lopressor tid and 3.125mg po Captopril tid without change in BP. R groin w/ ecchymotic area which is soft. Pulses +1/+1 bilat. c/o l calf numbing. Pneumoboots in place.\n\nResp - pt w/ productive cough into tissues. O2 removed as sats 100%. Sats on ra 96-100%. Encouraged to c/db.\n\nGU - Voiding on commode.\n\nGI - Appetite poor this am as pt afraid to eat. Encouraged po intake, which was better in the pm.\n\nActivity - OOB to dangle for am care, tolerated well. OOB to commode/chair w/ one assist, tolerated well. OOB to amb in room w/ one assist, tolerated well.\n\nSocial/teaching - Pt lives w/ husband in . Daughter from . Asking many questions. MD as well as this RN spent much time answering questions regarding cardiac anatomy, cardiac rehab, medications as well as risk factor modification. Pt and family w/ good understanding.\n\nA: 58yof s/p ant stemi w/ LAD stent c/b pericarditis.\n\nP: cont monitor pericarditis and med w/ Motrin RTC, cardiac echo planned for 11:30am , pt may eat breakfast without caffiene and may take meds, pt may have antianxiety meds pre rx, ambulance to be arranged, increase activity as tolerated, monitor response to beta blocker as well as ace, keep pt and family informed of poc per multidisiciplinary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2164-02-19 00:00:00.000", "description": "Report", "row_id": 1628751, "text": "CCU NPN 0700-1900\nPt to start metoprolol 6.25 mg this eve MD's. Pt foley dc's at 1815, pt dtv at 0215 . Pt to start nicotine patch this eve.\n" }, { "category": "Nursing/other", "chartdate": "2164-02-19 00:00:00.000", "description": "Report", "row_id": 1628752, "text": "CCU NPN 0700-1900\nS: \" I feel better sitting up.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 78-99 NSR no ectopy noted, NBP 83-97/44-58. Pt 0800 metoprolol dose 25 mg held d/t SBP <100, CCU Team aware, decreased to 12.5 mg metoprolol and SBP< 90. Metoprolol given in at 1040 with SBP 80's-pt asymptomatic, no c/o dizzyness, pt mentating, adequate u/o, ? pt dry-250 cc's IVF boluses given x2 with some improvement in SBP and u/o. Pt ordered for captopril-dose held d/t SBP <90, CCU intern and resident aware. Pt continues to deny CP. Bilat pedal pulses palp. R groin site CDI, area continues ecchymotic, no increase in ecchymotic area noted.\n\nResp: Pt LS CTA on Left and clear to diminshed/crackles at RLL. RR 18-23, O2 sats 96-98% on 2L n.c. Pt denies SOB, minimal non-productive cough noted.\n\nNeuro: Pt dozing intermittently throughout morning, pt with increasing alertness this afternoon A&Ox3. Pt asking appropriate questions re. disease, POC. Teaching done re. medications, smoking cessation-pt reenforced/verbalized understanding. Pt OOb to chair with minimal 2 assist (d/t lines), pt HD stable SBP 90's and HR 90's with layingdown, sitting and standing-orthostatics wnl. pt with c/o HA and lower back ache this am-relieved with repositioning and oxycodone 5mg.\n\nGI/GU: Pt abd soft, + BS x4, no stool this shift. Pt tol 2 slices of toast this am, 30-40% of macaroni and cheese. Pt enc to take PO's as ? pt dry. Pt with some c/o of indigestion (per pt, pt has felt this before with eating at home, discomfort is different than CP), maalox given, awaiting effect, + belching. Foley cath draining slightly cloudy to clearing u/o, UA sent this am, u/o 30-60 cc's/hr.\n\nID: T max 100.3 oral, bld cx's x1 sent and urine cx sent.\n\nSocial: Pt adult children and husband in at bedside this afternoon. Spoke with RN and MD re. pt condition, POC, disease, smoking cessation. Educational handouts given.\n\nA/P: 58 y/o female s/p anterior STEMI, low BP s/p beta blocker resulting in captopril being held and IVF boluses given with some effect, pt asymptomatic, denies CP. As discussed per CCU Team rounds, cont to monitor pt hemodynamics-titrate PO meds as tol, IVF as ordered. Cont to monitor resp status, u/o cx results. Cont to provide emotional support to pt and family, disease teaching. ? obtian evening lytes/hct as ordered. Awaiting further POC per CCU Team.\n" }, { "category": "Nursing/other", "chartdate": "2164-02-20 00:00:00.000", "description": "Report", "row_id": 1628753, "text": "ccu npn\n\ns:\" I can't believe that all this is happening to me\"\n\ncv: remains pain free. sr- hr 82-90. ace and bb dosages adjusted for low bp's. over the last 24/hrs meds held d/t low bp's. received captopril 3.125mg on eves and dropped bp 90/48 w map's 57-59. mn lopressor held d/t bp. md's aware of map's and bp. pt is asymptomatic w low bp. had received boluses on days ( ) for ? dry but they have had no effect on bp. sbp now 88-90 map's 58-65. hr unchanged 80-85. am ck 218 ( peak ck ). no c/o cp/sob. echo showed ef 30%,severe hypokinesis, akinesis of distal ant wall,septum,inf apex.\n\nresp; sl sob with exertion. returns to baseline w rest. bs cl/diminished @ bases. o2 @ 2l for sats 99-100%\n\ngi: tol po's and meds. denies n/v abd soft. no stool.\n\ngu: voiding on commode. steady on ft. needs assist of 1 and supervision. 1282. received lasix post procedure. creat 0.6\n\nskin; r groin w lg hematoma. area soft tender to touch. has not advanced outside markings. hct stable. ft wrm 2+/2+ bilat pulses\n\nneuro; a/o x3 follows commands. mae. intact. nicotine patch applied to r arm. social service consult ordered for support. pt talking about events of the past. the passing of her father. her mother is in nursing home.\n\nid: temp max 100.6. additional 1 set of bld cult drawn. result pending\n\nlabs: hct 32.4\n k+ 3.6 received 40 meq kcl am k+ 4.1\n\nsocial: no enquieres overnoc\n\ndispo: full\n\na/p: 58 yr old female adm initialy into w cp-rad l arm. pmh: hypothyroid,^ chol (300's) and smoker. s/p ant stemi c/b low bp. cath showed prox lad lesion- stent placed. lcx om1 50%,rca 50%. now unable to tol bb/ace introduction. follow vs,hct. f/u ss consult for suppport.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-02-20 00:00:00.000", "description": "Report", "row_id": 1628754, "text": "addendum; 0615 pt c/o mid sternal cp. states only has pain with deep inspiration and coughing. no changes in vs. md . likly pleuritic pain. cough non productive. no chg in vs. tylenol 2 tabs given.\n" }, { "category": "Echo", "chartdate": "2164-02-18 00:00:00.000", "description": "Report", "row_id": 86214, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 122/57\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:14\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. Normal IVC diameter (<2.1cm)\nwith 35-50% decrease during respiration (estimated RAP (0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - akinetic; mid anteroseptal -\nakinetic; mid inferoseptal - hypo; anterior apex - akinetic; septal apex-\nakinetic; inferior apex - akinetic; apex - akinetic;\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: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Physiologic MR\n(within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is\n0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. There\nis moderate regional left ventricular systolic dysfunction with severe\nhypokinesis/near akinesis of the distal half of the anterior wall and septum,,\ndistal inferior wall and apex. The basal anterior septum is also severely\nhypokinetic. The remaining segments contract normally (LVEF = 30 %). No masses\nor thrombi are seen in the left ventricle. 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 leaflets are mildly thickened. There is no mitral valve prolapse.\nPhysiologic mitral regurgitation is seen (within normal limits). The pulmonary\nartery systolic pressure could not be determined. There is a small pericardial\neffusion around the right atrium (clip ) without evidence of hemodynamic\ncompromise.\n\nIMPRESSION: Normal left ventricular cavity size with extensive regional\nsystolic dysfunction c/w CAD (proximal/mid LAD distribution).\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": "2164-02-24 00:00:00.000", "description": "Report", "row_id": 213979, "text": "\n\n\n" }, { "category": "ECG", "chartdate": "2164-02-23 00:00:00.000", "description": "Report", "row_id": 213980, "text": "Probable non-sinus supraventricular rhythm. Low limb lead voltage.\nST-T wave abnormalities. Late R wave progression with Q waves in\nleads I and II. Mild ST segment elevations and T wave inversions\nacross the precordium. Consider anterior myocardial infarction,\nage indetermiate. Compared to the previous tracing of \nno significant change.\n\n" }, { "category": "ECG", "chartdate": "2164-02-22 00:00:00.000", "description": "Report", "row_id": 213981, "text": "Sinus and ectopic atrial rhythm\nLow limb lead voltage\nShort P-R interval\nAnteroseptal infarct - age undetermined\nInferior/lateral T changes\nSince previous tracing of , atrial premature complexes not seen\n\n" }, { "category": "ECG", "chartdate": "2164-02-21 00:00:00.000", "description": "Report", "row_id": 213982, "text": "Probable ectopic atrial rhythm\nAtrial premature complex\nAnterior myocardial infarction with ST-T wave configuration suggesting\nacute/recent/in evolution process\nDiffuse ST-T wave abnormalities\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2164-02-21 00:00:00.000", "description": "Report", "row_id": 213983, "text": "Probable ectopic atrial rhythm\nAtrial premature complex\nAnterior myocardial infarction with ST-T wave configuration suggesting\nacute/recent/in evolution process\nDiffuse ST-T wave abnormalities\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2164-02-20 00:00:00.000", "description": "Report", "row_id": 213984, "text": "Atrial ectopic rhythm with atrial ectopic activity. Anteroseptal myocardial\ninfarction. Compared to the previous tracing of no major change.\n\n" }, { "category": "ECG", "chartdate": "2164-02-19 00:00:00.000", "description": "Report", "row_id": 213985, "text": "Sinus rhythm with atrial ectopy. Anteroseptal myocardial infarction pattern\nremains unchanged. No change from prior tracing.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2164-02-18 00:00:00.000", "description": "Report", "row_id": 213986, "text": "Sinus rhythm. Atrial and ventricular ectopy. Compared to the previous tracing\nanteroseptal myocardial infarction pattern persists. There is now occasional\nectopy.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2164-02-17 00:00:00.000", "description": "Report", "row_id": 213987, "text": "Sinus rhythm. Compared to the previous tracing anterior ST segment elevations\nare now more prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2164-02-17 00:00:00.000", "description": "Report", "row_id": 213988, "text": "Sinus rhythm. Probable anteroseptal myocardial infarction. No previous\ntracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2118-12-31 00:00:00.000", "description": "VISERAL SEL/SUPERSEL A-GRAM", "row_id": 1222849, "text": " 10:23 PM\n MESSENERTIC Clip # \n Reason: Angiography\n Admitting Diagnosis: ACUTE PANCREATITIS\n Contrast: OMNIPAQUE Amt: 105\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER EA 1ST ORDER ABD/PEL/LOWER EXT *\n * VISERAL SEL/SUPERSEL A-GRAM VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with chronic pancreatitis now w/ hematemesis and BRBPR likely\n pseudocyst eroding into vessels around pylorus/duodenum\n REASON FOR THIS EXAMINATION:\n Angiography\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old female with chronic pancreatitis complicated by multiple\n pseudocysts with active upper GI bleed.\n\n OPERATORS: Dr. (resident), Dr. (fellow),\n and Dr. (attending). The attending radiologist, Dr.\n , was present and supervised throughout the procedure.\n\n ANESTHESIA: Sedation was managed by the critical care nurse with divided\n doses of fentanyl and Versed with continuous hemodynamic monitoring. The\n patient was intubated and sedated throughout the procedure.\n\n PROCEDURE: As the patient was intubated and sedated at the time of requested\n procedure, written informed consent was obtained from the patient's husband\n via telephone after the risks, benefits, and alternatives were explained. The\n patient was brought to the angiography suite and positioned supine on the\n table. Both the right groin and right neck were prepped in usual sterile\n fashion. Using son and fluoroscopic guidance, a 19-gauge single-wall\n needle was utilized to access the right femoral artery. A 0.035 wire was\n advanced into the aorta. Subsequently, a C2 catheter was advanced over the\n wire and was utilized to cannulate the celiac axis. A selective celiac\n arteriogram was completed at this level , which demonstrated normal\n conventional anatomy without active extravasation. The gastroduodenal artery\n was well visualized and demonstrated no abnormal bleeding around the site of\n the known pseudocyst. Subsequently, the catheter was used to cannulate the\n SMA. Arteriogram at this level demonstrated normal conventional anatomy. At\n this point, a small branch of the inferior pancreaticoduodenal artery\n demonstrated active extravasation into the region of the pancreas. A repeat\n SMA angiogram was completed using an angle to further evaluate the access\n point for the small branch with bleeding. Multiple attempts were made to\n cannulate the selective branch which demonstrated active extravasation.\n Selective catheterization and arteriogram of the main\n inferiorpancreaticoduodenal artery trunk was obtained. Multiple microcatheters\n and wires including the Renegade and angled Merit microcatheters, and the\n Transend, Fathom, and Headliner wires were utilized. Despite multiple\n attempts, cannulation was unsuccessful. Decision was made to abort the\n (Over)\n\n 10:23 PM\n MESSENERTIC Clip # \n Reason: Angiography\n Admitting Diagnosis: ACUTE PANCREATITIS\n Contrast: OMNIPAQUE Amt: 105\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n procedure at this time, and all wires and catheters were removed. Pressure\n was held at the femoral arterial access site for a total of 15 minutes.\n\n TRIPLE TRIPLE-LUMEN CENTRAL VENOUS CATHETER: For additional access, a\n triple-lumen catheter was placed into the right internal jugular vein.\n Son guidance was utilized to access the right internal jugular vein\n with a micropuncture needle. Subsequently, wire was advanced into the\n SVC. A 5 French micropuncture sheath was advanced over the wire. The inner\n dilator and 0.018 wire were removed and exchanged for a 0.035 wire which\n was advanced into the SVC. The catheter tract was dilated with a 6 French\n dilator. Subsequently , a 7 French triple-lumen central venous catheter was\n advanced into the SVC with the tip terminating in the low SVC. The catheter\n was secured to the skin using sutures, and 4 cm of catheter remained outside\n of the skin.\n\n Sterile dressings were applied to both puncture sites. After the procedure, a\n 2 x 3-cm small hematoma was visualized at the right femoral puncture site.\n The patient was transferred to the ICU in stable condition.\n\n FINDINGS:\n 1. Conventional anatomy of the celiac axis with well-visualized\n gastroduodenal artery without active bleeding.\n 2. Conventional anatomy of the SMA origin with active extravasation seen from\n a small branch of the inferior pancreaticoduodenal artery.\n\n IMPRESSION:\n\n 1. Active extravasation of a branch of the inferior pancreaticoduodenal\n artery, which could not be selectively catheterized.\n\n 2. Successful placement of a triple-lumen central venous catheter in the\n right internal jugular vein with the tip in the lower SVC. Line is ready to\n use.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2174-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1221383, "text": " 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Single AP upright chest view was read in comparison with prior\n chest radiographs from , with the most recent from , .\n\n FINDINGS:\n\n Both lung volumes are low, but no opacities of concern. Left internal\n jugular line ends at mid/lower SVC. Patient is status post CABG with intact\n sternal sutures. Heart size, mediastinal and hilar contours are normal.\n There is no pleural abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-30 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1221589, "text": " 9:19 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for infarct post cardiac surgery\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with infarct in the rightcorona radiata and left centrum\n semi-ovale.\n REASON FOR THIS EXAMINATION:\n eval for infarct post cardiac surgery\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:36 PM\n Scattered foci of predominantly deep white matter infarctions, likely related\n to hypoperfusion, though also with cortical involvement of the largest focus\n within the left parietal white matter which may suggest a embolic etiology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with infarct in the right corona radiata and\n left centrum semiovale. Evaluate for infarction.\n\n EXAMINATION: MR of the head without intravenous contrast.\n\n COMPARISONS: CT from .\n\n TECHNIQUE: Multiplanar, multisequence MR images were obtained through the\n brain without the administration of intravenous contrast. Sequences include\n sagittal T1, axial FLAIR, axial T2, axial T2-GRE and axial diffusion-weighted\n images.\n\n FINDINGS:\n\n There are multifocal small scattered foci of slow diffusion, the largest focus\n measuring 13 mm centered within the left parietal white matter, most\n compatible with small areas of deep white infarction. There appears to be\n possible cortical infarction involving the left parietal lobe (8:19) In\n addition, there is subcortical and periventricular white matter compatible\n with mild changes related to small vessel ischemic disease. There is isolated\n focus of loss of signal on gradient-recalled images within the subarachnoid\n space adjacent to the right parietal lobe likely related to a thrombosed\n cortical vein. No calcification in this region is demonstrated on the current\n CT.\n\n There is no evidence of hemorrhage, edema, masses, or mass effect. The\n ventricles and sulci are normal in size and configuration.\n\n The major intracranial flow voids are preserved. The paranasal sinuses and\n mastoid air cells appear well aerated.\n\n IMPRESSION: Scattered foci of predominantly deep white matter infarctions,\n likely related to hypoperfusion, though also with cortical involvement of the\n largest focus within the left parietal white matter which may suggest a\n embolic etiology.\n (Over)\n\n 9:19 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for infarct post cardiac surgery\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2174-11-30 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1221590, "text": ", R. CSURG FA6A 9:19 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for infarct post cardiac surgery\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with infarct in the rightcorona radiata and left centrum\n semi-ovale.\n REASON FOR THIS EXAMINATION:\n eval for infarct post cardiac surgery\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Scattered foci of predominantly deep white matter infarctions, likely related\n to hypoperfusion, though also with cortical involvement of the largest focus\n within the left parietal white matter which may suggest a embolic etiology.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1220364, "text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh MON 10:35 AM\n Bibasilar atelectasis, more prominent on the left than the right. An\n underlying infectious process cannot be entirely excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post aortic valve replacement.\n\n STUDY: Portable AP semi-upright chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube sits 5 cm above the carina. A feeding tube\n tip projects over the stomach. A left-sided central venous catheter sits at\n the junction of brachiocephalic veins. A right-sided IJ catheter containing a\n Swan-Ganz catheter terminates in the right main pulmonary artery. Sternotomy\n wires and prosthetic valve are stable in appearance. The heart size is\n enlarged but stable. The mediastinal contours are also stable. The lungs\n show mild basilar atelectasis, more prominent on the left than the right.\n There is no large pleural effusion or pneumothorax.\n\n IMPRESSION: Bibasilar atelectasis, more prominent on the left than the right.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1220365, "text": ", R. CSURG CSRU 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Bibasilar atelectasis, more prominent on the left than the right. An\n underlying infectious process cannot be entirely excluded.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1220307, "text": " 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for DHT placement\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with DHT placed\n REASON FOR THIS EXAMINATION:\n eval for DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess Dobbhoff tube.\n\n Dobbhoff tube tip is in the stomach. The tube is coiled in the stomach.\n There is an air-distended loop of bowel in the right upper quadrant, likely\n colon. Normal diameter air-filled small bowel loops are also noted in the\n right upper quadrant.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1220386, "text": " 9:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: no contrast r/o bleed - s/p AVR with low plts\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p AVR with low plts\n REASON FOR THIS EXAMINATION:\n no contrast r/o bleed - s/p AVR with low plts\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n WET READ: TXPb MON 11:24 AM\n No evidence of hemorrhage or mass effect. Thickening of the falx at the\n vertex, likely non-specific. Scattered foci of cystic encephalomalacia likely\n old lacunar infarcts. If there is continued clinical concern, MRI is more\n sensitive for the detection of small hemorrhage and infarction. - Aerosolized\n secretions in sphenoidal sinuses and fluid opacification of ethmoid air\n cells.\n\n WET READ VERSION #1\n WET READ VERSION #2 TXPb MON 11:23 AM\n No evidence of hemorrhage or mass effect. Thickening of the falx at the\n vertex, likely non-specific. Scattered foci of cystic encephalomalacia likely\n old lacunar infarcts. If there is continued clinical concern, MRI is more\n sensitive for the detection of small hemorrhage and infarction.\n\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\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. No\n fracture is identified. Aerosolized secretions are noted in the bilateral\n sphenoidal sinuses with opacification of ethmoid air cells. The mastoid air\n cells and middle ear cavities are clear.\n\n IMPRESSION:\n\n 1. No evidence of hemorrhage.\n\n 2. Fluid opacification of sphenoid and ethmoid airspaces may be due to\n pooling of secretions due to recent operation, or inflammatory process in the\n appropriate clinical setting.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1219989, "text": " 5:22 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for position of new RIJ swan\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new swan\n REASON FOR THIS EXAMINATION:\n eval for position of new RIJ swan\n ______________________________________________________________________________\n WET READ: 8:24 PM\n Swan-Ganz catheter terminates in right main pulmonary outflow tract. ETT 3.8\n cm above carina. Left central line terminates at junction of brachiocephalic\n and SVC. Remainder of exam unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:30 P.M. \n\n HISTORY: New Swan-Ganz catheter.\n\n IMPRESSION: AP chest compared to :\n\n Pulmonary flotation catheter traverses a right jugular introducer and ends in\n the right pulmonary artery. Moderate cardiomegaly is stable. There is\n probably no pulmonary edema. Pleural effusions are small if any. No\n pneumothorax. ET tube in standard placement. Nasogastric feeding tube passes\n into the stomach and out of view, obscuring a feeding tube that takes the same\n course.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1220591, "text": ", R. CSURG CSRU 11:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p triple lumen insertion\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION: Status post central line replacement without evidence of\n complication.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-09 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1218731, "text": " 8:06 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: please eval for carotid stenosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with severe aortic stenosis\n REASON FOR THIS EXAMINATION:\n please eval for carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 63-year-old male with severe aortic stenosis.\n\n FINDINGS:\n\n RIGHT: B-mode images show minimal smooth plaque. The common carotid artery\n waveform is within normal limits and has a peak velocity of 62 cm/sec. The\n ICA velocities are 90/17. The ECA velocity is 101. The ICA/CCA ratio is 1.5.\n By velocity criteria, this correlates with a 1-39% stenosis.\n\n LEFT: B-mode images show mild, heterogeneous plaque. The common carotid\n waveform is within normal limits and has a peak velocity of 74 cm/sec. The\n ICA velocities are 71/25. The ECA velocity is 71. The ICA/CCA ratio is 1.0.\n By velocity criteria, this correlates with a 1-39% stenosis.\n\n Both vertebral arteries have antegrade, monophasic flow.\n\n IMPRESSION: Minimal plaque with bilateral 1-39% stenosis. Antegrade\n vertebral flow. No available studies for comparison.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1219526, "text": " 6:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p dialysis line placement, tip?\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with AVR, RV failure, renal failure\n REASON FOR THIS EXAMINATION:\n s/p dialysis line placement, tip?\n ______________________________________________________________________________\n WET READ: EAGg MON 7:04 PM\n New left IJ terminates at confluence of left brachiocephalic vein and SVC. ETT\n 4.3 cm above carina. Swan-Ganz/NGT unchanged. Low lung volumes with decreased\n post-operative mediastinal widening.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Renal failure, status post dialysis.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, patient has received a new\n internal jugular vein catheter. The tip projects over the confluence of the\n left brachiocephalic vein and the superior vena cava. The tip of the ETT is 4\n cm above the carina. Swan-Ganz catheter is unchanged. Low lung volumes with\n decreased postoperative transparency and mild mediastinal widening. No\n pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1220590, "text": " 11:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p triple lumen insertion\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE 2:47 PM\n IMPRESSION: Status post central line replacement without evidence of\n complication.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male, status post insertion of a triple-lumen central\n venous catheter.\n\n STUDY: Portable semi-upright AP chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The patient is rotated to the right. Midline sternotomy wires\n appear unchanged. There has been retraction of the Swan-Ganz catheter from\n the right IJ approach. There has been replacement of a left internal jugular\n line with a new line that terminates at the lower SVC. The endotracheal tube\n tip seats 3.5 cm above the carina. An endogastric tube tip projects over the\n expected region of the stomach. The heart size is enlarged but stable\n compared to prior study given differences in positioning and technique. There\n is no pneumothorax. Subtle haze over the right upper lung may a small amount\n of pleural fluid in that locale for which attention can be paid on follow-up\n imaging.\n\n IMPRESSION: Status post central line replacement without evidence of\n complication.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1218831, "text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube position, acute thoracic process, rib fracture\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with respiratory failure, VT arrest wtih CPR, intubated\n REASON FOR THIS EXAMINATION:\n ET tube position, acute thoracic process, rib fracture\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, rib fractures.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The tip of the endotracheal tube projects 3.5 cm above the carina.\n The nasogastric tube shows a normal course. Moderate cardiomegaly with mild\n pulmonary edema. No pleural effusions. No pneumonia. Minimal retrocardiac\n atelectasis. There is no evidence of rib fractures on the current radiograph.\n If clinically relevant, a dedicated rib series should be obtained.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219375, "text": " 7:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p ct d/c, check swan placement\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with avr\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, check swan placement\n ______________________________________________________________________________\n WET READ: GMSj SUN 9:12 PM\n ET tube 3.1 cm from the carina. Interval removal of right sided-chest tube. NG\n at least in the stomach, tip not imaged. Swan-Ganz catheter in standard\n position terminating within the mediastinal contours in the region of the main\n pulmonary artery. No pneumothorax. Stable enlargement of the\n cardiomediastinal contours. Mild pulmonary vascular congestion. No large\n effusions. Unchanged bibasilar atelectasis. GSenapati \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:11 P.M. ON \n\n HISTORY: AVR. Chest tube discontinued. Check Swan-Ganz line.\n\n IMPRESSION: AP chest compared to through 11:\n\n Post-operative widening of the cardiomediastinal silhouette is stable. Some\n of this is due to mediastinal venous distention. Lung volumes have improved,\n mild interstitial edema is still present. Pleural effusions are small if any.\n Atelectasis at the left base is subsegmental. No pneumothorax.\n\n Tip of the Swan-Ganz catheter points rightward probably in the proximal right\n pulmonary artery. Nasogastric tube passes below the diaphragm and out of\n view. ET tube has been advanced to the upper margin of the clavicles, no less\n than 4 cm from the carina, with the chin slightly flexed. Position is\n acceptable.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1218878, "text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man intubated s/p VT arrest\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cardiac arrest, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Low lung volumes, intubation, moderate cardiomegaly, and mild fluid\n overload. No pleural effusions. No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-19 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1220197, "text": " 10:12 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for ileus\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with high TF residual\n REASON FOR THIS EXAMINATION:\n eval for ileus\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with suspected ileus.\n\n Two views of the abdomen (limited) were brought to our review.\n\n There is no evidence of bowel dilatation to suggest ileus. No evidence of\n bowel obstruction or gas paucity is noted.\n\n Note again is made that this study is extremely limited due patient's habitus.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-16 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1219785, "text": " 12:48 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o DVT now with sig RV failure ? PE related\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man\n REASON FOR THIS EXAMINATION:\n r/o DVT now with sig RV failure ? PE related\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 63-year-old man with RV failure, question PE related.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, femoral vein, popliteal and tibial veins. Normal flow,\n compression, and augmentation is seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-16 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1219808, "text": " 2:06 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: elevated WBC and TB check gall bladder\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n elevated WBC and TB check gall bladder\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 63-year-old man with elevated WBC and TB, check gallbladder.\n\n COMPARISON: Liver ultrasound, .\n\n FINDINGS: Note is made that this is an extremely limited ultrasound due to\n the patient's body habitus. Despite diligent effort, the gallbladder could\n not be identified. No gross abnormality is seen within the liver; however,\n visualization is limited. No gross ductal dilatation is identified. No\n ascites is seen in the right upper quadrant. The main portal vein is patent\n with hepatopetal flow.\n\n IMPRESSION: Extremely limited ultrasound due to the patient's body habitus.\n Despite diligent effort, the gallbladder could not be identified. If further\n evaluation of the gallbladder is indicated, CT, MR, or nuclear medicine scan\n could be obtained.\n\n" }, { "category": "Radiology", "chartdate": "2174-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1219299, "text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:10 A.M. \n\n HISTORY: AVR. Check for effusions.\n\n IMPRESSION: AP chest compared to and 9:\n\n Postoperative widening of the cardiomediastinal silhouette is mild relative to\n the preoperative appearance, and unchanged since . Endotracheal\n tube has been partially withdrawn and now ends above the upper margin of the\n clavicles no less than 6 cm from the carina and should be advanced 3 cm for\n more secured seating, if the patient remains intubated.\n\n A Swan-Ganz catheter ends in the pulmonary outflow tract. Lung volumes are\n low but atelectasis is relatively mild and there is no pulmonary edema or\n pneumothorax. Nasogastric tube can be traced as far as the upper stomach and\n passes out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-16 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1219835, "text": " 4:56 PM\n PORTABLE ABDOMEN Clip # \n Reason: check dobhoff tube placement\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old\n REASON FOR THIS EXAMINATION:\n check dobhoff tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube check.\n\n FINDINGS: The film is of limited quality and fails to include the full\n anatomic area of interest. Accounting for this, it appears that the Dobbhoff\n tube is in the post-pyloric position, possibly in the third part of the\n duodenum. There is a nonspecific bowel gas pattern. Degenerative changes are\n noted about the lower lumbar spine.\n\n IMPRESSION: Accounting for limitations in film quality the Dobbhoff tube\n appears to be in appropriate position.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-11-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1219151, "text": " 5:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION\n Admitting Diagnosis: AORTIC STENOSIS\\AVR; CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with AVR\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION\n ______________________________________________________________________________\n WET READ: TXCf FRI 9:59 PM\n ET tube 2.5 cm above the carina. swan- catheter, right chest tube,\n mediastinal drain noted, NG tube in the stomach; medisatinum enlarged, likely\n postsurgical. decreased lung volumes. left lung base atelectasis. perihilar\n pulmonary vascular congestion.\n chadashvili \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:15 P.M., \n\n HISTORY: Recent AVR. Fast track for early extubation.\n\n IMPRESSION: AP chest compared to the preoperative chest radiograph on\n :\n\n Moderate widening of the postoperative cardiomediastinal silhouette could be\n due to vascular engorgement or some hematoma. Followup advised.\n\n Pulmonary edema is mild in the left lung, absent on the right, although there\n is more right lower lobe atelectasis than preoperatively. There is no\n pneumothorax or large pleural effusion. ET tube and Swan-Ganz catheter are in\n standard placements. Nasogastric tube would need to be advanced 5 cm to move\n all the side ports into the stomach. Midline or right pleural drain noted.\n No pneumothorax.\n\n\n" }, { "category": "Echo", "chartdate": "2174-11-29 00:00:00.000", "description": "Report", "row_id": 93772, "text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery with mechanical AVR. Re-evaluate RV/LV function\nHeight: (in) 67\nWeight (lb): 262\nBSA (m2): 2.27 m2\nBP (mm Hg): 134/90\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 13:00\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\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR].\n\nAORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients. Trace AR. [The amount\nof AR is normal for this AVR.]\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral\nannular calcification.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR. Mild PA systolic hypertension.\nGiven severity of TR, PASP may be underestimated due to elevated RA pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The right ventricular cavity is moderately dilated with normal\nfree wall contractility. [Intrinsic function may be depressed given the\nseverity of tricuspid regurgitation.] A mechanical aortic valve prosthesis is\npresent. The aortic valve prosthesis appears well seated, with normal disc\nmotion and transvalvular gradients. Trace aortic regurgitation is seen. [The\namount of regurgitation present is normal for this prosthetic aortic valve.]\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. Moderate to severe [3+] tricuspid regurgitation is seen. There\nis mild pulmonary artery systolic hypertension. [In the setting of at least\nmoderate to severe tricuspid regurgitation, the estimated pulmonary artery\nsystolic pressure may be underestimated due to a very high right atrial\npressure.] There is an anterior space which most likely represents a prominent\nfat pad.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global biventricular systolic function. Well\nseated, normal functioning aortic valve prosthesis. Moderate to severe\ntricuspid regurgitation. Pulmonary artery hypertension. Right ventricular\ncavity enlargement with preserved free wall motion.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis IS recommended. Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Echo", "chartdate": "2174-11-16 00:00:00.000", "description": "Report", "row_id": 93773, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function.\nHeight: (in) 67\nWeight (lb): 286\nBSA (m2): 2.36 m2\nBP (mm Hg): 102/54\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 14:39\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: 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: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. No thoracic aortic dissection.\n\nAORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well seated, normal\nleaflet/disc motion and transvalvular gradients. Trace AR. [The amount of AR\nis normal for this AVR.]\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). No glycopyrrolate was\nadministered. No TEE related complications. Echocardiographic results were\nreviewed by telephone with the MD caring for the patient.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. The interatrial septum\nbows towards the left atrium suggestive of increased right atrial pressure.\nOverall left ventricular systolic function is normal (LVEF>55%). The right\nventricular cavity is dilated with severe hypokinesis to akinesis of the basal\n2/3rds of the free wall. The ascending, transverse and descending thoracic\naorta are normal in diameter and free of atherosclerotic plaque to 40 cm from\nthe incisors. No thoracic aortic dissection is seen. A mechanical aortic valve\nprosthesis is present. The aortic valve prosthesis appears well seated, with\nnormal leaflet/disc motion. Trace aortic regurgitation is seen. [The amount of\nregurgitation present is normal for this prosthetic aortic valve.] The mitral\nvalve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Right ventricular cavity dilation with severely depressed systolic\nfunction and right atiral septal motion consistent with increased right atrial\npressure. Well seated, well functioning mechanical aortic valve prosthesis.\nMild to moderate mitral regurgitation. Mild to moderate tricuspid\nregurgitation.\nDr. was notified by telephone on at 11:40.\n\nCompared with the prior study (images reviewed) of /2011the right\nventricular apical function appears slightly worse.\n\n\n" }, { "category": "Echo", "chartdate": "2174-11-14 00:00:00.000", "description": "Report", "row_id": 93774, "text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Right ventricular function.\nHeight: (in) 67\nWeight (lb): 286\nBSA (m2): 2.36 m2\nBP (mm Hg): 92/47\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:38\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal ascending aorta diameter. No thoracic aortic\ndissection.\n\nAORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients. Trace AR. [The amount\nof AR is normal for this AVR.]\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). No glycopyrrolate was\nadministered. No TEE related complications. MD caring for the patient was\nnotified of the echocardiographic results by e-mail. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. The left atrial appendage is relatively small. The underlying\nrhythm appears to be complete heart block. No atrial septal defect is seen by\n2D or color Doppler. The interatrial septum bows towards the left atrium\nsuggestive of increased right atrial pressure. There is mild symmetric left\nventricular hypertrophy with relatively small cavity size. Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is dilated with severe hypokinesis of the basal 2/3rds of the free\nwall. The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque to 42 cm from the incisors. No\nthoracic aortic dissection is seen. A mechanical aortic valve prosthesis is\npresent. The aortic valve prosthesis appears well seated, with normal disc\nmotion. Trace aortic regurgitation is seen. . [The amount of regurgitation\npresent is normal for this prosthetic aortic valve.] The mitral valve leaflets\nare mildly thickened. Mild to moderate (+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nIMPRESSION: Right ventricular cavity dilation with severely depressed systolic\nfunction and right atrial septal motion consistent with increased right atrial\npressure. Well seated, well functioning mechanical aortic valve prosthesis.\nMild to moderate mitral regurgitation. Mild to moderate tricuspid\nregurgitation.\n\n\n" }, { "category": "Echo", "chartdate": "2174-11-13 00:00:00.000", "description": "Report", "row_id": 93775, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 67\nWeight (lb): 271\nBSA (m2): 2.30 m2\nBP (mm Hg): 107/56\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 14:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient is on Amiodarone 0.5 mg/h, milrinone at 0.375 mcg/kg/min, Levophed at\n0.1 mcg/kg/min and vassopressin at 2.4 units/h.\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%). Transmitral\nDoppler E>A and TDI E/e' <8 suggesting normal diastolic function, and normal\nLV filling pressure (PCWP<12mmHg).\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: No TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: Effusion echo dense, c/w blood, inflammation or other cellular\nelements. No echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - poor subcostal views. Suboptimal image quality -\nbandages, defibrillator pads or electrodes. The patient appears to be in sinus\nrhythm. Results were reviewed with the Cardiology Fellow involved with the\npatient's care.\n\nConclusions:\nSuboptimal images. The left atrium is elongated. The right atrium is\nmoderately dilated. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Overall left ventricular systolic\nfunction appears to be normal (LVEF>55%). Tissue Doppler imaging suggests a\nnormal left ventricular filling pressure (PCWP<12mmHg). The right ventricular\ncavity is moderately dilated with what appears to be normal free wall\ncontractility (suboptimal image quality). Trivial mitral regurgitation is\nseen. The pulmonary artery systolic pressure could not be determined. There is\nan echo dense effusion, consistent with blood, inflammation or other cellular\nelements. The effusion cannot be quantified due to poor image quality. There\nare no echocardiographic signs of tamponade. The gradient across the aortic\nvalve may be elevated.\n\nIMPRESSION: Limited study with suboptimal image quality. The left ventricular\nsystolic function is normal. Right ventricle is moderately dilated with what\nappears to be normal function. The gradient across the aortic valve may be\nelevated.\n\nMs. was notified by phone of the results on at 14:33.\n\n\n" }, { "category": "Echo", "chartdate": "2174-11-11 00:00:00.000", "description": "Report", "row_id": 93776, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment. Shortness of breath.\nHeight: (in) 67\nWeight (lb): 286\nBSA (m2): 2.36 m2\nBP (mm Hg): 116/67\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 12:28\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was under general anesthesia throughout the procedure. No TEE related\ncomplications. The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient. See Conclusions for\npost-bypass data\n\nConclusions:\nPRE-BYPASS: No spontaneous echo contrast is seen in the body of the left\natrium or left atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. Regional left ventricular wall motion\nis normal. Overall left ventricular systolic function is mildly depressed\n(LVEF= 40-45 %). Right ventricular chamber size and free wall motion are\nnormal. There are simple atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets are\nseverely thickened/deformed. There is critical aortic valve stenosis (valve\narea <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve\nleaflets are moderately thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion. Dr. was\nnotified in person of the results at time of surgery.\n\nPOST-BYPASS: The patient is in sinus rhythm. The patient is on an epinephrine\ninfusion. Right ventricular function on initial post-bypass images appears\nmoderately depressed, then improves back to baseline after chest closure. Left\nventricular function is unchanged. There is a well-seated, well-positioned\nmechanical prosthetic valve in the aortic position. No paravalvular leak is\nseen. Characteristic washing jets are seen. There is a mean gradient of 21\nmmHg at a cardiac output of 4.1 L/min. Mitral regurgitation is unchanged. The\naorta is intact post-decannulation.\n\n\n" }, { "category": "Echo", "chartdate": "2174-11-09 00:00:00.000", "description": "Report", "row_id": 93777, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. AS, LV s/p VF arrest.\nHeight: (in) 67\nWeight (lb): 286\nBSA (m2): 2.36 m2\nBP (mm Hg): 142/75\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 17:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root.\n\nAORTIC VALVE: Significant AS is present (not quantified) Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification.\n\nTRICUSPID VALVE: Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild regional left ventricular systolic dysfunction with probable\nhypokinesis of the distal anterior septum. Right ventricular chamber size and\nfree wall motion are normal. Significant aortic stenosis is present (not\nquantified). Moderate (2+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Aortic stenosis is probably severe. At least moderate aortic\nregurgitation. Image quality is suboptimal. The mid to distal anterior septum\nis probably mildly hypokinetic.\n\n\n" }, { "category": "ECG", "chartdate": "2174-11-19 00:00:00.000", "description": "Report", "row_id": 249355, "text": "Sinus tachycardia. Anterolateral ST-T wave changes may be due to myocardial\nischemia. Compared to the previous tracing of the heart rate is\nincreased. Wenckebach rhythm is not present. Anterolateral ST-T wave changes\npersist. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2174-11-16 00:00:00.000", "description": "Report", "row_id": 249356, "text": "Sinus rhythm with Wenckebach rhythm. Anterior and lateral ST-T wave changes\nmay be due to myocardial ischemia. Clinical correlation is suggested. Compared\nto the previous tracing of the rhythm appears to be Wenckebach on the\ncurrent tracing. Lateral ST-T wave changes are seen in leads V5 and V6.\nR wave voltage is increased in those leads. Clinical correlation is suggested.\n\n\n" }, { "category": "ECG", "chartdate": "2174-11-14 00:00:00.000", "description": "Report", "row_id": 249357, "text": "Sinus tachycardia, rate 120, with A-V dissociation and occasional\nA-V conduction. Compared to the previous tracing of evidence for\ninferior myocardial infarction is no longer recorded. Anterolateral ST-T wave\nchanges have improved. Followup and clinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2174-11-13 00:00:00.000", "description": "Report", "row_id": 249358, "text": "A-V dissociation. Q waves in leads III and aVF with slight ST segment elevation\nin leads III, aVF and lead V1 suggests myocardial injury/myocardial infarction\nof indeterminate age. ST segment depression with downsloping ST segments and\nT wave inversion in leads I and aVL and leads V2-V6 could be due to myocardial\nischemia or reciprocal changes. Could also be related to left ventricular\nhypertrophy. Clinical correlation is suggested. Non-specific intraventricular\nconduction delay. Compared to the previous tracing of the inferior\nQ waves and ST segment elevations are new. The ST-T wave changes in\nleads I and aVL are new. The precordial ST-T wave changes may be slightly\nmore pronounced.\n\n" }, { "category": "ECG", "chartdate": "2174-11-11 00:00:00.000", "description": "Report", "row_id": 249359, "text": "Sinus rhythm. Intraventricular conduction delay. Compared to the previous\ntracing of there is no change.\n\n" }, { "category": "ECG", "chartdate": "2174-11-11 00:00:00.000", "description": "Report", "row_id": 249360, "text": "Sinus rhythm. There is a late transition with notching of the QRS complex\nin the anterior leads consistent with possible myocardial infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nanterior QRS notching is now apparent.\n\n" }, { "category": "ECG", "chartdate": "2174-11-10 00:00:00.000", "description": "Report", "row_id": 249361, "text": "Sinus rhythm. Mild intraventricular conduction delay. Non-specific ST-T wave\nchanges. Compared to tracing #2 the rate has decreased.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2174-11-09 00:00:00.000", "description": "Report", "row_id": 249362, "text": "Sinus tachycardia with non-specific ST-T wave changes. Compared to\ntracing #1 the rate has increased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-11-20 00:00:00.000", "description": "Report", "row_id": 249354, "text": "Sinus tachycardia. Lateral and septal ST-T wave abnormalities. No significant\nchange compared to the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2174-11-09 00:00:00.000", "description": "Report", "row_id": 249363, "text": "Sinus rhythm. Mild intraventricular conduction delay. Non-specific ST-T wave\nchanges. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2162-05-01 00:00:00.000", "description": "Report", "row_id": 204065, "text": "Normal sinus rhythm. The ECG is within normal limits and unchanged compared to\nthe previous tracing of .\n\n" }, { "category": "Radiology", "chartdate": "2162-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909258, "text": " 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusion, edema, ptx\n Admitting Diagnosis: UPPER GIB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with UGIB s/p EGD\n REASON FOR THIS EXAMINATION:\n eval effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE\n\n INDICATION: 55-year-old man with upper GI bleeding.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed. No previous\n study is available for comparison.\n\n The lungs are clear. The heart and mediastinum are within normal limits.\n\n IMPRESSION: No active lung disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-05-02 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 909268, "text": " 2:06 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: portal vein thrombosis?, hepatoma?, ascites? please check do\n Admitting Diagnosis: UPPER GIB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with portal hypertension and suspected variceal bleed\n REASON FOR THIS EXAMINATION:\n portal vein thrombosis?, hepatoma?, ascites? please check dopplers and mark\n site for tap if ascites present.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Portal hypertension, suspected variceal bleed.\n\n There is comparison to .\n\n LIVER ULTRASOUND: The liver is echogenic and slightly nodular in appearance.\n No focal lesions are identified. There is no intrahepatic biliary ductal\n dilatation. The gallbladder is identified, without wall thickening or stones.\n A small amount of perihepatic ascites is identified.\n\n LIVER DOPPLER EXAMINATION: Normal direction of flow and spectral waveforms\n are seen in the right common, middle, and left hepatic arteries. Normal color\n flow and spectral waveforms are seen in the left portal, anterior right\n portal, posterior right portal, and main portal veins. Normal color flow and\n Doppler waveforms are seen in the main hepatic, left hepatic, and right\n hepatic veins.\n\n IMPRESSION:\n\n 1. Nodular cirrhotic liver with small amount of ascites.\n\n 2. Normal Doppler waveforms.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2160-05-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 956815, "text": " 8:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for fracture, bleed\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with hx of fall onto bathroom floor which pt. does not\n remember in the setting of medication overdose\n REASON FOR THIS EXAMINATION:\n please assess for fracture, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 26-year-old female with history of fall onto bathroom\n floor, which patient does not remember in the setting of medication overdose.\n Please assess for fracture, bleed.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There is no hemorrhage, mass, shift of normally midline\n structures, or hydrocephalus. The -white matter differentiation is\n preserved. No major vascular territorial infarct is apparent. No fractures\n are identified. The visualized paranasal sinuses and mastoid air cells remain\n normally aerated.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "Nursing/other", "chartdate": "2160-05-03 00:00:00.000", "description": "Report", "row_id": 1578923, "text": "npn: 1900-0700\ncode status: full\n\nall: nkda\n\npmh: bulemia, depression, cutting\n\nreason for admission: pt od on 150 benedrly after a fight with husband. pt was found down in bathroom confused and vomiting. husband called . pt was brought to ew. pt recieved charcol and physostigmine salicylate to reverse benedryl. pt sent to micu for further monitoring.\n\nsignifcant events: pt has sitter at bedside for sa. pt is to have physostigmine at bedside at all times incase she still is having side efffects from the 150 benedrly. pt had ct of head at start of shift d/t pt found down in bathroom. pt had low grade temp this am of 99.2\npt vomited times two after charcol in ed.\n\nneuro: alert and oriented. from . able to make needs own. follows all commands. denies pain. tearful at times. .\n\ncv: hemodynamically stable. bp 98-120. hr 70-100. nsr.\n\nresp: ra lungs clear. no cough noted.\n\ngi/gu: npo except meds. no n/v/d. pt allowed ice chips. pt voids in commode. pt is able to ambulate with assistance. uop adeaquate.\n\nskin: pt has abrasion on left hand. ? cutting. no signs of infection.\n\nplan: transfer to floor. psych to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-05-03 00:00:00.000", "description": "Report", "row_id": 1578924, "text": "neuro: alert and oriented x3. +mae noted. +perrla noted. denies pain or discomfort.\ncv: monitor shows nsr with no ectopy noted.\nresp: lscta. no sob or resp distress noted.\ngi: abd soft and nontender. +bs noted. no stools this shift. diet advanced to regular and tolerated well.\ngu: voiding clear yellow urine on commode without difficulty.\nskin: c/d/i. sm abrasions noted on l arm from ? cutting.\nm-s: oob-commode with steady gait noted.\npsy-soc: psych consult in place...? transfer home to in husband's care for treatment vs inpt placement. denies si/hi. 1:1 sitter at bedside at all time. c/o to floor awaiting bed availabilty.\n" }, { "category": "ECG", "chartdate": "2160-05-02 00:00:00.000", "description": "Report", "row_id": 225282, "text": "Sinus tachycardia\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Echo", "chartdate": "2105-07-02 00:00:00.000", "description": "Report", "row_id": 100936, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment. Right ventricular function.\nHeight: (in) 66\nWeight (lb): 181\nBSA (m2): 1.92 m2\nBP (mm Hg): 118/78\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 09:01\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast or\nthrombus in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Normal interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Mild regional LV systolic dysfunction.\nMildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; mid inferoseptal - hypo; mid inferior - hypo; anterior\napex - hypo; septal apex - hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial 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: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications. The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPREBYPASS:\n\nThe left atrium and right atrium are normal in cavity size. No spontaneous\necho contrast or thrombus is seen in the body of the left atrium or left\natrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left\nventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is mildly depressed (LVEF= 45 %). with mild\nglobal RV free wall hypokinesis. There are simple atheroma in the aortic arch.\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is a trivial/physiologic pericardial\neffusion.\n\nPOSTBYPASS:\n\nPatient is AV paced and receiving an infusion of phenylephrine. Biventricular\nsystolic function is unchanged. All other findings are consistent with\npre-bypass findings. The aorta is intact post-decannulation. All findings were\ncommunicated to the surgeon intraoperatively.\n\n\n" }, { "category": "ECG", "chartdate": "2105-07-02 00:00:00.000", "description": "Report", "row_id": 294430, "text": "Sinus bradycardia. Low limb lead voltage. Compared to the previous tracing\nof the rate has slowed. Otherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2176-04-23 00:00:00.000", "description": "Report", "row_id": 1601118, "text": "CCU NPN 7a-7p\nS: \"It would be easier to eat if I could sit up.\"\nO: please see carevue for complete assessment data\nno events\nNEURO: A&OX3, pleasant and cooperative w/ care. MAE, assists w/ turning. No c/o pain, no focal neuro deficits noted.\n\nCV: HD stable, titrating up captopril as BP tolerates. Cont PO lopressor w/ poor rate control. Remains in RAF 110s-140s occasionally bursting up into 180s. Also w/ occasional runs NSVT. PAP stable 30s/20s. Dobutamine off @ 1530, currently stable, MvO2 pending @ 1730. CO/CI improving w/ ^'d dose captopril. Distal pulses palp/dop bilaterally, R foot slightly cooler than L. To start coumadin tonight w/ lovenox as bridge to therapeutic INR. TTE today: LVEF 50%, basal /mid inferior and basal inferioseptal HD, mild RV HK.\n\nRESP: LSCTA, no c/o SOB, SpO2 98% on 2L NC. No cough.\n\nGI: abd soft, nontender, nondistended. +BS/-BM/+RF. Tolerating small amts heart healthy diet and all PO meds. No c/o N/V, cont bowel regimen for c/o constipation, LBM .\n\nGU: foley draining CYU, even for 24hrs.\n\nID: afebrile, no abx.\n\nSKIN: w/d/i. PIV x 1, R femoral venous sheath and PA line intact, old soft hematoma noted, unchanged, old ooze on dsg. No breakdown noted.\n\nSOC: multiple family members in to visit, updated on by RN, very supportive.\n\nA: 86yo s/p inferior STEMI c/b cardiogenic shock and Afib w/ RVR requiring brief dobutamine and hemodynamic monitoring. Currently HD stable.\nP: Per multidiciplinary rounds f/u hemodynamics off dobutamine, if pt remains stable consider d/c R femoral venous line and PA cath. Cont to titrate ACE-I/BB as tolerated. ? additional for rate control. Encourage diet, support to pt and family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2176-04-24 00:00:00.000", "description": "Report", "row_id": 1601119, "text": "CCU Nursing note\nS-\"You making me feel like I'm crazy and I'm not.....I know this isn't my room. Are you sure you didn't move me?\"\nO-See flowsheet for additional details.\n\nN-pt a/ox3 upon going to bed. Woke up shortly after and imagined she had been transferred to another unit temporarily Insisting that she was in the wrong room. Quikly reoriented x3. Denied confusion. Pt instructed and reminded about importance of using call bell for assistance. Bed alarm activated. Thereafter pt again woke and proceded to hurrily get OOB. Nursing staff into room to find pt standing with foley on floor with balloon still inflated and BRB from urethra. Pt stating she forgot about Foley and was tring to hurry to the bathroom to urinate. \"Maybe if this place wasn't so confusing and had a couple signs I could see where I was going!\" Again quickly reoriented and reminded of call bell use. Bed Alarm activated, posey waist belt on, and RN outside of room for remainder of shift. Pt continued to need orientation for intermittent confusion....such as wishing staff a \"Merry .\" Unsteady gait, MAE c equal stregth. Pt eval ordered.\n\nCV-Chronic a-fib now c poor rate control despite BB. Diltizem 5mg IVP x1 now c standing order. RAF 100-140s c occasional burst to 160s-team aware. 1 run NSVT. Titrating ACE as tolerated. BP 101-131 c MAP >65. Venous sheath and PA line D/C'd 2100. Groin site stable. Pulses palpable. Coumadin started @ HS c Lovenox bridge to therapeutic dose.\n\nResp-RA c sats >95%. LSCTA.\n\nGI/GU-pt d/c'd foley when got OOB. small amouth BRB per urethra. Foley replaced. Fluid bolus 250cc x2 for Low UO c desired effect. Blood/ red-tinged urine. BM x2. Pt OOB to commode and proceded to digitly disimpact self. Upon inquiring pt states she has need to do so for the last 6 months. Please Reccomend home bowel regime upon discharge to team during rounds. Pt also causing trauma to rectum as scant amount of blood noted. Tolerating diet.\n\nID-afebrile.\n\nA/P- STEMI during routine pacer generator change. Tx to for PCI-Stents x2 to RCA. EF 50% per Echo. C/B cardiogenic shock c resulting decrease in UO requiring short period of Dobutimine. Pressor now off as CO/CI increased c increased ACE. Dilt and BB for RAF-resumed coumadin. Groin sheaths now d/c'd. Am Labs WNL. Dose cardiac meds as ordered and contiue to monitor cardiac/renal function. Update pt and family per interdisiplanary rounds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-24 00:00:00.000", "description": "Report", "row_id": 1601120, "text": "CCU NPN 0700-TRANSFER\n\nS/O\nMS ORIENTED X3\nCV AFIB RATE 90 AT REST, 150 W/ ACTIVITY. RAPID AF NON SUSTAINED\nBP 92/53\nREC'D 15 MG OF PO DILT THIS AM, DOSE INCREASED TO 30MG PER BP PARAMETERS\nPM DRESSING INTACT\nGROIN SITE C/D/I NO HEMATOMA.\n\nRESP CTA BILAT\n02 SAT 100% RA\n\nA/P: MONITOR FOR BLEEDING ON MULT ANTI COAGULANTS.\nSAFETY PRECATIONS, RATE CONTROL AFIB.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-22 00:00:00.000", "description": "Report", "row_id": 1601116, "text": "Nursing Progress note\n\nS:\" I've had quite a day.\"\n\nO: Please see FHP for details of PMH. Please see flow sheet for objective data. Pt received from cath lab at approx 230pm s/p STEMI with DES to RCA Tele AF 90's 150's. BP stable. Given lopressor 5mg IV x's2 and 100mg po x's 1. Slight ooze from R fem sheath upon arrival. Lovenox given prior to admission here. Lg amt of bleeding noted from r fem site with hematoma. Dr up to pull sheath hemostasis achieved after 1 hr. distal pulses are palpable. Venous sheath and swan remain in place.\n\nResp: Lungs diminshed in bases otherwise clear. O2 sats > 95%.\n\nNeuro: Pt is alert and oriented x's 3. Able to MAE. Pt maintained on bedrest post sheath removal. leg brace in place.\n\nGU/GI: Pt NPO at present. Able is soft with bowel sounds present/ Foley placed draining CYU. Pt received 120 of contrast.\n\nSocial: Son and daughter in to visit and updated on coarse of events.\n\nA&P: 86 yo women s/p STEMI with DES to RCA. Cont to monitor hemodynamics. Monitor hct. Titrate cardiac meds as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-04-23 00:00:00.000", "description": "Report", "row_id": 1601117, "text": "CCU Nursing note\nS-\"I just wanna sit up.\"\nO-see flowsheet for additional details.\n\nN-a/ox3, MAE. One episode where pt awoke disoriented but easily reoriented. No deficits noted.\n\nCV-s/p STEMI-cath lab c 2 stents to RCA. Venous sheath remains-sight now stable c minimal ooze. Pulses dopplerable. Chronic and persistant a-fib. Rate 115-145 despite IVP Lopressor. Started on Captopril 6.25mg. Dobutimine started for low CO/CI 1.9 and 1.19 respectivly. Fluid bolus 250cc x1. F/U #'s this am 3.4/2.13 c Dobutamine @ 3.5mcg/kg/min. PADs 18-21. IVF completed. Frequent ectopy-team aware. 3 runs non-sustained VT-frequent pvcs. 2 PIVs. Denies pain.\n\nResp-LS clear to diminished. 2L NC c sats >95%. Encourage IS/ C&DB when awake.\n\nGU/GI-+BS, -BM. FOley initally c minimal UO. S/P dobutamine much improved. Now CYU. BUN/Crt WNL pre cath. +2.5 L LOS.\n\nID-afebrile.\n\nskin/activity-knee embolizer in place-pt requires frequent reminders to keep leg straght. Reverse T- log rolled side to side. Groin site stable. Skin intact.\n\nSocial-Husband of 65 years recently passed away. 2 Children.\n\nA/P-Pacer generator replaced @ OSH . s/p pt c STEMI. Tx to for PCI. RCA dz stented x2. Now c low CI/CO requiring Dobutamine. Wean off as tolerated c HR and ectopy. Echo scheduled for am. Replete lytes. Monitor groin site and pulses. Update per interdisiplanary rounds.\n" }, { "category": "Echo", "chartdate": "2176-04-23 00:00:00.000", "description": "Report", "row_id": 81842, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Right ventricular function. Atrial fibrillation/flutter.\nHeight: (in) 64\nWeight (lb): 140\nBSA (m2): 1.68 m2\nBP (mm Hg): 93/59\nHR (bpm): 140\nStatus: Inpatient\nDate/Time: at 09:48\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: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly\ndepressed LVEF. TVI E/e' >15, suggesting PCWP>18mmHg.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\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 mildly depressed. Tissue velocity imaging E/e' is\nelevated (>15) suggesting increased left ventricular filling pressure\n(PCWP>18mmHg). Resting regional wall motion abnormalities include basal to mid\ninferior and basal inferoseptal hypokinesis. Right ventricular chamber size is\nnormal. Right ventricular systolic function appears grossly preserved; there\nmay be focal hypokinesis. 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. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2176-04-23 00:00:00.000", "description": "Report", "row_id": 200299, "text": "Atrial fibrillation. Left axis deviation. Non-specific ST-T wave changes.\nPossible old inferior wall myocardial infarction. Compared to the previous\ntracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-04-22 00:00:00.000", "description": "Report", "row_id": 200300, "text": "Atrial fibrillation. Left axis deviation. Non-specific ST-T wave changes. Late\ntransition. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2110-04-17 00:00:00.000", "description": "Report", "row_id": 1507964, "text": "M/SICU Nursing Progress Note 3p-7p\n\n\nPt admitted 1400. Endoscopy done 1545-1645, small gastric erosion exposing small blood vessel. Cautery done locally to the site. Versed 2mg, fentanyl 100mcg given in divided doses. Hemodynamically stable throughout procedure. Awoke w/o complication, +gag, =cough, conversing w/in 15 min post procedure.\nTransfused w/ 1u PRBC @1630-1730, #2^ @1830. Labs to be done @ 2230. Per MICU team, no IVF inb/w PRBC.\nu/o 100-200/hr via condom cath.\nOctreotide infusing 1400-1800 when d/c'd. NGT d/c'd.\nA/P\nEndoscopy>small active gastric bleeding-cautery done. Tx 1more unit now, check labs 2230.\n\n" }, { "category": "Nursing/other", "chartdate": "2110-04-18 00:00:00.000", "description": "Report", "row_id": 1507965, "text": "npn\npt is 80 yo make who 2 days ago exp. brb in stool and exp episode of coffee ground emesis. . ngt plced in ew - at first coffee ground that would not clear wkith lavage. Egd done revealing lesion on artery wall of proximal body whcih was cauterized. A repeat EGD slhould be done today to reassess and possible to cauterize more.\n\nneuro: aox3. some anxiety.\n\ncad hr 60-70's afib with no ectopy noted systolic b/p 103-to 93 with maps in the 50;s no issues. cpk 29 and then 36 . hct 19.5 on eves to 23.9 after two units of prbc's pt currenlty receiving 4 th unit of pc's sine admit to miicu\n\nresp ls pt on 2l nc with rr teens to 20's with sats >95%\n\ngi: abd soft bs+ no bm this shift.\n\ngu: pt voiding clear yellow urine\n\nid pt afebrile\n\nplan: possible repeat EGD todya to reaassessgut, cont to monitor vs, labs follow hct , am labs due to blood complete. ? transfer to floor for cont. of care\n" }, { "category": "Nursing/other", "chartdate": "2110-04-18 00:00:00.000", "description": "Report", "row_id": 1507966, "text": "msicu npn 0700-1900\n\n\nA&O x3. Pleasant and cooperative. No n/v or diarrhea/stool. Hct stable all day @ ~30. EGD done. Tol well. Bleeding much improved per GI. See chart for their note. Plan to monitor in hospital for the next few days and transfer out of unit tomorrow. Follow Hcts as per GI. Next one at hrs. Tol cl liqs at present. UO gd w/ IVFs @ 100cc/hr. Stands at side of bed to use urinal.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-19 00:00:00.000", "description": "Report", "row_id": 1507967, "text": "SMICU nsg progress note\nGi- Denies nausea/abdominal pain. No s/s active bleeding. Hct check at 8pm back at 28.3. Pt recieving additional unit rbc with repeat hct pending. Cont on iv at 100/hr. Taking clear liquids without problem.\nCardiac- bp/hr. Cont with adquate uo.\nNeuro- Alert/oriented and cooperative.\nResp- Denies sob. Sats 97-99% on ra\nPlan- Cont to follow hcts. Will re-scope if necessary. ? transfer to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2110-04-19 00:00:00.000", "description": "Report", "row_id": 1507968, "text": "RESP: BS'S CLEAR.\nGI: HCT 34.6. NO FURTHER BLEEDING NOTED. NO STOOL TODAY. DIET ADVANCED. TOL WELL.\nRENAL: VOIDING. IVF'S INFUSED AND D/C'ED. PER HO.\nCV: IN NSR WITH OCCAS-FREQ PAC'S.\nACTIVITY: OOB TO CHAIR.\nSOCIAL: FAMILY INTO VISIT.\nTRANSFER NOTE WRITTEN. AWAITING A BED.\n" }, { "category": "Radiology", "chartdate": "2110-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 822867, "text": " 5:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, CHF\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CLL s/p EGD ?aspiration\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL, shortness of breath, status post EGD.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST, AP: There is patchy opacification of the left mid lung and\n lower lung zones. No pleural effusions are identified. The heart is on the\n upper limits of normal with slight unfolding of the aorta. The pulmonary\n vasculature appears within normal limits.\n\n IMPRESSION: Patchy opacity within the left mid and lower lung zones which is\n compatible with aspiration.\n\n" }, { "category": "ECG", "chartdate": "2110-04-20 00:00:00.000", "description": "Report", "row_id": 150155, "text": "Sinus rhythm with atrial premature beats. Left atrial abnormality. Modest\nnon-specific intraventricular conduction delay. - question incomplete left\nbundle-branch block. Left ventricular hypertrophy with ST-T wave abnormalities.\nClinical correlation is suggested. Since the previous tracing of no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2110-04-18 00:00:00.000", "description": "Report", "row_id": 150156, "text": "Sinus rhythm\nSupraventricular extrasystoles\nLong QTc interval\nLateral ST-T changes are nonspecific\nSince previous tracing, ST-T wave changes improved\n\n" }, { "category": "ECG", "chartdate": "2110-04-17 00:00:00.000", "description": "Report", "row_id": 150157, "text": "Probable sinus rhythm\nSupraventricular extrasystoles\nLateral ST-T changes are nonspecific\nSince previous tracing, ventricular premature complex absent, further ST-T wave\nchanges\n\n" } ]

[ { "category": "ECG", "chartdate": "2133-03-15 00:00:00.000", "description": "Report", "row_id": 282516, "text": "Sinus rhythm\nPoor R wave progression - ? lead placement\nNonspecific anterior ST segment elevation\nSince previous tracing, QRS changes in lead V3 - ? lead placement\n\n" }, { "category": "ECG", "chartdate": "2133-03-14 00:00:00.000", "description": "Report", "row_id": 282517, "text": "Sinus bradycardia\nInferior ST-T changes are nonspecific\nLow QRS voltages in limb leads\nConsider early repolarization\nBaseline artifact in limb leads\nSince previous tracing, baseline artifact seen\n\n" }, { "category": "ECG", "chartdate": "2133-03-13 00:00:00.000", "description": "Report", "row_id": 282518, "text": "Sinus bradycardia. Early repolarization in the anterior and anterolateral\nleads. Low QRS voltage in the limb leads. Compared to the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-03-12 00:00:00.000", "description": "Report", "row_id": 282519, "text": "Baseline artifact. Sinus bradycardia. Early repolarization in the anterior and\nanterolateral leads. The QRS voltage is low in the limb leads. Compared to the\nprevious tracing of no significant change.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2133-03-13 00:00:00.000", "description": "Report", "row_id": 1475646, "text": "RESP CARE: Pt recieved from ED intubated/on vent on AC 650/18/.40/5. Lungs coarse. Sxd small amt thick tan sputum. RSBI-42\n" }, { "category": "Nursing/other", "chartdate": "2133-03-13 00:00:00.000", "description": "Report", "row_id": 1475647, "text": "0200-0700 NPN\nPt. admitted from ER, intubated, ogt with charchoal, on monitor with pads, propafol, glucagon gtt and calcium gtt.\n\nNEURO: pt. awakes to deep pain stim on admit then to tactile stim or suct. with propafol at 5 mcw/kgk/min. mae, restrained upper ext for safety. does try to pull on ETT when awake. pupils pinpoint non reactive to 2 cm sluggish.\n\nCV: sinus brady 50's, hx of same in of this year. sys bp 80-90. fluid bolus of 1 liter early morning for map low 50. some response noted. urine out qs amber 90cc min./hr. afebrile. periph pulses intact. K 3.1 proceeding with peripheral replacements. completed CA++ and glugagon gtt. BS 90 last check.\n\nRESP: Intubated 7.5 ETT, 40% TV 650 p 5 rate 18 with acceptable abg. breathing at 18. suctioned for nothing. did vomit charchoal, no traces in ETT. breath sounds clear to bases bilaterally. propafol at 5 mcq/kgk/min.\n\nGU/GI: abd soft, hypoactive BT, ogt in postition. foley drains qs urine.\n\nPAIN: no pain noted\n\nACCESS: 2 # 16 PIV, 1 # 18 PIV patent.\n\nSOCIAL: pt. noted to be agoraphobic, psycho affective disorder with recent admit. Mother did call this am. She is having minor herself this am and working this pm so will not be in.\n\nPLAN: monitor VS, treat bradycardia, support with fluids/pressors if needed, extubated if able this day. psych to follow up with pt as this is second attempt at suicide this year.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2162-11-14 00:00:00.000", "description": "Report", "row_id": 1586147, "text": "ekg nsr, rate 80-90s, no ectopy. st to 120 when very light. sbp 95-140. neo titrated to off, but when turned from .5mcg to off for sbp 130s, dropped to 56, placed in trendelenberg, neo back on at 1mcg. uo adequate, f/c irrigated x 1 for no uop x 1 hr, was plugged, draining well now. temp continues to be in 100.4-100.8 range. acyclovir started. breath sounds clear, decreased at bases. ett suctioned x 3 for scant thick tan secretions, lavaged x 2 with no increase in secretions. abgs improving, vent settings per flow sheet. maintaining spo2 98-100% on fio2 50%. abd softly distended, no bowel sounds heard. ngt drainage now mostly bilious fluid. skin warm, moist. still has marked red rash over most of upper torso, groin, legs and hands, which is warm to touch. pupils 2mm, equal, react to light. when light, mae, appears to have equal strength, but does not open eyes to voice or follow any commands. sedated with ativan and fentanyl gtts. wife and family in x 2 during evening, many questions answered, wife called this am, seemed to be crying. reassured that pt was stable overnight, but is anxious for definite dx.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-14 00:00:00.000", "description": "Report", "row_id": 1586148, "text": "Resp Care: Pt continues sedated intubated and on ventilatory support with simv 1000x9/fio2 .5/+5 peep/psv 10 with improving abg; BS diminished throughout, minimal secretions, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-14 00:00:00.000", "description": "Report", "row_id": 1586149, "text": "Update\nO: Heme/Id:am hct 34 w decr plt cts. Tmax 100.2 ,ceftriax 2gm iv continues and acyclovir started last pm for antiviral coverage. Macular rash persists w erythema extent of rash relatively unchanged since pm.Pan cult results still pending. LP thus far. Coags and plt ct as noted.\n\nResp status: 7 ett at 23cm at lt lip. Abg gd on tv 1 liter x rr9 x 50% fio2 & peep 5. Pip mid to hi 20's. Dr on rounds w team this am -> pt briefly tried on cpap w ps 5 stv's ~ 500 returned to simv mode until mri results read.Ets x3 for sm amts thick tan bl tinged sputum. Bbs coarse ->clear ^ lobes very diminish bibas lt more decr than rt. Holding wean of fio2 until pt oxygentation/tolerance to wakefulness reassessed. Spo2 this am w pt \"light\" dwn to 94%-> fentanyl gtt titrated ^ w spo2 improved p pt fully sedated.\n\nNeuro status: remains sedated \"light\" this am & mae spont not to command. Perl at 3mm.Cont sedation w ativan/fentanyl. Additional sedation w propofol req for mri (* 50 mg ivb).\nMri done w contrast results pending.\n\nCv status: sr to w pt less sedate at times. Bp still req neo until iv fld bolus given 500cc ns. Neo now off.\n\nGi status: Ngt to lws w bilious to franky dk bldy secretions. Lavaged until clear w ~ 200cc ns sm dk clots noted back to liws w no futher episodes of ng.Abd slt firm to palp, ? hypoactive bowel snds+.\n\nGu status: huo qs amber urine w sm amts brwn sediment.\n\nSkin: Continues to have macular/erythematous rash entire bsa new ecchymosis noted lue otherwise no other ecchymosis noted.Rigors noted briefly this pm temp check at time 100.2 ax -resolved w/o rx recieving acyclov at time (over 1hr).\n\nTubes/Lines: rt and lt periph slock patent intact. Rt rad art line w gd wave -> correlates w cuff.Rsc tlc cvp wave gd w cvp ranging after fld bolus.\n\n\nA/P: Critically stable pt w persistent ^ wbc . Pan cult's pending. Cont to support and keep sedate until mri results back. Plan per team repeat hct at 5pm today. Oral cavity bldg x 1 today reasses if persists (packing remains in place).? recult if temp spike.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-15 00:00:00.000", "description": "Report", "row_id": 1586150, "text": "EKG CURRENTLY NSR, RATE 90S, NO ECTOPY. DROPPED TO 56-60 FROM 0200 TO 0400, DR. NOTIFIED, NO ORDERS. RATE INCREASED AGAIN WITH ACTIVITY OF AM BATH. SBP 88-140, TITRATING NEO TO MAINTAIN SBP > 100. TEMP 100.8 TO 101. UO EXCELLENT, YELLOW, SOMETIMES CLOUDT, WITH SEDIMENT. BREATH SOUNDS CLEAR, DECREASED AT BASES, ETT SUCTIONED FOR SMALL TO MOD AMTS THICK TAN SECRETIONS, LAVAGED X 1. VENT SETTINGS PER FLOW SHEET. PCO2 30 ON RECENT ABG, VT DECREASED TO 800, FIO2 ALSO DECREASED TO 40% FOR PO2 170. ABD DISTENDED, MUCH FIRMER THIS AM. SMALL AMTS NGT DRAINAGE, BILIOUS, BUT GUIAC POS. HCT 28.9 THIS AM. NO BLEEDING AT ALL FROM ORAL SITE. STILL HAS WARM, RED MACULAR RASH OVER LOWER FACE, TRUNK, HANDS, GROIN, AND THIGHS, SEEMS TO BE LESS VIVID THAN YESTERDAY. SEDATED WITH ATIVAN, RECENTLY DECREASED FROM 6 TO 4 MG, AND FENTANYL. OCC OPENS EYES TO VOICE OR ACTIVITY, SOMETIMES APPEARS TO LOOK RIGHT AT SPEAKER, OTHER TIMES EYES DEVIATE TO LEFT, THEN SLOWLY COME BACK TOWARD SPEAKER. WITHDRAWS LIMBS TO PAIN, WHEN LIGHT, MOVEMENTS APPEAR MORE PURPOSEFUL, TRYING TO TURN, RE2222ACHING TOWARD ETT. WIFE VISITED AND CALLED, REASSURED, QUESTIONS ANSWERED.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-15 00:00:00.000", "description": "Report", "row_id": 1586151, "text": "Resp Care: Pt continues sedated intubated and on ventilatory support with simv 800x9/fio2 .4/+5 peep/psv 10 with improving abg; BS diminished, sxn tan secretions, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-15 00:00:00.000", "description": "Report", "row_id": 1586152, "text": "CSRU NPN\n\nCV: HR 80's NSR at rest, up to 120's NST with aggitation. Neo gtt weaned to off with SBP 100-115's, up to 140-160's with aggitation. Skin warm, dry. Repeat Hct 30 this afternoon. Plt 117.\n\nResp: Changed to PSV with IPS 15, peep 5, 40% FiO2 w/ VT's in 500-600's. Stable ABG on above. IPS decreased to 10 with VT's in 400's-ABG 71/38/7.36/22/97%. MD aware and to evaluate. O2 sats 95% or more at rest, did have episode of decreased O2 sats to 89-90% and increased RR to 30's w/ aggitation. Suctioned for small amts slightly pink tinged secretions. O2 sats and resp rate recovered w/ resolution of aggitation.\n\nGI: NGT with bilious, clear brown, then thick dk brownish/maroonish dng. MD aware of brownish/maroonish dng-repeat hct at that time 30. Abd firm, distended but unchanged from yesterday MD's. No bleeding noted from mouth. Pt spit out surgicel during episode of aggitation-do not need to replace MICU MD.\n\nGU: Foley w/ adequate amts clear, yellow urine.\n\nID: Remains w/ low grade fevers. Cx's pnd. Ceftriaxone cont's. WBC decreased today.\n\nSkin: Light pink rash on face, trunk, hands, lower abdomen, thighs, and back reportedly improved per team. No change noted during day. Otherwise intact.\n\nNeuro: Weaning sedation. Off fentanyl gtt. Ativan gtt weaned to 2 mg/hr MD's--turned to off this afternoon MD request. Responses to requests inconsistent. Does withdraw extremities to nailbed pressure. Does open eyes to voice. ? if focusing. Has moved all extremities to request at various times. PERRL. Plan to have EEG today. Dilantin load ordered. No seizure activity noted. 2 episodes of aggitation w/ increased HR/BP/RR and decreased O2 sats. Resolved spontaneously. MD's aware.\n\nSocial: Wife in visiting. Updated on pt condition. She spoke w/ critical care attending regarding her husbands plan of care.\n\nA/P Neo gtt off w/ stable BP. Slightly PaO2-hold on extubation at this time. Recheck ABG at 1500. Monitor wakefullness in prep for extubation. Hct stable. Monitor NGT o/p closely. Check cx's. Follow temps. Monitor neuro status and monitor for seizure activity.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-15 00:00:00.000", "description": "Report", "row_id": 1586153, "text": "Addendum\n\nPt w/ aggitation lasting greater than 30 mins. MD aware. 1 mg IV ativan given without improvement. Decision by MICU team to extubate to see if aggitation improves. Pt extubated at 1510. Decreased aggitation, HR remains in 130's, RR remains in 30's with O2 sat 96% or greater. Not following commands/opening eyes. Will check ABG post extubation. No gag noted w/ yankaur to back of throat-MD aware.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-16 00:00:00.000", "description": "Report", "row_id": 1586156, "text": "CSRU NPN\n\nCV: HR remains tachy w/ rates 100-112's. SBP 140-160's, increases w/ movement/restlessness. Hct 26.5. Skin warm, pink. HIT sent. Plt 102. Coags WNL. D dimers and FDP pnd. Eccymotic areas at inner aspects of upper arms.\n\nResp: Expiratory wheezes noted primarily in upper airways. Diminished at lower lobes. Nebs ordered w/ some improvement. RR remains in upper 20's lower 30's, appears slightly labored. O2 sats 99% or more on 50% face tent. Does have moderately strong cough, moist but unproductive.\n\nGI/GU: NGT o/p clear brown/bilious. Did have 2 sips of water (ok per MICU attending) which he tolerated without coughing. Adeq u/o. IVF decreased to 75cc/hr. Incontinent x 2 for med-large soft stool--guiac negative both times.\n\nID: Afebrile. ABX cont. Cx's pnd.\n\nSkin: Intact. Rash just about gone. ? 1 area on left flank still pink. No breakdown.\n\nNeuro: Arousable to voice, sometimes w/ difficulty. Did ask where he was and what happened to him this morning. Making spontaneous statements. Speech difficult to understand. Oriented x 2. Inconsistent in responses. Does open eyes, move all extremities to request. Right arm grasp seemed slightly weaker than left in am but both seem equal this afternoon. PERRL. No seizure activity noted. Received 200mg IV dilantin today-to receive dose this evening. ? LP to be repeated this afternoon. To have EEG. Restless, requires repositioning frequently. Did remove restraints when family in room.\n\nA/P Monitor resp status. Nebs prn. Monitor Hct and coags. Follow temp and cx's. Monitor GI o/p. ? LP. Monitor neuro exam. Reorient pt prn. Dilantin level in am.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-16 00:00:00.000", "description": "Report", "row_id": 1586157, "text": "AROUSABLE TO VOICE,FOLLOWING COMMANDS INCONSISTENTLY BUT ASKING TO WATCH FOOTBALL & IF THE YANKEES WON.MAE X 4 W GOOD STRENGTH, RESTLESS AT TIMES,TRYING TO REMOVE FACE MASK,WRIST HOLDERS ON FOR SAFETY.FEVER SPIKE->PANCULTURED,CXR. TYLENOL GIVEN. RESP. STATUS SEEMS SLIGHTLY IMPROVED. LESS LABORED & TACHYPNEIC. C & R LG. THICK TAN PLUG,C & S SENT. WHEEZY AFTER TURNING BUT IMPROVED AFTER NEB TX.SEE FLOW SHEET.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-17 00:00:00.000", "description": "Report", "row_id": 1586158, "text": "NEURO Lethargic/restless. Knows he's in a hospital. Follows simple commands.\ncv/resp. aline positional. cuff applied for accuracy. constant ins/exp upper airway wheezing. albuterol nebs q4hr. by rtt. minimal improvement. temp 101.8 ax rx with tylenol. rr elevated with temp. nsr/st pac's. right tlc intact. productive cough.\ngi/gu pt. self dc'd ngt. unable to reinsert. asking to have bowel movement at this time. Will offer bedpan. foley qs uop. npo.\n\n" }, { "category": "Nursing/other", "chartdate": "2162-11-17 00:00:00.000", "description": "Report", "row_id": 1586159, "text": "CSRU Transfer Note\n\nMr. is a 55 year old man who was admitted to from home. Pt asleep when wife noted to be gargling/unresponsive and \"thrashing\" in sleep. Called 911. On route to hospital, pt noted to have 2 seizures. Pt intubated in EW for airway protection. WBC elevated to 29. Droplet precautions in place until today to r/o bacterial menningitis--LP neg MD's. Was started on Ceftriaxone and Acyclovir d/t petechial rash which has since subsided. Has had dropping Hct and Plt count which is being worked up. Temp max up to 102.2 . Urine cx neg, blood cx's still pnd, sputum cx w/ staph aureus coag + and gram neg rods-being further evaluated. Cr up to 1.6.\n\nNKDA\n\nPMH: Erectile dysfunction-seeing psychiatry for this\n Nephrolithiasis\n GERD\n Knee pain\n Idiopathic elevation in liver enzymes.\n\nMeds: Prilosec\n Viagra\n ASA\n Aleve\n IC ursodiol\n\nCV: HR currently 90-low 100's NSR, occ APC noted. BP 120-130/70-80's today. Does have increased HR's to 110's and increased BP's to 160-170's w/ aggitation. Skin warm, dry. Hct 26.6 this am. Plt 143 (low of 102 ). HIT antibody pnd. A line d/c'd this am.\n\nResp: Extubated without difficulty. RR low to mid 20's, breathing slightly labored at times. Increased wheezing over past 24 hours-receiving albuterol neb treatments and Atrovent added this am. Cough tight, non productive. Changed to NC at 2l this afternoon with O2 sats 97% or greater. Previously on face tent for moisture.\n\nGI: Abd round, soft, hypoactive BS. Had NGT in place which pt self d/c'd this am. Gastric occult positive. Tolerating clear liquids for lunch without signs of aspiration. ADAT. Incontinent of 2 large soft stools -both OB neg. Adult pad in place.\n\nGU: Adequate u/o via foley. BUN/Cr wnl.\n\nSkin: Rash resolved. Intact skin. 2 areas of eccymosis on inner upper arms bilat unchanged.\n\nNeuro: Was initially sedated on fentanyl and ativan gtt's which were d/c'd . Aggitation/restlessness requiring hand restraints has improved. Currently unrestrained. Wakefullness varies but able to arouse pt to voice or touch. More alert and aware today than he has been. Disoriented to date. Speech is slow and occasionally difficult to understand but is improving. Moves all extremities to request. Pt did verbalize feeling some weakness in left arm with lifting off MD evaluation noted to have some pain in shoulder w/ lifting. Will cont to monitor and consider x ray if no improvement. Loaded on Dilantin and to receive dose q hs. Dilantin level 8.9 this am-MD aware. No change in therapy.\n\nA/P Hemodynamically stable. Monitor neuro status closely. Dilantin per orders. Monitor temp and cultures. Monitor Hct, Plt's, WBC. ADAT. Transfer to 7 today.\n" }, { "category": "Nursing/other", "chartdate": "2162-11-13 00:00:00.000", "description": "Report", "row_id": 1586145, "text": "Adm note\nO: Pt to csru as micu pt.\nPmHx: Hx provided by wife. Hx knee pain taking ^ amts aleve past few days.Also hx ? stomach probs-> uses prilosec prn ^ use recent. Denies etoh abuse. Recent hx also includes environmental expos to inhaled paint fumes( painting indoors w masonry paint in poorly vent area).\n\nPt found by wife semi-responsive,? seizures,garbled speech, partial airway obstruction,? swelling mouth/tongue on exam according to wife.Called ems. Sat 90% bp160/90 hr 130's rr 12 on arrival. Adm to - on arrival to EW w marginal sat,unrespons abg metab acidosis-> intubated w #7 ett orally(traumatic) w much oral/nasal frank blood.\nAdm wbc 29 hct 51*** see carevue for remaining labs.Total ativan 18mg in ew for .\n\nAdm to csru w seizure like movement all extrems and Ativan 4mg ivp given w some improvment & propofol gtt started. Adm labs, lumbar puncture and rij tlc placed. Pan cultured. Newly developing macular rash noted on face,hands & shoulders -> rash ^ over trunk and upper arms and back of legs 2hrs after adm. Of note rash developing prior to any antibx treatment instituted.\n\nCV status: to sr after adeq sedation achieved w propofol. Req neo to maintain bp after sedation ^.Rt rad art line placed and correlating w cuff bp. rt subclav tlc placed w/o incident. Post line placement cxr pending.\n\nResp status: Metab acidosis on adm no nahco3 rec'd. Some correction of acidosis achieved w changes in vent settings. On cpap w ps5/5 & fio2 100% on adm to icu switched to simv mode tv100 rr 16 peep 5 fio2 100% rr and fio2 wean per abg's & ho orders.Bilat brth snds coarse but distant bibas brth snds. Sput sent for c&s. Sputum brwn.\n\nGi status: ngt placed rt nares w/o difficulty draining mod coffee grnd to dk grn drng. Protonix ivpb started.\nAbd slt firm distended, no active bowel snds audible.\n\nGu status: Urine initially bl tinged pink now brwn muddy urine via 14 fr foley cath.\n\nNeuro status: Per ew report -ct scan negative, neuro team eval in ew no further recommmedations for now -> will follow. Perl at 3-2mm brisk. ? intermitt seizures mild tonic/clonic on adm subsided after propofol started.spont movement of all extrems prior to further sedatives given. Rigors w ^ temp demerol 12.5 given x1\n\nIntegumentary: As noted above fine macular rash ^ in area over past few hrs first noted in csru prior to start of antibx therapy.Sm bruised area rt lateral ankle area.\n\nHeme/id/ Endocrine:labs in see carevue wbc 29. hct 51. Bl gluc stable.No steroids rec'd.\n\na/p: Alt neuro status w ^ wbc septic picture w poor oxygenation. orders per team. Support bp & maintain sedation.Antibx per orders.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-11-13 00:00:00.000", "description": "Report", "row_id": 1586146, "text": "End of shift note\nO: Pt seen by ent fellow,cauterized bldr in flr of mouth rt side decr bldg-> surgicel packing in place w no active bldg noted at site. fiberoptic exam of nares lt side w no active bldg noted in that area.Additional recommendations per ent-> correct coags as planned & minimize oral suct and manip as much as possible. FFp thawing and vit k ordered.\nFamily in waiting area(wife,,)updated periodically re: pt status & plans per micu team .\n\nReq reinstitut propofol for ent exam weaning to off. Ativan ^ to sedate per ho.? start fentanyl for additional sedation.\n\nResp status: sput c&s resent. Check for results.Fio2 req diminished. Bbs distant bibas coarse-> cl after suctioning.\n\nGi status: Gastric lavage w ~ 300cc ns till clear continues to have heme+ ng drng. Pt on protonix.\n\nGu status: huo qs pink-. muddy brwn to milky yellow urine.\n\nNeuro status: Sedate w propofol-> per micu team change to ativan and dc propfol when ent exam done. On ^ amts ativan and still restless w inconsistent vent compliance-. may req additional meds to keep sedate. ? fent gtt\n\n\nHeme/Id: hct dwn after hydration ivf ^ 150cc/hr at 1500.Tmax 101 pan cult earlier results pending. LP done and some prelim results back**see carevue for results.\n\nA/P: Hemodynamics labile dependant upon sedation level.Supportive care w antibx and pressors to maintain sbp>100. Rx coagulopathy as ordered.\nA/P:\n" }, { "category": "Nursing/other", "chartdate": "2162-11-15 00:00:00.000", "description": "Report", "row_id": 1586154, "text": "Update\nSt throughout the shift. Temp between 100.6 to 101.8. Discussed fever with Dr. . Tylenol given. Cultures remain pending from yesterday.\n\nWeak cough. Tachypneic throughout the shift. Mouth breathing all shift. Spo2 98-99% on 70% OFM this shift. Nebulizer Rx given by respiratory therapist x1.\n\nRNGT draining brown bilious material-guiac +. Unable to hear bowel sounds. No bowel movements.\n\nFoley draining yellow urine with sediment. .45% NS infusing @ 150cc/hr. KCl added to IV.\n\nPt remains flushed. Continues with macular rash on lower back Purple echymosis on l upper arm and r upper arm remain. Unable to locate oral area which recieved silver nitrate over the weekend. Lips dry.\n\nPt has made eye contact x2 this shift. When his name \"\" was called he said Ah-ah on 2 separate occasions. He has not followed any commands. He has multiple periods of restlessness moving his legs up and down and lifting his buttocks off the bed slightly. He has been moving his arms up on his chest and removing ekg leads. His wife has spent most of this shift at his side and is impressed by his progess over the last 24hrs.\n\nContact precautions continue.\n\nPlan to monitor temp, neuro signs and airway closely. Plan to check cultures tomorrow, check serum K @ 0400 and reschedule EEG tomorrow.\n\nMR HAS JUST SAID \"YES\" TO A QUESTION AND \"I HAVE TO PEE\". He did not answer any additional questions but did attempt to open his eyes when asked!!!\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-11-16 00:00:00.000", "description": "Report", "row_id": 1586155, "text": "CSRU Progress Note\nS/O: Neuro: Says name, wiggles toes and squeezes hands to command inconsistently. Spontaneous cough. Restless at times. No seizures.\n CV: HR 100 NSR, BP 130/70 but with restless periods, HR up to 120s and BP 200/.\n Resp: RR has come down from 30s to 27. Strong cough. BS coarse to diminished. SAO2 99% on .5 face tent.\n Renal: 1/2 NS at 150/hr with 40 KCL. Brisk Uo 120-300/hr. K 3.7, other lytes wnl. Wt down 1 kg.\n Heme: Hct 26.8. Active clot in blood bank.\n ID: Tmax 99.8, wbc 7.8, remains on ceftriaxone.\n GI: Bilious drg from ngt. On protonix.\n Endo: Glu 104.\n Skin: Intact. Lg bruises upper arms. Patches on flanks ?old rash.\n Family: Wife called.\nA: Slightly improved. ?hct drop.\nP: Cont close observation and safety measures. ?slow IV fluid. Obtain culture results and eval need for cont precautions, ceftriaxone. Dilantin qd.\n" }, { "category": "ECG", "chartdate": "2162-11-13 00:00:00.000", "description": "Report", "row_id": 269676, "text": "Sinus tachycardia. P-R interval 0.16. Right ventricular conduction delay. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 745247, "text": " 11:18 AM\n CHEST (PA & LAT) Clip # \n Reason: 50 yo with new sz, ?Aspiration PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new sz\n REASON FOR THIS EXAMINATION:\n 50 yo with new sz, ?Aspiration PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54 y/o man with new seizures. Rule out aspiration pneumonia.\n\n CHEST, PA AND LATERAL: Comparison is made to a prior study of .\n\n The mediastinal and hilar contours are unremarkable. The lung volumes are low\n however no consolidation is noted. There are no pleural effusions.\n\n IMPRESSION: No acute intrathoracic process.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 744929, "text": " 7:15 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 57 y/o man found unresponsive, intubated currently. Evaluat\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man found unresponsive, currently intubated.\n REASON FOR THIS EXAMINATION:\n 57 y/o man found unresponsive, intubated currently. Evaluate for bleed, mass.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found unresponsive, intubated.\n\n TECHNIQUE: Axial images of the brain were obtained without IV contrast.\n\n There are no prior CT's available for comparison.\n\n FINDINGS: There is no shift of normal midline structures or mass effect. The\n ventricles, cisterns and sulci are slightly prominent, probably related to\n mild atrophy. There are no pathologic intra or extraaxial fluid collections.\n There is extensive calcification of the carotid arteries. The visualized\n osseous structures are unremarkable. There is soft tissue density within\n bilateral frontal sinuses.\n\n IMPRESSION: 1. No evidence of intracranial hemorrhage.\n\n 2. Sinus disease more prominent in the frontal sinuses and posterior ethmoidal\n air cells.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744930, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with likely head bleed, now in CT scan, CXR after returns from\n CT.\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n\n History of probable cerebral hemorrhage with intubation. Evaluate for\n aspiration and for tube placement.\n\n Endotracheal tube is 3 cm above carina. Allowing for technique heart size is\n normal. Apart from linear atelectasis in the right mid zone the lungs are\n clear. No pulmonary consolidations.\n\n IMPRESSION: Linear atelectasis right mid zone. Otherwise no abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744954, "text": " 3:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new onset seizures, intubated traumatically, verify\n placement of right subclavian line\n REASON FOR THIS EXAMINATION:\n post central line placement\n ______________________________________________________________________________\n FINAL REPORT\n Chest single film.\n\n History of seizures with intubation and CT line placement.\n\n Endotracheal tube is 4 cm above carina. NG tube is in stomach. Heart size is\n within normal limits for technique. Apart from linear atelectases at the left\n base the lungs are grossly clear and the previous right-sided linear\n atelectases have resolved. No pneumothorax.\n\n IMPRESSION: Linear atelectases left base. No evidence for pneumonia. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 745137, "text": " 6:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: POST EXTUBATION FILM, POSSIBLE ASP PNEUMAONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new onset seizures, intubated traumatically, ?aspiration.\n NOW WITH FEVERS, TACHYPNEA\n REASON FOR THIS EXAMINATION:\n POST EXTUBATION FILM, POSSIBLE ASP PNEUMAONIA\n ______________________________________________________________________________\n FINAL REPORT\n History: New onset seizure status post urgent intubation.\n\n A single AP film performed is submitted. There is no endotracheal tube\n visualized. The patient is taking a very poor inspiratory effort. The tip of\n the NG tube projects below the diaphragm. Given the degree of poor\n inspiration, the lungs are grossly clear. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 745011, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate (?L base opacity on previous films)\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new onset seizures, intubated traumatically, ?aspiration.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate (?L base opacity on previous films)\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 54 YEAR OLD MAN WITH MAN WITH NEW ONSET SEIZURES, INTUBATED\n TRAUMATICALLY. RULE OUT ASPIRATION.\n\n CHEST PORTABLE: A comparison is made to a prior study of . The heart\n is normal in size. The mediastinal and hilar contours are unremarkable. The\n pulmonary vasculature is normal. There are increased opacities in the left\n lower lobe and the left hemidiaphragm is not visualized. An ET tube is noted_\n 5 cm from the carina. An NG tube is seen with its tip not detected on the\n film.\n\n IMPRESSION: Increased parenchymal opacities in the left lower lobe. This\n might represent aspiration or pneumonia. Question component of pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 745099, "text": " 10:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: STATUS-POST EXTUBATION YESTERDAY AFTERNOON. NOW WITH NEW WH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new onset seizures, intubated traumatically, ?aspiration.\n REASON FOR THIS EXAMINATION:\n STATUS-POST EXTUBATION YESTERDAY AFTERNOON. NOW WITH NEW WHEEZING. PLEASE\n EVALAUTE FOR ACUTE CARDIOPULMONARY PROCESS.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n INDICATIONS: Patient extubated and wheezing, ? aspiration.\n\n Comparison to the prior study from \n\n FINDINGS: Post removal of the ET tube. The nasogastric tube remains in. The\n heart, mediastinum, and lungs are unchanged. No focal opacity demonstrated.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-14 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 744984, "text": " 12:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: S/P SZ OF UNKNOWN ORIGIN, R/O BLEED/ENCEPHALITIS\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with above.\n REASON FOR THIS EXAMINATION:\n R/O intracranial bleed/encephalitis. Pt admitted s/p siezure. RBC's in tubes\n 1&4. Not responsive at this time. Intubated but easily ventilated.\n\n Please do diffusion weighted images and flare.\n\n Thanks,\n\n \n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with question of intracranial hemorrhage or\n encephalitis. For further evaluation.\n\n TECHNIQUE: T1 sagittal and axial, FLAIR, T2 and susceptibility axial images\n are obtained before Gadolinium. Diffuse weighted images were also acquired.\n Following the administration of Gadolinium, T1 axial and coronal images were\n obtained.\n\n FINDINGS: The diffusion weighted images demonstrate no definite area of\n restricted diffusion to indicate acute infarct. The brain images demonstrate\n a focal area of increased signal in the left frontal polar region and another\n area of signal abnormality in the right periventricular white matter along the\n anterior portion of the body of the right lateral ventricle. There is no\n intrinsic enhancement seen within these regions. The susceptiblity weighted\n images demonstrate no definite area of intracranial hemorrhage. A small\n linear area of increased signal is seen within on the FLAIR and T1 weighted\n images along the premotor sulcus in the right frontal lobe. No definite\n enhancement is seen in this region. This could be secondary to a prominent\n venous structure. Following the administration of Gadolinium, there is no\n evidence of abnormal parenchymal, vascular or meningeal enhancement seen. Note\n is made of extensive soft tissue changes in both frontal sinuses and mild\n mucosal thickening and fluid levels in maxillary and sphenoid sinus.\n\n IMPRESSION: No evidence of restricted diffusion to indicate infarct. Focal\n signal abnormalities in the left frontal lobe and in the right periventricular\n region are non specific. The left frontal lesion could be secondary to\n previous trauma. The appearances are not typical for demyelinating disease or\n encephalitis. No evidence of abnormal enhancement. Extensive soft tissue\n changes of the frontal sinuses.\n\n" }, { "category": "Radiology", "chartdate": "2162-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744943, "text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube positioning/ possible aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new onset seizures, intubated traumatically, verify\n placement and ? aspiration\n REASON FOR THIS EXAMINATION:\n et tube positioning/ possible aspiration\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE FILM\n\n History of seizures with intubation and possible aspiration.\n\n Endotracheal tube is 5 cm above carina. NG tube is in region of the stomach.\n Heart size is normal. Linear atelectases are present in right upper, ____\n lower zones as previously demonstrated. No pulmonary consolidation or new\n lung lesions. No pneumothorax.\n\n IMPRESSION: Linear atelectases on right with no evidence of pneumonia or\n aspiration.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2124-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049758, "text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for cause of lower O2 saturation\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with altered mental status and new O2 requirement\n REASON FOR THIS EXAMINATION:\n please evaluate for cause of lower O2 saturation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:52 A.M., \n\n HISTORY: Altered mental status.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs.\n Emphysema is severe. No focal abnormality is present to suggest pneumonia.\n 14-mm wide elliptical opacity projecting over the left sixth anterior\n interspace is probably the left nipple, since there is no lung nodule seen on\n the chest CT performed on . No pleural effusion. Heart size\n normal. Nasogastric tube needs to be advanced at least 8 cm to move all the\n side ports into the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1049755, "text": " 8:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: changes in hemorrhageRepeat on sunday AM\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with bleed s/p third ventriculostomy\n REASON FOR THIS EXAMINATION:\n changes in hemorrhageRepeat on sunday AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 12:04 PM\n 1. Significant worsening of a large parenchymal hemorrhage centered in the\n right basal ganglia extending into the mid brain, with no significant mass\n effect and compression of the right lateral ventricle and increased extension\n into the lateral and third ventricles and suprasellar cistern, new shift of\n the septum pellucidum.\n 2. Increase in diffuse sulcal effacement, compatible with increased\n intracranial pressure.\n 3. Persistent massive hydrocephalus and evidence of transependymal CSF\n migration.\n 4. Similar appearance of the posterior fossa with multiple partially\n calcified masses and tonsillar herniation.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 70-year-old man with cerebellar mass s/p third ventriculostomy\n and intracranial hemorrhage.\n\n COMPARISON: .\n\n NONCONTRAST HEAD CT: There is marked increase in size of the parenchymal\n hemorrhage which involves the right basal ganglia and surrounding white\n matter, thalamus, midbrain and pons. It now measures 4.9 x 3.4 cm in maximal\n axial cross-section.\n\n There is increased hemorrhage in the lateral ventricles. There is new\n hemorrhage in the third ventricle. The third ventricle is now compressed, and\n there is increased dilatation of the temporal horns of the lateral ventricles.\n There is increased compression of the frontal of the right lateral\n ventricle by the parenchymal hematoma. Periventricular hypodensities\n consistent with transependymal CSF flow are again seen.\n\n There are increased blood products along the right frontal ventriculostomy\n tract.\n\n There is a large amount of new subarachnoid blood products in the suprasellar\n cistern and other basal cisterns, and mild subarachnoid hemorrhage in the\n right temporal sulci.\n\n There is new shift of the septum pellucidum to the left. New right uncal\n herniation is likely present. There is further increase in diffuse effacement\n (Over)\n\n 8:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: changes in hemorrhageRepeat on sunday AM\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the sulci.\n\n The appearance of the cerebellum with partially calcified and/or hemorrhagic\n masses is grossly unchanged, with compression of the fourth ventricle.\n\n A right frontal burr hole is seen. No ventriculostomy catheter is present.\n\n IMPRESSION:\n 1. Marked increase in size of large right parenchymal hemorrhage, which\n extends into the thalamus, midbrain and pons. Marked increase in\n intraventricular hemorrhage. New subarachnoid hemorrhage, predominantly in\n the basal cisterns. Increased hemorrhage along the right frontal\n ventriculostomy track.\n\n 2. New compression of the third ventricle with enlargement of the temporal\n horns of the lateral ventricles, indicative of trapping. Persistent\n transependymal CSF flow.\n\n 3. Increased intracranial pressure with new right uncal herniation, increased\n sulcal effacement, increased effacement of the frontal of the right\n lateral ventricle, and new leftward shift of the septum pellucidum.\n\n 4. Cerebellar masses with compression of the fourth ventricle again noted.\n\n Findings were discussed with Dr. at 9:25 a.m. on .\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2124-11-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1049756, "text": ", C. NSURG TSICU 8:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: changes in hemorrhageRepeat on sunday AM\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with bleed s/p third ventriculostomy\n REASON FOR THIS EXAMINATION:\n changes in hemorrhageRepeat on sunday AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Significant worsening of a large parenchymal hemorrhage centered in the\n right basal ganglia extending into the mid brain, with no significant mass\n effect and compression of the right lateral ventricle and increased extension\n into the lateral and third ventricles and suprasellar cistern, new shift of\n the septum pellucidum.\n 2. Increase in diffuse sulcal effacement, compatible with increased\n intracranial pressure.\n 3. Persistent massive hydrocephalus and evidence of transependymal CSF\n migration.\n 4. Similar appearance of the posterior fossa with multiple partially\n calcified masses and tonsillar herniation.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2124-11-03 00:00:00.000", "description": "CT STEREOTAXIS W/ CONTRAST", "row_id": 1049583, "text": " 4:46 PM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: pre-op scan for stx 3rd ventriculostomy\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with cerebellar mass\n REASON FOR THIS EXAMINATION:\n pre-op scan for stx 3rd ventriculostomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe FRI 10:42 PM\n Persistent severe hydrocephalus from fourth ventricle compression by enhancing\n posterior fossa mass.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man with cerebellar mass for pre-operative\n evaluation.\n\n COMPARISON: .\n\n TECHNIQUE: Post-contrast CT imaging was obtained through the brain.\n\n FINDINGS: Again noted is massive hydrocephalus involving the lateral and\n third ventricles with hyperattenuation along the lateral ventricles consistent\n with transependymal flow secondary to an enhancing posterior fossa mass which\n is incompletely imaged.\n\n IMPRESSION: Unchanged severe non-communicating hydrocephalus secondary to\n cerebellar mass causing compression of the fourth ventricle. Steriotactic\n frame is in position for surgical planning.\n\n" }, { "category": "Radiology", "chartdate": "2124-11-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1049720, "text": " 9:57 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? primary tumor\n Admitting Diagnosis: HYDROCEPHALUS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with cerebellar mass\n REASON FOR THIS EXAMINATION:\n ? primary tumor\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi SUN 12:36 AM\n PFI: Suspicious soft tissue nodules within the left lung apex in the setting\n of severe emphysema. FDG PET imaging may be obtained to evaluate metabolic\n activity. Secretions within the distal trachea. Concentric soft tissue\n thickening within the cecum for which colonoscopy recommended to exclude\n underlying malignancy. Nodular contour to the liver suggesting component of\n cirrhosis.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT torso with contrast and reconstructions.\n\n INDICATION: Cerebellar mass. Please evaluate for primary tumor.\n\n COMPARISON: MRI head .\n\n TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet\n to the symphysis after the uneventful intravenous administration of 100 cc\n Optiray 350 contrast material. Multiplanar reformatted images were obtained\n and reviewed.\n\n CT CHEST WITH CONTRAST AND RECONSTRUCTIONS: An NG tube courses through the\n esophagus with tip terminating in the stomach. Numerous foci of secretions\n are detected within the distal trachea (series 2:image 18). No axillary,\n mediastinal or hilar lymphadenopathy is detected per CT size criteria. There\n is mild calcified atherosclerotic plaque within the thoracic aorta without\n dissection flap identified. No filling defects are identified within the\n pulmonary arteries. There is bibasilar dependent atelectasis, right greater\n than left. Severe emphysematous changes are noted within the lung apices with\n a focal soft tissue lesion within the left apex measuring approximately 1.5 x\n 0.8 cm and a second lesion with somewhat spiculated margins also in the left\n lung apex measuring 0.7 x 0.5 cm (series 2:image 16) in a region of scar.\n\n There is coarse calcification of the left anterior descending and right\n coronary arteries. Heart size appears within normal limits.\n\n CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: The liver demonstrates a\n nodular contour, suggesting component of cirrhosis. No enhancing lesions are\n identified in this portal venous phase study. Coarse calcification is present\n within the inferior tip of the liver (series 2:image 66). No splenomegaly is\n detected. There is no free fluid or free air present within the abdomen. No\n (Over)\n\n 9:57 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? primary tumor\n Admitting Diagnosis: HYDROCEPHALUS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n evidence of bowel obstruction is identified. The pancreas is normal in\n appearance without duct dilatation or focal enhancing mass. No paraaortic or\n mesenteric adenopathy is identified. A small amount of fluid is present\n surrounding the gallbladder, which is not distended, and the anterior aspect\n of the liver. Calcified atherosclerotic plaque is present within the\n abdominal aorta and iliac branches without significant aneurysmal dilatation.\n\n CT PELVIS WITH CONTRAST: A Foley catheter is present within the lumen of the\n bladder. Stool is noted within the rectum and sigmoid colon. There is focal\n thickening of the colon in the region of the cecum (series 2:image 84) without\n significant inflammatory stranding. The appendix is well visualized and\n normal in appearance.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified\n within the osseous structures. There is mild compression deformity of the L5\n vertebral body.\n\n IMPRESSION:\n\n 1. Concentric thickening of the colon in the region of the cecum. Direct\n visualization is recommended with colonoscopy to exclude colon carcinoma.\n\n 2. Severe emphysematous changes within the lungs with two suspicious soft\n tissue lesions within the left upper lobe. While these foci may\n represent scarring, further evaluation recommended with CT PET imaging to\n evaluate for metabolic activity in these foci which may exclude possiblity of\n carcinoma.\n\n 3. Moderate secretions within the distal trachea. Please correlate with\n recent intubation/extubation.\n\n 4. Minimal ascitic fluid surrounding the liver and gallbladder.\n\n 5. Cirrhosis witihout secondary evidence of decompensated liver disease\n aside from small amount of paragastric varices.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1049721, "text": ", C. NSURG TSICU 9:57 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? primary tumor\n Admitting Diagnosis: HYDROCEPHALUS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with cerebellar mass\n REASON FOR THIS EXAMINATION:\n ? primary tumor\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Suspicious soft tissue nodules within the left lung apex in the setting\n of severe emphysema. FDG PET imaging may be obtained to evaluate metabolic\n activity. Secretions within the distal trachea. Concentric soft tissue\n thickening within the cecum for which colonoscopy recommended to exclude\n underlying malignancy. Nodular contour to the liver suggesting component of\n cirrhosis.\n\n" }, { "category": "Radiology", "chartdate": "2124-11-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1049620, "text": " 12:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for interval change. Any evidence of right midbr\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with cerebellar mass, s/p III ventriculostomy now with right\n mydriasis and left hemiparesis.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change. Any evidence of right midbrain infarction?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cerebellar mass status post ventriculostomy with right mydriasis and\n left hemiparesis. Please evaluate for interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE HEAD WITHOUT CONTRAST: Interval right frontal craniectomy is seen.\n There is a hyperdense tract along the presumably prior ventriculostomy\n catheter placement within the right frontal lobe. A hyperdense focus is seen\n in the right basal ganglia and extending into the mid brain. Small\n pneumocephalus in the right lateral ventricle and bilateral small amount of\n layering intraventricular hemorrhage. No ventriculostomy catheter is still\n present.\n\n Again noted, massive hydrocephalus involving the lateral and third ventricle.\n There is evidence of transependymal flow of CSF. Diffuse effacement of the\n sulci may represent increased intracranial pressure. There is no shift of\n normally midline structures, major territorial infarct.\n\n Partially calcified masses within the posterior fossa are seen and unchanged.\n Mass effect over the fourth ventricle is stable. Cerebellar edema is again\n noted.\n\n Tonsillar herniation is unchanged.\n\n The visualized paranasal sinuses are clear.\n\n IMPRESSION: Status post ventriculostomy. Interval development of hemorrhage\n along the right basal ganglia extending into the mid brain. Hyperdense tract\n through the right frontal lobe, likely related to prior ventriculostomy\n catheter placement.\n\n Small amount of intraventricular hemorrhage. Persistent hydrocephalus and\n tonsillar herniation. Multiple masses within the posterior fossa.\n\n\n (Over)\n\n 12:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for interval change. Any evidence of right midbr\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2124-11-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1049428, "text": " 8:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH, CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with ? altered mental status\n REASON FOR THIS EXAMINATION:\n eval for ICH, CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:34 PM\n Massive acute hydrocephalus with transependymal CSF flow.\n Two calcified masses in cerebellum and ?vermis/4th ventricle with compression\n of 4th ventricle, accounting for hydrocephalus.\n Considerations include metastases (calcified mets can include mucinous\n neoplasms such as colon CA), hemangioblastoma, other malignancy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old with altered mental status. Evaluate for\n intracranial hemorrhage.\n\n No prior examinations.\n\n NON-CONTRAST HEAD CT: There is massive hydrocephalus involving the lateral\n and third ventricles, with hypoattenuation at the poles of the lateral\n ventricles consistent with transependymal flow of CSF. The sulci are\n moderately effaced. There is no midline shift or evidence of acute\n infarction. Within the posterior fossa, there are at least two partially\n calcified masses, best seen on the sagittal reconstructions. One mass, along\n the midline, measures approximately 2.6 x 1.9 cm and bulges anteriorly,\n effacing the fourth ventricle. An additional mass along the right inferior\n cerebellar hemisphere has indistinct borders and amorphous calcifications.\n There is a moderate amount of edema within the cerebellum. The suprasellar\n and basal cisterns are preserved, however there is evidence of tonsillar\n herniation into the foramen magnum.\n\n The calvarium soft tissues and visualized paranasal sinuses are normal.\n\n IMPRESSION: Acute severe noncommunicating hydrocephalus caused by at least\n two posterior fossa masses causing edema and mass effect on the fourth\n ventricle.\n\n The differential considerations include metastatic disease (including\n typically calcified metastases such as mucinous colorectal carcinoma) or\n primary intracranial malignancy such as hemangioblastoma or medulloblastoma.\n An MRI is recommended for further characterization. In addition, urgent\n neurosurgical consult is recommended for the patient's acute hydrocephalus.\n\n Findings were discussed with Dr. at the time of the exam.\n\n (Over)\n\n 8:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH, CVA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2124-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049873, "text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia / ETT placement\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with tonsilar herniation / ICH\n REASON FOR THIS EXAMINATION:\n hypoxia / ETT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 10:31 AM\n ET tube tip 7 cm above the carina. The NG tube tip is in the stomach. Lung\n hyperinflation due to most likely combination of emphysema and small airway\n disease.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia and placement of the ET tube.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 7 cm above the carina. The NG tube tip is in the stomach.\n The cardiomediastinal silhouette is stable. The lungs are hyperinflated but\n essentially clear except for minimal bibasilar atelectasis. The increased\n lucencies in the apices as well as irregularity of the lung parenchyma suggest\n presence of emphysema most likely in combination with small airway disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-05 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1049834, "text": ", C. NSURG TSICU 8:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement; ETT placement\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new OG tube\n REASON FOR THIS EXAMINATION:\n OG tube placement; ETT placement\n ______________________________________________________________________________\n PFI REPORT\n ET tube tip is in the stomach. Slight overinflation of the ET tube cuff.\n Lung hyperinflation.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049773, "text": " 10:20 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: distance from carina, etiology of hypoxia\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new endotracheal tube\n REASON FOR THIS EXAMINATION:\n distance from carina, etiology of hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:28 A.M., \n\n HISTORY: New endotracheal tube. Hypoxia.\n\n IMPRESSION: AP chest compared to , 8:52 a.m.:\n\n Tip of the new endotracheal tube is at the level of the sternal notch no less\n than 9 cm from the carina, 4 cm above optimal placement. Nasogastric tube\n needs to be advanced at least 8 cm to move all the side ports into the\n stomach. Linear scar-like lesions traverse areas of severe emphysema in the\n left upper lobe. Lower lungs are clear. There is no pulmonary edema. Heart\n size normal. Pleural effusion, if any, is minimal.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1049589, "text": " 5:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: POST BRAIN BX\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n WET READ: DXAe FRI 10:40 PM\n Minimal high density along the biopsy tract likely represents tiny hemorrhage\n within the spectrum of post surgical change. There is minimally improved\n hydrocephalus and unchanged posterior fossa mass without evidence of\n herniation.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Post-brain biopsy.\n\n Comparison exam performed one hour prior.\n\n TECHNIQUE: Non-contrast imaging was obtained through the head.\n\n FINDINGS: Again demonstrated is severe hydrocephalus with dilation of the\n third and fourth ventricles . Post-biopsy changes including right frontal\n craniotomy and tiny foci of high density along the biopsy tract likely\n represent tiny foci of parenchymal hemorrhage within the spectrum of post-\n surgical change. A heterogeneous enhancing posterior fossa mass is\n identified.\n\n IMPRESSION:\n 1. Findings are within the spectrum of post-surgical change .\n 2. Stable posterior fossa mass with residual enhancement from prior imaging\n noted.\n\n" }, { "category": "Radiology", "chartdate": "2124-11-05 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1049833, "text": " 8:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement; ETT placement\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new OG tube\n REASON FOR THIS EXAMINATION:\n OG tube placement; ETT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 8:55 AM\n ET tube tip is in the stomach. Slight overinflation of the ET tube cuff.\n Lung hyperinflation.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of OG tube placement.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 10:28 a.m.\n\n The OG tube tip is in the stomach. The ET tube tip is approximately 6 cm\n above the carina with slight overinflation of the ET tube cuff. The\n cardiomediastinal silhouette is stable. The lungs are hyperinflated but\n essentially clear. No pleural effusion or pneumothorax is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049416, "text": " 7:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with hypoxia, poor aeration on exam\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 19:27 HOURS.\n\n HISTORY: Hypoxia.\n\n COMPARISON: None.\n\n FINDINGS: Lung volumes are diminished with hazy opacity of both lung bases,\n likely atelectasis. No definite consolidation is seen. There is a tortuous\n atherosclerotic aorta. The cardiac silhouette is within normal limits for\n size. No definite effusion or pneumothorax is seen. The osseous structures\n are unremarkable.\n\n IMPRESSION: Bibasilar atelectasis. No definite consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049702, "text": " 6:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check NGT placement, patient will need PO contrast for CT sc\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new NGT placement\n REASON FOR THIS EXAMINATION:\n check NGT placement, patient will need PO contrast for CT scan\n ______________________________________________________________________________\n WET READ: DMFj SAT 7:29 PM\n New NG tube with sideport at GE junction. Advancement of cm recommended.\n Recommendation discussed with Dr. at 7:30 pm by Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:22 P.M., \n\n HISTORY: Check NG tube placement.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the new nasogastric tube is in the upper stomach but the tube needs to\n be advanced at least 6 cm to move all the side ports beyond the\n gastroesophageal junction. Lungs clear. Heart size normal. No pleural\n abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-03 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1049482, "text": " 8:09 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess posterior fossa mass\n Admitting Diagnosis: HYDROCEPHALUS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with posterior fossa mass\n REASON FOR THIS EXAMINATION:\n assess posterior fossa mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DPzb FRI 5:39 PM\n Comparison is with CT examination yesterday.\n\n Two separate _____ extra-axial lesions identified within the posterior fossa\n causing mass effect upon the fourth ventricle and associated massive\n hydrocephalus. No evidence of impending herniation. Differential includes\n meningioma, cavernoma/hemangioblastoma, and metastatic disease.\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITH AND WITHOUT CONTRAST\n\n INDICATION: 70-year-old male with posterior fossa mass.\n\n COMPARISON: CT head yesterday.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained without\n contrast. Additional multiplanar images were obtained with contrast.\n\n FINDINGS: Some image sequences are degraded by artifact from patient motion.\n\n There appears to be two separate masses with similar signal characteristics\n within the posterior fossa with extensive afjacent edema. The more superior\n midline mass measures approximately 2.6 x 4.2 x 3.2 cm (AP x transverse x CC).\n The lesion appears centrally necrotic containing both blood products and\n calcifications. There is heterogeneous predominantly peripheral enhancement on\n post-contrast examination. The lesion appears dural based and is suggestive\n of an extra- axial lesion.\n\n The second lesion within the right cerebellar region has similar signal\n characteristics with central necrosis and blood products and calcifications.\n An additional component is restricted diffusion within the posteroinferior\n aspect of the lesion. The lesion is somewhat more ill-defined measuring\n approximately 4.2 x 3.6 x 2.5 cm. This lesion also appears partly extra-\n axial inferioraly, but more infiltrative superiorly.\n\n Both lesions appear to contain prominent vessels within.\n\n Similar to CT, there is massive hydrocephalus involving the lateral and third\n ventricles with associated transependymal flow. This is unchanged from\n comparison CT yesterday. There is no evidence of supratentorial lesion. Aside\n from the transependymal CSF flow, there are few scattered foci of subcortical\n (Over)\n\n 8:09 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess posterior fossa mass\n Admitting Diagnosis: HYDROCEPHALUS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n T2/FLAIR white matter hyperintensity that do not enhance on post-contrast\n administration. There is no evidence of midline shift. The orbits and\n paranasal sinuses are unremarkable.\n\n IMPRESSION:\n 1. Two extra and intra-axial lesions within the posterior fossa\n demonstrating central necrosis, calcification/blood products, prominent\n vascularity and heterogeneous peripheral enhancement. Differential includes\n metastatic disease(? colon primary), aggresive meningiomas,hemangiopericytoma,\n hemangioblastoma, lymphoma and cavernomas .\n\n 2. Massive associated hydrocephalus involving the lateral/third ventricles\n with associated transependymal CSF flow.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-11-03 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1049483, "text": ", NSURG TSICU 8:09 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess posterior fossa mass\n Admitting Diagnosis: HYDROCEPHALUS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with posterior fossa mass\n REASON FOR THIS EXAMINATION:\n assess posterior fossa mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Comparison is with CT examination yesterday.\n\n Two separate _____ extra-axial lesions identified within the posterior fossa\n causing mass effect upon the fourth ventricle and associated massive\n hydrocephalus. No evidence of impending herniation. Differential includes\n meningioma, cavernoma/hemangioblastoma, and metastatic disease.\n\n" }, { "category": "Radiology", "chartdate": "2124-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049874, "text": ", C. NSURG TSICU 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia / ETT placement\n Admitting Diagnosis: HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with tonsilar herniation / ICH\n REASON FOR THIS EXAMINATION:\n hypoxia / ETT placement\n ______________________________________________________________________________\n PFI REPORT\n ET tube tip 7 cm above the carina. The NG tube tip is in the stomach. Lung\n hyperinflation due to most likely combination of emphysema and small airway\n disease.\n\n\n" }, { "category": "ECG", "chartdate": "2124-11-02 00:00:00.000", "description": "Report", "row_id": 243040, "text": "Sinus tachycardia. Non-specific ST-T wave changes. No previous tracing\navailable for comparison.\n\n" }, { "category": "Respiratory ", "chartdate": "2124-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 648508, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: 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 Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Comfort measures only\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was extubated to room air to CMO. See respiratory page of\n metavision for more information.\n" }, { "category": "Physician ", "chartdate": "2124-11-05 00:00:00.000", "description": "Intensivist Note", "row_id": 648319, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n today and was brought directly to hospital from airport by\n family members. In patient presentation was concerning for altered\n mental status although when daughter arrived, he appeared much more\n alert and interactive.\n Chief complaint:\n ataxia\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n decadron, RISS, nicotine patch, ppi, morphine, sch, thiamine\n 24 Hour Events:\n EVENTS:\n : had 3rd ventriculostomy placed. neuro status deteriorated, right\n eye ptosis, left sided weakness, non-verbal-->imaging shows likely\n midbrain injury\n : CT torso to eval for primary malignancy. Little improvement in\n Neuro exam\n .\n 24 HOUR EVENTS: CT torso to eval for primary malignancy. Little\n improvement in Neuro exam\n Post operative day:\n POD#2 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:10 PM\n Heparin Sodium (Prophylaxis) - 11:55 PM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.1\nC (97\n HR: 65 (64 - 78) bpm\n BP: 162/89(107) {107/53(70) - 164/110(116)} mmHg\n RR: 15 (10 - 17) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.4 kg (admission): 64 kg\n Total In:\n 2,646 mL\n 334 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,746 mL\n 334 mL\n Blood products:\n Total out:\n 2,080 mL\n 1,430 mL\n Urine:\n 2,080 mL\n 1,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 566 mL\n -1,096 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Right pupil dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), No(t) Moves all extremities, (LUE:\n Weakness), (LLE: Weakness)\n Labs / Radiology\n 119 K/uL\n 13.8 g/dL\n 101 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 39.5 %\n 11.0 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n 02:54 AM\n WBC\n 7.7\n 9.7\n 12.4\n 11.0\n Hct\n 35.2\n 34.1\n 37.0\n 39.5\n Plt\n 115\n 116\n 124\n 119\n Creatinine\n 0.9\n 0.8\n 0.7\n 0.9\n Glucose\n 121\n 106\n 99\n 101\n Other labs: PT / PTT / INR:14.5/26.9/1.3, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.2 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus, now s/p 3rd\n ventriculostomy (no drain) c/b midbrain injury\n Neurologic: /p 3rd ventriculostomy. con't decadron. Midbrain injury\n possibly secondary to surgery. Cont to monitor, repeat urgent CT if\n more decompensation, worry about hemorrhage\n Neuro checks Q:1h\n Pain: morphine\n Cardiovascular: no active issues\n Pulmonary: f/u CT torso read to look for possible primary malignancy\n Gastrointestinal / Abdomen: no issues. NGT placed for contrast for CT\n Nutrition: NPO, consider starting tube feeds if no plans for return to\n OR\n Renal: Foley, Adequate UO, stable\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, NGT\n Imaging: CT scan head today\n Fluids: NS, @ 70cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: Post-op complication, Other: hydrocephalus\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:01 AM\n 22 Gauge - 03:04 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n" }, { "category": "Nursing", "chartdate": "2124-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648321, "text": " Problem\n hydrocephalus, brain hemorrhage, brain mass\n Assessment:\n r. pupil non reactive, left paresis, left side weakness, poor gag/cough\n Action:\n Neurochecks q2h, cont on dexamethasone q6h, ct torso was done with\n contrast(po+iv) to locate primary malignancy prelim result:\n Suspicious soft tissue nodules within the left lung apex in the setting\n of severe emphysema. FDG PET imaging may be obtained to evaluate\n metabolic\n activity. Secretions within the distal trachea. Concentric soft tissue\n thickening within the cecum for which colonoscopy recommended to\n exclude\n underlying malignancy. Nodular contour to the liver suggesting\n component of\n cirrhosis.\n Response:\n More withdrawn and somnolent at 6am, icu team aware\n Plan:\n Repeat CT head in am, monitor neuro status\n" }, { "category": "Physician ", "chartdate": "2124-11-06 00:00:00.000", "description": "Intensivist Note", "row_id": 648473, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n Bleeding post ventriculostomy, now intubated.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n Acetaminophen, Albuterol 0.083% Neb Soln, Bisacodyl, Calcium Gluconate,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Dexamethasone, Docusate\n Sodium, Heparin, Insulin, Magnesium Sulfate, Mannitol, Morphine\n Sulfate, Nicotine Patch, Pantoprazole, Pneumococcal Vac Polyvalent,\n Potassium Chloride, Senna, Thiamine\n 24 Hour Events:\n INTUBATION - At 10:00 AM\n INVASIVE VENTILATION - START 10:00 AM\n extension of large parenchymal hemorrhage, intubated after discussion\n with family; Neurosurgery attending evaluated pt at the bedside,\n extremely poor prognosis; pt overbreathing the vent.\n Post operative day:\n POD#3 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Morphine Sulfate - 01:40 PM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:50 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: 37.1\nC (98.7\n HR: 70 (54 - 94) bpm\n BP: 154/76(94) {138/67(85) - 198/100(119)} mmHg\n RR: 21 (12 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.4 kg (admission): 64 kg\n Height: 64 Inch\n Total In:\n 2,261 mL\n 794 mL\n PO:\n Tube feeding:\n 79 mL\n 267 mL\n IV Fluid:\n 2,152 mL\n 467 mL\n Blood products:\n Total out:\n 3,475 mL\n 410 mL\n Urine:\n 3,475 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n 384 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): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 31 cmH2O\n Plateau: 13 cmH2O\n SPO2: 96%\n ABG: 7.50/30/106/24/1\n Ve: 4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Right pupil dilated, nonreactive\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Skin: sacral decub\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE: No\n movement), (RLE: No movement), (LLE: No movement)\n Labs / Radiology\n 134 K/uL\n 14.0 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.7 %\n 9.9 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n 02:54 AM\n 04:22 PM\n 02:51 AM\n WBC\n 7.7\n 9.7\n 12.4\n 11.0\n 9.9\n Hct\n 35.2\n 34.1\n 37.0\n 39.5\n 38.7\n Plt\n 115\n 116\n 124\n 119\n 134\n Creatinine\n 0.9\n 0.8\n 0.7\n 0.9\n 0.7\n TCO2\n 24\n Glucose\n 121\n 106\n 99\n 101\n 124\n 138\n Other labs: PT / PTT / INR:13.9/27.2/1.2, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.0 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.5\n mg/dL\n Imaging: CT head: Interval development of hemorrhage along the\n right basal ganglia extending into the mid brain\n CT head: Significant worsening of a large parenchymal\n hemorrhage, new shift of the septum pellucidum\n CXR: ETT 9cm from carina (we advanced it 4cm); NG tube needs to\n be advanced 8cm\n : CXR: ETT in place, OGT in place\n Microbiology: Urine culture: BETA STREPTOCOCCUS GROUP B.\n 10-100K\n MRSA screen: negative\n Assessment and Plan\n GRIEVING, IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus, now s/p 3rd\n ventriculostomy (no drain) c/b midbrain injury\n Neurologic: Neuro checks Q: 2 hr, s/p 3rd ventriculostomy with bleeding\n complication. con't decadron\n Cardiovascular: no active issues, allowing mild hypertension\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Tube feeding, 60ml/hr\n Renal: Cr 0.7; lyte replacement prn\n Hematology: INR 1.2; plt 119\n Endocrine: RISS\n Infectious Disease: Group B strep from Urine cx, pt afebrile, not\n treated\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids: NS, 70ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Post-op complication, Other: hydrocephalus\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:22 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:04 AM\n 20 Gauge - 02:42 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Family meeting with NuSu, likely will make pt this afternoon and\n extubate\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent:\n" }, { "category": "General", "chartdate": "2124-11-06 00:00:00.000", "description": "ICU Event Note", "row_id": 648506, "text": "Clinician: Fellow\n Family meeting held with family of Mr and Neurosurgery\n consultants. Family spoke with Dr. yesterday as well. Extensive\n discussions held with Neurosurgery over last 24 hours. Family\n understands poor prognosis and plan is to extubate and make patient CMO\n at this time.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2124-11-04 00:00:00.000", "description": "Intensivist Note", "row_id": 648139, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n today and was brought directly to hospital from airport by\n family members. In patient presentation was concerning for altered\n mental status although when daughter arrived, he appeared much more\n alert and interactive.\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n decadron, RISS, nicotine patch\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:15 AM\n OR SENT - At 04:14 PM\n OR RECEIVED - At 07:10 PM\n pt was due to go to step down, but nsgy was worried about possible\n worsening overall ms, and wanted back in icu post op. had 3rd\n ventriculostomy. post op, some L eye swelling and ? ptosis. noted new L\n arm weakness. repeat CT shows ? of midbrain injury from\n ventriculostomy.\n Post operative day:\n POD#1 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 06:14 AM\n Morphine Sulfate - 11:19 PM\n Heparin Sodium (Prophylaxis) - 11:20 PM\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: 68 (63 - 89) bpm\n BP: 123/61(77) {109/61(75) - 141/86(98)} mmHg\n RR: 10 (8 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.4 kg (admission): 64 kg\n Total In:\n 2,349 mL\n 263 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,249 mL\n 263 mL\n Blood products:\n Total out:\n 1,300 mL\n 450 mL\n Urine:\n 1,180 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,049 mL\n -187 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///17/\n Physical Examination\n General Appearance: Anxious, Cachectic\n HEENT: Right pupil dilated, EOMI, R sluggish to light\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n No(t) Moves all extremities, (LUE: Weakness)\n Labs / Radiology\n 124 K/uL\n 12.6 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 17 mEq/L\n 4.6 mEq/L\n 16 mg/dL\n 109 mEq/L\n 140 mEq/L\n 37.0 %\n 12.4 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n WBC\n 7.7\n 9.7\n 12.4\n Hct\n 35.2\n 34.1\n 37.0\n Plt\n 115\n 116\n 124\n Creatinine\n 0.9\n 0.8\n 0.7\n Glucose\n 121\n 106\n 99\n Other labs: PT / PTT / INR:14.5/26.9/1.3, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.2 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.5 mg/dL, Mg:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus\n Neurologic: Neuro checks Q: 1 hr, s/p 3rd ventriculostomy. con't\n decadron. repeat imaging, f/u neurosurgery recs regarding drain\n placement.\n Neuro checks Q:1h\n Pain: morphine\n Cardiovascular: no active issues\n Pulmonary: asthma, extensive smoking history, low O2 sat in triage\n although improved to mid 90's with 2L via NC, solumedrol in ER. needs\n CT torso for cancer w/u.\n Gastrointestinal / Abdomen: LFTs nonspecific, hx of \"liver disease\" may\n be EtOH; bowel regimen\n Nutrition: NPO, consider adat today, consider S&S prior\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: cipro for UTI\n Lines / Tubes / Drains: Foley, R hand 20g PIV, foley\n Wounds: Dry dressings, Right sacral decubitus ulcer\n Imaging: CT scan head today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: Other: hydrocephalus, uti, sacral decub\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:01 AM\n 22 Gauge - 03:04 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2124-11-06 00:00:00.000", "description": "Intensivist Note", "row_id": 648478, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n Bleeding post ventriculostomy, now intubated.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n Acetaminophen, Albuterol 0.083% Neb Soln, Bisacodyl, Calcium Gluconate,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Dexamethasone, Docusate\n Sodium, Heparin, Insulin, Magnesium Sulfate, Mannitol, Morphine\n Sulfate, Nicotine Patch, Pantoprazole, Pneumococcal Vac Polyvalent,\n Potassium Chloride, Senna, Thiamine\n 24 Hour Events:\n INTUBATION - At 10:00 AM\n INVASIVE VENTILATION - START 10:00 AM\n extension of large parenchymal hemorrhage, intubated after discussion\n with family; Neurosurgery attending evaluated pt at the bedside,\n extremely poor prognosis; pt overbreathing the vent.\n Post operative day:\n POD#3 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Morphine Sulfate - 01:40 PM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:50 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: 37.1\nC (98.7\n HR: 70 (54 - 94) bpm\n BP: 154/76(94) {138/67(85) - 198/100(119)} mmHg\n RR: 21 (12 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.4 kg (admission): 64 kg\n Height: 64 Inch\n Total In:\n 2,261 mL\n 794 mL\n PO:\n Tube feeding:\n 79 mL\n 267 mL\n IV Fluid:\n 2,152 mL\n 467 mL\n Blood products:\n Total out:\n 3,475 mL\n 410 mL\n Urine:\n 3,475 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n 384 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): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 31 cmH2O\n Plateau: 13 cmH2O\n SPO2: 96%\n ABG: 7.50/30/106/24/1\n Ve: 4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Right pupil dilated, nonreactive\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Skin: sacral decub\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE: No\n movement), (RLE: No movement), (LLE: No movement)\n Labs / Radiology\n 134 K/uL\n 14.0 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.7 %\n 9.9 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n 02:54 AM\n 04:22 PM\n 02:51 AM\n WBC\n 7.7\n 9.7\n 12.4\n 11.0\n 9.9\n Hct\n 35.2\n 34.1\n 37.0\n 39.5\n 38.7\n Plt\n 115\n 116\n 124\n 119\n 134\n Creatinine\n 0.9\n 0.8\n 0.7\n 0.9\n 0.7\n TCO2\n 24\n Glucose\n 121\n 106\n 99\n 101\n 124\n 138\n Other labs: PT / PTT / INR:13.9/27.2/1.2, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.0 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.5\n mg/dL\n Imaging: CT head: Interval development of hemorrhage along the\n right basal ganglia extending into the mid brain\n CT head: Significant worsening of a large parenchymal\n hemorrhage, new shift of the septum pellucidum\n CXR: ETT 9cm from carina (we advanced it 4cm); NG tube needs to\n be advanced 8cm\n : CXR: ETT in place, OGT in place\n Microbiology: Urine culture: BETA STREPTOCOCCUS GROUP B.\n 10-100K\n MRSA screen: negative\n Assessment and Plan\n GRIEVING, IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus, now s/p 3rd\n ventriculostomy (no drain) c/b midbrain injury\n Neurologic: Neuro checks Q: 2 hr, s/p 3rd ventriculostomy with bleeding\n complication. con't decadron\n Cardiovascular: no active issues, allowing mild hypertension\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Tube feeding, 60ml/hr\n Renal: Cr 0.7; lyte replacement prn\n Hematology: INR 1.2; plt 119\n Endocrine: RISS\n Infectious Disease: Group B strep from Urine cx, pt afebrile, not\n treated\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids: NS, 70ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Post-op complication, Other: hydrocephalus\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:22 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:04 AM\n 20 Gauge - 02:42 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Family meeting with NuSu, likely will make pt this afternoon and\n extubate\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31\n" }, { "category": "Nursing", "chartdate": "2124-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648242, "text": " Problem - Description In Comments Hydrocephalus and\n midbrain hemorrhage\n Assessment:\n Post-op head CT showing persistant massive hydrocephalus, new\n hemorrhage in midbrain, multiple calcified masses in the cerebullum .\n R sided facial droop, R eye closed, R pupil 5mm and fixed, L arm & leg\n with minimal movement. Speech whisper/hoarse, sometimes\n understandable, often incomprehensible sounds. Comunicates by nodding\n and gesturing. Follows commands consistently with R arm & leg. L\n pupil reacts to light. Occ reports headache pain, relieved with 0.5 mg\n morphine. Clearly recognizes family.\n Action:\n Decadron as ordered, HOB > 30 degrees, asses neuro status q2.\n Response:\n Voice somewhat stronger this afternoon than this morning. Slight\n movement of L arm & leg, has sensation in L arm & leg.\n Plan:\n Continue actions, CT of torso to look for masses. Informational\n support to family.\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer to R of coccyx Allevyn intact.\n Stage I pressure ulcer to L heel\n unblanchable areas, ? deep\n tissue injury\n No new pressure areas.\n Action:\n Barrier cream applied to stage I; heels off bed; multipodus boots\n on\n Response:\n Pressure ulcers unchanged. Heels remain off bed.\n Plan:\n Continue to monitor skin integrity. Continue to keep heels off bed.\n Reposition q2h.\n" }, { "category": "Nursing", "chartdate": "2124-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648249, "text": " Problem - Hydrocephalus and midbrain hemorrhage\n Assessment:\n Post-op head CT showing persistant massive hydrocephalus, new\n hemorrhage in midbrain, multiple calcified masses in the cerebullum .\n R sided facial droop, R eye closed, R pupil 5mm and fixed, L arm & leg\n with minimal movement. Speech whisper/hoarse, sometimes\n understandable, often incomprehensible sounds. Comunicates by nodding\n and gesturing. Follows commands consistently with R arm & R leg. L\n pupil reacts to light. Occ reports headache pain, relieved with 0.5 mg\n morphine. Clearly recognizes family.\n Action:\n Decadron as ordered, HOB > 30 degrees, asses neuro status q2.\n Response:\n Voice somewhat stronger this afternoon than this morning. Slight\n movement of L arm & leg, has sensation in L arm & leg. Family in\n visiting pt, supportive to pt and each other.\n Plan:\n Continue actions, Give enteral contrast, then CT of torso to look for\n masses. Informational support to family.\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer to R of coccyx Allevyn intact.\n Stage I pressure ulcer to L heel\n unblanchable areas, ? deep\n tissue injury\n No new pressure areas.\n Action:\n Barrier cream applied to stage I; heels off bed; multipodus boots\n on\n Response:\n Pressure ulcers unchanged. Heels remain off bed.\n Plan:\n Continue to monitor skin integrity. Continue to keep heels off bed.\n Reposition q2h.\n" }, { "category": "Physician ", "chartdate": "2124-11-06 00:00:00.000", "description": "Intensivist Note", "row_id": 648460, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n Bleeding post ventriculostomy, now intubated.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n Acetaminophen, Albuterol 0.083% Neb Soln, Bisacodyl, Calcium Gluconate,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Dexamethasone, Docusate\n Sodium, Heparin, Insulin, Magnesium Sulfate, Mannitol, Morphine\n Sulfate, Nicotine Patch, Pantoprazole, Pneumococcal Vac Polyvalent,\n Potassium Chloride, Senna, Thiamine\n 24 Hour Events:\n INTUBATION - At 10:00 AM\n INVASIVE VENTILATION - START 10:00 AM\n extension of large parenchymal hemorrhage\n Post operative day:\n POD#3 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 PM\n Morphine Sulfate - 01:40 PM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:50 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: 37.1\nC (98.7\n HR: 70 (54 - 94) bpm\n BP: 154/76(94) {138/67(85) - 198/100(119)} mmHg\n RR: 21 (12 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.4 kg (admission): 64 kg\n Height: 64 Inch\n Total In:\n 2,261 mL\n 794 mL\n PO:\n Tube feeding:\n 79 mL\n 267 mL\n IV Fluid:\n 2,152 mL\n 467 mL\n Blood products:\n Total out:\n 3,475 mL\n 410 mL\n Urine:\n 3,475 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n 384 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): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 31 cmH2O\n Plateau: 13 cmH2O\n SPO2: 96%\n ABG: 7.50/30/106/24/1\n Ve: 4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Right pupil dilated\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Skin: sacral decub\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE: No\n movement), (RLE: No movement), (LLE: No movement)\n Labs / Radiology\n 134 K/uL\n 14.0 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.7 %\n 9.9 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n 02:54 AM\n 04:22 PM\n 02:51 AM\n WBC\n 7.7\n 9.7\n 12.4\n 11.0\n 9.9\n Hct\n 35.2\n 34.1\n 37.0\n 39.5\n 38.7\n Plt\n 115\n 116\n 124\n 119\n 134\n Creatinine\n 0.9\n 0.8\n 0.7\n 0.9\n 0.7\n TCO2\n 24\n Glucose\n 121\n 106\n 99\n 101\n 124\n 138\n Other labs: PT / PTT / INR:13.9/27.2/1.2, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.0 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.5\n mg/dL\n Imaging: CT head: Interval development of hemorrhage along the\n right basal ganglia extending into the mid brain\n CT head: Significant worsening of a large parenchymal\n hemorrhage, new shift of the septum pellucidum\n CXR: ETT 9cm from carina (we advanced it 4cm); NG tube needs to\n be advanced 8cm\n Microbiology: Urine culture: BETA STREPTOCOCCUS GROUP B.\n 10-100K\n MRSA screen: negative\n Assessment and Plan\n GRIEVING, IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus, now s/p 3rd\n ventriculostomy (no drain) c/b midbrain injury\n Neurologic: Neuro checks Q: 2 hr, s/p 3rd ventriculostomy with bleeding\n complication. con't decadron\n Cardiovascular: no active issues, allowing mild hypertension\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Tube feeding, 60ml/hr\n Renal: Cr 0.7; lyte replacement prn\n Hematology: INR 1.2; plt 119\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids: NS, 70ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Post-op complication, Other: hydrocephalus\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:22 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:04 AM\n 20 Gauge - 02:42 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2124-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648397, "text": " Problem - Midbrain bleed\n Assessment:\n 0800, pt not following commands, no phonation, declining neuro status\n since 0500. Also with decreased O2 sats to 80\n Action:\n O2 changed from nasal canula to simple face mask with increases in O2\n sats. Pt to Radiology for urgent head CT after O2 sats up.\n Response:\n CT shows\n 1. Significant worsening of a large parenchymal hemorrhage centered in\n the\n right basal ganglia extending into the mid brain\n 2. Increase in diffuse sulcal effacement, compatible with increased\n intracranial pressure.\n 3. Persistent massive hydrocephalus\n 4. Similar appearance of multiple partially\n calcified masses and tonsillar herniation.\n Plan:\n Family notified of increased bleeding, with no hope of recovery and\n impending resp arrest. Family opted to have pt intubated even given\n grave prognosis\n Increased bleeding\n Assessment:\n Per Dr. , increase in bleeding in midbrain is incompatible with\n life.\n Action:\n Family agrees to make pt DNR status; pt intubated and ventilated and\n given mannitol 25 gm x 1.\n Response:\n Pt with improved neuro exam briefly: impaired corneal reflexes\n returned. Cough stronger, pt fluttering eye lids, arms with withdrawl\n to nailbed pressure instead of extesion and rotation.\n Plan:\n Continue neuro checks, dexamethasone, ventilate to normal CO2.\n Grieving\n Assessment:\n Pt\ns children, grandchildren and other relatives tearful, upset by pt\n decreased responsiveness. Many family members here, hugging and\n consoling each other, holding pt\ns hand.\n Action:\n Red Cross notified of pt\ns condition so pt\ns grandson who is in\n military service may be granted leave. Letters stating that pt is here\n in critical condition given to family to show their employers. Priest\n of family\ns in to comfort family and privacy provided for priest\n and family to pray with pt. Emotional support to family. Continued\n gentle care given to pt.\n Response:\n Family appreciative of care, asking many appropriate questions.\n Plan:\n Continue informational and emotional support of family. Continue\n routine care of pt\n hygiene, re-positioning, suctioning, skin care,\n lyte replacement, etc.\n" }, { "category": "Physician ", "chartdate": "2124-11-05 00:00:00.000", "description": "Intensivist Note", "row_id": 648290, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n today and was brought directly to hospital from airport by\n family members. In patient presentation was concerning for altered\n mental status although when daughter arrived, he appeared much more\n alert and interactive.\n Chief complaint:\n ataxia\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n decadron, RISS, nicotine patch, ppi, morphine, sch, thiamine\n 24 Hour Events:\n EVENTS:\n : had 3rd ventriculostomy placed. neuro status deteriorated, right\n eye ptosis, left sided weakness, non-verbal-->imaging shows likely\n midbrain injury\n : CT torso to eval for primary malignancy. Little improvement in\n Neuro exam\n .\n 24 HOUR EVENTS: CT torso to eval for primary malignancy. Little\n improvement in Neuro exam\n Post operative day:\n POD#2 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:10 PM\n Heparin Sodium (Prophylaxis) - 11:55 PM\n Other medications:\n Flowsheet Data as of 04:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.1\nC (97\n HR: 65 (64 - 78) bpm\n BP: 162/89(107) {107/53(70) - 164/110(116)} mmHg\n RR: 15 (10 - 17) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.4 kg (admission): 64 kg\n Total In:\n 2,646 mL\n 334 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,746 mL\n 334 mL\n Blood products:\n Total out:\n 2,080 mL\n 1,430 mL\n Urine:\n 2,080 mL\n 1,430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 566 mL\n -1,096 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Right pupil dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), No(t) Moves all extremities, (LUE:\n Weakness), (LLE: Weakness)\n Labs / Radiology\n 119 K/uL\n 13.8 g/dL\n 101 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 39.5 %\n 11.0 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n 02:54 AM\n WBC\n 7.7\n 9.7\n 12.4\n 11.0\n Hct\n 35.2\n 34.1\n 37.0\n 39.5\n Plt\n 115\n 116\n 124\n 119\n Creatinine\n 0.9\n 0.8\n 0.7\n 0.9\n Glucose\n 121\n 106\n 99\n 101\n Other labs: PT / PTT / INR:14.5/26.9/1.3, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.2 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus, now s/p 3rd\n ventriculostomy (no drain) c/b midbrain injury\n Neurologic: /p 3rd ventriculostomy. con't decadron. Midbrain injury\n secondary to surgery. Cont to monitor, repeat urgent CT if more\n decompensation, worry about hemorrhage\n Neuro checks Q:1h\n Pain: morphine\n Cardiovascular: no active issues\n Pulmonary: f/u CT torso read to look for possible primary malignancy\n Gastrointestinal / Abdomen: no issues. NGT placed for contrast for CT\n Nutrition: NPO, consider starting tube feeds if no plans for return to\n OR\n Renal: Foley, Adequate UO, stable\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids: NS, @ 70cc/hr\n Consults: Neuro surgery\n Billing Diagnosis: Post-op complication, Other: hydrocephalus\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:01 AM\n 22 Gauge - 03:04 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2124-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648444, "text": "Events\n T. feeding started last night\n Grieving\n Assessment:\n Pt is a DNR, Family is in the room during the night,\n Action:\n Comfort for the family provided, questions answered\n Response:\n Family cooperative, to situation , awaiting rest of the family to\n come together\n Plan:\n Continue meeting with family, daughter, team approach\n Problem\n brain hemorrhage\n Assessment:\n Poor gag/cough, corneals on/off, r.pupil fixed, extends to stimuli,\n moves r.arm only, overbreathes the vent 5-6/min\n Action:\n Neuro assessment q2h, decadrone, ventilated\n Response:\n No change in neuro status\n Plan:\n" }, { "category": "Nursing", "chartdate": "2124-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648390, "text": " Problem - Midbrain bleed\n Assessment:\n Pt not following commands, no phonation, neuro change. Also with\n decreased O2 sats.\n Action:\n O2 changed from nasal canula to simple face mask with increases in O2\n sats. Pt to Radiology for urgent head CT after O2 sats up.\n Response:\n CT shows\n 1. Significant worsening of a large parenchymal hemorrhage centered in\n the\n right basal ganglia extending into the mid brain\n 2. Increase in diffuse sulcal effacement, compatible with increased\n intracranial pressure.\n 3. Persistent massive hydrocephalus\n 4. Similar appearance of multiple partially\n calcified masses and tonsillar herniation.\n Plan:\n Family notified of increased bleeding, with no hope of recovery and\n impending resp arrest. Family opted to have pt intubated even given\n grave pronosis. Pt intubated and ventilated. Pt also given mannitol\n 25 gm x 1.\n Increased bleeding\n Assessment:\n Per Dr. , increase in bleeding in midbrain, incompatible with\n life.\n Action:\n Family agrees to make pt DNR status; pt ventilated and given mannitol.\n Response:\n Pt with improved neuro exam briefly: impaired corneal reflexes\n returned. Cough stronger, pt fluttering eye lids, arms with withdrawl\n to nailbed pressure instead of extesions and rotation.\n Plan:\n Continue neuro checks.\n Grieving\n Assessment:\n Action:\n Red Cross notified of pt\ns condition so pt\ns grandson who is in service\n may be granted leave. Letters stating that pt is here in critical\n condition given to family to show their employers. Priest of family\n in to comfort family and privacy provided for family to pray\n with pt. Emotional support to family. Continued gentle care given to\n pt.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2124-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648445, "text": "Events\n T. feeding started last night\n Grieving\n Assessment:\n Pt is a DNR, Family is in the room during the night,\n Action:\n Comfort for the family provided, questions answered\n Response:\n Family cooperative, to situation , awaiting rest of the family to\n come together\n Plan:\n Continue meeting with family, daughter, team approach\n Problem\n brain hemorrhage\n Assessment:\n Poor gag/cough, corneals on/off, r.pupil fixed, extends to stimuli,\n moves r.arm only, overbreathes the vent 5-6/min\n Action:\n Neuro assessment q2h, decadrone, ventilated\n Response:\n No change in neuro status\n Plan:\n Continue to monitor neuro status, consider discussing CMO status with\n family\n" }, { "category": "Physician ", "chartdate": "2124-11-03 00:00:00.000", "description": "Intensivist Note", "row_id": 647918, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n today and was brought directly to hospital from airport by\n family members. In patient presentation was concerning for altered\n mental status although when daughter arrived, he appeared much more\n alert and interactive. CT scan showed obstructive hydrocephalus.\n Patient has mildly cachectic appearance and is admitted to TICU for\n neurochecks + management of hydrocephalus, workup for malignancy.\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n decadron, RISS, nicotine patch, albuterol, bowel regimen, lyte\n replacement, heparin, protonix\n 24 Hour Events:\n NASAL SWAB - At 03:18 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 90 (78 - 93) bpm\n BP: 95/57(66) {92/24(41) - 131/69(85)} mmHg\n RR: 14 (12 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 64 kg\n Total In:\n 270 mL\n PO:\n Tube feeding:\n IV Fluid:\n 270 mL\n Blood products:\n Total out:\n 0 mL\n 390 mL\n Urine:\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n )\n Abdominal: Soft, Non-distended, Non-tender\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Clonus in LLE, weakness in b/l \n / Radiology\n 115 K/uL\n 12.5 g/dL\n 121 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 109 mEq/L\n 141 mEq/L\n 35.2 %\n 7.7 K/uL\n [image002.jpg]\n 02:36 AM\n WBC\n 7.7\n Hct\n 35.2\n Plt\n 115\n Creatinine\n 0.9\n Glucose\n 121\n Other labs: PT / PTT / INR:14.5/26.9/1.3, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Albumin:3.2 g/dL, LDH:219 IU/L,\n Ca:8.7 mg/dL, Mg:2.0 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR: Bibasilar atelectasis\n CT head: prelim read: Massive acute hydrocephalus with\n transependymal CSF flow; Two calcified masses in cerebellum and vermis\n with compression of 4th ventricle accounting for hydrocephalus\n Microbiology: Urine culture : pending (UA with mod bacteria +\n WBCs)\n MRSA screen : pending\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing obstructive hydrocephalus\n Neurologic: Neuro checks Q: 1 hr, possible VP shunt during this\n admission, followed by neurosurgery\n Cardiovascular: no active issues\n Pulmonary: asthma, nebs prn, O2 prn\n Gastrointestinal / Abdomen: AST 51, Alk phos 150, alb 3.2, hx of \"liver\n disease\" may be EtOH; bowel regimen\n Nutrition: NPO\n Renal: Cr 1.0; lyte replacement prn\n Hematology: INR 1.3\n Endocrine: RISS\n Infectious Disease: Check cultures, cipro for UTI; urine culture\n pending\n Lines / Tubes / Drains: R hand 20g PIV, foley\n Wounds: Right sacral decub ulcer\n Imaging: CT head, CXR\n Fluids: NS@70ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Other: hydrocephalus\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2124-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648384, "text": " Problem - Midbrain bleed\n Assessment:\n Pt not following commands, no phonation, neuro change. Also with\n decreased O2 sats.\n Action:\n O2 changed from nasal canula to simple face mask with increases in O2\n sats. Pt to Radiology for urgent head CT.\n Response:\n Plan:\n Grieving\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2124-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648533, "text": " Problem\n pt. with hydrocephalus, IVH, impaired neurological\n stutus\n Assessment:\n At best exam, pt. localizing deep pain (pinch to nipple/torso) with\n RUE. LUE either weakly withdraws or does not respond. Triple flexion\n to deep pain in bilateral LE\ns. Pupils fixed, non-reactive as noted.\n Pt. unresponsive without spontaneous movement (purposeful or non).\n Action:\n Neuro exam was done Q2hrs until pt. made CMO at 1400. Decadron\n administered until d/c\n Response:\n Exam essentially unchaged throughout the day.\n Plan:\n At present, pt. is CMO. Cont. to support and educate family and\n optimize pt. comfort.\n Grieving\n Assessment:\n Pt.\ns family met with neurosurgical resident ( ) on and off\n for most of a.m. Poor communication noted between pt\ns daughters \n and son. Pt. made CMO, then two hours later pt\ns daughter was angry\n that the pt. was being\nstarved\n Action:\n Ongoing attempts of open communication with staff and family. Family\n ed.\n Response:\n Many of pt\ns children not in agreement with goals and expectations.\n Plan:\n Dr. to meet with family between 1800-1830 this eve to discuss\n plan, goals, expectaions, etc. At present, pt. is CMO as discussed at\n length with family over the past few days.\n Impaired Skin Integrity\n Assessment:\n Pt. with decubiti as noted.\n Action:\n Prior to CMO status, pt. turned Q2hr. Allevyn, MP boots.\n Response:\n No change.\n Plan:\n At present, optimize pt. comfort.\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648010, "text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648001, "text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2124-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648122, "text": "Mr. is a 70 year old man who had for the last 5months had an\n increasing weakness, more so on the right side. Flew from \n on and came from the airport to the emergency department.\n : Head CT showed massive acute hydrocephalus and two masses in\n the cerebellum with likely 4^th ventricle compression. Admitted to the\n T/SICU for close monitoring.\n : Pt to OR for stereotactic third ventriculostomy with\n ventriculoscopy\n : Head CT\n Problem\n Acute Hydrocephalus\n Assessment:\n Pt to OR for stereotactic third ventriculostomy.\n Q2h neuro exam:\n Alert, oriented x2 (self and birthdate)\n L pupil 3mm, reactive and R pupil 5mm, non-reactive;\n +corneals/gag/cough\n Right sided facial droop; increasing difficulty with speech\n RUE nml strength, no movement to LUE; RLE lifts and holds; LLE\n moves on bed\n Action:\n Head CT obtained\n Q2h neuro exams, HOB <30 degrees as ordered\n Decadron administered as ordered\n Response:\n Head CT showed edema to midbrain most likely result of OR\n procedure.\n Neuro exam unchanged\n Plan:\n Continue to assess neuro q2h. Administer decadron as ordered.\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer to R of coccyx\n Stage I pressure ulcer to L heel\n unblanchable areas, ? deep\n tissue injury\n Action:\n Duoderm gel and allevyn applied to stage II pressure ulcer\n Barrier cream applied to stage I; heels off bed; multipodus boots\n on\n Response:\n Pressure ulcers unchanged. Heels remain off bed.\n Plan:\n Continue to monitor skin integrity. Continue to keep heels off bed.\n Reposition q2h.\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648057, "text": "Mr. is a 70 year old man who had for the last 5months had an\n increasing weakness, more so on the right side. Flew from \n on and came from the airport to the emergency department.\n : Head CT showed massive acute hydrocephalus and two masses in\n the cerebellum with likely 4^th ventricle compression. Admitted to the\n T/SICU for close monitoring.\n Events:\n : MRI head\n : OR for ventriculostomy placement (in 4^th ventricle)\n Impaired Skin Integrity\n Assessment:\n Right coccyx with stage II pressure ulcer on admission. Left heel with\n stage I pressure ulcer on admission. Otherwise skin intact.\n Action:\n Lotion applied to heels and elevated on pillows. Allyven dressing\n applied to coccyx, pt turned and kept of bottom.\n Response:\n No change.\n Plan:\n Maintain skin integrity, promote healing of present breakdown.\n Problem\n Acute Hydrocephalus\n Assessment:\n Spanish speaking only, does understand English. MAE\ns to command, BUE\n equal strength BLE weaker/deconditioned. Pupils equal and reactive R\n has cataract. s/p Ventric placement\n Action:\n Hourly Neuro checks, decadron Q6hrs\n Response:\n Stable neuro status\n Plan:\n Close monitoring of neuro status.\n" }, { "category": "Nursing", "chartdate": "2124-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648282, "text": " Problem\n hydrocephalus, brain hemorrhage, brain mass\n Assessment:\n r. pupil non reactive, left paresis, left side weakness, poor gag/cough\n Action:\n Neurochecks q2h, cont on dexamethasone q6h, ct torso was done with\n contrast(po+iv) to locate primary malignancy prelim result:\n Suspicious soft tissue nodules within the left lung apex in the setting\n of severe emphysema. FDG PET imaging may be obtained to evaluate\n metabolic\n activity. Secretions within the distal trachea. Concentric soft tissue\n thickening within the cecum for which colonoscopy recommended to\n exclude\n underlying malignancy. Nodular contour to the liver suggesting\n component of\n cirrhosis.\n Response:\n No neuro changes overnight, 1 hour of polyurea\n Plan:\n Repeat CT head in am, monitor neuro status\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648056, "text": "Mr. is a 70 year old man who had for the last 5months had an\n increasing weakness, more so on the right side. Flew from \n on and came from the airport to the emergency department.\n : Head CT showed massive acute hydrocephalus and two masses in\n the cerebellum with likely 4^th ventricle compression. Admitted to the\n T/SICU for close monitoring.\n Events:\n : MRI head\n : OR for ventriculostomy placement (in 4^th ventricle)\n Impaired Skin Integrity\n Assessment:\n Right coccyx with stage II pressure ulcer on admission. Left heel with\n stage I pressure ulcer on admission. Otherwise skin intact.\n Action:\n Lotion applied to heels and elevated on pillows. Allyven dressing\n applied to coccyx, pt turned and kept of bottom.\n Response:\n No change.\n Plan:\n Maintain skin integrity, promote healing of present breakdown.\n Problem\n Acute Hydrocephalus\n Assessment:\n Spanish speaking only, does understand English. MAE\ns to command, BUE\n equal strength BLE weaker/deconditioned. Pupils equal and reactive R\n has cataract. s/p Ventric placement\n Action:\n Hourly Neuro checks, decadron Q6hrs\n Response:\n Stable neuro status\n Plan:\n Close monitoring of neuro status.\n" }, { "category": "Respiratory ", "chartdate": "2124-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 648429, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: 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: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\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: Cannot protect\n airway\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": "2124-11-04 00:00:00.000", "description": "Intensivist Note", "row_id": 648104, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n today and was brought directly to hospital from airport by\n family members. In patient presentation was concerning for altered\n mental status although when daughter arrived, he appeared much more\n alert and interactive.\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n decadron, RISS, nicotine patch\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:15 AM\n OR SENT - At 04:14 PM\n OR RECEIVED - At 07:10 PM\n pt was due to go to step down, but nsgy was worried about possible\n worsening overall ms, and wanted back in icu post op. had 3rd\n ventriculostomy. post op, some L eye swelling and ? ptosis. noted new L\n arm weakness. repeat CT shows ? of midbrain injury from\n ventriculostomy.\n Post operative day:\n POD#1 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 06:14 AM\n Morphine Sulfate - 11:19 PM\n Heparin Sodium (Prophylaxis) - 11:20 PM\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: 68 (63 - 89) bpm\n BP: 123/61(77) {109/61(75) - 141/86(98)} mmHg\n RR: 10 (8 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.4 kg (admission): 64 kg\n Total In:\n 2,349 mL\n 263 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,249 mL\n 263 mL\n Blood products:\n Total out:\n 1,300 mL\n 450 mL\n Urine:\n 1,180 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,049 mL\n -187 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///17/\n Physical Examination\n General Appearance: Anxious, Cachectic\n HEENT: Right pupil dilated, EOMI, R sluggish to light\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n No(t) Moves all extremities, (LUE: Weakness)\n Labs / Radiology\n 124 K/uL\n 12.6 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 17 mEq/L\n 4.6 mEq/L\n 16 mg/dL\n 109 mEq/L\n 140 mEq/L\n 37.0 %\n 12.4 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n WBC\n 7.7\n 9.7\n 12.4\n Hct\n 35.2\n 34.1\n 37.0\n Plt\n 115\n 116\n 124\n Creatinine\n 0.9\n 0.8\n 0.7\n Glucose\n 121\n 106\n 99\n Other labs: PT / PTT / INR:14.5/26.9/1.3, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.2 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.5 mg/dL, Mg:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus\n Neurologic: Neuro checks Q: 1 hr, s/p 3rd ventriculostomy. con't\n decadron. repeat imaging, f/u neurosurgery recs regarding drain\n placement.\n Neuro checks Q:1h\n Pain: morphine\n Cardiovascular: no active issues\n Pulmonary: asthma, extensive smoking history, low O2 sat in triage\n although improved to mid 90's with 2L via NC, solumedrol in ER. needs\n CT torso for cancer w/u.\n Gastrointestinal / Abdomen: LFTs nonspecific, hx of \"liver disease\" may\n be EtOH; bowel regimen\n Nutrition: NPO, consider adat today, consider S&S prior\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: cipro for UTI\n Lines / Tubes / Drains: Foley, R hand 20g PIV, foley\n Wounds: Dry dressings, Right sacral decubitus ulcer\n Imaging: CT scan head today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: Other: hydrocephalus, uti, sacral decub\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:01 AM\n 22 Gauge - 03:04 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2124-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648101, "text": "Mr. is a 70 year old man who had for the last 5months had an\n increasing weakness, more so on the right side. Flew from \n on and came from the airport to the emergency department.\n : Head CT showed massive acute hydrocephalus and two masses in\n the cerebellum with likely 4^th ventricle compression. Admitted to the\n T/SICU for close monitoring.\n : Pt to OR for stereotactic third ventriculostomy with\n ventriculoscopy\n : Head CT\n Problem\n Acute Hydrocephalus\n Assessment:\n Pt to OR for stereotactic third ventriculostomy.\n Q2h neuro exam:\n Alert, oriented x2 (self and birthdate)\n L pupil 3mm, reactive and R pupil 5mm, non-reactive;\n +corneals/gag/cough\n Right sided facial droop; increasing difficulty with speech\n RUE nml strength, no movement to LUE; RLE lifts and holds; LLE\n moves on bed\n Action:\n Head CT obtained\n Q2h neuro exams, HOB <30 degrees as ordered\n Decadron administered as ordered\n Response:\n Head CT showed edema to midbrain most likely result of OR\n procedure.\n Neuro exam unchanged\n Plan:\n Continue to assess neuro q2h. Administer decadron as ordered.\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer to R of coccyx\n Stage I pressure ulcer to L heel\n unblanchable areas, ? deep\n tissue injury\n Action:\n Duoderm gel and allevyn applied to stage II pressure ulcer\n Barrier cream applied to stage I; heels off bed; multipodus boots\n on\n Response:\n Pressure ulcers unchanged. Heels remain off bed.\n Plan:\n Continue to monitor skin integrity. Continue to keep heels off bed.\n Reposition q2h.\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 647875, "text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2124-11-03 00:00:00.000", "description": "Intensivist Note", "row_id": 647943, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n today and was brought directly to hospital from airport by\n family members. In patient presentation was concerning for altered\n mental status although when daughter arrived, he appeared much more\n alert and interactive. CT scan showed obstructive hydrocephalus.\n Patient has mildly cachectic appearance and is admitted to TICU for\n neurochecks + management of hydrocephalus, workup for malignancy.\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n decadron, RISS, nicotine patch, albuterol, bowel regimen, lyte\n replacement, heparin, protonix\n 24 Hour Events:\n NASAL SWAB - At 03:18 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 90 (78 - 93) bpm\n BP: 95/57(66) {92/24(41) - 131/69(85)} mmHg\n RR: 14 (12 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 64 kg\n Total In:\n 270 mL\n PO:\n Tube feeding:\n IV Fluid:\n 270 mL\n Blood products:\n Total out:\n 0 mL\n 390 mL\n Urine:\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n )\n Abdominal: Soft, Non-distended, Non-tender\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Clonus in LLE, weakness in b/l \n / Radiology\n 115 K/uL\n 12.5 g/dL\n 121 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 109 mEq/L\n 141 mEq/L\n 35.2 %\n 7.7 K/uL\n [image002.jpg]\n 02:36 AM\n WBC\n 7.7\n Hct\n 35.2\n Plt\n 115\n Creatinine\n 0.9\n Glucose\n 121\n Other labs: PT / PTT / INR:14.5/26.9/1.3, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Albumin:3.2 g/dL, LDH:219 IU/L,\n Ca:8.7 mg/dL, Mg:2.0 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR: Bibasilar atelectasis\n CT head: prelim read: Massive acute hydrocephalus with\n transependymal CSF flow; Two calcified masses in cerebellum and vermis\n with compression of 4th ventricle accounting for hydrocephalus\n Microbiology: Urine culture : pending (UA with mod bacteria +\n WBCs)\n MRSA screen : pending\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing obstructive hydrocephalus\n Neurologic: Neuro checks Q: 1 hr, possible VP shunt during this\n admission, followed by neurosurgery MRI today ? OR\n Cardiovascular: no active issues\n Pulmonary: asthma, nebs prn, O2 prn\n Gastrointestinal / Abdomen: AST 51, Alk phos 150, alb 3.2, hx of \"liver\n disease\" may be EtOH; bowel regimen\n Nutrition: NPO\n Renal: Cr 1.0; lyte replacement prn\n Hematology: INR 1.3\n Endocrine: RISS\n Infectious Disease: Check cultures, cipro for UTI; urine culture\n pending\n Lines / Tubes / Drains: R hand 20g PIV, foley\n Wounds: Right sacral decub ulcer\n Imaging: CT head, CXR\n Fluids: NS@70ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Other: hydrocephalus\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 647877, "text": "Admission note:\n NKDA\n Hx ETOH, last drink 5 months ago, 2 PPD smoker, asthma, GI bleed from\n gastric ulcer.\n Pt takes no medication at home\n Pt presented with increasing weakness and listing to the right side.\n Head CT showing massive acute hydrocephalus, two masses in the\n cerebellum with possible 4th ventricle compression. To TSICU for hourly\n neuro checks\n Impaired Skin Integrity\n Assessment:\n Right coccyx with stage II pressure ulcer on admission. Left heel with\n stage I pressure ulcer on admission. Otherwise skin intact.\n Action:\n Lotion applied to heels and elevated on pillows. Allyven dressing\n applied to coccyx, pt turned and kept of bottom.\n Response:\n No change.\n Plan:\n Maintain skin integrity, promote healing of present breakdown.\n Problem\n acute hydrocephalus\n Assessment:\n Pt is speaking only, but dose understand English. Per daughter,\n patient is alert but oriented to self only. Moves all extremities to\n command, BUE with equal strength. Lower extremities weak and\n deconditioned. Left foot with Clonus present. Right foot able to resist\n pressure. Pupils\n equal, occasionally right pupil is sluggish to react.\n Action:\n Hourly neuro checks, decadron loading does and continue with q6 doses.\n Response:\n No change in neuro exam.\n Plan:\n In neuro exam becomes worse, plan for bedside EVD placement. Routine\n MRI and CT today. Cont neuro checks Q hour.\n" }, { "category": "Nursing", "chartdate": "2124-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648098, "text": "Mr. is a 70 year old man who had for the last 5months had an\n increasing weakness, more so on the right side. Flew from \n on and came from the airport to the emergency department.\n : Head CT showed massive acute hydrocephalus and two masses in\n the cerebellum with likely 4^th ventricle compression. Admitted to the\n T/SICU for close monitoring.\n : Pt to OR for stereotactic third ventriculostomy with\n ventriculoscopy\n : Head CT\n Problem\n Acute Hydrocephalus\n Assessment:\n Pt to OR for stereotactic third ventriculostomy.\n Q2h neuro exam:\n L pupil 3mm, reactive and R pupil 5mm, non-reactive;\n +corneals/gag/cough\n Right sided facial droop; increasing difficulty with speech\n RUE nml strength, no movement to LUE\n RLE lifts and holds; LLE moves on bed\n Action:\n Head CT obtained\n Q2h neuro exams, HOB <30 degrees as ordered\n Decadron administered as ordered\n Response:\n Head CT showed edema to midbrain most likely result of OR\n procedure.\n Neuro exam unchanged\n Plan:\n Continue to assess neuro q2h. Administer decadron as ordered.\n Impaired Skin Integrity\n Assessment:\n Stage II pressure ulcer to R of coccyx\n Stage I pressure ulcer to L heel\n unblanchable areas, ? deep\n tissue injury\n Action:\n Duoderm gel and allevyn applied to stage II pressure ulcer\n Barrier cream applied to stage I; heels off bed; multipodus boots\n on\n Response:\n Pressure ulcers unchanged. Heels remain off bed.\n Plan:\n Continue to monitor skin integrity. Continue to keep heels off bed.\n Reposition q2h.\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648642, "text": "HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n Impaired Skin Integrity\n Assessment:\n Pt with stage 2 to left buttock came in on admission allevyn to area\n changed . Also stage one ulcer to left heel also present on\n admission- m boots.\n Action:\n Allevyn to left buttock, m boots- cream\n Response:\n healing\n Plan:\n Continue m boots and allevyn\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648643, "text": "HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n *** Pt unresponsive since Sunday morning.*******\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n Impaired Skin Integrity\n Assessment:\n Pt with stage 2 to left buttock came in on admission allevyn to area\n changed . Also stage one ulcer to left heel also present on\n admission- m boots.\n Action:\n Allevyn to left buttock, m boots- cream\n Response:\n healing\n Plan:\n Continue m boots and allevyn\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648639, "text": "HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648625, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648679, "text": "HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n *** Pt unresponsive since Sunday morning.*******\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n Impaired Skin Integrity\n Assessment:\n Pt with stage 2 to left buttock came in on admission allevyn to area\n changed . Also stage one ulcer to left heel also present on\n admission- m boots.\n Action:\n Allevyn to left buttock, m boots- cream\n Response:\n healing\n Plan:\n Continue m boots and allevyn\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYDROCEPHALUS\n Code status:\n Comfort measures only\n Height:\n 64 Inch\n Admission weight:\n 64 kg\n Daily weight:\n 63.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma, ETOH, GI Bleed, Smoker\n CV-PMH:\n Additional history: last drink 5 months ago\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:72\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 60 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 87% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 124 mL\n 24h total out:\n 1,035 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 07:29 AM\n Potassium:\n 3.5 mEq/L\n 07:29 AM\n Chloride:\n 105 mEq/L\n 02:51 AM\n CO2:\n 24 mEq/L\n 02:51 AM\n BUN:\n 17 mg/dL\n 02:51 AM\n Creatinine:\n 0.7 mg/dL\n 02:51 AM\n Glucose:\n 127 mg/dL\n 07:29 AM\n Hematocrit:\n 38.7 %\n 02:51 AM\n Finger Stick Glucose:\n 167\n 08:00 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: 1127\n Date & time of Transfer: 1840\n" }, { "category": "Nursing", "chartdate": "2124-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648018, "text": "Mr. is a 70 year old man who had for the last 5months had an\n increasing weakness, more so on the right side. Flew from \n on and came from the airport to the emergency department.\n : Head CT showed massive acute hydrocephalus and two masses in\n the cerebellum with likely 4^th ventricle compression. Admitted to the\n T/SICU for close monitoring.\n Events:\n : MRI head\n : OR for ventriculostomy placement (in 4^th ventricle)\n Impaired Skin Integrity\n Assessment:\n Right coccyx with stage II pressure ulcer on admission. Left heel with\n stage I pressure ulcer on admission. Otherwise skin intact.\n Action:\n Lotion applied to heels and elevated on pillows. Allyven dressing\n applied to coccyx, pt turned and kept of bottom.\n Response:\n No change.\n Plan:\n Maintain skin integrity, promote healing of present breakdown.\n Problem\n Acute Hydrocephalus\n Assessment:\n Spanish speaking only, does understand English. MAE\ns to command, BUE\n equal strength BLE weaker/deconditioned. Pupils equal and reactive R\n has cataract. s/p Ventric placement\n Action:\n Hourly Neuro checks, decadron Q6hrs\n Response:\n Stable neuro status\n Plan:\n Close monitoring of neuro status.\n" }, { "category": "Physician ", "chartdate": "2124-11-07 00:00:00.000", "description": "Intensivist Note", "row_id": 648612, "text": "TSICU\n HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n .\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n Current medications:\n Acetaminophen, Albuterol 0.083% Neb Soln, Bisacodyl, Calcium Gluconate,\n Chlorhexidine Gluconate 0.12% Oral Rinse, Dexamethasone, Docusate\n Sodium, Heparin, Insulin, Magnesium Sulfate, Mannitol, Morphine\n Sulfate, Nicotine Patch, Pantoprazole, Pneumococcal Vac Polyvalent,\n Potassium Chloride, Senna, Thiamine\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 01:58 PM\n EXTUBATION - At 02:00 PM\n ~3pm Patient made CMO by Nsurg\n Post operative day:\n POD#4 - drain placed to fourth ventricle\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 AM\n Infusions:\n Morphine Sulfate - 1 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 35.8\nC (96.5\n HR: 65 (63 - 87) bpm\n BP: 168/86(106) {145/74(94) - 178/93(112)} mmHg\n RR: 10 (7 - 16) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.4 kg (admission): 64 kg\n Height: 64 Inch\n Total In:\n 1,969 mL\n 55 mL\n PO:\n Tube feeding:\n 846 mL\n IV Fluid:\n 1,002 mL\n 55 mL\n Blood products:\n Total out:\n 1,060 mL\n 800 mL\n Urine:\n 1,060 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 909 mL\n -745 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 12 cmH2O\n SPO2: 97%\n ABG: ////\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: Right pupil dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Labs / Radiology\n 134 K/uL\n 14.0 g/dL\n 127 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 105 mEq/L\n 139 mEq/L\n 38.7 %\n 9.9 K/uL\n [image002.jpg]\n 02:36 AM\n 10:47 AM\n 02:50 AM\n 02:58 AM\n 02:54 AM\n 04:22 PM\n 02:51 AM\n 07:29 AM\n WBC\n 7.7\n 9.7\n 12.4\n 11.0\n 9.9\n Hct\n 35.2\n 34.1\n 37.0\n 39.5\n 38.7\n Plt\n 115\n 116\n 124\n 119\n 134\n Creatinine\n 0.9\n 0.8\n 0.7\n 0.9\n 0.7\n TCO2\n 24\n 25\n Glucose\n 121\n 106\n 99\n 101\n 124\n 138\n 127\n Other labs: PT / PTT / INR:13.9/27.2/1.2, ALT / AST:23/51, Alk-Phos / T\n bili:150/0.6, Amylase / Lipase:74/42, Lactic Acid:2.3 mmol/L,\n Albumin:3.2 g/dL, LDH:219 IU/L, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.5\n mg/dL\n Imaging: CT head: Significant worsening of a large parenchymal\n hemorrhage, new shift of the septum pellucidum\n Microbiology: Urine culture: BETA STREPTOCOCCUS GROUP B.\n 10-100K\n MRSA screen: negative\n Assessment and Plan\n GRIEVING, IMPAIRED SKIN INTEGRITY, PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 70M cachectic appearing with possible neoplastic\n compression of 4th ventricle causing hydrocephalus, now s/p 3rd\n ventriculostomy (no drain) c/b midbrain injury. CMO .\n Neurologic: s/p 3rd ventriculostomy with bleeding complication.\n morphine PRN\n Comfort measures only\n Cardiovascular: no active issues\n Pulmonary: extubated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley, no labs\n Hematology: no issues\n Endocrine: ntd\n Infectious Disease: ntd\n Lines / Tubes / Drains: Foley\n Wounds: sacral decubs from time of admission, wound care\n Imaging: ntd\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), Post-op complication, Other:\n hydrocephalus\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:04 AM\n 20 Gauge - 02:42 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Social Work", "chartdate": "2124-11-07 00:00:00.000", "description": "Social Work Admission Note", "row_id": 648621, "text": "Next of : daughter/ \n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: same\n Communication or visitation restriction: none\n Family Information\n Patient Information:\n Previous living situation: Pt was living in \n Previous level of functioning: Required some assistance with care\n recently due to being ill.\n Previous or other hospital admissions: none\n Past psychiatric history: none known\n Past addictions history: none known\n Employment status: Pt retired\n Legal involvement: none known\n Mandated Reporting Information: n/a\n Additional Information:\n Patient / Family Assessment:\n SW initially met w/pt's family on . Pt is 70 yr-old gentleman\n who is originally from & has h/o ETOH abuse & according to\n dtr, liver disease and ulcers from h/o drinking. He developed headaches\n several weeks ago and one of his brought him back to the States\n for exam. Pt found to have mets in his brain, multiple bleeds and is\n currently extubated (yesterday) and CMO. Pt has 5 and 1 son. \n are all named . SW met w/2nd oldest dtr yesterday and next oldest\n dtr today. Numerous family members around and supporting each other as\n they grieve impending loss of pt. Family is large and includes numerous\n nieces & nephews, several of whom are crying and clearly distressed. Pt\n has been called to step-down floor & awaiting bed. SW disc w/\n possibility of pt going home with Hospice to pass away & she stated\n that she will disc with her sibs and rest of family as they arrive at\n hosp over course of day. Spoke W/ , NP, Palliative Care and\n she will follow-up w/this pt/family. SW facilitating expression of\n grief as family anticipates demise of pt & providing emotional\n support.\n Clergy Contact: Name: Clergy following\n Communication with Team:\n Primary Nurse: /\n / Follow up: SW will continue to follow closely and assess coping\n of family, will assist w/exploring home with Hospice and provided\n support as needed. Please page PRN.\n , LICSW\n #\n" }, { "category": "Nursing", "chartdate": "2124-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648235, "text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments Hydrocephalus and\n midbrain hemorrhage\n Assessment:\n Post-op head CT showing persistant massive hydrocephalus, new\n hemorrhage in midbrain, multiple calcified masses in the cerebullum .\n R sided facial droop, R eye closed, R pupil 5mm and fixed, L arm & leg\n with minimal movement. Speech whisper/hoarse, sometimes\n understandable, often incomprehensible sounds. Comunicates by nodding\n and gesturing. Follows commands consistently with R arm & leg. L\n pupil reacts to light. Occ reports headache pain, relieved with 0.5 mg\n morphine.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648598, "text": "Pt . Morphine drip commenced overnight @ 1mg/hr. Family at bedside.\n Pt non responsive. Vital signs stable overnight. ? Tx to floor today.\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648673, "text": "HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n *** Pt unresponsive since Sunday morning.*******\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n Impaired Skin Integrity\n Assessment:\n Pt with stage 2 to left buttock came in on admission allevyn to area\n changed . Also stage one ulcer to left heel also present on\n admission- m boots.\n Action:\n Allevyn to left buttock, m boots- cream\n Response:\n healing\n Plan:\n Continue m boots and allevyn\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYDROCEPHALUS\n Code status:\n Comfort measures only\n Height:\n 64 Inch\n Admission weight:\n 64 kg\n Daily weight:\n 63.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma, ETOH, GI Bleed, Smoker\n CV-PMH:\n Additional history: last drink 5 months ago\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:72\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 60 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 87% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 124 mL\n 24h total out:\n 1,035 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 07:29 AM\n Potassium:\n 3.5 mEq/L\n 07:29 AM\n Chloride:\n 105 mEq/L\n 02:51 AM\n CO2:\n 24 mEq/L\n 02:51 AM\n BUN:\n 17 mg/dL\n 02:51 AM\n Creatinine:\n 0.7 mg/dL\n 02:51 AM\n Glucose:\n 127 mg/dL\n 07:29 AM\n Hematocrit:\n 38.7 %\n 02:51 AM\n Finger Stick Glucose:\n 167\n 08:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648670, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n Impaired Skin Integrity\n Assessment:\n Pt with stage 2 to left buttock came in on admission allevyn to area\n changed . Also stage one ulcer to left heel also present on\n admission- m boots.\n Action:\n Allevyn to left buttock, m boots- cream\n Response:\n healing\n Plan:\n Continue m boots and allevyn\n" }, { "category": "Nursing", "chartdate": "2124-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648669, "text": "HPI:\n 70M with incontinence, change in personality and progressive weakness\n since resulting in immobility. Patient just arrived from\n , was brought directly to hospital from airport by\n daughter. In patient was found to have hydrocephalus and was\n admitted to TSICU for neurochecks while awaiting ventriculostomy.\n ISSUES:\n 1. hydrocephalus\n 2. Significant worsening of large parenchymal hemorrhage of basal\n ganglia/midbrain\n 3. UTI\n 4. sacral decubitus ulcer stage II\n Chief complaint:\n difficulty ambulating\n PMHx:\n asthma, liver disease, sacral ulcers, peptic ulcer disease\n *** Pt unresponsive since Sunday morning.*******\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remained unresponsive today. Family at the bedside throughout the\n day. Provided reassurance from this nurse. Pt on morphine gtt for\n comfort.\n Action:\n Morphine gtt increased from 1mg- 3 mg family felt that he was\n uncomfortable.\n Response:\n Pt VS remain stable. HR 50-60\ns sats 90-95 RR 3-10- with periods of\n apnea.\n Plan:\n Continue transfer to floor when bed available. Social work did\n discuss with family the option of going home with hospice- family will\n discuss and get back to us when decision is made.\n Impaired Skin Integrity\n Assessment:\n Pt with stage 2 to left buttock came in on admission allevyn to area\n changed . Also stage one ulcer to left heel also present on\n admission- m boots.\n Action:\n Allevyn to left buttock, m boots- cream\n Response:\n healing\n Plan:\n Continue m boots and allevyn\n" }, { "category": "Respiratory ", "chartdate": "2124-11-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 648373, "text": "Demographics\n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\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 Plan\n Next 24-48 hours: waiting for family meeting, pt with poor prognosis.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nutrition", "chartdate": "2124-11-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 648374, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 cm\n 64 kg\n 63.4 kg ( 01:00 AM)\n 24\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 108\n Diagnosis: hydrocephalus\n PMH : 2 PPD smoker, asthma, GIB from gastric ulcer, liver disease, etoh\n Food allergies and intolerances:\n Pertinent medications: NS @ 70ml/hr, Dexamethasone, Colace, SS lytes,\n Thi, Mannitol, RISS\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 02:54 AM\n Glucose Finger Stick\n 157\n 08:00 PM\n BUN\n 16 mg/dL\n 02:54 AM\n Creatinine\n 0.9 mg/dL\n 02:54 AM\n Sodium\n 143 mEq/L\n 02:54 AM\n Potassium\n 3.6 mEq/L\n 02:54 AM\n Chloride\n 109 mEq/L\n 02:54 AM\n TCO2\n 23 mEq/L\n 02:54 AM\n pH (urine)\n 5.0 units\n 02:36 AM\n Albumin\n 3.2 g/dL\n 02:36 AM\n Calcium non-ionized\n 8.5 mg/dL\n 02:54 AM\n Phosphorus\n 3.4 mg/dL\n 02:54 AM\n Magnesium\n 2.1 mg/dL\n 02:54 AM\n ALT\n 23 IU/L\n 02:36 AM\n Alkaline Phosphate\n 150 IU/L\n 02:36 AM\n AST\n 51 IU/L\n 02:36 AM\n Amylase\n 74 IU/L\n 02:36 AM\n Total Bilirubin\n 0.6 mg/dL\n 02:36 AM\n WBC\n 11.0 K/uL\n 02:54 AM\n Hgb\n 13.8 g/dL\n 02:54 AM\n Hematocrit\n 39.5 %\n 02:54 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Replete w/ Fiber @ 60ml/hr (goal) -- not running\n GI: soft, hypoactive bs\n Skin: stage II on coccyx, stage I on heel\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, ? nutrition status PTA, skin\n breakdown\n Estimated Nutritional Needs\n Calories: 1600- (BEE x or / 25-30 cal/kg)\n Protein: 70-90 (1.1-1.4 g/kg)\n Fluid: team\n Estimation of previous intake: ? inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 70 y/o male w/ increasing weakness since . Pt came from\n directly to ED. Head CT showed massive acute\n hydrocephalus, 2 masses in the cerebellum w/ possible 4^th ventricle\n compression. s/p stereotactic third ventriculostomy . Post op\n head CT showed persistent massive hydrocephalus, new hemorrhage in\n midbrain. Pt intubated today. NGT in place\n needs to be advanced per\n Xray. TF ordered, not started yet. Goal TF will provide 1440calories\n and 89g protein which will likely underfeed pt.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Rec advance NGT\n Rec begin TF: Replete w/ Fiber @ 20ml/hr, advance as\n tolerated to goal of 65ml/hr = 1560calories and 97g protein\n Check residuals, hold TF if >/= 200ml\n BS mgmt\n Check chemistry 10 panel daily\n" } ]

[ { "category": "Radiology", "chartdate": "2133-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198761, "text": " 9:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Any acute cardiopulmonary process?\n Admitting Diagnosis: ASPIRIN DESENSITIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CP and DOE admitted for aspirin desensitization prior to\n cardiac cath. 90-94% on RA without known lung disease.\n REASON FOR THIS EXAMINATION:\n Any acute cardiopulmonary process?\n ______________________________________________________________________________\n WET READ: IPf MON 5:49 AM\n Low lung volumes. Possible mild pulmonary edema. However, suboptimal\n radiogarph. Repeat radiograph in full inspiration is recommended.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain and dyspnea on exertion.\n\n FINDINGS: In comparison with the study of , there are lower lung volumes\n that accentuate the prominence of the transverse diameter of the heart. There\n is fullness of indistinct pulmonary vessels consistent with elevated pulmonary\n venous pressure, beyond that which would be expected with poor inspiration on\n a portable examination.\n\n\n" }, { "category": "ECG", "chartdate": "2133-08-17 00:00:00.000", "description": "Report", "row_id": 126644, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of no\nsignificant difference.\n\n" }, { "category": "ECG", "chartdate": "2133-08-16 00:00:00.000", "description": "Report", "row_id": 126645, "text": "Sinus rhythm. Tracing is within normal limits. Compared to the previous tracing\nof there is no change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2120-11-16 00:00:00.000", "description": "Report", "row_id": 1593081, "text": "Micu Acceptance Note\n\n37 yo male presents from hopital with GIB. Pt with hx of etoh cirrhosis, depression/anxiety, esphogeal varices and smoking. Last etoh . Pt presented to MVH on with c/o passing BRBPR x 3 in one day. No hematemesis. c/o dizziness x one week when getting oob. Reports having occas blood in his stools x one months which had been attributed to hemorrhoids. Hct 27.5 at MVH. No blood products administered. Pt on liver transplant list. Sent to for liver and GI eval.\n\nReview of Systems\n\nNeuro - Pt alert and oriented x 3. Reports episodes of anxiety and insomnia - rx wtih paxil and resperidol. Given ambien to aid sleep. Also medicated with 1 mg morphine iv for c/o epigastric discomfort with good effect.\n\nResp - LS clear. RR 15-20. 02 sat > 98 on RA. Pt states has not smoked in 5 days. Has smoked 1 to 2 pks/day x 20 years.\n\nC-V - HR 70-85 NSR. NBP 120-130/60's. Pt c/o dizziness with position changes. + orthostasis. Lying 147/77 Standing 123/81 98. EKG wnl. + palp pedal pulses.\n\nGI - Abd soft and sl distended. No ascites. NPO. Protonix administered. NG lavage performed by MD neg. Passed ~200ccs brown liquid stool with areas of BRB. + internal hemorrhoids on exam. Lactulose prophylactically for encephelopathy.\n\nHeme - Hct 27.5 on arrival to MICU. Transfused one unit PRBCS without incident. Repeat hct sent almost immed after 1st unit completed was 28.4. MD aware. No further transfusions at this time. Hct checked q 4 hrs. Goal is to transfuse hct > 30. INR 1.7.\n\nF/E - IV D5 NS infusing at 100ccs/hr x 2 liters. K 3.5 - receiving a total of 60 meq kcl iv over 6 hrs. Voiding sufficient amts yellow urine via urinal.\n\nSkin - Warm, dry and intact.\n\nAccess - 2 # 18 peripheral in bilat antecubs.\n\nSocial - Pt spoke with friends and family on cellphone. No family contacts with RN.\n\nA+P - Continue to monitor GIB - serial hcts. ? diverticular bleed vs hemorrhoids. Liver and GI to evaluate this am. Plan is ? for angio if LGIB increases. Monitor for etoh withdrawal although pt denies any current use. Recheck lytes this am when K repletion completed. ? c/o if pt remains stable.\n" }, { "category": "Nursing/other", "chartdate": "2120-11-16 00:00:00.000", "description": "Report", "row_id": 1593082, "text": "Correction - pt being worked-up for ? liver transplant list.\n" }, { "category": "Nursing/other", "chartdate": "2120-11-16 00:00:00.000", "description": "Report", "row_id": 1593083, "text": "MICU NPN 0700-transfer to 10\nPlease see carevue for all objective data. Please see Transfer note for shift review.\n" }, { "category": "ECG", "chartdate": "2120-11-15 00:00:00.000", "description": "Report", "row_id": 199206, "text": "Sinus rhythm\nSince previous tracing,QRS changes in lead V2 - ? lead placement\n\n" }, { "category": "Radiology", "chartdate": "2120-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 940182, "text": " 12:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: admission CXR\n Admitting Diagnosis: GI BLEED,ESOPHAGEAL VARICIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with LGIB.\n REASON FOR THIS EXAMINATION:\n admission CXR\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:31 A.M. .\n\n HISTORY: Lower GI bleed.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Lungs are clear. Heart size top normal particularly left atrium. No\n pulmonary edema or pleural abnormality.\n\n\n" } ]

[ { "category": "Respiratory ", "chartdate": "2178-03-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528110, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 61.7 None\n Ideal tidal volume: 246.8 / 370.2 / 493.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n :\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: /\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 Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Hemodynimic instability, Underlying\n illness not resolved\n" }, { "category": "Respiratory ", "chartdate": "2178-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528048, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 61.7 None\n Ideal tidal volume: 246.8 / 370.2 / 493.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: 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: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Hemodynimic\n instability\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2178-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528206, "text": "Pt was made CM this am,nephew was at bedside throughout the time,social\n work/pastoral care was involved,pt was pronounced dead at 1050am.\n" }, { "category": "Physician ", "chartdate": "2178-03-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 528197, "text": "Chief Complaint: altered ms\n HPI:\n This is an 88 year old male with history of gastric CA, CKD HTN, mental\n retardation (non-verbal at baseline) who was admitted for\n weakness and lethargy and found to have E.Coli UTI. Today he presents\n from his nursing home where he was found to have altered mental status\n with a BP of 144/85 and HR 150. He had been vomiting the previous day.\n .\n In the ED, initial VS were T:99.1 BP:116/72 HR: 176 RR: 24 O2Sat:\n 98%NRB. Blood pressure reportedly dipped to systolics in 70's. He was\n found to be in Afib and cardioverted to sinus which returned to Afib.\n Given RR of 48 and hypoxia to the 70's he was intubated. Sepsis line in\n RIJ placed and levophed started. Got Vanc and Zosyn. CT abdomen\n concerning for ischemic gut. Lactate initially 8 resolved to 4 with\n IVF. Surgery was consulted wished to speak with family to gauge goals\n of care. Also given Bicarb, tylenol, fentanyl/versed gtt, kayexalate\n for hyperkalemia. He received 6 liter of IVF.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, non-verbal at baseline\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:37 PM\n Piperacillin - 12:34 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 06:30 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Based on his group home emergency fact sheet his past medical history\n includes the following:\n Hypertension\n Aspiration\n GERD\n Dysphagia\n Arthritis\n Renal insufficiency -- baseline Cr not documented\n \"Stomach cancer\"\n Hypothyroidism\n Mental retardation: type unknown, nonverbal at baseline\n Injury to back-- was wearing brace until \n Arthritis\n NC\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives in nursing home\n Review of systems: unable to obtain\n Flowsheet Data as of 02:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (99\n HR: 119 (118 - 154) bpm\n BP: 85/43(54) {85/43(54) - 131/68(108)} mmHg\n RR: 23 (17 - 36) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 65 Inch\n CVP: 319 (10 - 330)mmHg\n CO/CI (Fick): (11.9 L/min) / (6.2 L/min/m2)\n ICP: 89 (89 - 89) mmHg\n Mixed Venous O2% Sat: 86 - 86\n Total In:\n 4,817 mL\n 531 mL\n PO:\n TF:\n IVF:\n 4,817 mL\n 531 mL\n Blood products:\n Total out:\n 10 mL\n 0 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,807 mL\n 531 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 18 cmH2O\n Compliance: 46.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/26/117/10/-12\n Ve: 14.3 L/min\n PaO2 / FiO2: 234\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: NC/AT, PERRL, MMM\n CARDIAC: s1/s2 present, no murmurs\n LUNG: Anterior lung fields clear\n ABDOMEN: no bowel sounds, firm, +guarding R>L\n GI: foley in place, +hematuria\n EXT: feet cool, no LE edema, no mottling\n NEURO: sedated\n DERM: no skin lesions\n Labs / Radiology\n 199 K/uL\n 12.6 g/dL\n 126 mg/dL\n 3.9 mg/dL\n 59 mg/dL\n 10 mEq/L\n 122 mEq/L\n 5.5 mEq/L\n 147 mEq/L\n 40.1 %\n 7.6 K/uL\n [image002.jpg]\n \n 2:33 A3/21/ 08:07 PM\n \n 10:20 P3/21/ 08:12 PM\n \n 1:20 P3/22/ 12:18 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.6\n Hct\n 40.1\n Plt\n 199\n Cr\n 3.9\n TC02\n 14\n 13\n Glucose\n 126\n Other labs: PT / PTT / INR:13.2/26.7/1.1, Differential-Neuts:74.8 %,\n Lymph:17.7 %, Mono:5.1 %, Eos:1.2 %, Lactic Acid:4.4 mmol/L, LDH:288\n IU/L, Ca++:6.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.3 mg/dL\n Imaging: CTA Chest:\n 1. segment of sigmoid colon with is ahaustral, thickened, with areas of\n hypoenhancement and surrounding fat stranding, concerning for ischemia.\n No perforation. Vasculopathy; no arterial embolus seen.\n 2. No PE.\n 3. Ascending aortic aneurysm.\n 4. bilateral atrophic kidneys\n Microbiology: Blood and urine cxs pending\n ECG: Afib at 106. No prior comparisons\n Assessment and Plan\n This is an 88 yo male presenting with altered mental status, found to\n be septic requiring emergent intubation and initiation of vasopressors.\n .\n # Septic Shock: Gut is likely source. Concern for gut ischemia versus\n inflammation. Watery foul smelling stool suggestive of CDiff Colitis.\n CT Chest with ?LLL infiltrate. Currently CVP 8-12 after 7 liters NS.\n MAPS >65.\n -PO Vanc and IV Flagyl for possible CDiff\n -IV Vanc and Zosyn for possible PNA\n -cont levophed for now for goal MAPS>65\n -cont to bolus IVF to keep CVP 8-12\n -place arterial line\n -CVL in place\n -send stool for cdiff and cx\n -send sputum cx\n -follow up blood and urine cxs\n .\n # Metabolic Acidosis: elevated lactate in setting of sepsis. Has\n improved with IVF.\n -cont management of sepsis as per above.\n .\n # ? Sigmoid Ischemia: Surgical team feels pt is a very poor surgical\n candidate. nephew and HCP agrees that surgery would be too\n aggressive.\n -cont serial abdominal exams\n -cont IVF resucitation\n -f/u final read CT abd\n .\n # Afib with RVR: Afib is new diagnosis. Failed DC cardioversion in ED.\n Possible etiologies include ACS (given possible NSTEMI) vs sepsis vs\n ?h/o mitral valve disease.\n -Start Amiodarone (no bolus)\n -TFTs pending\n .\n # Elevated Cardiac Enzymes: NSTEMI versus CE elevation in setting of DC\n cardioversion.\n -cycle enzymes\n -consider ECHO in am\n .\n # Acute on Chronic Renal Failure: Likely related to hypotension in\n setting of sepsis. Possible this has resulted in ATN.\n -cont fluid resucitation\n -check urine lytes\n -renally dose all meds\n .\n # Hyperkalemia: Related to acute on chronic kidney failure. Given\n kayexalate in ED. No peaked T's on ECG.\n -cont to monitor.\n .\n # GERD: pantoprazole 40mg IV\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Presep Catheter - 05:00 PM\n 18 Gauge - 05:00 PM\n Arterial Line - 08:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Nephew \n Code status: DNR / DNI\n Disposition: ICU for now\n ------ Protected Section ------\n I have seen and examined the patient, discussed the case with the\n resident, and agree with the assessment and plan as above with the\n following modifications/emphasis:\n Overnight, patient continued to deteriorate with increased abdominal\n distension, loss of bowel sounds, and mottling across abdomen and lower\n extremity. He is on 3 vasopressors and worsening.\n T 100.7 BP 60s/30 P 115 RR 16 on mechanical ventilation with oxygen\n saturation 98%\n Gen: intubated, sedated, unresponsive\n Abd: Distended, firm, mottled\n Ext: cool, mottled,\n Labs\n as above\n Assessment:\n 1) Shock\n 2) Respiratory Failure\n 3) Probable ischemic bowel\n Discussion: Overall, patient is in refractory hypotensive shock with\n rising lactate despite fluid resuscitation and vasopressor support. In\n addition, his abdomen has become increasing more distended, firm,\n discolored, with lack of bowel sounds with the background of an\n abdominal CT scan showing inflammation in the colon. I suspect the\n patient has either ischemic bowel or C. dif with diffuse bowel\n involvement and ischemia. The nephew spoke with the surgeons and\n decided that he did not want to pursue an operation given the poor\n prognosis even with surgery. Given the decision not to pursue surgery\n and the worsening shock in the face of abdominal catastrophe, the\n prognosis is dismal. The nephew decided this morning to pursue comfort\n care measures and we will discontinue vasopressors after a priest\n becomes available in the next few minutes. We will focus on the\n comfort of the patient.\n Time Spent: 30 minutes\n Patient is Critically Ill\n ------ Protected Section Addendum Entered By: , MD\n on: 10:10 AM ------\n" }, { "category": "Physician ", "chartdate": "2178-03-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 528096, "text": "Chief Complaint: altered ms\n HPI:\n This is an 88 year old male with history of gastric CA, CKD HTN, mental\n retardation (non-verbal at baseline) who was admitted for\n weakness and lethargy and found to have E.Coli UTI. Today he presents\n from his nursing home where he was found to have altered mental status\n with a BP of 144/85 and HR 150. He had been vomiting the previous day.\n .\n In the ED, initial VS were T:99.1 BP:116/72 HR: 176 RR: 24 O2Sat:\n 98%NRB. Blood pressure reportedly dipped to systolics in 70's. He was\n found to be in Afib and cardioverted to sinus which returned to Afib.\n Given RR of 48 and hypoxia to the 70's he was intubated. Sepsis line in\n RIJ placed and levophed started. Got Vanc and Zosyn. CT abdomen\n concerning for ischemic gut. Lactate initially 8 resolved to 4 with\n IVF. Surgery was consulted wished to speak with family to gauge goals\n of care. Also given Bicarb, tylenol, fentanyl/versed gtt, kayexalate\n for hyperkalemia. He received 6 liter of IVF.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, non-verbal at baseline\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:37 PM\n Piperacillin - 12:34 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 06:30 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Based on his group home emergency fact sheet his past medical history\n includes the following:\n Hypertension\n Aspiration\n GERD\n Dysphagia\n Arthritis\n Renal insufficiency -- baseline Cr not documented\n \"Stomach cancer\"\n Hypothyroidism\n Mental retardation: type unknown, nonverbal at baseline\n Injury to back-- was wearing brace until \n Arthritis\n NC\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives in nursing home\n Review of systems: unable to obtain\n Flowsheet Data as of 02:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (99\n HR: 119 (118 - 154) bpm\n BP: 85/43(54) {85/43(54) - 131/68(108)} mmHg\n RR: 23 (17 - 36) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 65 Inch\n CVP: 319 (10 - 330)mmHg\n CO/CI (Fick): (11.9 L/min) / (6.2 L/min/m2)\n ICP: 89 (89 - 89) mmHg\n Mixed Venous O2% Sat: 86 - 86\n Total In:\n 4,817 mL\n 531 mL\n PO:\n TF:\n IVF:\n 4,817 mL\n 531 mL\n Blood products:\n Total out:\n 10 mL\n 0 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,807 mL\n 531 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 18 cmH2O\n Compliance: 46.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/26/117/10/-12\n Ve: 14.3 L/min\n PaO2 / FiO2: 234\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: NC/AT, PERRL, MMM\n CARDIAC: s1/s2 present, no murmurs\n LUNG: Anterior lung fields clear\n ABDOMEN: no bowel sounds, firm, +guarding R>L\n GI: foley in place, +hematuria\n EXT: feet cool, no LE edema, no mottling\n NEURO: sedated\n DERM: no skin lesions\n Labs / Radiology\n 199 K/uL\n 12.6 g/dL\n 126 mg/dL\n 3.9 mg/dL\n 59 mg/dL\n 10 mEq/L\n 122 mEq/L\n 5.5 mEq/L\n 147 mEq/L\n 40.1 %\n 7.6 K/uL\n [image002.jpg]\n \n 2:33 A3/21/ 08:07 PM\n \n 10:20 P3/21/ 08:12 PM\n \n 1:20 P3/22/ 12:18 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.6\n Hct\n 40.1\n Plt\n 199\n Cr\n 3.9\n TC02\n 14\n 13\n Glucose\n 126\n Other labs: PT / PTT / INR:13.2/26.7/1.1, Differential-Neuts:74.8 %,\n Lymph:17.7 %, Mono:5.1 %, Eos:1.2 %, Lactic Acid:4.4 mmol/L, LDH:288\n IU/L, Ca++:6.6 mg/dL, Mg++:2.2 mg/dL, PO4:5.3 mg/dL\n Imaging: CTA Chest:\n 1. segment of sigmoid colon with is ahaustral, thickened, with areas of\n hypoenhancement and surrounding fat stranding, concerning for ischemia.\n No perforation. Vasculopathy; no arterial embolus seen.\n 2. No PE.\n 3. Ascending aortic aneurysm.\n 4. bilateral atrophic kidneys\n Microbiology: Blood and urine cxs pending\n ECG: Afib at 106. No prior comparisons\n Assessment and Plan\n This is an 88 yo male presenting with altered mental status, found to\n be septic requiring emergent intubation and initiation of vasopressors.\n .\n # Septic Shock: Gut is likely source. Concern for gut ischemia versus\n inflammation. Watery foul smelling stool suggestive of CDiff Colitis.\n CT Chest with ?LLL infiltrate. Currently CVP 8-12 after 7 liters NS.\n MAPS >65.\n -PO Vanc and IV Flagyl for possible CDiff\n -IV Vanc and Zosyn for possible PNA\n -cont levophed for now for goal MAPS>65\n -cont to bolus IVF to keep CVP 8-12\n -place arterial line\n -CVL in place\n -send stool for cdiff and cx\n -send sputum cx\n -follow up blood and urine cxs\n .\n # Metabolic Acidosis: elevated lactate in setting of sepsis. Has\n improved with IVF.\n -cont management of sepsis as per above.\n .\n # ? Sigmoid Ischemia: Surgical team feels pt is a very poor surgical\n candidate. nephew and HCP agrees that surgery would be too\n aggressive.\n -cont serial abdominal exams\n -cont IVF resucitation\n -f/u final read CT abd\n .\n # Afib with RVR: Afib is new diagnosis. Failed DC cardioversion in ED.\n Possible etiologies include ACS (given possible NSTEMI) vs sepsis vs\n ?h/o mitral valve disease.\n -Start Amiodarone (no bolus)\n -TFTs pending\n .\n # Elevated Cardiac Enzymes: NSTEMI versus CE elevation in setting of DC\n cardioversion.\n -cycle enzymes\n -consider ECHO in am\n .\n # Acute on Chronic Renal Failure: Likely related to hypotension in\n setting of sepsis. Possible this has resulted in ATN.\n -cont fluid resucitation\n -check urine lytes\n -renally dose all meds\n .\n # Hyperkalemia: Related to acute on chronic kidney failure. Given\n kayexalate in ED. No peaked T's on ECG.\n -cont to monitor.\n .\n # GERD: pantoprazole 40mg IV\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Presep Catheter - 05:00 PM\n 18 Gauge - 05:00 PM\n Arterial Line - 08:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Nephew \n Code status: DNR / DNI\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2178-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528160, "text": "88 y.o. man group home resident with\n history of gastric CA, CRF (baseline Cr 2.0), HTN, and mental\n retardation (nonverbal at baseline) found to be unresponsive at group\n home. Intubated, hypotensive and was given 7 L IVFs in ED, RIJ placed,\n started on levophed. Abdominal CT concerning for ischemic bowel,\n lactate 8. Cr 4.7. Also new Afib, patient cardioverted in ED. ABG\n 7.13/33/349 on 100% FiO2. Started on vanco/zosyn. Surgical evaluation\n in ED - felt to be high morbidity/mortality risk for surgical\n intervention.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Passing green foul smelling liq stool. Abd firm distended.\n Action:\n Stool specimen sent for Cdiff, Started on abx vanco PO and flagyl IV,\n GI following\n Response:\n Pt is too instable to discus about surgical options now.\n Plan:\n Cont abx, Follow cultures.\n Atrial fibrillation (Afib)\n Assessment:\n In the begning of the shift HR was in 120 to 140 w/ frequent burst of\n RVR to 180\ns, levophed was running @ 0.24mics/kg/min.\n Action:\n Neo started and weaned off levophed pt cont to drop BP to 70\ns, Started\n on vasopressin and started Amiodarone drip @ 0.1mics/min for 6 hrs\n and titrated down to 0.5mics/min which should run for next 16hrs.\n Response:\n BP dropped to 70\ns Rhythm converted to sinus tachy w/ occasional PAC\n HR in low 100\ns. Levophed restarted and titrated to BP.\n Plan:\n Cont amiodarone if BP drops further titrate up on levophed.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Lactate up to 8 and metabolic alcolosis on the ABG. BP in 70\ns to 90\n Action:\n Received total 10lit fluid from ED and in ICU. Maxed out on neo and\n vasopressin, Levophed titrating to BP currently running @\n 0.1mics/kg/min. On abx to treat colitis. No urine output in this shift\n renal following\n Response:\n Hemodynamically very unstable.\n Plan:\n Family meeting in AM he is DNR/DNI\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n No urine output for this shift. K+ up to 6.3\n Action:\n Given key exalate 30grams and glucose insulin, Creatinine climbing up\n to 5.2, Renal following\n Response:\n Pending\n Plan:\n Family meeting w/ nephew to discuss the goal of care.\n" }, { "category": "Nursing", "chartdate": "2178-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528089, "text": "88 y.o. man group home resident with\n history of gastric CA, CRF (baseline Cr 2.0), HTN, and mental\n retardation (nonverbal at baseline) found to be unresponsive at group\n home. Intubated, hypotensive and was given 7 L IVFs in ED, RIJ placed,\n started on levophed. Abdominal CT concerning for ischemic bowel,\n lactate 8. Cr 4.7. Also new Afib, patient cardioverted in ED. ABG\n 7.13/33/349 on 100% FiO2. Started on vanco/zosyn. Surgical evaluation\n in ED - felt to be high morbidity/mortality risk for surgical\n intervention.\n" }, { "category": "Nursing", "chartdate": "2178-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528155, "text": "88 y.o. man group home resident with\n history of gastric CA, CRF (baseline Cr 2.0), HTN, and mental\n retardation (nonverbal at baseline) found to be unresponsive at group\n home. Intubated, hypotensive and was given 7 L IVFs in ED, RIJ placed,\n started on levophed. Abdominal CT concerning for ischemic bowel,\n lactate 8. Cr 4.7. Also new Afib, patient cardioverted in ED. ABG\n 7.13/33/349 on 100% FiO2. Started on vanco/zosyn. Surgical evaluation\n in ED - felt to be high morbidity/mortality risk for surgical\n intervention.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Passing green foul smelling liq stool. Abd firm distended.\n Action:\n Stool specimen sent for Cdiff, Started on abx vanco PO and flagyl IV,\n GI following\n Response:\n Pt is too instable to discus about surgical options now.\n Plan:\n Cont abx, Follow cultures.\n Atrial fibrillation (Afib)\n Assessment:\n In the begning of the shift HR was in 120 to 140 w/ frequent burst of\n RVR to 180\ns, levophed was running @ 0.24mics/kg/min.\n Action:\n Neo started and weaned off levophed pt cont to drop BP to 70\ns, Started\n on vasopressin and started Amiodarone drip @ 0.1mics/min for 6 hrs\n and titrated down to 0.5mics/min which should run for next 16hrs.\n Response:\n BP dropped to 70\ns Rhythm converted to sinus tachy w/ occasional PAC\n HR in low 100\ns. Levophed restarted and titrated to BP.\n Plan:\n Cont amiodarone if BP drops further titrate up on levophed.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Lactate up to 8 and metabolic alcolosis on the ABG. BP in 70\ns to 90\n Action:\n Received total 10lit fluid from ED and in ICU. Maxed out on neo and\n vasopressin, Levophed titrating to BP currently running @\n 0.1mics/kg/min. On abx to treat colitis. No urine output in this shift\n renal following\n Response:\n Hemodynamically very unstable.\n Plan:\n Family meeting in AM he is DNR/DNI\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n No urine output for this shift. K+ up to 6.3\n Action:\n Given key exalate 30grams and glucose insulin, Creatinine climbing up\n to 5.2, Renal following\n Response:\n Pending\n Plan:\n Family meeting w/ nephew to discuss the goal of care.\n" }, { "category": "Physician ", "chartdate": "2178-03-08 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 528061, "text": "Chief Complaint: hypotension, respiraotry 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 88 y.o. man group home resident with history of gastric CA, CRF\n (baseline Cr 2.0), HTN, and mental retardation (nonverbal at baseline)\n found to be unresponsive at group home. Intubated, hypotensive and was\n given 7 L IVFs in ED, RIJ placed, started on levophed. Abdominal CT\n concerning for ischemic bowel, lactate 8. Cr 4.7. Also new Afib,\n patient cardioverted in ED. ABG 7.13/33/349 on 100% FiO2. Started on\n vanco/zosyn. Surgical evaluation in ED - felt to be high\n morbidity/mortality risk for surgical intervention.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, intubated\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 HTN\n Aspiration GERD\n Dysphagia\n CRI\n Gastric cancer\n Hypothyroidism\n Mental retardation\n Chronic low back pain\n Unable to obtain\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: , HCP\n Review of systems:\n Gastrointestinal: Diarrhea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 118 (118 - 120) bpm\n BP: 131/58(108) {131/58(108) - 131/58(108)} mmHg\n RR: 32 (32 - 36) insp/min\n SpO2: 98%\n Height: 65 Inch\n CVP: 19 (19 - 19)mmHg\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n FiO2: 50%\n PIP: 32 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 15.6 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\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: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : dependently)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Cool\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 273\n 44.5\n 4.7\n 66\n 13.8\n [image002.jpg]\n Imaging: CT chest with dependent alveolar inflitrates L>R, small\n effusions\n ECG: Afib without acute STTW changes\n Assessment and Plan\n 1. Shock, hypovolemic vs. sepsis: Probable source is ischemic bowel\n vs. PNA. Aggressive volume repletion and pressors. CVP 8 so rebolused\n here in ICU. Agree with vanco/zosyn IV.\n 2. Afib: New onset afib in setting of critical illness. Plan to load\n with amiodarone.\n 3. Diarrhea: Foul smelling green stool, concerned for C. Diff\n colitis. Sending stool. Given how sick he is will treat with IV\n flagyl/po vanco in addition to above antibiotics.\n 4. Code status: Had a meeting with the patient's who is also\n his designated HCP. is aware of how critically ill his uncle is and\n that he is a high risk surgical candidate. Feels that course most\n consistent with goals for the patient given prior discussions would be\n to continue to support with IVFs, antibiotics, pressors and ventilatory\n support. No surgical intervention. No shocks for life threatening\n arrhythmias, may cardiovert for afib. Will readdress goals of care in\n next 12-24 hours depending on clinical course.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2178-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528127, "text": "88 y.o. man group home resident with\n history of gastric CA, CRF (baseline Cr 2.0), HTN, and mental\n retardation (nonverbal at baseline) found to be unresponsive at group\n home. Intubated, hypotensive and was given 7 L IVFs in ED, RIJ placed,\n started on levophed. Abdominal CT concerning for ischemic bowel,\n lactate 8. Cr 4.7. Also new Afib, patient cardioverted in ED. ABG\n 7.13/33/349 on 100% FiO2. Started on vanco/zosyn. Surgical evaluation\n in ED - felt to be high morbidity/mortality risk for surgical\n intervention.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Passing green foul smelling liq stool. Abd firm distended.\n Action:\n Stool specimen sent for Cdiff, Started on abx vanco PO and flagyl IV,\n GI following\n Response:\n Pt is too instable to discus about surgical options.\n Plan:\n Cont abx, Follow cultures.\n Atrial fibrillation (Afib)\n Assessment:\n In the begning of the shift HR was in 120 to 140 w/ frequent burst of\n RVR to 180\ns, levophed was running @ 0.24mics/kg/min.\n Action:\n Started neo@ 5 mics/kg/min and weaned off levophed which stopped RVR\n but his HR cont to be 140\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2178-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528230, "text": "Pt was made CMO this am,nephew was at bedside throughout the\n time,social work/pastoral care was involved,pt was pronounced dead at\n 1050am.\n" }, { "category": "ECG", "chartdate": "2178-03-09 00:00:00.000", "description": "Report", "row_id": 228722, "text": "Probable multifocal atrial tachycardia. Low limb lead QRS voltage. Left axis\ndeviation may be due to left anterior fascicular block and/or possible prior\ninferior myocardial infarction. Delayed R wave progression with late precordial\nQRS transition is non-specific. Since the previous tracing of there is\nprobably no significant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2178-03-08 00:00:00.000", "description": "Report", "row_id": 228723, "text": "Probable multifocal atrial tachycardia. Left axis deviation may be due to left\nanterior fascicular block and/or possible prior inferior myocardial infarction.\nDelayed R wave progression with late precordial QRS transition is non-specific.\nSince the previous tracing of same date the ventricular rate is faster.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2178-03-08 00:00:00.000", "description": "Report", "row_id": 228724, "text": "Probable multifocal atrial tachycardia. Left axis deviation may be due to left\nanterior fascicular block or possible prior inferior myocardial infarction.\nDelayed R wave progression with late precordial QRS transition is non-specific.\nSince the previous tracing of same date the ventricular rate is slower.\nTRACING #2\n\n\n" }, { "category": "ECG", "chartdate": "2178-03-08 00:00:00.000", "description": "Report", "row_id": 228725, "text": "Irregular narrow complex tachycardia of uncertain mechanism but may be atrial\nfibrillation or possible multifocal atrial tachycardia with rapid ventricular\nresponse. Left axis deviation may be due to left anterior fascicular block or\npossible prior inferior myocardial infarction. Delayed R wave progression with\nlate precordial QRS transition is non-specific. Baseline artifact makes\nassessment difficult. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2178-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126799, "text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man found unresponsive with ?ischemic gut. Has small bilat\n effusions likely CHF in setting of new afib\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Unresponsive.\n\n FINDINGS: Indwelling devices are unchanged in position, and cardiomediastinal\n contours are stable in appearance. Worsening opacity in left retrocardiac\n region is likely due to a combination of atelectasis and small pleural\n effusion, but infectious pneumonia should also be considered in the\n appropriate clinical setting.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126708, "text": " 1:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with tachypnea, resp failure\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Tachypnea, respiratory failure, intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 3 cm above the carina.\n A nasogastric tube has been placed, the tip is not visible on today's image.\n\n Unchanged moderate cardiomegaly with tortuosity of the thoracic aorta.\n Interval development of minimal pulmonary edema. No evidence of focal\n parenchymal opacity suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-08 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1126709, "text": " 1:44 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock, tachypnic/hypotensive, clear lungs\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd SUN 3:02 PM\n 1. segment of sigmoid colon with is ahaustral, thickened, with areas of\n and surrounding fat stranding, concerning for ischemia. No\n perforation. Vasculopathy; no arterial embolus seen.\n 2. No PE.\n 3. Ascending aortic aneurysm.\n 4. bilateral atrophic kidneys.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man with shock, tachypnea and hypotension. Rule out\n pulmonary embolism.\n\n COMPARISON: None.\n\n TECHNIQUE: Axially acquired images were obtained through the chest prior to\n and after the administration of 100 cc of Visipaque intravenous contrast.\n Coronal, sagittal, and oblique reformatted images were also obtained.\n\n Axially acquired images were also obtained through the abdomen and pelvis\n after the administration of 100 cc of Visipaque intravenous contrast. Coronal\n reformatted images were also displayed of the abdomen and pelvis.\n\n\n FINDINGS:\n\n CT OF THE CHEST WITH IV CONTRAST: There is no dissection. There is no\n pulmonary embolism. The patient is intubated with the endotracheal tube\n ending approximately 2.1 cm above the carina. There is dependent atelectasis\n bilaterally at the lung bases. Otherwise, the lungs are clear. The heart\n size is normal. There is a trace amount of pericardial fluid. The ascending\n aorta is dilated and measures 6.2 x 5.4 cm (3A:56). There is vascular\n calcification throughout the aorta.\n\n There is no hilar, mediastinal, or axillary lymphadenopathy.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: NG tube is noted within the stomach. The\n adrenal glands, pancreas, gallbladder, and liver are within normal limits.\n There is a small splenic cyst near the splenic hilum. The kidneys are shrunken\n and atrophic bilaterally. Multiple cysts are noted with the largest in the\n right kidney measuring up to 2.6 cm. There is no retroperitoneal or\n mesenteric lymphadenopathy. There is no free air or free fluid.\n\n (Over)\n\n 1:44 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o PE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid colon are abnormal\n with wall thickening, adjacent fat stranding, and relative of\n the wall. The remainder of the bowel wall appears within normal limits.\n There is no evidence of obstruction.\n\n The abdominal and pelvic arterial vasculature is heavily calcified. However,\n there is no evidence of filling defect within the arterial vasculature.\n\n A Foley catheter is within a nearly decompressed bladder. The prostate is\n markedly enlarged with a prostatic stent. The stent remains in the prostate.\n The Foley catheter is inflated within the prostate proximal to the stent. The\n tip of the Foley catheter is external to the lumen of the stent, ending along\n the outer, posterior edge There are small bilateral fat-containing inguinal\n hernias. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No concerning osseous lesions are identified.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism or dissection. Aneurysm of the ascending\n aorta. Trace pericardial fluid.\n\n 2. Dilated, ahaustral, and hypoenhancing segments of the sigmoid colon with\n bowel wall thickening and adjacent fat stranding, concerning for infectious\n process, less likely ischemia.\n\n 3. Enlarged prostate with prostatic stent. Foley catheter ends proximal to\n stent with balloon inflated within the prostate.\n\n 4. Small atrophic bilateral kidneys.\n\n Findings were discussed with Dr. shortly after review on .\n\n Revised findings were discussed with Dr. and Foley catheter and\n prostate findings were discussed with Dr. on .\n\n" } ]

[ { "category": "Radiology", "chartdate": "2159-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961259, "text": " 11:59\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with sob, HIV\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old female with HIV and shortness of breath.\n\n COMPARISON: PA and lateral chest x-ray dated .\n\n PA AND LATERAL CHEST X-RAY: The cardiac silhouette is enlarged, and may be\n exaggerated by AP technique. New bilateral and symmetric air space opacities\n are most consistent with pulmonary edema. Plate and screws are again seen\n within the right humeral head.\n\n IMPRESSION: Bilateral symmetric air space opacities are most consistent with\n pulmonary edema. However, in the setting of patient's underlying HIV,\n infectious etiologies could also be considered.\n\n" }, { "category": "Radiology", "chartdate": "2159-04-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961646, "text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please re-evaluate lung fields post-diuresis.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n pt with hiv, asthma and hypoxia, with CT suggestive of pulmonary edema, now\n with slight improvement post-diuresis\n REASON FOR THIS EXAMINATION:\n Please re-evaluate lung fields post-diuresis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old female with HIV, asthma, and hypoxia with CT findings\n suggestive of pulmonary edema status post slight improvement after diuresis.\n\n Comparison is made to prior radiographs dated , , and as well as prior CTA chest dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n When compared to most recent radiographs, there continues to be improvement to\n diffuse ground-glass opacities within the lung fields, best appreciated within\n the lower lungs likely representing resolving alveolar edema. No evidence of\n pneumothorax or large effusions. Cardiomediastinal silhouette and hilar\n contours remain unchanged.\n\n IMPRESSION:\n\n Resolving alveolar edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-04-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 961817, "text": " 6:18 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval progress\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with pulmonary edema\n REASON FOR THIS EXAMINATION:\n eval for interval progress\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 18:19 HOURS\n\n HISTORY: Pulmonary edema, assess for interval change.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Cephalization and pulmonary vascular indistinctness persists.\n There is no focal consolidation. A tortuous aorta is again evident. The\n cardiac silhouette remains borderline enlarged with a left ventricular\n configuration. No definite effusion or pneumothorax is seen. Prior fixation\n hardware is noted in the included right humeral head.\n\n IMPRESSION: Central vascular congestion with mild edema. Overall continued\n slight improvement although not completely resolved.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961439, "text": " 3:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pna, chf, other pathology\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n pt with hiv, asthma and hypoxia\n REASON FOR THIS EXAMINATION:\n evaluate for pna, chf, other pathology\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The heart size is normal. There is improvement in bilateral areas of opacity\n most likely representing pulmonary edema. There is no sizeable pleural\n effusion. There is no pneumothorax.\n\n IMPRESSION: Improving of pulmonary edema which still is of at least moderate\n degree.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-04-12 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 961528, "text": " 2:29 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please assess for PE\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with hypoxic respiratory distress want to rule out PE,\n elevated d-dimer\n REASON FOR THIS EXAMINATION:\n please assess for PE\n CONTRAINDICATIONS for IV CONTRAST:\n Hive, premed protocol written\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA CHEST DATED .\n\n CLINICAL HISTORY: 50-year-old woman with hypoxic respiratory distress. Rule\n out pulmonary embolism. Elevated D-dimer.\n\n Comparison made to prior chest radiographs, most recent dated as well\n as prior CTA chest dated .\n\n TECHNIQUE: Multiple transaxial images of the chest were obtained with and\n without intravenous contrast, utilizing pulmonary embolism protocol. Coronally\n and sagittally reformatted images were also obtained.\n\n CTA CHEST: Evaluation is somewhat limited secondary to body habitus. The\n pulmonary artery is normal in size and appearance. No intraluminal filling\n defect is seen in the main pulmonary arteries and proximal branches. The\n aorta is normal in caliber, without evidence of dissection or aneurysm. The\n left subclavian vein is occluded, with intravenous contrast flowing into the\n SVC via collateral vessels, suggesting this is a chronic process.\n\n There is enlarged right hilar lymph node measuring 1.3 cm in short-axis\n diameter (sequence 3, image #27). There are prominent but nonpathologically\n enlarged mediastinal lymph nodes in the prevascular space and inferior\n mediastinum, measuring up to 9 mm.\n\n There is extensive, diffuse ground-glass opacity throughout the lungs in a\n relatively uniform distribution in the upper lung fields and more patchy\n distribution inferiorly. Multiple nodular opacities are seen at the periphery\n of the lungs, which were not present on the prior study of .\n Further evaluation of these noduluar densities may be obtained after re-\n treatment. No pleural or pericardial effusions. No evidence of pneumothorax.\n\n Multiplanar reformatted images were useful in the delineation of the above\n findings.\n\n Findings were discussed with house officer, .\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism, as clinically questioned.\n (Over)\n\n 2:29 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please assess for PE\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Extensive ground-glass opacities throughout the lungs. This appearance\n most likely represents pulmonary edema, although cannot exclude superimposed\n infection. Peripheral nodular densities may represent focal atalecasis.\n Recommend follow up imaging after appropriate treatment.\n\n 3. Chronic occlusion of left subclavian vein.\n\n" }, { "category": "Radiology", "chartdate": "2159-04-16 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 962045, "text": " 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval interval changes, resolution of nodularities, effusion\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with hypoxic respiratory distress on admission, now with\n persistent oxygen requirement 5L NC, nodular opacities on admission CT\n concerning for pneumonia, along with bilateral effusions, now post diuresis.\n REASON FOR THIS EXAMINATION:\n eval interval changes, resolution of nodularities, effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST \n\n COMPARISON: chest CTA.\n\n INDICATION: Respiratory distress on admission. Status post diuresis.\n\n Multidetector CT of the chest was performed without intravenous or oral\n contrast administration. Images are presented for display in the axial plane\n at 5 mm and 1.25 mm collimation.\n\n FINDINGS: The lungs demonstrate diffuse areas of ground-glass attenuation\n throughout all lobes of both lungs. As compared to the previous CT, the\n extent of ground-glass attenuation and the density of the ground glass areas\n have both improved. Additionally, several previously described discrete\n nodular opacities have resolved. One new small nodular opacity has developed\n in the right lower lobe laterally measuring about 4 mm (image 112, series 4).\n A few thickened septal lines are present on the thin section images, but the\n predominant abnormality is the ground glass attenuation. No concerning\n endobronchial lesions are identified. A few areas of retained secretions are\n noted within the trachea.\n\n Numerous small lymph nodes are present within the mediastinum and do not meet\n size criteria for significant enlargement. Heart size is normal. It has\n decreased in size since the prior CT slightly. No pericardial or pleural\n effusion is seen. A small hiatal hernia is noted.\n\n In the imaged portion of the upper abdomen, surgical clips are present\n consistent with prior cholecystectomy. The remaining imaged upper abdomen is\n unremarkable but absence of intravenous contrast and extensive image noise\n limits assessment on this exam that was not specifically tailored to evaluate\n these structures. Chest wall collaterals are present and are seen to better\n detail on the previous contrast-enhanced CT.\n\n Skeletal structures demonstrate no suspicious lytic or blastic skeletal\n lesions.\n\n IMPRESSION:\n\n Rapidly improving diffuse ground-glass attenuation and resolution of\n (Over)\n\n 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval interval changes, resolution of nodularities, effusion\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n previously described focal nodular opacities. Considering interval diuresis,\n these findings are likely due to hydrostatic edema.\n\n However, differential diagnosis for diffuse ground glass opacities is broad;\n in the appropriate clinical setting, pulmonary hemorrhage, hypersensitivity\n reaction (to drug or other antigens) and infection (viral or PCP) should also\n be considered.\n\n\n\n" }, { "category": "Echo", "chartdate": "2159-04-12 00:00:00.000", "description": "Report", "row_id": 95085, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 307\nBSA (m2): 2.45 m2\nBP (mm Hg): 137/66\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 12:59\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. No ASD by 2D or color\nDoppler. Dilated IVC (>2.5cm) with no change with respiration (estimated RAP\n>20 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. No 2D or Doppler evidence of\ndistal arch coarctation.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS. Prolonged (>250ms) transmitral\nE-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is >20 mmHg. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF 70%). 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 number of aortic valve leaflets cannot be\ndetermined. There is no aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , no gross or obvious change, but the technically\nsuboptimal nature of both studies precludes definitive comparison. The\npulmonary artery pressure could not be determined owing to the technically\nsuboptimal nature of this study.\n\n\n" }, { "category": "ECG", "chartdate": "2159-04-11 00:00:00.000", "description": "Report", "row_id": 254881, "text": "Sinus tachycardia\nProbable inferior myocardial infarction, age indeterminate - may be old\nLow precordial lead QRS voltages - is nonspecific\nAnterior myocardial infarct, age indeterminate\nDiffuse nonspecific ST-T wave abnormalities - cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , sinus tachycardia, precordial lead Q waves\nand further ST-T wave changes present\n\n" }, { "category": "Nursing/other", "chartdate": "2159-04-12 00:00:00.000", "description": "Report", "row_id": 1478938, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: sulfonamides, motrin, compazine, vanco, haldol, nitrofurantoin.\n\nEvents: CT scan, ECHO done, weaning oxygen as tolerated.\n\nNeuro: Pt alert and oriented x 3, MAE, OOB to commode with 2 assists, following commands, able to make needs known. Pt complaining of HA , received PRN oxycodone with some effect () then later Imitrex.\n\nCV: HR NSR 70-80 with rare PVC, NBP 101-137/61-73. Heparin decreased from 2450 to 2350 for PTT of 88.2, next due to be drawn at 2100. Pt had ECHO this AM to assess cadiac function, results pending. Pt also had CTA that was negative for PE but results preliminary read revealed ? occluded subclavian vessel. Pt recevied Lasix IVP for fluid overload with good response. receive additional dose this PM. Peripheral pulses strong. PIV x 2.\n\nResp: Pt on 5LNC and face tent 100% on 10L, RR 14-22 with sats >90%. Lung sounds clear with crackles in bases. Pt with non-productive cough, sputum sample needed.\n\nGI: BS x 4, small soft stool this shift, guiac negative. Pt tolerating heart healthy diet well.\n\nGU: Foley patent and draining adequate amounts of clear, yellow urine. UO 40-400cc/hr. Pt negative 1L since MN.\n\nSkin: Intact, warm and dry.\n\nID: Pt afebrile, on Azithromycin and Ceftriaxone for PNA.\n\nPlan:\nfollow up ECHO/CTA results\nwean 02 as tolerated by pt\npain management\nsputum sample needed\nfollow up culture data\nPTT at 2100\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2159-04-13 00:00:00.000", "description": "Report", "row_id": 1478939, "text": "Resp Care\nPt given nebs as ordered. Bs course to dimished whith slight wheezes that resolve after Neb. No resp distess. On 4 - 6 lpm Nc and 70% face tent with sats 90- 95%. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-13 00:00:00.000", "description": "Report", "row_id": 1478940, "text": "MICU nursing progress note 7P-7A\nChest CTA showed pulmonary edema, chronic left subclavian clot, no P. Heparin gtt d/c'd.\n\nNeuro - A&O x 3. Slept all night, easily aroused. MAE on bed, assists wit turns. C/O HA this AM, oxycodone with relief.\n\nResp - Cont on 5L NC and humidified FT, FiO2 increased from .5->.7 o/n d/t decreasing sats to mid 80s. Pt also desats mid 80s with FT off for PO intake. Lungs clear, faint bibasilar crackles, much less than yesterday. R 16-23, ^^ 30 with activity. + non-productive cough, much less so than yesterday. Nebs, steroids, antibx.\n\nCV- NBP 114-126/62-72. NSR 60s-70s. Pt autodiuresing, neg 1600cc at minite, 800cc neg so far today.\n\nGI - Abd soft, +BS. No stool. Taking PO fluids, lots of ice chips. FSBS WNL.\n\nGU - UOP 40-210 cc clear yellow urine.\n\nID - T max 98.8 axillary, cont on ceftriaxone and azithromycin.\n\nPlan - Wean FiO2 as tolerated. Antibx, nebs, seroids. Follow I&O.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-11 00:00:00.000", "description": "Report", "row_id": 1478933, "text": "Nursing Admit Note\n\nThis is a 50 year old female with a PMH sig HIV/Hep B&C, who presented to the EW with increasing SOB/wheezes. She was recently seen in EW for Rx of sinus infection, nonproductive cough and worsening SOB, she was D/C'd from EW with RX for augmentin & steriods (did not start steroids) she returned to the EW last evening for worsening SOB. In EW she had a low grade temp of 100.5, HR 120's, Hemodynamically stable sats were noted to be 74 on RA. SHe was placed on a NRB with sats improving to 90%. Her ABG at that time was 7.27/54/61 with a lactate of 2.1. She was Rx with solumedrol, nebs, ceftriaxone with symptomatic improvement. She was transferred to MICU for futher monitoring\n\nNeuro: A&Ox3. Pt OOB to commode with moderate one assist sats 90-91 on NRB during activity. Pt with complaints of HA, given 10 mg oxycodone with poor effect, given AM methadone dose early.\n\nResp: Lung sounds with exp wheezes throughout. RR low 20's. Up to 30 with activity or talking. Pt remains on 100% NRB, sats down to mid 80's with mask off. Sats 91-94% at rest. Pt feels symptomatically better\n\nCardiac: Tele SR-ST 90-100's with occ PVC's. BP 100-130/60-70's. No edema +4 pt/dp bilaterally. Cardiac enzymes mildly elevated CK 310, trop .07, BNP 500, to be R/O next set due at 10 am\n\nGI: Abdomen obese, + BS in 4 quadrents. Small loose BM upon admission, to start on Cardiac heart healthy diet this AM\n\nRenal: Foley draining adequate amounts of clear yellow urine.\n\nID: Afebrile, started on ceftriaxone in EW, given a dose of azithromycin upon arrival to MICU. U/A set, WBC up to 12.8, remains on HARRT therapy for her HIV, h/o VRE on contact precautions\n\nFEN: repeat set of lytes due at 10 am\n\nSocial: Lives alone, ambulates with cane at baseline, spokesperson is simons who is her friend & home health aid. Full code\n\n\nPlan:\n\n1. Wean 02 as tolerated, monitor resp status, nebs ATC\n2. R/O for MI\n3. Follow temp curve, WBC, ANBX as ordered\n4. Routine ICU monitoring and care\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-04-11 00:00:00.000", "description": "Report", "row_id": 1478934, "text": "Resp Care Note\n\nPt is 50 YO female wth HIV and Hep B and C. She has HX asthma and has high pitched, mostly exp wheezes bilaterally wth diminished BS @ bases. Pt is febrile to 100 F, ADM SDX in the EU is pneumonia. She was very hypoxic and remains so but Spo2 is stable in low to mid 90's on NRM. Pt is ordered for ALB Q 4 and Q2 PRN and ATRV Q 6 nebs. Last rx was ~ 0530. She is feeling better @ present time. Goal is to wean O2 as tolerated and continue to abate bronchospasm.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-11 00:00:00.000", "description": "Report", "row_id": 1478935, "text": "nursing Progress note 0700-1900\nReview of Systems:\n\nNeuro: Pt X 3, occas dozing but easily woken. She transfers to commode with minimal assist of 1. Pt C/O frontal HA, relieved with Oxycodone 5mg po.\n\nResp: Pt rec'd on non-rebreather FM. NC @ 5l trialed during breakfast, however O2 sat dropped quickly into low 80's without non-rebreather. Pt has remained on both non-rebreather and NC since with O2 sat 91-97%. When she receives her neb tx (with NC also in place),O2 sat drops to 88%. RR 15-24 and regular. Lung sounds with crackles in bases and scattered wheezes. Cough congested, non-productive. Pt rec'ing neb tx Q4-6hrs.\n\nCV: HR 76-90SR with rare PVC's. BP 110/62-131/78. D-dimer 1089 and Heparin qtt ordered. Awaiting results of PTT to start drip.\n\nGI: Pt with fair appetite on heart healthy diet. Abd soft/obese with hypoactive bowel snds. Pt had small-mod amt loose brown stool in am X 3.\n\nGU: Urine amber/clear, draining 20-50ml/hr. 24hr fluid balance +700ml.\n\nAccess: Pt with periph IV #20 X 2.\n\nSocial: mother is in Hosp. She was able to speak with her by phone.\n\nPlan: Cont frequent neb tx. Encourage C&DB. Begin Heparin qtt when PTT back.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-12 00:00:00.000", "description": "Report", "row_id": 1478936, "text": "MICU nursing progress note 7P-7A\nNeuro - A&O x 3, able to MAE on bed. Remained on bedrest O/N. C/o frontal HA, relieved with oxycodone 5 mg PO.\n\nResp - Received on 100% NRB & 5L NC. Sats 90-92%, occ ^^ 94-97% with activity. ABG 7/29/57/70/29. HO aware, following Sats and pts resp status. No resp distress O/N, RR 15-22. No SOB with talking but felt SOB when lying flat during bath, relieved with HOB^^ again. Breath sounds coarse with bibasilar crackles. Nebs, solumedrol and ceftriaxone for PNA.\n\nCV - NP 106-132/52-79. NSR 70s-80s. Heparin gtt @ 2250U/hr. PTT sent at 12:30AM, results not available until 4:10AM--HO aware. PTT 45.8, will wait for 3AM results to adjust heparin (goal 60-80)\n\nGI - Abd obese, tolerating heart healthy diet. Taking large amt ice chips. FSBS 219, started on insulin sliding scale. No stool. +BS.\n\nGU - UOP 30-110cc/hr. Pt is 900cc pos LOS.\n\nID - T max 99.8, now 98.6. On azithromycin and ceftriaxone for PNA.\n\nPlan - CTA chest today, pt not to have CTA before 12noon as she needs minimum 24hrs on steroids before exam--will also need benedryl and zantac prior to CTA d/t dye allergy. Follows sats, resp status. FSBS. Titrate heparin gtt to PTT, will go by 3AM result when available.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-12 00:00:00.000", "description": "Report", "row_id": 1478937, "text": "AGB drawn as note d x 2, first sample clotted. Pt is not severely dyspneic but very quickly becomes hypoxemic when O 2 is decreased. Po2 by ABG is ~ 70 on NRM and NC. Pt gvn alb/atv nebs Q 4-6 hrs. Helps reduces wheezes.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-13 00:00:00.000", "description": "Report", "row_id": 1478941, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\n\nPt had uneventful day.\n\nNeuro: Pt A&O x 3, cooperative with care, MAE in bed, able to make needs known. Pt complaining of HA this afternoon , received PRN initrex with good effect.\n\nCV: HR NSR 69-81 with no ectopy noted, NBP 116-125/58-69, received 10mg lasix IVP. Pt currently negative 1.5L since midnight. Peripheral pulses strong, PIV x 1. ECHO from showed EF 70%. CXR this afternoon to evaluate pulmonary edema.\n\nResp: Currently on 5L NC and 50% cool mist neb. RR 20-30 with sats >90%, pt desats quickly when face tent removed. Pt has mild non-productive cough. Lung sounds clear in apices with faint crackles in bases. Pt needs sputum specimen to rule out PCP.\n\nGI: BS x 4, no stool this shift. Pt tolerating heart healthy diet well, good appetite.\n\nGU: Foley patent and draining adequate amounts clear, yellow urine.\n\nEndo: Pt ordered for RISS. Steroid dose decreased and changed to PO.\n\nID: Pt afebrile, all blood cultures no growth to date. Continues on azithromax and ceftriaxone.\n\nPlan:\npt called out to floor, awaiting bed\ncontinue diuresis\nwean oxygen as tolerated by pt\ncontinue ABX\npain management\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2159-04-13 00:00:00.000", "description": "Report", "row_id": 1478942, "text": "resp care\npt followed for bronchodilator therapy as ordered. bs crackles and wheezes. sputum induction done in am for thick yellow, lab discarded for insufficient amount. attempted to repeat in am, pt unable due to headache/fatigue. will reattempt this evening. remains on high fio2 but weaning slowly.\n" }, { "category": "Nursing/other", "chartdate": "2159-04-13 00:00:00.000", "description": "Report", "row_id": 1478943, "text": "nursing progress note (1900-2300):\n\nPt alert and oriented x 3. C/O mild abdominal gassy pain and H/A ..given 5mg oxycodone w/ good effect. Pt cont on 5L NC and 50% cool face tent w/ O2 sats >90%. VSS. RR regular. given neb txs by RT. LS CTA in apices w/ faint bibasilar crackles. Abd. soft, obese, hypoactive BS. Tolerating diabetic heart healthy diet. No BM this shift. Urine clear/yellow. UOP wnl. Plan: transfer to floor (CC7 712), wean O2 as tolerated, collect sputum for cx.\n" } ]

[ { "category": "ECG", "chartdate": "2111-02-05 00:00:00.000", "description": "Report", "row_id": 196557, "text": "Sinus tachycardia\nST junctional depression is nonspecific\n\n" }, { "category": "ECG", "chartdate": "2111-02-06 00:00:00.000", "description": "Report", "row_id": 196558, "text": "Sinus rhythm\nLong QTc interval\nSince previous tracing, rate slower\n\n" }, { "category": "Nursing/other", "chartdate": "2111-02-06 00:00:00.000", "description": "Report", "row_id": 1277315, "text": "NPN 7a-7p\nPt is a 20y/o admitted from the floor with DKA. Pt has since closed her anion gap but is continuing on insulin gtt, reqs, until tomorrow morning. Pt has her own insulin pump which is running at a low basal rate to make for an easier transition tomorrow. She was changed over form KCL fluid to D5% 1/2NS which she received 1L of. She has transitioned to POs and tolerating a diabetic diet well. Lytes are being drawn Q4H, needing Mg and phos repleated x2. Last ABG 7.37/27/134/16.\n\nNeuro: Pt is a@ox3, independent with care. She transfers to commode and chair with minimal assist. Pt was upset and teaful today about being in hospital, support given to her and her mother.\n\nCV: NSR/St 90s-120, no ectopy noted. Bp 100s-120s/50s-60s, although when OOB BP^^ 140s-160s. Pt is grossly edematous t/o. PPP.\n\nRESP: RR 16-20, sats 98-100% on RA. LS CTA, no crackles.\n\nGI: abd is soft, nontender. No BM this shift, +BS. Tolerating POs well. On diabetic diet.\n\nGU: Pt is spontaneously voiding large amounts of clear yellow urine. D5% 1/2NS running KVO.\n\nENDO: Insulin gtt. BS 94-211. Continue protocol until tomorrow, then transition to her own Humalog pump which is set up and attached to her abd.\n\nSOCIAL: Pts boyfriend in room most of morning, and mother here in sfternoon and will stay overnight.\n\nPLAN: Q1H FS, insulin gtt. Q4H labs, replete lytes prn. Change over to insulin pump tomorrow and then D/C to floor.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-07 00:00:00.000", "description": "Report", "row_id": 1277316, "text": "Neuro: Pt slept well. No c/o. OOB to commode during night.\n\nResp: Lungs CTA. Sats 97-100% RA.\n\nC/V: HR 70's to 80's. Had been tachy until tonight. Pt is afebrile. MAP's 60's to 70's. No c/o.\n\nGU/GI: Pt OOB to commode. Voiding large amts clear yellow urine. +BS. No BM tonight.\n\nEndo: Ins gtt titrated clinic. When ins down to the point where it would be shut off it was only lowered to 0.5u/hr as MD did not want it to be turned off, even if it meant that glucose would need to be given. Pt given OJ with her Kcl powder and blood sugars back up. Also given 20meq Kcl IV. D5 infusing at 125/hr. Lytes drawn at and 0100. Anion gap closed. Will draw lytes again at 0500.\n\nSocial: Pts mother stayed the night in a chair in pts room.\n\nPlan: Pt will most likely be started back on her ins pump adn gtt will be titrated off. When pt off she will be able to go out to the floor. Monitor lytes and repleat as necessary. Diabetic diet.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-02-06 00:00:00.000", "description": "Report", "row_id": 1277314, "text": "20 y.o. pt, admitted from the floor with DKA requiring insulin gtt. Pt reports several days of nausea and vomiting. Pt felt to be dehydrated and is now receiving NSS with 10meq Kcl/L for 3 liters at 500/hr. She is presently receiving the 2nd liter.Pt has been a diabetic since age 3 and uses an insulin pump. It is thought that the pump was not functioning as it should.\n\nUpon arrival to the MICU, FS 398. Ins gtt started at 0115 at 5u/hr, with Q1hr FS's. As of 0400 pt was receiving 13u/hr. Her pump is off.\n\npH at 2200 7.28. WBC's 16.2 and pt reports a slight soar throat.\nPt also has h/o autoimmune hepatitis.\n\nNeuro: Pt A&O. She has her boyfriend staying over in the room. She is from the MA area and is in school here .\n\nResp: Pt is on RA without cough. Lungs are CTA. Sats have been 100% when checked.\n\nC/V: HR 1teens to 120's with low grade temp. BP is low 100's to 120's/25-40.\n\nGU/GI: Pt is voiding in commode in large amounts of pale yellow urine. Abd is soft. No c/o nausea since admitted. Pt is NPO except for ice and sips of water.\n\nPlan: Continue Q1hr FS's. Monitor labs. Of note bicarb 5. Pt is a difficult stick so intern is attempting to insert an a line. Pt will need 1 more Liter of iv fluid when this liter is done. K+ at 0200 4.9.\nMonitor temp. WBC's 16.2.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-07 00:00:00.000", "description": "Report", "row_id": 1277317, "text": "MICU NPN 0700-discharge\nPlease see carevue for all objective data. Pt AA&Ox3. LS CTA, Hemodynamically stable. Tolerating diet. pt able to ambulate to commode without difficulty. Abdomen soft. non tender. Denies pain throughout. Pt to be d/ced to home.\nPt transitioned from Regular insulin gtt to humalog insulin pump with reccomendations. Pt started insulin pump at 2units basal rate. Insulin gtt shut off 30 minutes after restarting insulin pump. BS checked q 1 hour. Pt bolusing 1 unit for every 20 points above 100. BS remain stable. Anion gap remains closed. MG and phos repleted as needed. Discharge instructions gone over with pt.\n" }, { "category": "Radiology", "chartdate": "2111-02-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 901845, "text": " 6:22 AM\n CHEST (PA & LAT) Clip # \n Reason: please r/o for pna, px\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with IDDM and autoimmune hep now with increased wbc (on\n prednisone)\n REASON FOR THIS EXAMINATION:\n please r/o for pna, px\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Diabetes, hepatitis, increased white blood cell count.\n Immunosuppressed.\n\n CHEST, TWO VIEWS: The cardiac and mediastinal contours are normal. There are\n no infiltrates, effusions, pneumothorax, or pulmonary vascular congestion.\n There are no comparisons.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-07-15 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 793335, "text": " 6:35 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BRAIN TUMOR\n Admitting Diagnosis: BRAIN TUMOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cerebellar tumor\n REASON FOR THIS EXAMINATION:\n Pre-op clearance\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: PREOP PA AND LATERAL CHEST\n\n INDICATION: Preop for cerebellar tumor.\n\n There is no prior study for comparison.\n\n FINDINGS: The heart is normal in size. The mediastinal and hilar contours\n are unremarkable. The pulmonary vasculature is normal. No pleural effusions.\n The lungs are clear.\n\n Minor degenerative changes of the thoracic spine are seen.\n\n IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-07-16 00:00:00.000", "description": "Report", "row_id": 1333830, "text": "1630-1900\npt admitted from OR @ 1630 extubated on 10 l cfm, suboccipital craniotomy, c-1 laminectomy, resection of cerebellar tumor done in or, pt lethargic, easily aroused, following commands, moving all extremities, perl, pt on nipride gtt @ 0.4 mic/kg/min on admission to keep sbp < 140, head dsg d&i, venodyne boots on, iv fluids stated @ 75 cc/hr(NS), c/o HA & pt medicated with 2 mg iv ms04 x 5 over 1 hr with fair relief\ncv: nsr, no ectopy, sbp 124-154, snp gtt increased to keep sbp< 140, now @ 1.25 mic/kg/min\nresp: bs+ all lobes & clear, now on 4 l np, sats 100, rr 10-16, no resp distress noted\ngi: npo, abd soft, no nausea or vomiting\ngu: clear yellow urine via foley, good uo\nsocial: husband in & updated on pt's condition\nplan: neuro vs q 1 hr, titrate nipride gtt to keep sbp < 140, iv mso4 as ordered for headache\n" }, { "category": "Nursing/other", "chartdate": "2101-07-17 00:00:00.000", "description": "Report", "row_id": 1333831, "text": "7p-7a; Full assessment in flow sheet.\n\nneuro; A+OX3. Clear speech. Follow directions. MAE - strong, bilaterally. Clear speech. Pain in back of neck - morphine ivp - good effect. Easily arousable. Equal smile. tongue midline. Slept most of the night. PERL - 2mm brisk.\n\ncv; NSR with rare PVC (90-106). BP 110-160/54-66. Nipride drip wean off SBP <140. Lopressor and Hydralazine ivp given. warm, dry, no edema.\n\nresp; Clear lung sound bilaterally. 2L NC - SaO2 >98%. RR 9-20.\n\ngu/gi; soft abd. +BSX4. no bm. no flatus. foley patent - clear yellow urine.\n\nskin; intact. small abrasion in coccyx - .5X.5. back of neck and head - dressing d/c/i, no drainage, no hematoma feel in the head and neck area. Pt able to move neck without difficulty.\n\n pt and husband verbally. and all question.\n\nPlan; Continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-17 00:00:00.000", "description": "Report", "row_id": 1333832, "text": "condition update\nd.vss.lopressor and hydralazine changed to po today.\n neuro signs also stable. when pt was assisted oob to stand,she was physically very shakey but was able to walk to chair with assistance of 2.\n pt is tolerating diet and fluids .thus iv hl.\n pt c/o of ha x1 while sitting up in bed for which she requested tylenol with good relief.\na.still awaiting bed availability on floor.\nr. sbp remains <160. stable.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-18 00:00:00.000", "description": "Report", "row_id": 1333833, "text": "7p-7a; Full assessment in flow sheet.\n\nA+OX3. Clear speech. MAE, Follow commands. Headache and neck pain per - morphine ivp given - good effect. PERL. VSS, afebrile. warm, dry, no edema. Slightly unsteady transfer from chair to bed. back and neck dressing - d/c/i, no drainage, no hematoma, no pain on light palpation. Stiff muscle per pt - less stiff when lying down. Clear lung sound bilaterally. Soft abd. +BSX4. no bm, no n/v, no flatus. foley patent - clear, yellow urine. Am lab to be done.\n\nPlan; Continue to monitor. Transfer to floor.\n" }, { "category": "ECG", "chartdate": "2101-07-15 00:00:00.000", "description": "Report", "row_id": 181289, "text": "Sinus rhythm. Delayed precordial R wave progression. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 827325, "text": " 4:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for CHF.\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/p renal transplant with decreasing oxygen saturations.\n REASON FOR THIS EXAMINATION:\n Evaluate for CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal transplant with respiratory distress and decreasing oxygen\n saturation.\n\n No significant change since film of . There are low lung volumes.\n The heart size is borderline or possibly slightly enlarged for technique, but\n there is no evidence for CHF. There is discoid atelectasis in the left upper\n lobe and bibasilar linear and discoid atelectasis. Probable small bilateral\n pleural effusions. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 827719, "text": " 11:17 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with ESRD sp CRT\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53 year old post renal transplant.\n\n PA and lateral radiograph. Comparison .\n\n Cardiac and mediastinal contours are unchanged. There are persistently low\n lung volumes. An area of discoid atelectasis in the left upper lobe as well as\n bibasilar linear atelectasis and pleural effusions are unchanged. There are no\n new focal consolidations. Pulmonary vasculature is normal. Subclavian and\n superior vena cava stent is unchanged in appearance.\n\n IMPRESSION: No change compared to .\n\n\n" }, { "category": "Radiology", "chartdate": "2153-07-07 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 827498, "text": " 11:06 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: amount of fluid around kidney\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman POD #3 from cadaveric renal transplant with urine leak\n REASON FOR THIS EXAMINATION:\n amount of fluid around kidney\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post op day 3, status post renal transplant with urine leaking.\n\n Comparison is made to the prior ultrasound dated .\n\n FINDINGS: The transplant kidney measures 11.1 cm. There is mild prominence\n to the collecting system of the lower pole without frank hydronephrosis. The\n resistive indices measured in the upper mid and lower pole of the transplant\n kidney measure 0.68, 0.73 and 0.74 respectively. The main renal vein is\n patent. Free fluid is noted in the right lower quadrant adjacent to the\n transplanted kidney which measures approximately 5.4 x 4.3 x 1.7 cm in its\n largest dimension.\n\n IMPRESSION:\n 1. Patent renal vasculature with normal resistive indices.\n 2. Perirenal fluid collection consistent with the history of urine leak.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 827420, "text": " 9:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLEASE ASSESS FOR CHF\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/p renal transplant with decreasing oxygen saturations.\n\n REASON FOR THIS EXAMINATION:\n PLEASE ASSESS FOR CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE: Compared to previous study of earlier the same day.\n\n CLINICAL INDICATION: Decreasing oxygen saturation.\n\n Cardiac and mediastinal contours are stable compared to recent study. Again\n demonstrated is a linear area of opacity in the left upper lobe consistent\n with discoid atelectasis. Patchy areas of opacity at the bases as well as\n small pleural effusions are unchanged. Overall, there has been no change\n since the recent exam of earlier the same day.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 827253, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?low sats\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p renal translant with decreasing sats\n\n REASON FOR THIS EXAMINATION:\n ?low sats\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53 y/o post renal transplant with hypoxia.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH:\n\n COMPARISON: and \n\n There are low lung volumes with bibasilar linear atelectatic changes. There\n is also an area of discoid atelectasis in the left upper lobe. No focal\n consolidations are seen. There is no pneumothorax and the pulmonary\n vasculature is normal. Again is seen a left subclavian vein and superior vena\n cava stent, unchanged.\n\n IMPRESSION:\n\n Bibasilar and left upper lobe atelectatic changes. No new consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 827166, "text": " 12:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: central line\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p renal translant\n REASON FOR THIS EXAMINATION:\n central line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Renal transplant and CV line placement.\n\n No CV line is detected. Endovascular stents are present in the left\n brachiocephalic vein and superior vena cava. No pneumothorax. Linear\n atelectasis/scarring in left apical region and left lung base.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-03 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 827094, "text": " 6:59 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHRONIC RENAL FAILURE\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with ESRD pre-op for CRT\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 53-year-old woman with end-stage renal disease who is undergoing\n preoperative evaluation for renal trasplant.\n\n COMPARISON: .\n\n FINDINGS: PA and lateral views. The heart, mediastinum and pulmonary vessels\n are within normal limits. Metallic stents are again noted in the left\n brachiocephalic vein and superior vena cava. There is stable linear scarring\n in the left upper lobe. There are no new lung opacities. There is no pleural\n effusion. The visualized osseous structures are grossly unremarkable.\n\n IMPRESSION: No evidence of an acute cardiopulmonary abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-08 00:00:00.000", "description": "O PORTABLE ABDOMEN IN O.R.", "row_id": 827570, "text": " 8:05 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: LOST INSTRUMENT\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of missing surgical instrument.\n\n FINDINGS: No surgical instruments detected. A drain overlies the right lower\n flank. The left flank and diaphragms are not included on this film.\n Vascular access catheter overlies the left common iliac vessel.\n\n" }, { "category": "Radiology", "chartdate": "2153-07-04 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 827197, "text": " 4:56 PM\n RENAL TRANSPLANT U.S. PORT Clip # \n Reason: ?flow abnd function of Cadveric transplant\n Admitting Diagnosis: CHRONIC RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman POD #0 now anuric in the PACU\n REASON FOR THIS EXAMINATION:\n ?flow abnd function of Cadveric transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low urine output, renal transplant performed today.\n\n There are no prior studies for comparison.\n\n FINDINGS: In the right lower quadrant there is the transplanted kidney which\n measures 12.3 cm. There are no perirenal fluid collections. There is mild\n fullness in the collecting system of the lower pole without hydronephrosis.\n The main renal artery and vein are patent with normal wave forms. Resistive\n indices measured in the upper mid and lower pole of the transplanted kidney\n range from 0.63 to 0.70. The bladder is collapsed.\n\n IMPRESSION:\n 1) Patent renal vasculature with normal resistive indices.\n 2) No hydronephrosis.\n\n" }, { "category": "ECG", "chartdate": "2153-07-06 00:00:00.000", "description": "Report", "row_id": 288209, "text": "Sinus rhythm. Probable left atrial abnormality. Left ventricular hypertrophy\nwith ST-T wave abnormalities. The ST-T wave changes are diffuse, with slight\npeaking of the T waves in the precordial leads, may be due in part to left\nventricular hypertrophy, but consider also possible metabolic/drug effect\n(possible hyperkalemia). Clinical correlation is suggested. Since the previous\ntracing of sinus tachycardia is absent and ST-T wave changes have\ndecreased.\n\n" }, { "category": "ECG", "chartdate": "2153-07-04 00:00:00.000", "description": "Report", "row_id": 288210, "text": "Sinus tachycardia. Left ventricular hypertrophy with ST-T waev abnormalities.\nThe ST-T wave changes are diffuse with slight peaking of the T waves in the\nprecordial leads - this may be due to left ventricular hypertrophy but consider\nalso possible metabolic/drug effect (possible hyperkalemia). Clinical\ncorrelation is suggested. Since the previous tracing of sinus\ntachycardia and ST-T wave changes are present.\n\n" }, { "category": "ECG", "chartdate": "2153-07-03 00:00:00.000", "description": "Report", "row_id": 288211, "text": "Sinus rhythm. Left ventricular hypertrophy by voltage. Since the previous\ntracing of no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2153-07-07 00:00:00.000", "description": "Report", "row_id": 1486923, "text": "continued w huge amts thin serous dng from open incisional area saturating lg. sofsorb & 4x 8's within minutes. pt. c/o constantly feeling wet & itchy. small pouch applied to area w containment & increased pt. comfort.draining copious amts thin material.+ fluid balance,minimal response to lasix. replacement fluid & maint. fluid dc'd & lasix dose increased. excellent appetite,tolerating renal diet well.oob->chair w encouragement.remains sob w exertion. bibasilar crackles,poor response to lasix.will re-eval. need for hemo in a.m. + bruit/thrill in av fistula.minimal pain,using mso4 pca sparingly.\n" }, { "category": "Nursing/other", "chartdate": "2153-07-05 00:00:00.000", "description": "Report", "row_id": 1486919, "text": "ADMIT NOTE\nPT ADM TO CSRU FROM PACU S/P CADAVAR RENAL TRANSPLANT . PT TRANSFERRED HERE FOR PURPOSE OF GETTING HEMODIALYSIS THIS AFTERNOON.\n\nNEURO: A&O, PLEASANT. DENIES PAIN. HAS MORPHINE PCA BUT HAS NOT USED SINCE ARRIVAL.\n\nCV: NSR, NO ECTOPY. ON NEO IV DRIP TO KEEP SBP >130. SBP CURRENTLY IN 140'S BY CUFF. HAS R PERIPH AND L FEM IV'S. VENODYNES TO BIL LE'S.\n\nRESP: LUNGS CLEAR. SPO2 98% ON 4L NCO2.\n\nG.I.: +BS. EATING PUDDING AND ICE CHIPS.\n\nG.U./RENAL: MINIMAL RESPONSE TO 80MG LASIX IN PACU. UO 30-40ML/HR VIA FOLEY. HD STARTED VIA L AVF @ 1430. DR. (RENAL) IN TO VISIT).\nATG IV FINISHED SHORTLY AFTER ARRIVAL. IV CELLCEPT INFUSING.\n\nSKIN: INTACT. ABD DRSG W/ SCANT AMT SEROSANG DRNG @ DISTAL END.\n\nI.D.: CONTACT PRECAUTIONS INITIATED FOR PMH +MRSA AND HEP C.\n\nSOCIAL: SON IN TO VISIT AND WILL BE SPOKESPERSON. COMPANION \"\" OUT OF TOWN AND WILL RETURN THIS WK.\n\nA/P: STABLE POST TRANSFER. COMFORTABLE. TOLERATING HD WELL SO FAR; ABLE TO WEAN NEO SLIGHTLY. CONT PULM TOILET. ADV DIET AND ACTIVITY AS TOL. CONT ANTI-REJECTION RX AND MONITOR UO.\n" }, { "category": "Nursing/other", "chartdate": "2153-07-06 00:00:00.000", "description": "Report", "row_id": 1486920, "text": "POD 2 S/p Cadaver kidney transplant.\n\nNEURO: A+Ox3, Mae, following commands and very pleasant. Denied c/o discomfort. Recieving Mso4 Pca pump. Total 3mg Mso4 iv given.\n\nCV: During report, pt converted into SVT 120-130's Sbp w/ stable bp. Asymptomatic. Had Neo gtt infusing. Called Dr. . Gave ordered dose of Labetolol po. Hr decreased to 80-90's no ectopy. Continued to wean neo gtt throughtout the night, keeping sbp > 130 as ordered.\n\nRESP: Has bilat crackles. Spo2 >94% on 4L. Noticed Spo2 trending down. Called Dr. . Stopped IVF's. Obtain stat CXR. Pt denied sob but was noticebly sob w/ exertion. Encouraged pt to CDB and use IS. CXR unchanged per Dr. . Resumed IVF.\n\nRENAL: Oliguric. Uop < 30cc/hr. Urine clear yellow. Minimal response to 80 iv lasix. Replacing uop w/ cc per cc ivf's.\n\nID: Afebrile. Maintaining contact precautions.\n\nPLAN: Continue to wean neo gtt. Keep Sbp > 130. Replace uop w/ ivf cc per cc qhr. Advance activity and diet. Transfer to 6.\n" }, { "category": "Nursing/other", "chartdate": "2153-07-06 00:00:00.000", "description": "Report", "row_id": 1486921, "text": "7a-7p\n\nNEURO: ALERT AND ORIENTED. MAE AND FOLLOWS COMMANDS. PLEASANT AND COOPERATIVE. MSO4 PCA WITH GOOD RELIEF. OOB->CHAIR WITH 2 ASSIST.\n\nCV: NSR/ST. NEO GTT WEANED OFF, MAINTAIN SBP 120-130'S. PO LABATOLOL DC'D, LOPRESSOR IV PRN FOR HR>120'S. PAPABLE PEDAL PULSES. GENERALIZED EDEMA.\n\nRESP: LS CLEAR WITH DIM BASES. NONPRODUCTIVE COUGH. USING IS INDEPENDENTLY. O2 SATS 96-98% ON 4L NC. SOME DECREASE IN SAT AND SOB NOTED WITH AMBULATION.\n\nENDO: BG'S NOT REQUIRING SSRI.\n\nGI/GU: BS+. ABD SOFT. TOLERATING PO'S. OLIGURIC. LASIX WITH MIN RESPONSE. C/Y/U.\n\nINT: ABD INCISION WITH SEROUS DRAINAGE.\n\nID: AFEBRILE, WBC COUNT DOWN THIS AM.\n\nPLAN: TRANSFER TO 6. MONITOR UO AND HEMODYNAMICS. MONITOR LABS. INCREASE DIET AND ACTIVITY.\n" }, { "category": "Nursing/other", "chartdate": "2153-07-07 00:00:00.000", "description": "Report", "row_id": 1486922, "text": "7p-7a update\npt had an episode getting from chair to bed at 2045 with c/o SOB and ? asystolic pause (?? if ekg lead came off). pt sat in bed and started stating \"I can't breath. I can breath\" The pt closed her eyes and stopped talking -> ekg showed a pause (?? if ekg lead came loose/off). Pt on 4 L nc -> 100% face tent added. o2 sats 100%. LS clear with dim bases bil. RR in the 30's. SBP in the 190's (see flow sheet for vitals). DR to bedside. 12 lead EKG done. CK's and lytes sent. CXR done. SOB resolved with rest. 100% face tent removed and pt left on 4 L nc -> o2 sats > 92%. SBP down to the 150's. pt in NSR.\n\n\npt alert and orientated x3. pt able to MAE. pt remains on morphine PCA for pain control. pt remains nsr/st. HR 70-100's. SBP 150-130's/ 70's. LS clear with dim bases bil. pt on 4 L nc, o2 sats 92-96%. + BS. no stool. abd firm and distended. RLQ with staples. last night 1 staple noted to be attached on 1 side and not on the other side (DR ). staple removed. 1 small open area on suture line -> small amount of pink tissue showing. incision draining copious amount of sersouanginous drainage. afebrile. started on levaquin for UTI. foley draining clear yellow urine.\n\nplan: monitor rhythm, keep SBP > 130, monitor incision, continue antiobiotics and current meds, replacing UOP with cc per cc ivf\n" } ]

[ { "category": "Radiology", "chartdate": "2148-06-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1199418, "text": " 6:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for post-op change in patient s/p left temporal lob\n Admitting Diagnosis: FRONTAL LOBE SEIZURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with epilepsy s/p left temporal lobectomy\n REASON FOR THIS EXAMINATION:\n evaluate for post-op change in patient s/p left temporal lobectomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:01 PM\n S/p left temporal lobectomy with expected post surgical changes including left\n temporal craniotomy, pneumocephalus and overlying skin changes.\n\n A small amount of layering hyperdensity along the resection bed is likely a\n small amount of blood. Hyperdensity in the left temporal also reflects a\n small volume of blood.\n\n Residual left temporal is hypodense, possibly reflecting a component of\n edema.\n\n No hydrocephalus is seen. No midline shift is seen. While the left lateral\n ventricle was asymmetrically smaller than the right on the preoperative MRI it\n may be minimally compressed giving it an even smaller appearance. The bulk of\n the pneumocephalus fills the resection bed with air tracking along the frontal\n convexity and falx.\n\n d/ 1900\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Epilepsy, status post left temporal lobectomy, assess for\n postoperative change.\n\n TECHNIQUE: Contiguous axial images obtained through the brain without\n intravenous contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISONS: MR brain from the same date.\n\n FINDINGS: The patient is status post left temporal craniotomy and partial left\n temporal lobectomy, with expected post-surgical changes with overlying soft\n tissues and pneumocephalus in the resection bed as well as layering\n non-dependently along the bifrontal convexities. Scattered additional foci of\n pneumocephalus are seen.\n\n Layering hyperdensity along the resection bed (2:11) could reflect small\n amount of layering blood. Hypodensity in the left temporal also likely\n reflects a small amount of blood. The residual left temporal is\n hypodense, which likely reflects edema. No hydrocephalus is seen. There is\n no shift of normally midline structures.\n\n The prior MR demonstrated that the left lateral ventricle is asymmetrically\n (Over)\n\n 6:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for post-op change in patient s/p left temporal lob\n Admitting Diagnosis: FRONTAL LOBE SEIZURE/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n smaller than the right; however, it may even be slightly compressed giving an\n even smaller appearance on the current examination.\n\n IMPRESSION: Status post left temporal lobectomy with post-surgical changes as\n described above, with layering blood along the resection margin and in the\n temporal of the left lateral ventricle and slight mass effect on the left\n lateral ventricle.\n\n This was discussed with by Dr. by phone at 19:00 on\n .\n\n" }, { "category": "Radiology", "chartdate": "2148-06-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1199602, "text": " 7:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evalaute for change in patient with mental status change s/p\n Admitting Diagnosis: FRONTAL LOBE SEIZURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with mental status change\n REASON FOR THIS EXAMINATION:\n evalaute for change in patient with mental status change s/p left temporal\n lobectomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 9:04 PM\n Interval decrease in degree of pneumocephalus without other change. Post\n surgical changes of left temporal lobectomy with hypodensity of residual\n temporal lobe and hyperdense likely blood in the left temporal . No\n midline shift, hydrocephalus or acute hemorrhage.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes, history of recent temporal lobectomy.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast.\n\n COMPARISONS: CT head dated from one day prior.\n\n FINDINGS: The patient is status post left temporal craniotomy and partial\n left temporal lobectomy with post-surgical changes as expected in the\n overlying soft tissues and decreased pneumocephalus since the prior study.\n The extra-axial space beneath the craniotomy site is partially filled with air\n and fluid. Small amount of hyperdensity along the resection margin is likely\n layering blood. Hypodensity in residual temporal lobe likely reflects edema.\n Hyperdensity is still seen in the left temporal , compatible with a small\n amount of blood. No hydrocephalus is seen. Asymmetry of the lateral\n ventricles is partially congenital; however, a slight amount of mass effect is\n also appreciated in the left lateral ventricle. There is no shift of normally\n midline structures. No evidence of hydrocephalus. No new hemorrhage is\n identified.\n\n IMPRESSION: Status post temporal lobectomy with interval decrease in the\n degree of pneumocephalus without other change.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-06-13 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1199307, "text": " 5:47 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-surgical mapping for L temporal lobectomy\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with l frontal lope seizures\n REASON FOR THIS EXAMINATION:\n pre-surgical mapping for L temporal lobectomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 30-year-old male with known left temporal lobe\n seizures. For presurgical mapping for left temporal lobectomy.\n\n EXAMINATION: Limited MR of the head with intravenous contrast only.\n\n TECHNIQUE: Multiplanar MR images were obtained through the brain after the\n uneventful administration of 15 cc of gadolinium intravenous contrast with\n axial, sagittal, and coronal MP-RAGE T1-weighted post-contrast imaging and\n axial T1 post-contrast images provided for review.\n\n FINDINGS:\n\n Fiducial markers are in place for the presurgical mapping. There is no\n evidence of hemorrhage, edema, masses, mass effect, or infarction. The\n ventricles and sulci are normal in size and configuration. There is no\n abnormal parenchymal, leptomeningeal, or dural enhancement. The major\n intracranial flow voids are preserved. Note is made of a stable right frontal\n and left cerebellar developmental venous anomalies. The paranasal sinuses and\n mastoid air cells are clear.\n\n IMPRESSION: Stable appearance of incidentally noted right frontal and left\n cerebellar developmental venous anomalies. Otherwise, unremarkable appearance\n of the brain, limited presurgical planning post-contrast MR sequences\n performed only.\n\n" }, { "category": "Radiology", "chartdate": "2148-06-14 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1199623, "text": " 10:13 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for post-op change in patient s/p left temporal lob\n Admitting Diagnosis: FRONTAL LOBE SEIZURE/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with epilepsy s/p left temporal lobectomy\n REASON FOR THIS EXAMINATION:\n evaluate for post-op change in patient s/p left temporal lobectomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITHOUT AND WITH CONTRAST \n\n HISTORY: Epilepsy status post left temporal lobectomy.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. After administration of 15 cc of Magnevist intravenous contrast,\n axial imaging was performed with , TR, long TE fast spin echo,\n gradient echo, diffusion, and short TR, short TE spin echo technique.\n Sagittal MP-RAGE imaging was performed and reformatted into axial and coronal\n orientations. Comparison to brain MRs and .\n\n FINDINGS: The patient is status post left temporal lobectomy with expected\n post-operative changes including scalp swelling, a small subdural fluid\n collection, and hyperintensity on at the margins of the surgical site.\n There is also slow diffusion at the periphery of the left temporal lobectomy\n site. In the setting of acute surgery, it is impossible to distinguish\n surgical trauma from possible infarction in these areas. No other\n abnormalities are detected. The remainder of the brain demonstrates no\n evidence of hemorrhage, edema, masses, or infarction.\n\n CONCLUSION: Status post left temporal lobectomy with expected post-operative\n changes.\n\n Foci of slow diffusion at the margins of the surgical site may reflect\n surgical trauma or infarction.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2148-04-27 00:00:00.000", "description": "P BABYGRAM (ABD ANY SGL VIEW) (74000) PORT", "row_id": 790104, "text": " 6:23 AM\n BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # \n Reason: r/o abnormal bowel gas pattern\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with abd distention, blood tinged spits. s/p LGI\n REASON FOR THIS EXAMINATION:\n r/o abnormal bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n KUB: 6:00 am\n\n CLINICAL HISTORY: This is a 2-day-old preterm infant with abdominal\n distention and blood tinged stool. Some form of positive contrast GI study\n was recently performed.\n\n A single portable view of the abdomen was obtained and is compared to the\n previous film dated .\n\n The NG tube tip is in the left sided stomach. Contrast is seen distributed\n through the colon and rectum. There is also some contrast seen in a more\n proximal loop. This loop seems a bit distended. Very proximal bowel small\n loops appear decompressed.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-04-26 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 790015, "text": " 3:16 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate bowel gas pattern\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with abdominal distension and tenderness\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE , :\n\n HISTORY: One day old boy with abdominal distention and tenderness.\n\n COMPARISON STUDIES: None are available.\n\n FINDINGS: There are numerous mildly to moderately dilated loops of bowel\n throughout the abdomen. No clear evidence for wall thickening, pneumatosis,\n or portal venous gas. No abnormal masses or calcifications. The bony\n structures are unremarkable. The basilar lungs are clear.\n\n IMPRESSION: Numerous mildly to moderately dilated loops of bowel throughout\n the abdomen. This suggests a developing low bowel obstruction. Other\n considerations include early necrotizing enterocolitis and adynamic ileus.\n\n RECOMMENDATION: If the patient fails to pass meconium, would consider further\n evaluation with a contrast enema, which can be diagnostic and therapeutic.\n Follow up imaging is also recommended.\n\n" }, { "category": "Radiology", "chartdate": "2148-04-26 00:00:00.000", "description": "P BABYGRAM (ABD ANY SGL VIEW) (74000) PORT", "row_id": 790036, "text": " 9:33 AM\n BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # \n Reason: evaluate bowel gas pattern\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with abd distention\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n :\n\n FINDINGS: A single portable view of the abdomen was obtained and is compared\n to the previous film dated at 3:25 am.\n\n An NG tube tip is in the left sided stomach. The bowel gas pattern is\n actually normal. Perhaps the transverse colon is ever so slightly dilated.\n This not definite. The lung bases are clear.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993768, "text": "Nursing Progress Note 1900-0700\n\n\nID:Infant remains alert and active with cares.Cont's on IV\nAmpi and Gent as ordered.Heme to consult today( per\nnotes)regarding neutropenia.A:Stable P:F/U with Heme\nregarding plan.\n\nF/E/N:Infant cont's on ad lib demand schedule.TF over last\n24 hrs.is 140cc's/kg/day.Infant rec.E20 bottling 85-90cc's q\n3-4 hrs.Weight=3.250kg up 50 grams.Abd. soft,pos bs,no loops\nor spits.Girth=27.Infant voiding and stooling guiac negative\nstool.A:Stable P:Cont. to assess tolerance of feeds.\n\n:Dad in initially asking appropriate\nquestions.Apperas very invested in infant.Mom also in after\ndad accompanied by RN.Mom verbalized that dad has not\nbeen understanding.Mom is presently bee\\ing seen by SW on\nfloor.This RN called dad at mom's request to come back and\nsee infant,dad very willing,came up from .Mom held\nand bottled infant well.A/P:Cont. to update,support and\neducate.\n\nDEV:AFSF.Infant alert and active with cares.Waking prior to\nfeeds.Sleeping soundly b/t cares.Temp. slightly warm d/t\nswaddling,will cont. to assess.Infant presently in flex\nposition.swaddled with nested boundaries.A:AGA P:Cont. to\nsupport growth and dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993771, "text": "Social Work\nInfant's mo. struggling today w/ stress of infant's uncertain medical status and her own recent medical problems. Expressing directed at fa. for his perceived inadequacies. Mo. seen by Psych and felt to be struggling w/ adjustment/mgt. of crisis, but not fitting criteria for major depression, psychosis or any mental disorder placing her at risk to self/others.\n\nFa. was reached today on his cell phone. He will be back here this eve, and agrees to stop in at the NICU first for update. Also agrees to meet w/ me and interp. . am to have his own opportunity to talk.\n\nPlease contact me re: any fam. mtgs. or significant new developments. Thank you.\n\n #\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993772, "text": "Nursing Progress Note\n\n\n2. FEN O/A Inf is ad lib demand feeding. Inf waking\nq3.5-4hrs taking 85-130cc. Tol well. No spits. Belly\nsoft, no loops. Inf voiding, stooling guiac neg. P cont to\nassess fen needs.\n3. O/A Dad in this AM for visit and cares.\nUpdates given. Attentive father, asking appropriate\nquestions. Independent with temp taking, diapering, cord\ncare, feeding baby. in this afternoon to meet with\nhematology. NNP updated Mom as well. Inf put\nto breast with Mom. SW is involved with this\nfamily, see SW note. P cont to support, enc calls and\nvisits.\n4. DEV O/A remains in an open crib with\nstable temp. A/A w/cares, waking for feeds. Likes\npacifier. P cont to assess dev needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993773, "text": "1 Pot for Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Pot for Sepsis; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993774, "text": "3. : O: Mom and Dad and Mom \ngrandmother), came in @ 8p to visit. They met w/ R. NNP\nwho answered Mom's questions. Mom put infant to breast and\nwas surprised at the strength of his suck. Infant breast\nfeeds very well. Dad changed the diaper, took the temp and\ndid cord care, and did well. Mom was very short w/ Dad and\nvery critical. At one point, he left the unit. He returned\nlater to feed the infant some more. Mom and her mother left\nat some point and he was in the room alone w/ the infant.\nDad seemed calm and appropriate, focussed on the infant and\ndelighted w/ him. Mom asked appropriate questions and was\nattentive and appropriate w/ me, but seemed unable to say\nanything in a pleasant way to the Dad. A: Family appropriate\nw/ respect to the infant but having difficulties between\neach other. P: Continue to support. Social services are\ninvolved.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-05-01 00:00:00.000", "description": "Report", "row_id": 1993775, "text": "2. F/n: O: Infant is on an ad lib, demand schedule, bottling\nwell. He took in 192cc/k/d yesterday, based on BW. ABd is\nbenign, he is voiding and stooling, yellow, seedy stools,\ng-. He also breast fed well w/ Mom. A: Bottling well. P:\nCheck wt. Continue w/ plan.\n\n3. (See note written before mn.)\n\n4. G/d: O: Infant's temp is stable in the open crib. He is\nvigorous and active and eats well. A/P: Continue to support\ninfant needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-05-01 00:00:00.000", "description": "Report", "row_id": 1993778, "text": "NPN 0700-1900\n\n\n#2 FEN S/O: Infant on ad lib deamnd schedule of E20 or\nbreast milk. Infant took 120cc at 10am feed. Infant\nattempted to breastfeed. Latched on for about 5 min. Infant\nthen bottled the remainder of volume. Infant abdomen benign,\nvoiding, had guiac neg stool. Feeding q4h. A: Infant\ntolerating po feeds. P: Continue to monitor and encourage\nbreast feeding when possible.\n\n#3 S/O: Mom and dad in this am for feeding. Family\nmeeting scheduled for 3pm. Dad unable to make the meeting.\nMeeting then rescheduled for 1730. Mom stated that she would\nnot like to be discharged without her baby. Infant may be\ndischarged tonight and go to the nursery with mom. A:\nInvolved. P: Continue to support.\n\n#4 DEV S/O: Infant maintaining temps in . Sucking on\npacifier, bringing hands to face. Alert and active with\ncares, sleeping in between. A: AGA P: Continue to support\ndevelopment.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-05-01 00:00:00.000", "description": "Report", "row_id": 1993779, "text": "NPN 8p\n\n\nInfant Po bottling E 20 adeq amts and breast feeding. Abd\nsoft, full, AG 29. Active bowel sound. Voiding and heme -\nstool. awaiting trans to Mothers room. DC planning\ngone over. Mother able to repeat back S&S of infection and\nwhen to call the doctor. Infant is to come back to NICU in\nam for lab work prior to DC home. Infant with stable temps\nin . A/A with cares. On neutrapenic precautions. Will\ngive verbal report to #5 nursery and check tags.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-05-01 00:00:00.000", "description": "Report", "row_id": 1993780, "text": "Neonatology Attending Addendum\n\n\nBaby is doing well with feedings both bottle and breast.\nPlan is to transfer to the Newborn Nursery so that baby can room in with mother.\n\nCareful follow-up has been set up with primary pediatrician, VNA, Hematology, and Early Intervention.\n\n , NNP met with both to review plans for management and follow-up in detail.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993769, "text": "Neonatology Attending Progress Note\n\nNow day of life 5.\n\nCardiorespiratory status stable in RA.\n\nHR 130-140s\nBP 77/39 54\n\nWt. 3250gm up 50gm on ad lib feedings - took in 140cc/kg/d of E20 - breastfeeding planned.\nFeedings well tolerated, no abdominal distension.\nNormal urine and stool output.\n\nID - on amp and gent\n\nHeme - awaiting final consult recommendations - work-up for profound neutropenia in progress - differential includes possible maternal antibodies, Kostmann's syndrome, cyclic neutropenia, etc.\n\nAssessment/plan:\nGI status much improved - will need sweat test to rule out CF.\nNeutropenia w/u proceeding.\nFamily meeting today to update.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1993770, "text": "Neonatal NP-Exam and Family Meeting\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. active bowel sounds. Infant active with exam.\n\n\nFamily meeting:\n\nattendees: Dr. , mom, myself and Dr. from hematology at .\n\nDiscussed with mother increased concern for CF secondary to meconium plug. Also discussed need for \"sweat test\" as final determinate test.\n\nHematology discussed concerns and possible causes for Neutropenia and the testing that is needed. Discussed staging of investigation. Written notes from meeting were taken by myself and given to mom to help with reminders from meeting.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-29 00:00:00.000", "description": "Report", "row_id": 1993764, "text": "NPN\n\n\n#1Sepsis No change. Remains on ampi/gent. Hem. consult\ntoday.\n#2F/N o- Infant bottling every 3-4 hrs. Taking 60-80cc's\nE20. Voiding well. Passing soft stool g-. No spits noted.\nAbdomen soft with good bowel sounds. Girth 28cm. Wt. 3200\ndown 20gms. A- Feeding well. P- As per team.\n#3Family O-Dad in to visit at and 2200. Dad bottling\ninfant and changing diaper. Dad aware that hem. consult to\nbe done for neutropenia P-Support and teach as needed.\n#4 Dev. No change.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-29 00:00:00.000", "description": "Report", "row_id": 1993765, "text": "Neonatology Attending Progress Note\nNow day of life 4 for this term infant with initial presentation with possible bowel obstruction - contrast enema normal study except for meconium plug.\n\nHR 120-150s\nWt. 3200gm down 20gm on ad lib feedings (70-75cc) of E20 or MM.\nFeedings well tolerated with no spitting.\nNormal urine and stool output.\nHeme negative.\n\nID - day 4 of amp and gent\nProfound neutropenia persists - ANC - 0.\n\nAssessment/plan:\nTerm infant with normal feeding tolerance now.\nWill continue antibiotics as work-up of neutropenia persists.\nHematology consulted.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-29 00:00:00.000", "description": "Report", "row_id": 1993766, "text": "Neonatology-NNP PRogress Note\n\nPE: remains in his open crib, in room air, bbs cl=, rrr s1s2 no murmur, abd soft nontender, cord drying, afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2148-04-29 00:00:00.000", "description": "Report", "row_id": 1993767, "text": "0700- NPN\n\n\nSEPSIS: Cont on IV Ampicillin and Gentamicin for possible\nSepsis. Last WBC count was drawn yesterday and was 5.8 (up\nfrom 4.9). Pt in for Hematology consult tomorrow. VSS, no\ns/s of infection. A: Possible sepsis. P: Cont to monitor.\n\nFEN: Cont on ad lib demand shedule with no minimun, waking\napproximately Q3.5-4.5hrs to feed, and taking 60-90cc at\neach feed. Pt is receiving BM20/E20. No spits. Abd girth\nstable at 28cm. Abdomen benign. Pt is voiding, stools x 3\n(heme-). A: FEN status stable. P: Cont to monitor.\n\nG&D: Temps stable in , pt is dressed/swaddled. MAE,\nalert/active with cares. Sleeps between cares, waking\nindependently for feeds. Sucks pacifier and brings hands to\nface for comfort. Fontanels soft/flat. A: AGA. P: Cont\nto support growth and development.\n\nSOCIAL: Dad in to visit this AM, updated by RN, asking\nappropriate questions. Dad participated in care at time of\nvisit. Mom called x 1, came up to visit, updated by RN,\nasking appropriate questions. Mom not feeling well,\naccompanied by her RN. Mom attempted to feed pt, but d/t\nnot feeling well, had to stop. No further contact from\n. A: loving and invested. P: Cont to\nsupport/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-05-01 00:00:00.000", "description": "Report", "row_id": 1993776, "text": "Neonatology Attending Progress Note\nNow day of life 6.\nCardiorespiratory status stable.\nRR 30-50s.\nHR 130-160s\n\nWt. 3330gm up 80gm on E20 - took in 192cc/kg/d\nFeedings well tolerated - breastfeeding just starting\nNormal urine and stool output.\nDS 66\nNormal urine and stool output - stools heme neg.\n\nHeme wbc 6,200 1P 0B plat 228,000 Hct 42%\n\nAssessment/plan:\nBaby is well except for persistent profound neutropenia.\nWork-up per Hematology consultants, Dr. , attending, pending.\n\nPossible discharge to home tomorrow or Friday.\n up to date.\n" }, { "category": "Nursing/other", "chartdate": "2148-05-01 00:00:00.000", "description": "Report", "row_id": 1993777, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Skin intact with red rash on bum likely contact dermatitis but has some fine \"bump's\" will treat with Nystatin Powder in light of his immonocomprimised state.\n\nSpoke with the covering pediatrician for Dr. , Dr. and discussed infants hospital course and ongoing issues that need attention after discharge.\n\nMother's blood to be obtained today for analysis of Neutrophil Antibodies/Type. Specimen sent out to South West Blood Bank for analysis. Telephone number 1 X6187.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-27 00:00:00.000", "description": "Report", "row_id": 1993758, "text": "npn\n\n\n#1&#4\nInfant awake and alert with cares. Eagerly fed via botle.\nMaintainng temperature on an off warmer double wrapped.AM\ncbc wbc 4.7 4 polys 0 bands 73 lymphs.no signs of sepsis at\nthis time.\n#2\nPIV heplocked this am at 11:oo. Surgery examined infant.\nRepogyle tube pulled. minimal drainage noted.Abdominal exam\nwnl. a.g 27 with + bs .Voiding and stooling earlier today.\nno void with last diaper. d/s before 1pm feed = 54. Ate 30\ncc's at 9am then 45cc's at 12:45. Will continue to monitor\nand feed as tolerated.\n#3 Dad up for visit this morning. held infant and was\nupdated at the bedside.by surgery.Mom is not feeling well on\nthe floor.Wants to breastfeed at some point but not today\nper dad.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 1993759, "text": "NPN\n\n\n#1Sepsis Remains on antibiotics. Gent levels to be sent with\nrepeat CBC.\n#2F/N O- Infant waking every 4 hours and bottling E20\n40-50cc's. Voiding well. No stool passed. Abd. girth\n27.5-28cm. Abd. soft with bowel sounds. No spits noted. Wt.\n3220 down 30gms. A- Infant tol. feeds P- Follow closely.\nfollow wts.\n#3Family Dad in for cares and shown how to take\ntemp/change diaper. Dad bottling infant. A-Dad updated with\nson's status. Pleased he is doing better. P- Update and\nsupport as needed.\n#4Dev. O- Infant placed in open crib at 2200. Temps stable.\ninfant awake and alert for all cares. A- term infant AGA P-\nSupport dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 1993760, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. BS clear and equal, color pink/jaundiced. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Noncirced male, testes down bilaterally. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 1993761, "text": "Neonatology - NP Physical Exam\nAddendum: Peripheral IV in left hand patent, without reddness or swelling at site.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 1993762, "text": "Neonatology Attending Note\nDay 3\n\nRA. RR40-50s. BP 73/47, 53. HR 120s.\n\nCBC 5.8 (0n,0b)/43.4/174\n\nWt 3220, down 30. PO ad lib demand E20. ~ 80 cc/k/day. Nl voiding and now stooling.\nd/s 67\n\nOn amp/gent.\n\nIn open crib.\n\nA/P:\nTerm infant with meconium plug (improved with contrast enema), also profound neutropenia.\n - Con't to feed ad lib and monitor stool output.\n - Obtain heme consult re: neutropenia.\n - Continue abx until etiology of neutropenia more clear.\n - Check state screen, r/o CF.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 1993763, "text": "NPN 0700-1900\n\n\n1. Sepsis: Conts on ampi and gent. Gent levels this am\nwere wnl. Team aware of CBC results. Heme consult to be\ndone tomorrow. Parents aware.\n\n2. FEN: Taking ad lib amounts E20. Took in ~ 83cc/kg in\n24hrs. Today bottled 35cc, 60cc, and 70cc. 1 sm spit with\nburping. V&S green guiac neg stools. AG=27.5cm - 28cm.\nAbd is flat and soft with active bs. No loops.\n\n3. Parents: Dad was in 3 times today. Performed cares and\nbottled infant with verbal cueing at 0800 and 1600 feedings.\nBoth parents were in at 1330. Updated at bedside, but\nstayed very briefly as Mom was not feeling well. Cont to\noffer support and updates.\n\n4. G&D: Infant wakes ~ q3-4hrs for feeds. Alert and\nactive with cares. Sleeps well between cares. Temps stable\nswaddled in open crib. AFSF.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-27 00:00:00.000", "description": "Report", "row_id": 1993756, "text": "NPN\n\n\n#1 Infant remains on ampi and gent. CBC sent tonight--WBC\n4.7 4N 0B 73L 13M. Hct 43.3 Plt 161. Infant active and\nalert.\n\n#2 TF 80cc/k/d. Infant NPO receiving IVF of D10W with 2meq\nNaCl and 1meq KCl. DS 77. Abd soft, + hyperactive BS. no\nloops. AG 26-26.5cm. Repogle remains to continuous LWS\ndraining 8.8cc this shift. Infant stooling green guiac neg\nstool. UO 1.9cc/k/hr x12hrs. Wt down 140gms. To have KUB\nat 6am.\n\n#3 Father up with other visitors. Updated by NNP Rivers.\n\n#4 Infant swaddled on off warmer with stable temp. Infant\nactive and alert--irritable at times. Sucks on pacifier.\nBrings hands to face.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-27 00:00:00.000", "description": "Report", "row_id": 1993757, "text": "Newborn Med Attending\n\nDOL#2. Cont in RA. AF flat, clear BS, no murmur, abd soft, good BS, MAE. S/P BE yesterday for removal of mec plug.\nA/P: Infant admitted for R/O sepsis and abdominal distention. Cont amp and gent for 48 h R/O. D/C reploglr today. Trial of feeds later today.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993754, "text": "Neonatology\nRemains in RA. Comfortable appearing. No murmur.\n\nCV stable. Well perfused and saturated in RA. Activity normal. Sucking vigorously on pacifier.\n\nCBC to be repeated. AMp/ GEnt continue.\n\nAbdomen remains softly distended. Perhaps less so over course of morning. No masses or tenderness. BS quiet. Passing stool\nSerial KUBs have shown persistent dilation. No evidence of free air or pneumotosis. Seen by surgery. On review with radiology have arranged for BA enema later today.\n\nCSF exam shows 5WBC 1 RBC. INitial CBC showed marked neutropenia.\n\nSpoke with father at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993755, "text": "NPN 0700-\n\n\n1. TEMPS STABLE B/T 98.2-99.5. BP ASSESED Q4HR. WITH MAPS\nB/T 53-59. WBC 4.7 WITH 0 BANDS AND 5 NEUTS. LP DONE TODAY\nAT 0930 ANS NEGATIVE. CONT ON AMP AND GENT. DROWSY IN AM AND\nBECOMING MORE A/A WITH CARES IN AFTERNOON. BCX PENDING.\nPLAN; CONT TO MONITOR FOR S/SX SEPSIS. MONITOR BP Q 4HRS.\nOBTAIN CBC IN AM.\n\n2. TF AT 80CC/K/D. REMAINS NPO WITH D10 RUNNING VIA\nPERIPHERAL IV. IVF AT 11.3CC/HR. VOIDING AND STOOLING WELL.\nPASSING MECONIUM STOOL. U/O .7CC/K/HR. REPOGAL TUBE HOOKED\nUP TO LWS WITH OUTPUT .5CC/K/HR OF BILIOUS DRAINAGE. DSTICKS\nSTABLE AT 74, 58, 67. HAD BARIUM ENEMA TODAY. KUB DONE\nTODAY. ABD SOFT, DISTENDED, NO LOOPS + BS. STABLE ON IV\nFLUIDS. PLAN; CONT TO MONITOR ABD CLOSELY. MONITOR TOLERANCE\nTO IV FLUIDS.\n\n3. MOM . BEING FOLLOWED BY MSW FOR EMOTIONAL ISSUES. MOM\nAND DAD IN TO SEE BABY. MOM HOLDING FOR ABOUT 1HR TODAY.\nAPPEARS VERY CARING AND LOVING. PLAN; CONT TO SUPPORT AND\nEDUCATE PARENTS.\n\n4. RECEIVED PT ON WARMER. TEMPS 99.2-99.5, NOW SWADDLED\nUNDER OFF WARMER. A/A WITH CARES. DROWSY EARLIER IN DAY BUT\nNOW MORE AWAKE. MOVING ALL EXTREMETIES WELL. SUCKING\nVIGEROUSLY ON PACIFIER.. PLAN; CONT TO PROMOTE G/D.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993750, "text": "Nursing Admission Note\n\n\nPlease see Attending MD/NNP note for maternal history and\ninfant' physical exam.\n\n1. : CBC and blood culture sent after KUB done. Ampi\nand Gent started.\n\n2. F&N: Pt admitted with loopy and tender abdomen. KUB\ndone. NPO. TF 80cc/k/d of D10W infusing well via PIV. D/S\n61. BS+. Repogle placed and hooked up to low intermittent\nsuction. Voiding and passing small meconium stool. Passing\ngas.\n\n3. PAR: Parents in at bedside. Mom very . They\nasked approrpiate questions and spoke with surgeon from TCH.\nThey spoke lovingly to .\n\n4. DEV: is active and alert. Temp stable\nnested on radiant warmer. Sucking on his fingers.\n\nPLan to TCH at somepoint today for further studies.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993751, "text": "NNP Physical Exam\n\nPE: pink, well perfused, AFOF, breath sounds clear/equal with easy WOB, no murmur, +2/= pulses, abd softly distended, bowel loops palpable, seems slightly tender, soft bowel sounds present, passed meconium, no rashes, active and slightly irritable when examined but otherwise quiet, sucking on pacifier with exam, normal tone and reflexes with exam.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993752, "text": "NNP Procedure Note\nProcedure: LP\nIndication: R/O meningitis\nAnalgesia: 1% Lidocaine\nInformed consent obtained from mother\n\nThe infant was held on his left side and using sterile technique the lumbar spine was prepped with betadine then alcohol and sterile drapes applied. Given 0.1cc lidocaine sc. A 22 g spinal needle was inserted into lumbar space with clear csf return. CSF sent for the usual studies. Infant tolerated the procedure.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993753, "text": "Social Work\nInfant's mo. well-known to me from prenatal period. She is a 31 y.o. married Haitian social worker who lives w/ new husb. of less than one yr., Wailex, in . Her mo. and sister also live in the area. Infant is her/their first preg./baby.\n\nMo. has a hx. ulcerative colitis and associated surgeries which she experienced as traumatic. After her last surgery, she was assured by a doctor that she should have no further GI problems, but she did have a bowel obstruction and additional surgery early in the preg., further reinforcing her sense that she is a person to whom bad things happen. She has struggled w/ anxiety throughout the preg.: re: whether she would be able to have a healthy baby and, later on, re: whether she would be a good enough parent. Since learning of her infant's bowel anomolies, mo. has been quite anxious and distressed, but she seems to be benefitting from Ativan and from provider and family support. Husb. has appeared to be managing well, and he has the week off to be w/ mo. and baby. MGM and . have a historically complex rela., but mo. appears to appreciate her presence, and her sister's.\n\nMo. has formal support already in place once she goes home - incl. visiting RN and a psychotherapist(*NOTE-she does not want family members to know she is obtaining counseling*). I will cont. to follow here and to be avail. PRN after she and baby are d/c'ed.\n\nShould mo. appear to be decreasingly able to cope over the weekend, please contact the social worker on call via the page operator.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-26 00:00:00.000", "description": "Report", "row_id": 1993749, "text": "Neonatology Attending\n\n14 hr old 38 week male admitted for evaluation of abd distension.\n\n3390 gram 38 week male born to a 31 yo G3 P0->1 Haitian female\nPNS: O+/Ab-/RPR NR/RI/HBsAg-/GBS unknown\nUncomplicated pregnancy. Primary C/S under combined epidural spinal anesthesia secondary to prior colon resection. Apgars . In RN breastfeeding well. Noted to have spitting of old blood and abdominal distension. Has passed stool x 2. Brought to NICU for evaluation.\n\nExam Term AGA male pink and comfortable in RA\nT 98.2 P 138 R 46 BP 72/41 mean 60 O2 sat 99%\nAF soft, flat, nondysmorphic, intact palate, nevus flammeus on forehead, clear bs, no murmur, distended, tender abd, hyperactive bs, no hsm, normal male genitalia, testes descended, patent anus, no hip click, no sacral dimple, + Mongolian spot, normal tone\n\nKUB diffusely distended loops of bowel, featureless, air almost to rectum, no free air\n\nA: FT male with bowel obstruction.\n\nP: Monitor\n Repogle to suction\n CBC, BC. A/G.\n NPO with IV fluids\n Surgical consult\n Contrast study\n Support parents\n\n" } ]

[ { "category": "Radiology", "chartdate": "2141-07-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1145827, "text": " 2:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with assault\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd SAT 3:08 AM\n Subarachnoid hemorrhage overlying the left hemisphere with possible tiny\n subdural measuring up to 1 mm in thickness over the left frontal lobe. no\n shift of midline structures. no fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man status post assault.\n\n COMPARISON: None.\n\n TECHNIQUE: Axially acquired images were obtained through the head without\n contrast. Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS: There is a subarachnoid hemorrhage seen overlying the left cerebral\n hemisphere. There may also be a tiny right-sided subdural hematoma over the\n left frontal lobe (2:14) measuring only 1 mm in thickness. There is no shift\n of midline structures. However, the left lateral ventricle is slightly\n smaller than the right and there may be some mild mass effect on the side.\n There is no acute intraparenchymal hemorrhage. -white matter\n differentiation is preserved.\n\n Visualized paranasal sinuses and mastoid air cells are clear. No fractures\n are identified. The soft tissues of the orbits and nasopharynx are within\n normal limits.\n\n IMPRESSION: Left-sided subarachnoid hemorrhage. No shift of midline\n structures. Findings were discussed with Dr. at the time of\n review on .\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-29 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1145828, "text": " 2:38 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with assault\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd SAT 3:10 AM\n No fracture. Alignment maintained.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man status post assault. Evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Axially acquired images were obtained through the cervical spine\n without contrast. Coronal and sagittal reformatted images were also\n displayed.\n\n FINDINGS: Alignment is maintained. No fracture is identified. Prevertebral\n soft tissues are within normal limits. Visualized lung apices are clear.\n\n IMPRESSION: No fracture. Alignment maintained.\n\n Findings were discussed with Dr. at the time of review on , .\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1145880, "text": " 2:56 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess for interval change.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with small SAH,SDH. Please obtain scan 12 hours after previous\n CT scan.\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old male with assault.\n\n COMPARISON: .\n\n TECHNIQUE: Helical MDCT images were acquired through the brain without\n intravenous contrast.\n\n FINDINGS: Subarachnoid hemorrhage in the left sylvian fissure and adjacent\n sulci has become nearly isodense to brain, indicating evolution of blood\n products. No definite subdural collection is seen. There is no new\n hemorrhage. No sulcal effacement is appreciated, and there is no shift of\n normally midline structures. However, the left lateral ventricle remains\n smaller than the right. The third ventricle is midline and normal in size.\n\n The imaged paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Evolving left subarachnoid hemorrhage. No definite subdural collection.\n No new hemorrhage.\n 2. Asymmetry of the lateral ventricles could be due to anatomic variation or\n volume loss in the right cerebral hemisphere. If clinically warranted, MRI\n could help exclude a subtle obstructing lesion in the region of the right\n foramen of .\n\n" }, { "category": "Radiology", "chartdate": "2141-07-29 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1145829, "text": " 2:41 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with assault\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old man status post assault.\n\n SINGLE FRONTAL VIEW OF THE CHEST: Overlying trauma board limits evaluation.\n Lungs are clear. There is no pleural effusion or pneumothorax.\n Cardiomediastinal silhouette is within normal limits. No displaced rib\n fractures are noted.\n\n SINGLE FRONTAL VIEW OF THE PELVIS: Overlying trauma board limits evaluation.\n There is no fracture or dislocation seen. No concerning osseous lesions are\n identified. There is no radiopaque foreign body.\n\n IMPRESSION: No acute traumatic thoracic or pelvic injury.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2145-09-11 00:00:00.000", "description": "Report", "row_id": 1665855, "text": "CCU Nursing Progress Note 1900-0700\nS: \"I'm fine.\"\nO:Please see carevue for all objective data and trends.\n\nNeuro- A&Ox3. Flat affect- unable to determine how pt is coping w/ 3rd hospitalization in one week. Needs social work consult. Cooperative w/ care. MAE in bed.\n\nCV- HR 60-80 NSR, no ectopy. NIBP 110s-170s/60s-80s. L arm AV fistula +thrill, +Bruit. Diff to palp DP/PT bilat. No edema noted. Orthostasis not assessed o/n as pt sleeping for almost entire shift.\n\nResp- LS CTA. SPO2 >95% room air. RRR. No cough.\n\nGI- Denied N/V. No stool. Reglan for gastroparesis. +BS x 4 quad.\n\nGU- ESRD. HD T,TH,Sat. Does make urine but none this shift.\n\nEndo- FS 2200= 310 (30lantus, 6R); 2400= 271 (4R); 0400=103.\n\nID- Afebrile. WBC 9.3.\n\n Husband is contact person. 2 sons. Active w/ VNA.\n\nAccess- PIV x 3. AV fistula. **Difficult phlebotomy stick! - attempted AM labs x 3 without success. Obtain at HD later today.\n\nSkin- New rash lower left lateral back. Area pink w/ small pimple-like bumps. Denied pain/pruritis. team aware. No change o/n. Otherwise, skin intact.\n\nPLAN- Continue to monitor hemodynamics. Goal BP 100-180: Call team if persistently >180. Orthostatic VS prior to OOB this AM. Safety/fall precautions. Continue to monitor effects of new med fludrocortisone for orthostatic hypotension. Assess GI status. Tight glucose control. Social wk consult. Case mgt involved- pt active w/ VNA. ?Med compliance issues at home. Dialysis due today, uncertain of time. Needs AM labs w/ HD. Emotional support to family and patient.\n" }, { "category": "Nursing/other", "chartdate": "2145-09-10 00:00:00.000", "description": "Report", "row_id": 1665853, "text": "CCU Nursing Progress Note boarder\n51yof wiht h/o type 1 IDDM-poorly controlled, ESRD Cr 4.0 on HD for past 7 months, severe gastroparesis with 3 admissions , 7/28 in the past week for hematemesis, HTN crisis, labile BS. Went to OSH with hematemesis NGT placed with +coffee grounds-zofran. Transferred to EW BP 220/109 lopressor 7.25mg IVB total started NTG gtt, nausea and vomiting-zofran/ativan/protonix. Transferred to CCU/ boarder arrived at 0500 with SBP 143/73 NTG gtt off. No c/o pain or SOB, n/v. NGT in place. Right arm fistula +bruit/thrill.\nBS elevated 248 with gap 26, plan to start Insulin/D5W.\nGoal SBP 150-160\n" }, { "category": "Nursing/other", "chartdate": "2145-09-10 00:00:00.000", "description": "Report", "row_id": 1665854, "text": "CCU Nursing Progress Note/ boarder 7am-7pm\nS: I feel fine.\n\nO: GI - pt w/ ngt clamped, asp for small amt bilious drainage, OB(+). Denies nausea. NGT dc'd per team @ 11am. Diet advanced to nas/low chol. Abd soft w/ + bs. No stool. Cont on Reglan 5mg po bid prior to meals.\n\nEndo - Insulin gtt started per protocol at 8am w/ D5NS @ 125cc/hr. Gap from 26 to 14. Gtt titrated then dc'd at 11am. Pt now on standing pm dose of glargine and RISS.\n\nCV - HR 70-80's nsr w/ no vea. BP continues to be labile and pt is orthostatic. BP range 123-186/60's. Pt exhibited orthostasis while up to bathroom, and became unresponsive. Team notified. ECG normal. When back to bed, BP 140/70's. Pt quickly regained consciousness, and states that she had felt slightly dizzy when she got up from bathroom. 575cc nss administered post orthostatic event. Through afternoon, BP 138-182/. Fludrocortisone Acetate 0.1mg started for bp control\n\nResp - ls clear on RA w/ sats 97-100%.\n\nGU - Pt does void. Spec sent.\n\nID - afebrile.\n\nSocial - Husband and has spoken w/ MD's. Has been updated on POC.\n\nA: 50yof w/ Type I DM w/ severe gastricparesis requiring multiple admits for hypotension, vomiting and hyperglycemia.\n\nP: cont close monitoring of BP and response to Fludrocortisone, if oob please maintain safe environment, all movements slowly so to decrease chance of orthostatics, phlebotomy for lab draws, keep pt and family informed of poc per multidisiciplinary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2145-09-11 00:00:00.000", "description": "Report", "row_id": 1665856, "text": "CCU NPN 0700-1900\n\n50 Y/O Female w/ medical complications from poorly controlled insulin dependent DM. see admit note/transfer note.\nCurrently has issue w/ orthostatic hypotension.\n\nNeuro: Intact, Ambulated to BR on Monitor. Experienced lightheadednes on Return w/ 40point drop in SBP (147/70 to 101/70).\n\nCV: As above, Norvasc and Toprol held until 11 am d/t hypotensive episode. SBP increased to 176/ -> then BP meds were given.\nBP 195/80 prior to HD. Cont's on florinef for orthostatic hypotension.\n\nK+ prior to hd 3.1. Repleted at HD. All Labs drawn at HD. No excess fluid removed at HD, I&O ran even.\n\nGI: Eating well, no nausea/emesis d/t gastroparesis. cont'd on reglan.\nGU: voided 650 this am\nEndo: BS 58 this am at 8am, breakfast given. BS at 12n 209, covered per ss.\n\nA: Hypertensive episodes w/ orthostatis hypotension.\nP: Supervise all transfers/ ambulations. Cont florinef. Called out to floor, awaiting bed avail. Follow BS.\n\n" }, { "category": "ECG", "chartdate": "2145-09-13 00:00:00.000", "description": "Report", "row_id": 148254, "text": "Baseline artifact. Sinus rhythm. Q waves in leads V1-V2. Consider\nseptal myocardial infarction. Since the previous tracing of \nR waves in leads V1-V2 are less apparent. T waves are improved.\nClinical correlation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2173-01-16 00:00:00.000", "description": "Report", "row_id": 1537666, "text": "NURSING MICU NOTE 7A-7P\n\n74Y/O MALE PMH COPD, CHF, HTN, PRESENTED TO ED W/ SOB. PT INTUBATED FOR RESP DISTRESS, BIL PNA. BIL LOWER EXTREMITIE US DONE SHOWING RIGHT DVT. PLACED ON HEPARIN GTT. TRANSFERED TO MICU. CHEST CT SHOWING PNA AND PE.\n\nNEURO: PT SEDATED ON PRN DOSES FENANYL AND VERESD. PT AROUSES TO STIMULI, FOLLOWS COMMANDS, KNODS HEAD YES AND NO TO QUESTIONS. DENIES ANY PAIN EXCEPT FOR ETT BEING UNCOMFORTABLE. NO SEIZURE ACTIVITY NOET.\n\nRESP: LS DIMINSHED AT BASES, COARSE IN UPPER AIRWAY. PT SUCTIONED SMALL AMTH THICK PALE YELLOW SECRETIONS.\n\nCV: HR 70-80'S NSR. SBP 100-120'S. AFEBRILE. CK TROPOIN SENT. PT STARTED ON HEPARIN GTT PRIOR TO LEAVING ER. GTT AT 1100U/HR. PTT DUE AT . BC SENT IN ER.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT NPO. FOLEY INTACT DRAINING SMALL AMT YELLOW CLEAR URINE.\n\nENDO: PT HAS INSULIN GTT ORDERED, NOT STARTED. LAST BS 128. PT 2ND DOSE OF DECADRON THIS EVENING.\n\nACCESS: PT HAS 2 18G PIV.\n\nDISPO: PLAN TO TITRATE HEPARIN GTT. KEEP PT COMFORTABLE, FENTANYL AND VERSED GTT'S ORERED. PT HAS 5 CHILDREN, SON IS SPOKESPERSON. WIFE DIED LESS THAN 2MTHS AGO. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2173-01-17 00:00:00.000", "description": "Report", "row_id": 1537668, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support. Attempted to change FIO2 on two separate occasions; however, patient dropped his SPO2 requiring a return to the current FIO2. VT increased from 550 ml to 600 ml to compensate for hypercarbia by abg. Last abg revealed a respiratory acidemia with moderate hypoxemia.\n\nNo RSBI measured due to cardiac instability and brittle oxygenation issues..\n" }, { "category": "Nursing/other", "chartdate": "2173-01-17 00:00:00.000", "description": "Report", "row_id": 1537669, "text": "NURSING MICU NOTE 7A-7P\n\nPT EXTUBATED THIS AM, DOING WELL. DENIES ANY CP.\n\nNEURO: SEDATION GTT'S OFF THIS AM. PT 3, MAE, FOLLOWS COMMNADS. PT DENIES ANY PAIN OR DISCOMFORT.\n\nRESP: PT EXTUBATED THIS AM W/ PROBLEM. PT DENIES ANY SOB. RR 20-30'S. CHEST XRAY DONE THIS AM. O2 SATS HAVE RANGED 82-93% POST EXTUBATION. TEAM HAS TOLERATED O2 SATS 86-93% DUE TO FACT PT AT HOME LIVES IN HIGH 80% PER FAMILY AND PRIMARY MD. ABG DRAWN ON 50% COOL NEB AND 4LNC. 7.44/39/55. TEAM DISCUSED W/ RESP TEAM AND INCREASED FIO2 TO 70% W/ 4L NC. CONT TO TOLERATE O2 SATS HIGH 80'S TO 90'S. CURRENT SAT 94%.\n\nCV: HR 70-100'S NSR, OCCASIONAL PVC'S. SBP 130-150'S. PT CONT ON LOPRESSOR, ASA, LIPITOR ALONG WITH HEPARIN GTT. HEPARIN GTT THIS AM AT 1100U/HR. PTT 80. REPEAT PTT AT 1600 PENDING. TMAX 98.8. EKG DONE. MAG REPLEATED WITH 3GMS.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT TOLERATING , CARDIAC DIET. FOLEY INTACT DRAINING CLEAR YELLOW URINE.\n\nDISPO: PLAN FOR ECHO TOMORROW. REPEAT ABG THIS PM. CONT TO MONITOR MS AND O2 SATS. WILL NEED PTT TONIGHT. CK DUE AT 2400. SON IN THROUGH OUT DAY. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2173-01-17 00:00:00.000", "description": "Report", "row_id": 1537667, "text": "NPN 1900-0700\n74 yr old male with bilateral PNA, PE by CT, right leg DVT ruling in for MI by cardiac enzymes, on heparin gtt and intubated on mechanical ventilation.\n\nNEURO: Intubated, fentanyl gtt 50mcg/h, versed 1mg/h. Alert, awake most of the night, denies pain, nausea and SOB. Communicates by mouthing words, follows commands, MAE, perl 3mm, equal hand grips.\n\nRESP: Intubated on AC ventilation. Tried decreasing FiO2 from 60% to 40%, SpO2 dropped to 90%, returned to 60%, then again tried to decrease fio2 to 55% from 60%, again SpO2 dropped, FiO2 remains at 60%, maintaining SpO2 at 95-97%. ABG 7.33/51/65 on 60% 550/14 PEEP 8, Tv increased to 600. RR 14-22. Lungs coarse and diminished bilaterally at bases. Suctioned scant to small amt of clear thick secretions from ETT.\n\nCV: Afebrile. NIBP 105/59-132/86. HR 70-80's NSR without ectopy noted until 0130 occassional PAC's and PVC's noted and continues, HR 60's, stable BP, pt denied chest pain and SOB. EKG performed and evaluated by MD. inversions noted, but not changed from EKG done in EW 16hs earlier. Latest CPK trending down, troponin trending up. K at 0130 4.5, repleting a Mg of 1.7 with 3g. Heparin gtt increased from 1100units/h to 1200units/h per protocol for a therapeutic goal of PTT 60-100. Skin w/d/i. RLE pulses weaker than LLE, RLE edema (+) > LLE (2+). 20 mg lasix given, uo responded with 450cc/2h.\n\nGI: ABD soft, non-tender, present bs, no bm this shift. NPO, OGT inserted, placement confirmed by CXR. Tolerating meds via OGT.\n\nGU: Foley draining yellow/clear urine with a minimal output of 30cc/h, 20mg lasix given with an increase of uo to 450cc/2h.\n\nPlan: Monitor heart rhythm, repeat cpk/trop, ptt 0930, repeat EKG in am, possible echo?. Wean vent settings as tol. Continue supportive care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2173-01-18 00:00:00.000", "description": "Report", "row_id": 1537670, "text": "NPN 1900-0700\nPt c/o being tired and not being able to sleep, pt states that he was able to sleep for one hour during shift.\n\nNEURO: A/Ox3, MAE, follows commands, denies pain.\n\nRESP: Remains on aerosol cool mist mask with FiO2 of 70% and NC 4L/min with an ABG 7.44/68/41/29/+3. SpO2 91-96%, RR 20-30's. Atrovent nebulizer given at 0000, pt stated breathing felt a little better after neb. Lung sounds are coarse, diminished at bases bilaterally, crackles in lower right lobe. Denies SOB.\n\nCV: NSR with intermittent runs of 2, 3 up to 9 beats of ventricular bigeminy and PVC's throughout shift. Pt denies chest pain, palpatation, and SOB. BP stable 120/70-140/78. Team is aware. Heparin gtt at 1350 units/h, last ptt is therapeutic at 72.2. RLE (3+) edema > LLE (2+). +PP. Skin warm/dry/intact. Tmax 99.4\n\nGI: Abd soft/non tender,+ BS, no bm this shift. Heart/healthy diet, denies nausea.\n\nGU: Foley catheter draining clear/yellow urine. UO minimal overnight 25-30cc/h expcept for the last hour, it increased to 100cc/h.\n\nPLAN: Continue heparin gtt at 1350units/h, next ptt due at 0600, adjust gtt per protocol. Echo and ECG on order for this morning. Continue to monitor rhythm and pt for symptoms of ischemia. Wean supplemental O2 as tolerated, goal of 2 L/min via NC, as pt lives at home with supplemental o2 of 2 L/min via NC. Continue all monitoring and supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2173-01-18 00:00:00.000", "description": "Report", "row_id": 1537671, "text": "NPN 0700-1900:\nNeuro: pt is alert, oriented x 3, not c/o pain, ambulated to the chair withn good tolerance.\n\nResp: Breathing regularly on O2 NC 4 L/min and cool nebulizor, LS coarse, RR 22-29, SPO2 85-96%, desats whenever the mask is removed, not coughing, not expectorating.\n\nCV: SR with frequent PVCs, HR 80-96, BP 130-155/60-90, with 2 peripheral IVs lt and Rt hand, on Heparin drip 1350 units/hr, PTT maintained between 60-100, peripheral pulses weak to palpate. Fs 116, no insulin needed.\n\nGI/GU: On Regular diet well tolerated, abd soft, BS present, no BM during the shift, voiding via foley cath 40-60 ml/hr clear yellow u/o.\n\nInt: Skin integrity is intact, T max 98.7.\n" }, { "category": "Nursing/other", "chartdate": "2173-01-19 00:00:00.000", "description": "Report", "row_id": 1537672, "text": "npn 7p-7a (see also carevue flownotes of objective data)\n\ndx: inc SOB/Resp failure---pna, CHF, ?PE\n DVT\n\nPt w/ hx COPD, on home O2, came in for resp distress/failure, was intubated, now extubated and remains on 4 l nc O2 w/ face mask moist mist;\n found to have pna, and chf; started on Levaquin; today pt's WBC down, normal in 10's; pt afebrile overnight;\n inhalers adjusted last eve, to a longer acting type related to atrovent, and atrovent decreased from q8 rtc to prn;\n pt ordered for Lasix 20 mg IV at approx 22:45 last eve, received, with very good diuretic effect; appeared more comfortable over the night, resp rate abit down, somewhat less DOE with turning;\n pt's foley did leak after receiving Lasix, smaller lumen noted, likely could not keep up with diuresis flow, therefore leaked around; did not leak later in the shift as urine output decreased;\n\npt w/ occasional PVC's and frequent PAC's, likely d/t chronic effects of COPD on heart tissue, and ischemic demand of initial crisis resulting in troponin leak; MD team made aware again at approx 23:00, floor EKG done, seen by MD;\n\nstarted on Warfarin last eve, received 5 mg PO at approx 22:30; pt's lab results show mild lability of heparin on PTT; early yesterday was 61, down from 72; at 20:30 was 58.8, checked w/ MD, increased by only 50 u/hr, 04:30 result was 95;\n\nson called last eve, asked about results of pt's u/s (cardiac); not documented in chart, pt's son will check w/ MD's this a.m.;\n\nPLAN:\n1) check a.m. lytes re diuresis\n2) check when next PTT should be drawn\n3) skin cares\n4) emotional support to pt/ and family\n5) IV Abx, inhalers\n" }, { "category": "Nursing/other", "chartdate": "2173-01-19 00:00:00.000", "description": "Report", "row_id": 1537673, "text": "RESP: BS'S COARSE. LESS COUGHING TODAY. O2 SATS ON 50% FM RANGE FROM 90-95%. USING NP AT 4L WHILE EATING. DOES DESAT TO HIGH 80'S, BUT APPEARS ASYMPTOMATIC. NO C/O SOB OR CP.\nCV: CONT. WITH PVC'S AND PAC'S, BUT FEWER THEN YESTERDAY. CARDIAC ECHO REVEALED MOD MR AND AN EF OF >55%. STARTED ON CAPTOPRIL. PEDAL EDEMA PERSISTS, BUT + PULSES.\nENDOC: MG+ AND K+ REPLETED THIS AM. WOULD RECHECK A K+ AT 16PM.\nRENAL: CONT. TO DIURESE WELL. WILL NEED TO WATCH CREAT WITH CAPTOPRIL ON BOARD.\nNEURO: ALERT AND ORIENTATED. STATES HE FEELS MUCH BETTER, BUT IS TIRED FROM LAST NIGHT. HE DID SAY TO ME, THAT HE WANTED TO DIE AND THAT'S WHY HE DIDN'T COME INTO THE HOSPITAL SOONER. NEEDS A SOCIAL WORK CONSULT TO DEAL WITH HIS DEPRESSION, FROM WIFE DEATH.\n: PTT THERAPEUTIC THIS AM. NEED TO CHECK AT 16PM. IF THERAPEUTIC, CHECK ONLY 1X A DAY. COUMADIN THIS EVENING. INR 1.9 AFTER ONLY 1 DOSE.\nID: ANTIBIOTIC CHANGED TO ORAL DOSE. AFEBRILE. WBC'S NORMAL.\nGI: NEEDS ENCOURAGEMENT WITH DIET. UP TO COMMODE THIS AM-MOD FORMED STOOL.\nPT.: PT. REFUSED TO GET UP OOB TO CHAIR D/T EXHAUSTION. COULD TRY AGAIN THIS EVENING. PT. IS STEADY ON HIS FEET.\nSOCIAL: SON INTO VISIT. SUPPORTIVE FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2173-01-19 00:00:00.000", "description": "Report", "row_id": 1537674, "text": "MICU NPN 3PM-11PM:\nNeuro: Pt remains alert and oriented times three. Visited with his son. Does not have much of an appetite and ate very little for supper.\n\nResp: Remains on 50% CN while at rest and when eating uses only 4L N/C but desats to 80's on this without complaints. Dry cough noted. Getting inhalers by RT. Denies SOB.\n\nCV/Heme: PTT high this evening so heparin drip held for one hour and restarted at 1150u/hr at 8PM. Pt needs repeat at 2AM please. Vital signs are stable on lopressor and captopril. HR 80-100 NSR with frequent PAC's and PVC's. Denies chest pain.\n\nGI/GU: Poor appetite noted, taking liquids OK though. Takes pills without difficulty. No bowel movements. Urine output adequate via foley.\n\nID: afebrile.\n\nPlan: Pt called out to the floor and awaiting bed assignment on the floor.\n" }, { "category": "Nursing/other", "chartdate": "2173-01-20 00:00:00.000", "description": "Report", "row_id": 1537675, "text": "npn 11p-7a:\n\ndx: bil pna, w/ acute PE/DVT/hypoxemia\n\npt a/o x3; PTT 57.7 this a.m., therefore heparin gtt increased only by 50 units/hr d/t pt's significant lability in anticoagulative response to hearping gtt levels;\n\nremains on abx; currently on qd longer acting broncho-dilater; pt appeared comfortable this night, respirations nl rate and effort, O2 needs w/out change;\n\nno meals overnight;\n\nnew order for captopril as of yesterday; parameter stated hold for serum K+ >5.0, this am's result 5.0, so will check with team before giving am dose;\n\npt's son called last eve, received update(s) previous RN;\n\nPLAN:\n1) call out to floor/or rehab\n2) continued management w/ abx for pna\n3) re DVT: heparin gtt, goal PTT 60-100, until INR in therapeutic range\n4) updates to pt and pt's son prn\n5) keep sats >90%\n6) daily broncho-dialter\n7) chekc PTT at approx 11 a.m.\n" }, { "category": "Echo", "chartdate": "2173-01-18 00:00:00.000", "description": "Report", "row_id": 64280, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 68\nWeight (lb): 140\nBSA (m2): 1.76 m2\nBP (mm Hg): 157/86\nHR (bpm): 82\nStatus: Outpatient\nDate/Time: at 16:22\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Mildly dilated\nRV cavity. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild to moderate (+) MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The right ventricular cavity is mildly dilated. There is mild global right\nventricular free wall hypokinesis.\n3. The ascending aorta is mildly dilated.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2173-01-21 00:00:00.000", "description": "Report", "row_id": 122659, "text": "Sinus rhythm with occasional ventricular premature beats. Other than\nventricular ectopy, no significant change compared to the previous tracing\nof .\n\n" }, { "category": "ECG", "chartdate": "2173-01-18 00:00:00.000", "description": "Report", "row_id": 122660, "text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Left axis\ndeviation. Non-specific ST-T wave changes. Compared to the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2173-01-18 00:00:00.000", "description": "Report", "row_id": 122661, "text": "Sinus rhythm with frequent ventricular premature beats. Right bundle-branch\nblock. Left axis deviation. Non-specific ST-T wave changes. Compared to the\nprevious tracing no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2173-01-17 00:00:00.000", "description": "Report", "row_id": 122662, "text": "Sinus rhythm\nPremature ventricular contractions\nAtrial premature complexes\nRight bundle branch block\nST-T wave changes - are probably in part primary and are nonspecific\nSince previous tracing of , atrial ectopy and further ST-T wave changes\npresent\n\n" }, { "category": "ECG", "chartdate": "2173-01-16 00:00:00.000", "description": "Report", "row_id": 122663, "text": "Sinus tachycardia\n - frequent premature ventricular contractions\nPossible left atrial abnormality\nLeft axis deviation\nRBBB with left anterior fascicular block\nSince last ECG, rate slower and new left anterior fascicular block and\nventricular premature complexes\n\n" }, { "category": "Radiology", "chartdate": "2173-01-16 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 891702, "text": " 1:20 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: would like to r/o PE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with resp failure and presumed pna but now w/ rle dvt - would\n like chest cta to r/o pe and also to eval for pulm infarct\n REASON FOR THIS EXAMINATION:\n would like to r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with respiratory failure and presumed pneumonia.\n Now with right lower extremity DVT. Evaluate for pulmonary embolism.\n\n TECHNIQUE: Contiguous axial CT images of the chest were obtained with\n multiplanar reconstructions.\n\n CONTRAST: 100 cc of IV Optiray was administered.\n\n COMPARISON: .\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: The soft tissue window images\n reveal stable appearance of multiple enlarged mediastinal lymph nodes. These\n are present in the AP window prevascular and precarinal region. The largest\n one measures 1.5 cm and is seen in the precarinal region. There is no\n significant hilar or axillary lymphadenopathy. There are multiple filling\n defects seen in the segmental and subsegmental branches of the right middle\n and lower as well as left upper and lower lobes consistent with pulmonary\n emboli. The heart, pericardium and aorta are unremarkable. A small left-\n sided pleural effusion is present.\n\n The soft tissue window images reveal bilateral moderate consolidations at the\n lung bases. Additionally, patchy opacities are visualized at both lung bases.\n There is some prominence of interstitial markings at the lung bases, likely\n representing pulmonary edema along with some ground-glass opacities. Few\n opacities are also visualized in the left upper lobe. In the imaged portion\n of the upper abdomen, the visualized portion of the liver, spleen, adrenals\n and kidneys appear unremarkable.\n\n An endotracheal tube is present with its tip about 6 cm above the carina.\n\n There are no suspicious lytic or blastic lesion in the osseous structures.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the above findings.\n\n IMPRESSION:\n 1. Multiple bilateral pulmonary emboli.\n 2. Moderate bilateral consolidations as well as patchy opacities at the lung\n bases.\n 3. Prominence of interstitial markings at the lung bases, likely representing\n (Over)\n\n 1:20 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: would like to r/o PE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2173-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891853, "text": " 5:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval status of infiltrates and pleural effusions\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 male w/ htn, copd, and resp failure thought secondary to bibasilar pna,\n intubated. Now s/p OG tube placement.\n REASON FOR THIS EXAMINATION:\n eval status of infiltrates and pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:26 A.M. .\n\n HISTORY: COPD, respiratory failure and bibasilar pneumonia.\n\n IMPRESSION: AP chest compared to and 4:\n\n Moderate pulmonary edema has worsened, accounting in part for progressive\n opacification of large region of pneumonia in the right mid lung, also\n exaggerated by extubation of the airway. Heart size remains top normal.\n Moderate right pleural effusion has increased. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891768, "text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 male w/ htn, copd, and resp failure thought secondary to bibasilar pna now\n s/p intubation - would like to confirm ett placement\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 9:17\n\n INDICATION: Failure.\n\n COMPARISON: at 21:15.\n\n FINDINGS:\n\n Lines and tubes remain in place with the ETT 3 cm above the carina. Compared\n to the prior exam, there is more confluent opacity at the right lower lung\n zone. This suggests progression of the airspace process. The remainder of\n the study is unchanged and there is no PTX.\n\n IMPRESSION:\n\n Progressing airspace consolidation in the right lower lobe.\n\n ETT in good position.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892010, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate infiltrates, evaluate for interval change.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 male w/ htn, copd, and resp failure thought secondary to bibasilar pna,\n B/L small PEs. Extubated .\n REASON FOR THIS EXAMINATION:\n please evaluate infiltrates, evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:49 A.M. \n\n HISTORY: Respiratory failure and bibasilar pneumonia.\n\n IMPRESSION: AP chest compared to , 4th and 5th:\n\n Moderate pulmonary edema has changed in distribution on the supine view, but\n probably not in severity compared to the upright view on . Dense\n consolidation in the right mid and lower lungs zones has improved slightly\n while moderate right and small left pleural effusion is stable. Moderate\n cardiomegaly unchanged. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891683, "text": " 10:50 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirm ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 male w/ htn, copd, and resp failure thought secondary to bibasilar pna now\n s/p intubation - would like to confirm ett placement\n REASON FOR THIS EXAMINATION:\n confirm ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with respiratory failure, endotracheal tube\n placement.\n\n CHEST AP: There has been interval placement of an endotracheal tube with its\n tip about 5 cm above the carina. There is stable appearance of bilateral\n basilar consolidations and pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2173-01-16 00:00:00.000", "description": "RP UNILAT LOWER EXT VEINS RIGHT PORT", "row_id": 891687, "text": " 11:22 AM\n UNILAT LOWER EXT VEINS RIGHT PORT Clip # \n Reason: RESPIRATORY FAILURE, RIGHT LOWER EXTREMITY GREATER THAN THE LEFT, R/O DVT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with respiratory failure and now right greater than left lower\n extremity edema\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n WET READ: JCT SAT 12:24 PM\n DVT extending from mid right superficial femoral vein to popliteal vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old man with respiratory failure and right greater than left\n lower extremity edema.\n\n FINDINGS: Grayscale and Doppler son of the right common femoral,\n superficial femoral, and popliteal veins were performed. Intraluminal\n thrombus is identified from the mid superficial femoral vein extending down to\n the popliteal vein. The thrombus is occlusive and no flow or compressibility\n of the vein is demonstrated. The common femoral vein is patent with normal\n flow, augmentation, compressibility, and waveforms.\n\n IMPRESSION: Deep venous thrombosis extending from the mid right superficial\n femoral vein to the popliteal vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-01-21 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 892371, "text": " 4:54 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval for evidence of abd/pelvic mass, occult malignan\n Admitting Diagnosis: PNEUMONIA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new DVT/PEs, ? hypercoagulable state, no cancer screening\n REASON FOR THIS EXAMINATION:\n please eval for evidence of abd/pelvic mass, occult malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old man with DVT/PE, question hypercoagulable state, no\n cancer screening.\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with oral and IV contrast. 150 cc Optiray.\n\n CT ABDOMEN: Again noted are patchy bilateral lobe consolidations. Prominent\n interstitial markings are also observed. There is a tiny low attenuation\n focus in the right hepatic lobe, which is too small to be characterized. The\n gallbladder, pancreas, spleen, right adrenal gland, and kidneys are within\n normal limits. There is fullness of the left adrenal gland without focal mass\n lesion identified. The stomach and small bowel loops are unremarkable. There\n is no free air or free fluid. There is no mesenteric or retroperitoneal\n lymphadenopathy. Note is made of extensive atherosclerotic disease in the\n abdominal aorta.\n\n CT PELVIS: The bladder, prostate, seminal vesicles, and rectum are within\n normal limits. There is a short segment of apparent focal wall thickening in\n the distal sigmoid colon. Scattered sigmoid diverticula are observed without\n evidence of diverticulitis. There is no free fluid and no pelvic or inguinal\n lymphadenopathy. Bilateral fat containing inguinal hernias are noted.\n\n BONE WINDOWS: There are degenerative changes of the lumbar spine. No\n suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Apparent focal wall thickening of the distal sigmoid colon. This most\n likely represents material within the bowel or peristalsis of the bowel. Less\n likely possibilities include residua of prior diverticulitis or colonic mass.\n If there is concern for a colonic neoplasm, further evaluation could be\n obtained with colonoscopy or CT colonography.\n 2. Nonspecific fullness of the left adrenal gland without demonstrable focal\n mass.\n 3. Tiny low attenuation focus in the liver which is too small to be\n characterized.\n 4. Increased bilateral lower lobe consolidations consistent with worsening\n pneumonia. Continued pulmonary edema.\n\n (Over)\n\n 4:54 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval for evidence of abd/pelvic mass, occult malignan\n Admitting Diagnosis: PNEUMONIA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891736, "text": " 9:03 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate OG tube placement.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 male w/ htn, copd, and resp failure thought secondary to bibasilar pna,\n intubated. Now s/p OG tube placement.\n REASON FOR THIS EXAMINATION:\n evaluate OG tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON at 21:15.\n\n INDICATION: OG tube placement.\n\n COMPARISON: at 11:03.\n\n FINDINGS: An NGT is seen extending below the diaphragm, coiled in the stomach\n with the tip in the fundal region. Bilateral patchy air space findings are\n unchanged. ETT tip located 5.9 cm above the carina.\n\n IMPRESSION: NGT coiled in stomach with tip in fundal region. No other\n significant interval changes.\n\n" }, { "category": "Radiology", "chartdate": "2173-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891678, "text": " 9:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sob ? CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with\n REASON FOR THIS EXAMINATION:\n sob ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with shortness of breath.\n\n CHEST AP: The heart size and mediastinal contours are unremarkable. There\n are bibasilar cosolidations present along with pulmonary edema and a small\n left pleural effusion. No focal areas of consolidation are visualized.\n\n IMPRESSION: Bibasilar consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2173-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892162, "text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 male w/ htn, copd, and resp failure thought secondary to bibasilar pna,\n B/L small PEs. Extubated .\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 74-year-old male patient with COPD and respiratory failure,\n pneumonia.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n with the previous study of yesterday.\n\n The patient has underlying emphysema. There is continued mild-to-moderate\n congestive heart failure with cardiomegaly associated with bilateral\n multifocal opacities indicating pneumonia. There is continued loculated right\n pleural effusion. No pneumothorax is identified.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2110-03-12 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 1131395, "text": " 1:59 PM\n CAROT/CEREB Clip # \n Reason: Angio ? CoilingAnesthesia has been book for on waitlist\n Contrast: OPTIRAY Amt: 80ML OPTI240; 100ML OPTI320\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY CAROTID/CEREBRAL UNILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL UNILAT *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with known aneurysm\n REASON FOR THIS EXAMINATION:\n Angio ? CoilingAnesthesia has been book for on waitlist\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: This is a 65-year-old woman with known history of aneurysmal\n subarachnoid hemorrhage from ruptured right PCOM aneurysm with possible\n recanalization.\n\n REASON FOR EXAM: Possible coiling.\n\n PROCEDURE: Cerebral angiogram with right common carotid arteriogram, right\n internal carotid arteriogram and right common femoral arteriogram.\n\n INTERVENTIONAL PROCEDURE: Recoiling of right PCOM aneurysm using two GDC-10\n 360 soft coils 2 x 4 cm.\n\n OPERATOR: Dr. .\n\n ASSISTANT: Dr. .\n\n ANESTHESIA: The procedure was done under general anesthesia.\n\n DETAILS OF THE PROCEDURE:\n Written informed consent was obtained from the patient after explaining\n indications, risks, benefits, and alternative management. The patient was\n brought into the neurointerventional suite and placed in supine position on\n biplane table. Pre-procedure time-out documenting the nature of the\n procedure, patient identity and relevant blood work up was done using two\n independent verifiers. After that, anesthesia was induced and patient was\n intubated. Then, both groins were prepped and draped in standard sterile\n fashion. After using local anesthesia into the right common femoral area, the\n right common femoral artery was successfully accessed using micropuncture set.\n Then Using Seldinger technique, a 6 French vascular sheath was inserted over\n the wire and then connected to continuous drip of pressurized mixture\n of heparin and saline. Through the sheath using a 5 French catheter\n with the aid of 0.038 guide wire system was connected to continuous drip of\n pressurized heparin and saline mixture, the right common carotid artery was\n selectively catheterized. AP, lateral, oblique and three-dimensional imaging\n was obtained. After reviewing the imaging and under road map guidance, an\n (Over)\n\n 1:59 PM\n CAROT/CEREB Clip # \n Reason: Angio ? CoilingAnesthesia has been book for on waitlist\n Contrast: OPTIRAY Amt: 80ML OPTI240; 100ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n exchange-length Glidewire was successfully placed into the distal ICA. The\n catheter was removed and replaced by 6 French Neuron catheter and\n under fluoroscopy and road map guidance, was placed into the distal cervical\n segment of Right ICA. Then, after using the best working projection, using an\n SL-10 microcatheter with a Synchro standard microwire, the aneurysm was safely\n catheterized. Then, coil embolization of the aneurysm was done using two\n GDC-10 360 soft 2 x 4 coils. Post-successful embolization of the aneurysm\n runs showed adequate flow in the PCA with minimal filling of the aneurysm. The\n catheter and wire were removed; the sheath was later withdrawn when the ACT\n was less than 180, and pressure was held for a total of 25 minutes until\n hemostasis was obtained. The patient was sent to the unit with post-procedure\n orders.\n\n FINDINGS:\n\n Right common carotid arteriogram showed normal carotid bifurcation with some\n atherosclerotic disease in the posterolateral wall of internal carotid with no\n significant degree of stenosis. Normal filling of the internal carotid along\n the cervical, petrous, cavernous and supraclinoid portions. Both middle\n anterior cerebral arteries were seen and appeared normal with prominent right\n PCOM. There was some filling of the previously coiled right PCOM aneurysm at\n the aneurysm neck \"anterio-superior portion\". This portion was successfully\n embolized using GDC-10 coils. Post-embolization runs showed adequate flow in\n the posterior communicating artery.\n\n Right common femoral arteriogram showed normal filling of the common femoral\n and its branches. There is no extravasation or dissection.\n\n IMPRESSION: underwent cerebral angiogram which showed some\n filling of the aneurysm neck, the \"anterior superior portion\" of the aneurysm,\n which was successfully embolized using GDC-10 coils.\n\n" }, { "category": "Nursing", "chartdate": "2110-03-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 534713, "text": "Aneurysm, other\n Assessment:\n - alert, oriented X 3, MAE equally, full strength, ambulatory\n to commode\n - complains of mild headache\n - angio site dsd c/d/I, soft to palpation\n Action:\n - Tylenol 650mg\n - Instructed on assessment of angio site\n Response:\n - adequate pain relief after Tylenol\n - pt slightly anxious about going home\n - requesting VNA services at home to come assess angio site\n for a few days, which she had received after previous coiling\n Plan:\n - discharge home\n" }, { "category": "Nursing", "chartdate": "2110-03-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 534714, "text": "65 y/o F with h/o prior aneurysm s/p elective recoiling of R PCOM\n aneurysm. procedure uneventful. admitted for 24 hrs obs.\n Aneurysm, other\n Assessment:\n - alert, oriented X 3, MAE equally, full strength, ambulatory\n to commode\n - complains of mild headache\n - angio site dsd c/d/I, soft to palpation\n Action:\n - Tylenol 650mg\n - Instructed on assessment of angio site\n Response:\n - adequate pain relief after Tylenol\n - pt slightly anxious about going home\n - requesting VNA services at home to come assess angio site\n for a few days, which she had received after previous coiling\n Plan:\n - discharge home\n" }, { "category": "Physician ", "chartdate": "2110-03-13 00:00:00.000", "description": "Intensivist Note", "row_id": 534686, "text": "SICU\n HPI:\n 65 y/o F with h/o prior aneurysm s/p elective recoiling of R PCOM\n aneurysm. procedure uneventful. admitted for 24 hrs obs.\n Chief complaint:\n R PCOM aneurysm\n PMHx:\n right PCOM origin aneurysm with daughter sac coiled \n Current medications:\n Active Medications ,\n 1. 2. 1000 mL NS 3. Acetaminophen-Caff-Butalbital 4. Acetaminophen 5.\n Aspirin 6. Docusate Sodium\n 7. Famotidine 8. Heparin 9. HydrALAzine 10. Senna 11. Sodium Chloride\n 0.9% Flush\n 24 Hour Events:\n Admitted for obs.\n Allergies:\n Codeine\n Throat swelling\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Dilaudid (Oral) (Hydromorphone Hcl)\n Nausea/Vomiting\n Bee Sting Kit\n allergic to bee\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n worsening heada\n Succinylcholine\n malignant hyper\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 500 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:43 AM\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: 98 (59 - 98) bpm\n BP: 115/68(87) {93/45(62) - 143/76(102)} mmHg\n RR: 13 (13 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 500 mL\n 775 mL\n PO:\n 400 mL\n Tube feeding:\n IV Fluid:\n 500 mL\n 375 mL\n Blood products:\n Total out:\n 620 mL\n 455 mL\n Urine:\n 620 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n -120 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 233 K/uL\n 11.1 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 110 mEq/L\n 143 mEq/L\n 32.8 %\n 7.2 K/uL\n [image002.jpg]\n 02:56 AM\n WBC\n 7.2\n Hct\n 32.8\n Plt\n 233\n Creatinine\n 0.7\n Glucose\n 113\n Other labs: PT / PTT / INR:12.4/26.2/1.0, Ca:8.5 mg/dL, Mg:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n ANEURYSM, OTHER\n Assessment and Plan: 65 y/o F s/p recoiling of R PCOM aneurysm\n Neurologic: - A&O. no active issues.\n - APAP PRN pain\n Cardiovascular: - no active issues.\n - Hydralazine 10 mg IV Q6H:PRN SBP>160\n - on home dose ASA\n Pulmonary: - no active issues.\n Gastrointestinal / Abdomen: - no active issues.\n - NPO o/n.\n Nutrition: - NPO o/n.\n - ADAT regular today.\n Renal: - no active issues\n - foley\n Hematology: - no active issues\n - trend Hct\n Endocrine: - RISS for goal < 150\n Infectious Disease: - no active issues\n Lines / Tubes / Drains: PIV, foley, aline\n Wounds: femoral sites C/D/I\n Imaging:\n Fluids: NS @ 75\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:43 PM\n 18 Gauge - 05:44 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, 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": "2110-03-13 00:00:00.000", "description": "Intensivist Note", "row_id": 534712, "text": "SICU\n HPI:\n 65 y/o F with h/o prior aneurysm s/p elective recoiling of R PCOM\n aneurysm. procedure uneventful. admitted for 24 hrs obs.\n Chief complaint:\n R PCOM aneurysm\n PMHx:\n right PCOM origin aneurysm with daughter sac coiled \n Current medications:\n Active Medications ,\n 1. 2. 1000 mL NS 3. Acetaminophen-Caff-Butalbital 4. Acetaminophen 5.\n Aspirin 6. Docusate Sodium\n 7. Famotidine 8. Heparin 9. HydrALAzine 10. Senna 11. Sodium Chloride\n 0.9% Flush\n 24 Hour Events:\n Admitted for obs.\n Allergies:\n Codeine\n Throat swelling\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Dilaudid (Oral) (Hydromorphone Hcl)\n Nausea/Vomiting\n Bee Sting Kit\n allergic to bee\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n worsening heada\n Succinylcholine\n malignant hyper\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 500 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:43 AM\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: 98 (59 - 98) bpm\n BP: 115/68(87) {93/45(62) - 143/76(102)} mmHg\n RR: 13 (13 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 500 mL\n 775 mL\n PO:\n 400 mL\n Tube feeding:\n IV Fluid:\n 500 mL\n 375 mL\n Blood products:\n Total out:\n 620 mL\n 455 mL\n Urine:\n 620 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n -120 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 233 K/uL\n 11.1 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 110 mEq/L\n 143 mEq/L\n 32.8 %\n 7.2 K/uL\n [image002.jpg]\n 02:56 AM\n WBC\n 7.2\n Hct\n 32.8\n Plt\n 233\n Creatinine\n 0.7\n Glucose\n 113\n Other labs: PT / PTT / INR:12.4/26.2/1.0, Ca:8.5 mg/dL, Mg:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n ANEURYSM, OTHER\n Assessment and Plan: 65 y/o F s/p recoiling of R PCOM aneurysm\n Neurologic: - A&O. no active issues.\n - APAP PRN pain\n Cardiovascular: - no active issues.\n - Hydralazine 10 mg IV Q6H:PRN SBP>160\n - on home dose ASA\n Pulmonary: - no active issues.\n Gastrointestinal / Abdomen: - no active issues.\n Nutrition:\n - ADAT regular today.\n Renal: - no active issues\n Hematology: - no active issues\n - stable anemia\n Endocrine: - RISS for goal < 150. BG well controlled.\n Infectious Disease: - no active issues\n Lines / Tubes / Drains: PIV, foley, aline\n Wounds: femoral sites C/D/I\n Imaging:\n Fluids: NS @ 75\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:43 PM\n 18 Gauge - 05:44 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments:\n Code status: Full code\n Disposition: Discharge home\n Total time spent: 15 minutes\n" }, { "category": "Nursing", "chartdate": "2110-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 534601, "text": "65 year-old female with PMH malignant hyperthermia, smoking, SAH\n and status-post Right PCOM coiling, arthritis and status-post right\n ankle fusion 30 years ago. recoiling of a right PCOM aneurysm.\n Aneurysm, other\n Assessment:\n A+OX3. Able to verbalize needs. PERRLA: 3mm/3mm, brisk. MAE\n 5/5 strength. Strong non-productive cough. Denies headache, blurred\n vision and pain.\n Goal SBP between 90-160\n Action:\n Q 1 hour neurological exams.\n Patient to remain flat in bed with right leg straight until\n 1 AM on .\n R-groin sheath discontinued by MD . R-groin site no\n hematoma/bleeding. Dressing CDI.\n Response:\n Patient resting comfortably.\n Neurological exam remains intact.\n Plan:\n Q 1 hour neurological exams.\n Continue to closely monitor groin site for hematoma and\n signs of bleeding.\n Heparin drip to be started at 20:00 on and\n discontinued at 7:00AM on .\n Maintain SBP between 90-160.\n Provide supportive care to patient and family.\n" }, { "category": "Nursing", "chartdate": "2110-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 534658, "text": "65 year-old female with PMH malignant hyperthermia, smoking, SAH\n and status-post Right PCOM coiling, arthritis and status-post right\n ankle fusion 30 years ago. recoiling of a right PCOM aneurysm.\n Aneurysm, other\n Assessment:\n Patient alert orientated x 3\n Perrla, denies visual disturbances, numbness/tingling.\n Mae equal strength.\n Sbp 90-130\n Denies headache, but complains of backache.\n Femoral site intact, no hematoma noted, pulses present.\n Action:\n Monitor neuro exam Q1\n Iv heparin 500units started at 8pm as ordered, dc at 07am as ordered.\n Iv fluids kvo as patient tolerating good po intake.\n Bed rest completed at 1am, foley discontinue per patient request,\n passing adequate amounts of urine.\n Labs obtained and reviewed.\n Response:\n Patient remains alert orientated.\n Plan:\n Iv heparin to be dc at 07am pr dr orders\n ?Mri\n" }, { "category": "Nursing", "chartdate": "2110-03-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 534768, "text": "65 y/o F with h/o prior aneurysm s/p elective recoiling of R PCOM\n aneurysm. procedure uneventful. admitted for 24 hrs obs.\n Aneurysm, other\n Assessment:\n - alert, oriented X 3, MAE equally, full strength, ambulatory\n to commode\n - complains of mild headache\n - angio site dsd c/d/I, soft to palpation\n Action:\n - Tylenol 650mg\n - Instructed on assessment of angio site\n Response:\n - adequate pain relief after Tylenol\n - discharge teaching done, med reconciliation done, pt fully\n understands all discharge planning\n - ambulating on own, full strength, neuro status completely\n intact\n Plan:\n - discharged home at approx 1600\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CEREBRAL ANEURYSM/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 71.8 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Throat swelling\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Dilaudid (Oral) (Hydromorphone Hcl)\n Nausea/Vomiting\n Bee Sting Kit\n allergic to bee\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n worsening heada\n Succinylcholine\n malignant hyper\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Malignant hyperthermia, status-post right ankle\n sugery 30 years-ago. Satus-post R-PCOM aneurysm coiling on .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:90\n Temperature:\n 98.5\n Arterial BP:\n S:124\n D:66\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 72 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 870 mL\n 24h total out:\n 955 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:56 AM\n Potassium:\n 3.7 mEq/L\n 02:56 AM\n Chloride:\n 110 mEq/L\n 02:56 AM\n CO2:\n 25 mEq/L\n 02:56 AM\n BUN:\n 11 mg/dL\n 02:56 AM\n Creatinine:\n 0.7 mg/dL\n 02:56 AM\n Glucose:\n 113 mg/dL\n 02:56 AM\n Hematocrit:\n 32.8 %\n 02:56 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: back pack with belongings, pt reports she has all of\n her things\n Clothes: Sent home with: patient and pts brother\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu\n Transferred to: home\n Date & time of Transfer: 12:00 AM\n" } ]

[ { "category": "Radiology", "chartdate": "2120-02-22 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 859448, "text": " 4:38 PM\n LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with lower back pain s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Low back pain status post fall.\n\n LUMBOSACRAL SPINE, TWO VIEWS: No comparisons. There are aortic\n calcifications. There are anterior osteophytes and degenerative changes at\n most lumbar levels, greatest at L4-5 and L5-S1. There is limited visualization\n of the L1 vertebral body on the lateral view, but the remainder of the\n vertebral bodies appears normal. No compression deformities are seen.\n\n IMPRESSION: No acute fractures.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-23 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 859599, "text": " 8:17 PM\n MR CERVICAL SPINE Clip # \n Reason: Clear c- spinePlease use Stir to r/o ligamentous injury\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p unwitnessed fall\n REASON FOR THIS EXAMINATION:\n Clear c- spinePlease use Stir to r/o ligamentous injury\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRI of the cervical spine.\n\n CLINICAL INFORMATION: The patient with unwitnessed fall, rule out cervical\n spine injury.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient echo axial\n images of the cervical spine were acquired. The examination is limited, and\n several sequences were repeated.\n\n FINDINGS: From skull base to T4 level, no evidence of abnormal signal seen\n within the vertebral bodies or ligamentous structures. The prevertebral soft\n tissues are maintained. There is no evidence of intraspinal fluid collection\n seen. Mild degenerative changes are seen in the cervical region from T3-4 to\n T6-7 level. Evaluation for foramina is limited on axial images secondary to\n artifacts.\n\n At C4 level to the right of midline, small area of increased signal is seen on\n the spinal cord on T2 and inversion recovery sagittal images. This could be\n secondary to intrinsic spinal cord signal abnormality. This could also be\n secondary to an artifact as the examinations are limited by pulsations. If\n the patient has myelopathic signs, consider a repeat study with sedation.\n\n IMPRESSION: No evidence of abnormal ligamentous or vertebral body signal\n noted to indicate acute trauma to the cervical spine. However, on this motion\n limited study a subtle area of increased signal is seen on the right side of\n the spinal cord at C4 level, which could be due to an intrinsic spinal cord\n signal abnormality from myelomalacia. If the patient has acute signs of\n spinal cord injury, consider a repeat study with proper sedation. The\n findings were discussed with Dr. of neurosurgery on at\n 10:30 a.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 859433, "text": " 2:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: , s/p fall, h/o alcohol abuse, intoxicatedR/O ICH (SDH)\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n , s/p fall, h/o alcohol abuse, intoxicatedR/O ICH (SDH)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:32 PM\n small subarachnoid blood in right sylvian fissure\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 51-year-old man with fall, history of alcohol abuse.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a small amount of increased attenuation in the sylvian\n fissure on the right, indicating subarachnoid blood. No hydrocephalus, shift\n of normally midline structures, vascular territorial infarct, or other foci of\n hemorrhage are seen. The -white differentiation remains intact. Osseous\n structures and soft tissues are unremarkable.\n\n IMPRESSION: Small subarachnoid hemorrhage in the right sylvian fissure. This\n finding was relayed to the ED dashboard at 4:00 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-23 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 859608, "text": " 10:11 PM\n C-SPINE, TRAUMA Clip # \n Reason: Clear c-spine\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p fall\n REASON FOR THIS EXAMINATION:\n Clear c-spine\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall.\n\n C-SPINE, SIX VIEWS: There are multilevel degenerative changes with large\n anterior and tiny posterior osteophytes and multilevel mild disk space\n narrowing. There is also associated facet degenerative change. No acute\n fracture, malalignment, or bone destruction is detected. Lateral views are\n slightly limited for evaluation of C7-T1. There is no prevertebral soft\n tissue swelling. The lateral masses of C1 align with C2.\n\n IMPRESSION: Multilevel degenerative changes. No acute fracture identified.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-24 00:00:00.000", "description": "T-SPINE", "row_id": 859646, "text": " 11:04 AM\n T-SPINE Clip # \n Reason: Please r/o fracture, dislocation.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p unwitnessed fall. H/O cervical fracture with resultant\n left sided weakness.\n REASON FOR THIS EXAMINATION:\n Please r/o fracture, dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unwitnessed fall. History of old cervical spine fracture.\n\n T-SPINE, FIVE VIEWS: AP, and four lateral views of the thoracic spine are\n obtained. No malalignment or bone destruction is seen. There is anterior,\n superior compression deformity of the L1 vertebral body, seen on one of the\n lateral views. Note that this study was targeted to the thoracic spine. There\n is minimal loss of height of T8. Acuity of these findings cannot be\n determined on this study. No other bony abnormalities are seen.\n\n Findings called to Dr. (Neurosurgery) on at time of official\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 859525, "text": " 11:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: SAH, EVAL FOR PROGRESSION\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with R SAH\n REASON FOR THIS EXAMINATION:\n progression?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with right subarachnoid hemorrhage.\n\n COMPARISON: CT scan of the head, , 1420.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: In the region of the previously identified subarachnoid hemorrhage,\n there is a trace amount of hyperdensity outlining the sulci in the right\n sylvian fissure. No new regions of hemorrhage are seen. No hydrocephalus,\n shift of normally midline structures, vascular territorial infarction, or\n intracranial mass lesion. This examination is otherwise stable.\n\n IMPRESSION: Reduced, but not resolved, subarachnoid hemorrhage. This was\n related to Dr. at 3:00 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-25 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 859736, "text": " 11:22 AM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: assess for fractures, dislocation\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p fall with back pain and loss of height seen on plain\n films\n REASON FOR THIS EXAMINATION:\n assess for fractures, dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall with back and loss of height seen on plain films.\n Is there a fracture?\n\n TECHNIQUE: Contiguous axial images were obtained from T1 through T12-L1. No\n contrast was administered.\n\n COMPARISON: To plain films of .\n\n FINDINGS:\n\n No fractures are detected in the thoracic spine. There is a fracture of the\n superior endplate of the L1 vertebral body. This is not fully evaluated on\n this study.\n\n There is an Schmorl's node and disc protrusion, extending into the spinal\n canal in the midline and to the right, T8-T9. This produces mild encroachment\n on the thecal sac. This noncontrast CT scan does not display the spinal cord.\n I cannot determine whether there is spinal cord encroachment.\n\n There is a similar, although smaller, disc protrusion at T9-T10, again larger\n on the right than left. As noted above, I cannot determine whether this\n produces spinal cord encroachment. Alignment of the thoracic spine is normal.\n There is wedging of the T7 and T8 vertebral bodies with a small fracture of\n the superior endplate of T7. These may be chronic changes. If it is\n clinically important to determine whether these are acute, a radionuclide bone\n scan may be the best next step.\n\n CONCLUSION:\n\n Alignment of the thoracic spine is normal. Wedging of T7 and T8 vertebral\n bodies maybe chronic.\n\n Disc protrusions at T8-T9 and T9-T10 encroaching on the right side of the\n spinal canal. Fracture of the superior endplate of L1 is not fully evaluated\n on this examination.\n\n (Over)\n\n 11:22 AM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: assess for fractures, dislocation\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2120-02-25 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 859737, "text": " 11:22 AM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: assess for fractures/dislocation\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p fall with back pain and loss of height seen on plain\n films\n REASON FOR THIS EXAMINATION:\n assess for fractures/dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT LUMBAR SPINE \n\n HISTORY: Fall with back pain.\n\n Contiguous axial images were obtained from T12 through S1. No contrast was\n administered. Comparison to plain films of . Sagittal and\n coronal reformatted images were prepared.\n\n FINDINGS: There is a fracture of the superior end plate of L1 with fragments\n extending anteriorly into the prevertebral space and slight posterior\n extension into the spinal canal. This reduces only minimal engorgement on the\n spinal canal.\n\n Axial images at L3-L4 demonstrate a prominent bulging disk that is partially\n calcified. This extends into the neural foramina and may contact the exiting\n L3 nerve roots. There is only minimal encroachment on the spinal canal\n itself. There are bilateral facet osteophytes at this level.\n\n At L4-L5, there is asymmetric bulge of the intervertebral disk with minimal\n encroachment on the spinal canal. The disk extends into the right neural\n foramen, along with an osteophyte, it may compromise the right L4 nerve root.\n\n At L5-S1, there is a bulge of the intervertebral disk. This is more prominent\n on the left than right and it may compromise the traversing left S1 nerve\n root. There is mild thickening of the ligament and flavum and mild facet\n joint osteophyte formation.\n\n CONCLUSION:\n\n L1 vertebral body compression fracture with slight retropulsion of the\n posterior fragment into the spinal canal.\n\n Degenerative disk disease at L3 - S1.\n\n\n (Over)\n\n 11:22 AM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: assess for fractures/dislocation\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2120-02-26 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 859891, "text": " 5:24 PM\n MR W & W/O CONTRAST; MR THORACIC SPINE Clip # \n MR CONTRAST GADOLIN\n Reason: assess for new fractures/ligamentous injury, please include\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p fall with back pain and loss of height seen on plain\n films\n REASON FOR THIS EXAMINATION:\n assess for new fractures/ligamentous injury, please include lower thoracic\n levels. Please include Fat suppression images\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Status post fall with back pain and loss of height seen\n on plane films, question new fracture or ligamentous injury.\n\n MRI OF THE THORACIC SPINE.\n\n FINDINGS: There is no evidence of acute fracture or malalignment. The\n thoracic cord is not remarkable. There is no evidence of focal thoracic disc\n protrusion.\n\n LUMBAR SPINE WITH GADOLINIUM.\n\n FINDINGS: There is a mild anterior wedge compression deformity of L1 with\n increased signal consistent with an acute fracture. There is preservation of\n height posteriorly. There is no evidence of retropulsion of material into the\n spinal canal. The alignment is maintained. There is disc desiccation at\n multiple lumbar levels. There is a small left-sided disc protrusion at L4-5\n encroaching upon the L5 nerve root. There is no evidence of canal or\n foraminal stenosis. There is a small central disc protrusion at L5-S1\n touching the thecal sac but not encroaching upon neurologic structures.\n\n IMPRESSION: Compression fracture of L1 without significant gibbus. No\n evidence of retropulsion of material into the spinal canal. Degenerative\n changes of the lower lumbar spine.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-23 00:00:00.000", "description": "Report", "row_id": 1389175, "text": "SICU ADM NPN:\n\n\nS-\"Am I able to go out to smoke!\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-Pleasant and cooperative with care. Occasionally anxious and tremelous and pt will verbalize feelings of anxiety. Neuro exam intact througout shift. C/o neck, back, and HA overnight. Normally wears Fentanyl patch and takes oxycodone PRN at home. Overnight given Percocet and MSO4 PRN with releif. In addition following CIWA scale with Q1HR neuro checks and treating with Ativan IVP. Thus far CIWA have been, and pt has received 2mg of Ativan IVP Q2-4H overnight.\nHemodynamics stable. Goal BP < 140. Nipride ordered if needed. Metoprolol ordered Q6H with BPs maintaining 110-130s. Breath sounds clear with few exp wheeze. (+) Smoker. Cough congester but non productive. O2Sats 97-99% on RA. Void in urinal but has not voided overnight. IVFs at 70cc/hr(NS w/ 20KCL). Afebrile. No issues.\n\nA/P:s/p fall, SAH\nq1H neuro checks\nGoal BPs < 140\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-29 00:00:00.000", "description": "T-SPINE", "row_id": 860338, "text": " 6:59 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: Please take films STANDING and in brace\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pt with compression fx\n REASON FOR THIS EXAMINATION:\n Please take films STANDING and in brace\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient with compression fracture.\n\n SEVEN VIEWS, AP AND LATERAL THORACIC AND LUMBAR SPINE: Comparison is made\n with the prior AP and lateral thoracic spine dated . Again,\n noted is a compression fracture of the L1 vertebral body. Additionally, there\n is mild height loss in multiple vertebral bodies within the thoracic spine.\n The intervertebral disc space heights are preserved. Bilateral sacroiliac\n joints, and bilateral hips are unremarkable. There is diffuse\n atherosclerosis.\n\n\n" }, { "category": "ECG", "chartdate": "2120-02-22 00:00:00.000", "description": "Report", "row_id": 189929, "text": "Sinus rhythm\nLong QTc interval\nNonspecific inferolateral T wave flattening\nNo previous tracing\n\n" } ]

[ { "category": "ECG", "chartdate": "2145-09-03 00:00:00.000", "description": "Report", "row_id": 309759, "text": "Supraventricular tachycardia with variable block, atrial rate 180 beats per\nminute. QS deflections in lead III. T wave inversion in leads I and aVL.\nNon-specific T wave inversions in leads I, aVL and V5-V6. QS deflections in\nlead VI with minimal ST segment elevation. INT: Atrial tachycardia with\nvariable block. Possible inferior and anteroseptal myocardial infarctions which\ndo not fulfill electrocardiographic criteria for same. Compared to the previous\ntracing of there was previously 2:1 block - A-V block is currently\nvariable.\n\n" }, { "category": "ECG", "chartdate": "2145-09-04 00:00:00.000", "description": "Report", "row_id": 309760, "text": "Atrial tachycardia at 200 with 2:1 AV block\nProbable old septal infarct\nNonspecific inferolateral ST-T wave changes - ? rate/rhythm related\nSince last ECG, further T wave inversion\n\n" }, { "category": "Nursing/other", "chartdate": "2145-09-04 00:00:00.000", "description": "Report", "row_id": 1453830, "text": "FIANRD 4 ICU NPN\n YO resident if admitted with pneumonia, sepsis protocol. Developed acute SOB . IN EW SBP 70's, sats 80's, temp to 102.6. Treated with IVF w/o, levophed, antibiotics. levo d/c'd ~0600. Transfered to 4 ICU for further managment.\nPt DNR/DNI.\nSBP ~110, HR 90's AF, Afeb Had been receiving tylenol PRN for general pain (back, neck)\nOreinted. Follows simple commands.\nA/P:\nStable.\nCont sepsis protocol intil 0200 .\n" }, { "category": "Nursing/other", "chartdate": "2145-09-05 00:00:00.000", "description": "Report", "row_id": 1453831, "text": "NPN-MICU\nMrs. has min improved since adm.\nResp:By 9pm,pt with increased resp distress and HTN/tachycardia.CXR with worsening CHF. She was given IV lopressor and lasix for which she had a mild rsp to. She cont to get increasing restless and agitated, RR up to 40. She than got more lasix and lopressor and also got some MSO4 IV. She would not weat the FT or Fm O2 so she was put on 4L NP she has since been more comfortable.Her lungs exam still with crackles half up lung field.Her u/o rsp has been min but she is more comfortable with RR 280-30. Her O2 sats are 94-96%. She is afebrile on IV and po antibiotics. She has a juncky sounding cough (specimen sent) but has been swallowing alot of the secretions.\nCV:her BP has been good btw 100-140/70's HR has occas gone up to 160's AF. Hr has rsp to increased lopressor, her usual po dose given at 4am. EKG is sl improved\nID:she is afebrile. IVAB changed, cx pnd.\nGI:no c/o n/v, +BS no stool as yet.\nGU: u/o now marginal, some rsp to lasix, still with CHF but sl improved RR.\nNeuro: pt sl confused but able to be oriented, MAE\nHeme:hct has been stable at 35-38\nA/P:Will cont to follow lung exam and CXR for pulm edema improvement, note O2 sats\n Will follow for BP changes\n" }, { "category": "Nursing/other", "chartdate": "2145-09-06 00:00:00.000", "description": "Report", "row_id": 1453832, "text": "MSICU NSG ACCEPTANCE NOTE 1000-1900\n\n yo resident of Rehab, presented to ER w/SOB. She was being treated for URI symptons at rehab but dev worsening cough,dyspnea and fever. Sent to ER and was given Lasix on route. Arrived hypotensive and was transferred to ICU for MUST protocol. pt is /DNR. Treated w/NS,Levophed(weaned overnight) and antibiotics. Transferred to 11R last eve. This am she was found to be hypotensive and hypoxic. Of note she had received Lasix overnight and on the last dose had no response from UO.\n\nArrived on Neo at .63mcg/kg/min and Dopa at 15 mcg/kg/min. Normotensive. O2sats on 100% NRB 94%. Pt lethargic but arousable. Presept cath in place. SvO2 64 and placed on continuous monitoring. Dopa changed to Dobutamine. SvO2 running 68-77. Remains oliguric. Given 500cc IVB with no response and CVP on arrival was 14. Neo currently at 1mcg and Dobut is at 2 mcg/kg/min. Plan to titrate Dobutamine to maintain SvO2 ~70. Titrate Neo to MAP 60.\n\nPt is DNR/DNI but with full treat. No intub or mask ventilaton per dgt. Dgt does not want her mother to be uncomfortable or in pain. Will remain at bedside for now.\n\n" }, { "category": "Nursing/other", "chartdate": "2145-09-07 00:00:00.000", "description": "Report", "row_id": 1453833, "text": "O. Neuro alert to lethagic mae, fc becoming agitated when sob given morphine .5 to 1mg iv with adequate relief of discomfort.\ncardiac HR 70-90 NSR with freq pvc multifocal K+ 3.9 am pnding mag 2.1 bp map > 60 with neo at 1-.5mcg/kg/min and dobutamine 2.5mcg/kg/min given 250cc ns bolus, skin w+d extremities purple. PT 35.2, INR 7.8 PTT 60.3 hct36.1\nresp on 100% nrb lungs diminished and coarse throughout 02 sat 78-98% now in the 80's\nID afebrile wbc 18.9 on antibx\ngu u/o 0-40cc brownish cloudy urine bun 45 cr 1.8\ngi npo no BM\naccess 18gRLA, RIJ\npt is dnr/dni\nsocial dgt with pt all night spoke with dgt and attending regarding making pt comfort measures only. Daughter very concerned over pt comfort but not comfortable withdrawing tx at this time which may hasten pt demise.\na.rll pnx prob sepsis on pressors, hx of chf, arf, dm,\nelevated INR\np. support pt continue discussion with dgt regarding comfort measures support daughter. Morphine 1mg q 1-2hrs\n" }, { "category": "Nursing/other", "chartdate": "2145-09-07 00:00:00.000", "description": "Report", "row_id": 1453834, "text": " 4 ICU NPN 0700-1800\n\nPt made CMO after discussion with dtr . Mso4 gtt started. Pt expired with dtr & family at bedside.\n" } ]

[ { "category": "Radiology", "chartdate": "2154-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 816625, "text": " 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u ?pneumonia\n Admitting Diagnosis: LT SIDED STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with s/p stroke with hypoxia\n\n REASON FOR THIS EXAMINATION:\n f/u ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP portable semi-erect chest of compared to .\n\n CLINICAL INDICATION: Hypoxia. ? pneumonia.\n\n The heart is upper limits of normal in size. There is upper zone vascular\n redistribution. A diffuse bilateral hazy pattern of increased lung opacity\n shows interval improvement with residual perihilar haziness remaining.\n Thickening of the septal lines has also decreased in the interval. Please\n note that the left lower lobe laterally has been excluded from the radiograph\n and cannot be assessed.\n\n IMPRESSION: Improving diffuse pulmonary opacities consistent with pulmonary\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2154-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 816493, "text": " 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess infiltrate, CHF\n Admitting Diagnosis: LT SIDED STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with s/p stroke with hypoxia\n\n REASON FOR THIS EXAMINATION:\n assess infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia.\n\n AP SUPINE CHEST: There are no prior studies for comparison. There are\n diffuse bilateral interstitial infiltrates consistent with pulmonary edema.\n The heart is at the upper limits of normal in size. There are no pleural\n effusions or focal consolidations.\n\n IMPRESSION: Findings consistent with pulmonary edema and left heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-01-03 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 816461, "text": " 5:38 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR-ANGIO NECK WITHOUT CONTRAST\n Reason: MRI/MRA of Brain and Neck with DWI- recnet CEA on right now\n Admitting Diagnosis: LT SIDED STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with\n REASON FOR THIS EXAMINATION:\n MRI/MRA of Brain and Neck with DWI- recnet CEA on right now with acute left\n sided weakness\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: New stroke signs, left arm and leg weakness, following\n endarterectomy four days ago.\n\n MRI OF THE BRAIN AND MRA OF THE CIRCLE OF AND CERVICAL VASCULATURE:\n\n TECHNIQUE: Multiplanar T1 and T2W imaging of the brain was performed.\n Diffusion weighted scans are provided.\n\n 2D and 3D time of flight MRA of the cervical vasculature was performed. 3D\n time of flight MRA of the Circle of was performed. Multiplanar\n reformatted images and source image data were reviewed.\n\n FINDINGS: There are no previous studies available for comparison.\n\n T1W images demonstrate a right frontal lobe area of increased signal. Signal\n abnormality is primarily along the cortical margin and in the subcortical\n white matter. In this same location on the T2W scans there is increased\n signal intensity and findings are compatible with the presence of a subacute\n infarction. There is a tiny amount of susceptibility artifact in this\n area, and the T1 hyperintensity is felt to be related to mineralization and\n laminar necrosis. On diffusion weighted images the right frontal lobe area of\n signal abnormality is hyperintense, however, at the most superior aspect of\n the right posterior frontal lobe, there is an even greater intensity gyral\n region of diffusion signal abnormality. This superior and posterior frontal\n lobe area may represent acute infarction. There is also patchy increased\n diffusion and T2 signal in the right high parietal lobe. This likely\n represents infarction, either subacute or acute.\n\n There is motion artifact blurring detail, but there is no evidence of signal\n abnormality in the left hemisphere. The ventricles are not dilated. There is\n no shift of midline structures. Brain stem and cerebellum have normal signal\n intensity.\n\n MRA of the cervical vasculature demonstrates continuous flow signal throughout\n both carotid and vertebral arteries. There has been a right carotid\n endarterectomy. The right carotid bifurcation and internal carotid artery\n have a normally patent appearance. The left internal carotid artery\n demonstrates some irregularity of flow signal, suggesting atherosclerotic mild\n to moderate narrowing.\n\n (Over)\n\n 5:38 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR-ANGIO NECK WITHOUT CONTRAST\n Reason: MRI/MRA of Brain and Neck with DWI- recnet CEA on right now\n Admitting Diagnosis: LT SIDED STROKE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n MRA of the Circle of is limited by motion artifact. There is flow in\n both intracranial internal carotid arteries and in the proximal branches of\n the anterior and middle cerebral arteries. Flow signal is seen in both\n intracranial vertebral arteries, though the left vertebral artery signal is\n not as well seen, and in the basilar artery and the posterior cerebral\n arteries.\n\n An additional finding is an area of increased T1 signal in the right caudate\n head. There is faintly increased signal in this location on the FLAIR images\n and no susceptibility artifact. This may represent a subacute infarction.\n Comparison to previous examinations would be helpful.\n\n IMPRESSION:\n\n 1. MRI of the brain shows an area of right frontal lobe subacute infarction.\n There is suspicion of superimposed acute infarction in the superior posterior\n right frontal lobe. There is also some signal abnormalities in the right\n superior parietal lobe and caudate head which probably represents infarction,\n of uncertain duration. Comparison to previous outside examinations would be\n helpful to determine which findings are truly acute. An ADC map would also\n distinguish between acute and subacute infarction. CT might be considered to\n wxclude intracranial hemorrhage.\n 2. MRA of the cervical vasculature demonstrates continued flow signal through\n both carotid and vertebral arteries. There is no sign of occlusion or\n hemodynamically significant stenosis of the internal carotid arteries.\n 3. MRA of the Circle of is limited, but demonstrates flow in the major\n proximal branches of the circulation.\n Findings were discussed with Dr. of vascular surgery on at\n 9;30 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2154-01-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 816510, "text": " 1:27 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for infarct\n Admitting Diagnosis: LT SIDED STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R frontal infarct\n REASON FOR THIS EXAMINATION:\n assess for infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53 year old woman with right frontal infarct.\n\n COMPARISON: MR study of at 5:00AM.\n\n TECHNIQUE: Multiple axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is a region of low attenuation in the right frontal lobe\n extending posteriorly into the watershed zone, correlating with the patient's\n recent MR study, which was suspicious for a region of infarction in this area.\n No definite acute hemorrhage is seen. There is no shift of normally midline\n structures. The ventricles, sulci and cisterns are unremarkable. The\n partially visualized paranasal sinuses are clear.\n\n IMPRESSION: Right frontal lobe infarct without any definite hemorrhage. No\n hydrocephalus.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2154-01-03 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 816511, "text": " 1:28 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: CTA to R/O PE\n Admitting Diagnosis: LT SIDED STROKE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R frontal infarct with hypoxia\n REASON FOR THIS EXAMINATION:\n CTA to R/O PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST WITHOUT AND WITH CONTRAST.\n\n INDICATION: 52 year old female with right frontal lobe infarction. Patient\n with hypoxia. Evaluate for pulmonary embolism.\n\n TECHNIQUE: CT imaging of the chest performed before and after the intravenous\n administration of 100 cc of Optiray. Non-ionic contrast was used due to\n patient debility. Additional reformatted imaging in multiple planes was also\n obtained.\n\n CT OF THE CHEST WITHOUT AND WITH CONTRAST: There is no evidence of pulmonary\n embolism. The heart, pericardium, and great vessels are within normal limits.\n Several prominent mediastinal lymph nodes are identified, none of which reach\n pathologic size by CT criteria. No pathologically enlarged axillary or hilar\n lymph nodes are seen. There is evidence of emphysematous change within both\n lungs. There is septal thickening and ground-glass opacity suggestive of\n pulmonary vascular congestion. There is infiltrate present within the\n posterior/dependent portions of both lungs associated with the bilateral\n pleural effusions. No evidence of pneumothorax. Within the visualized\n portions of the upper abdomen, limited views of the liver are unremarkable.\n Bone windows show degenerative change within the thoracic spine with no\n suspicious lytic or sclerotic lesions.\n\n CT RECONSTRUCTIONS: Images reformatted in multiple planes were essential in\n evaluating the patient's pulmonary arterial vasculature and show no evidence\n of pulmonary embolism.\n\n IMPRESSION:\n\n 1) No evidence of pulmonary embolism.\n\n 2) Pulmonary parenchymal infiltrate within the dependent/posterior portions of\n both lungs.\n\n 3) Pulmonary vascular congestion associated with small bilateral pleural\n effusions.\n\n 4) Emphysema.\n (Over)\n\n 1:28 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: CTA to R/O PE\n Admitting Diagnosis: LT SIDED STROKE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2154-01-04 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 816678, "text": " 4:42 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: assess for hypo versus hyperperfusion in area of diffusion a\n Admitting Diagnosis: LT SIDED STROKE\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with pre op R frontal/parietal stroke s/p R-CEA 4d later with\n headache, ? seizure, and worsened L sided weakness. Question new stroke versus\n post-CEA hyperperfusion syndrome. Do not need to repeat full study, but please\n perform diffusion and perfusion scans.\n REASON FOR THIS EXAMINATION:\n assess for hypo versus hyperperfusion in area of diffusion abnormality\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient status post right carotid endarterectomy with\n seizures. Rule out hyper or hypoperfusion.\n\n TECHNIQUE: Diffusion axial images were obtained. A single set of perfusion\n images is also available for interpretation. Comparison was made with the\n previous MRI study of .\n\n FINDINGS: Again, an infarct is identified in the right frontal and parietal\n region. No evidence of new signal abnormalities or infarcts are identified\n compared to the previous study. On perfusion images, decreased signal\n indicating perfusion is identified in both cerebral hemispheres. Evaluation\n of time-to-peak and mean transit times would be requirement for assessment of\n decreased or increased blood flow.\n\n IMPRESSION: No change in the right frontal infarct compared to the previous\n study on diffusion-weighted images.\n\n\n" }, { "category": "ECG", "chartdate": "2154-01-08 00:00:00.000", "description": "Report", "row_id": 187843, "text": "Sinus rhythm, rate 80. Non-specific lateral and mid-precordial repolarization\nchanges. Acute ischemia and/or focal anteroseptal injury cannot be excluded.\nCompared to the previous tracing of the repolarization changes are more\nexaggerated.\n\n" }, { "category": "ECG", "chartdate": "2154-01-03 00:00:00.000", "description": "Report", "row_id": 188071, "text": "Sinus rhythm, upper normal rate\nLate R wave progression - probable normal variant\n\n" }, { "category": "Nursing/other", "chartdate": "2154-01-04 00:00:00.000", "description": "Report", "row_id": 1434391, "text": "altered neuro status\nd: PT A&O X3 BUT INAPPROPRIATE AT TIMES- ATTEMPTING TO GET OOB, PULLING OFF O2 SATS AND THEN BECOMING SLIGHTLY SOB, AND REMOVING VENODYNES TO LOWER EXTREMITIES. PUPILS EQUALLY REACTIVE TO LIGHT. MAE'S THOUGH L EXTREMITES WEAKER THAN R. ACCORDING TO PT'S STRENGHTH HAS IMPROVED FROM YESTERDAY. WILL CONTINUE TO REMIND PT NOT TO MEDICAL EQUIPMENT. CONCERNED THAT PT ATTEMPT TO GET OOB SO PT 1:1 OBSERVER NOW AT BEDSIDE. WITH HER HUSBAND AND THE BEDSIDE SHE WAS AT THE FOOT OF BED TRYING TO GET OUT. ATIVAN 1 MG IVP GIVEN WITH GOOD EFFECT.DILANTIN LEVEL=8.1 ANDWAS GIVEN ADDTIONAL DOSE OF 300MG IV DILANTIN. WILL FOLLOW LEVELS AS ORDERED\n\nRESP: PT HAS O2 AT 4L/M NC WITH O2 SATS> 95%. GAOL IS TO KEEP O2 SATS> 93%. COASRSE BS BIL ON AUSCULTATION BUT DIMINSHED AT THE BASES. C&R MOD AMTS OF RUSTY COLORED SPUTUM. REPEAT SPUTUM CX SENT OFF. PT THIS AFTERNOON WITH FINE CRACKLES BIL. MEDICATED WITH LASIX 20 MG IVP AND WILL FOLLOW PT'S OUTPUT. PT DOES DROP HER O2 SATSTO LOW 90'S WHEN SHE REMOVES HER O2. WILL ENCOURAGE PT TO KEEP O2 ON.\n\nCV: HR 80'S WITHOUT ECTOPY. K+ 3.7 AND GIVEN 20 MEQ KCL PO. WILL FOLLOW ELECTROLYTES AS ORDERED AND REPLETE AS NEEDED. ALSO REPLETED WITH 2 GM MG. GOAL IS TO KEEP SBP >140. NOW ON ENALOPRIL 0.625 MG IV Q 6 HRS AND LOPRESSOR 12.5 MG PO BID. WILL CONTINUE WITH MEDICAL TX TO CONTROL BP.\n\nGI: PT NOW ON HOUSE DIET. ABD OBESE SOFT AND NONTENDER WITH NO STOOL OUTPUT. NOW ON FAMOTIDINE 20 MG PO BID. HCT STABLE AT 33.5. NOW STARTED ON QD FOLIC ACID AND MVI.\n\nGU: FOLEY CATH IN PLACE WITH ADEQAUTE HOURLY UO. LASIX 20 MG IV GIVEN AND WILL FOLLOW UO CLOSELY. BUN=9 AND CREAT=0.6\n\nSOCIAL: PT IS A FULL CODE. WILL CONTINUE TO FOLLOW PT'S NEURO STATUS. WILL KEEP ALINE IN PLACE FOR ANOTHER 24 HRS WHILE ANTIHYPERTENSIVES ARE BEIG ADJUSTED. WILL KEEP PT'S FAMILY INFORMED ON DAILY BASIS AND OFFER EMOTIONAL SUPPORT.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-01-03 00:00:00.000", "description": "Report", "row_id": 1434389, "text": "CSRU NPN\n\nNeuro: Alert most of time. One episode that required shaking to wake her from sleep but patient c/o feeling very tired from all she has been through since last night. Tolerated 400mg Dilantin dose. Otherwise appropriate in conversation. Right side w/ normal strength/movement. Lifts left arm/leg off bed slowly. Unable to bend left leg. Unable to oppose fingers on left hand. Speech clear. PERRL. c/o HA with coughing, otherwise no c/o pain. Had one brief episode of left leg spasm which was quickly relieved with flexing left foot.\n\nCV: HR 80-low 100's NST, rare PVC noted. SBP occasionally down to 90's but often related to a line position. Tolerated IV lopressor. CPK/MB and troponin sent at 1800.\n\nResp: BS wheezey which cleared w/ neb treatment. Attempted weaning to 12L NRB but O2 sats drifting down to 92%. Evening ABG pnd. Clearing thick yellow, occ pink tinged secretions. 20 mg IV lasix given.\n\nGI: Abd soft. NPO. No ice chips per team.\n\nGU: Adequate u/o.\n\nID: Temp 99 oral. Sputum cx sent. No abx ordered at this time.\n\nSkin: Intact. Psoriasis lesions scattered but not bothering pt at this time.\n\nComfort: Denies pain. Only 1 brief episode spasm which resolved quickly. Multipodus boot ordered.\n\nA: Neurologically unchanged. Clearing thick secretions.\n\nP: Cont to monitor neuro status closely. Pulmonary hygiene. O2 to keep O2 sats 93% or greater. Monitor effect of lasix. Monitor cx results.\n" }, { "category": "Nursing/other", "chartdate": "2154-01-04 00:00:00.000", "description": "Report", "row_id": 1434390, "text": "Nursing Progress Note MICU A\n\nNeuro: Alert and oriented x 3, but at times is inappropriate. Pt pulling off NRB, attempting to get OOB, throwing legs over side of bed. Pt is aware that she needs to stay in bed and keep NRB on. Needs frequent reminding. C/O headache. Does not want pain meds for it at this time. PEARL, 3mm/bsk. +4 strength in right extremities, +3 in left extremities.\n\nCV: SR to ST, with no ectopy noted. HR 87-105. Denies any chest pain or discomfort. ABP 99-141/59-84. +palp pedal pulses, no edema.\n\nResp: LS coarse, diminished in bases. On NRB most of night, pt pulling off repeatedly so attemted to put on 6L NC. O2 sats on 6L 95-96%. Denies any SOB. Abg on NRB 7.46/39/87.\n\nGI: Abd softly distened, non-tender, +bs, -bm. Remains NPO.\n\nGU: Foley cath intact with clear yellow urine. UO good.\n\nSkin: Patchy dry area of psoriasis on back, legs, elbows and head.\n\nAccess: 2 PIV's, Aline with sharp waveform.\n\nSocial: Husband and daughter in to visit last evening.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2154-01-03 00:00:00.000", "description": "Report", "row_id": 1434386, "text": "NURSING PROGRESS NOTE 0700-1500\nNEURO--VERY ANXIOUS. PT IS HAVING SEVERE L LEG CRAMPS WHICH RADIATE UP TO HER SHOULDER BLADE. SHE HAS L FOOT DROP WHICH SHE HAS HAD SINCE THE 1ST CVA ~1MOS AGO. HER L LEG HAS DYSTONIA AND HER CALF, WHEN IN SPASM HAS A HUGE KNOT. PER PT, SHE HAS HER HUSBAND MASSAGE IT OUT AND MASSAGE FOOT. THIS HELPS RELIEVE HER DISCOMFORT. L LEG WILL LIFT AND HOLD BUT UNABLE TO FLEX KNEE. L ARM HAS GROSS MOTOR MOVEMENT, CAN FLEX ELBOW BUT NOT OPPOSE FINGERS. PT EXTREMELY ANXIOUS WITH ALL THE PAIN AND SPASM. SHE RECEIVED 2MG IV ATIVAN WITH GREAT RESULTS AND 4 MG IV MSO4 FOR PAIN. SHE IS PAIN FREE AT PRESENT.\n\nCARDIAC--INITIALLY HYPOTENSIVE BUT WITH PAIN SBP INCREASED TO 220/134. NOW IT IS 100-110/60'S. HR SR/ST 80-130. EKG DONE . NO CHANGE FROM EW. PT 5 MG IV LOPRESSOR FOR TACHY AND HTN.\n\nRESP--SAO2 DECREASING THRU SHIFT AND O2 REQUIREMENT INCREASING. CXR SHOWED INFILTRATES ON L . ABG WITH HYPOXIA. PT IS NOW GOING TO CTA, CT HEAD AND CHEST. SHE IS ON 100%NRB.\n" }, { "category": "Nursing/other", "chartdate": "2154-01-03 00:00:00.000", "description": "Report", "row_id": 1434387, "text": "CON'T OF NURSING NOTE\nGI--REMAINS NPO EXCEPT FOR SIPS WITH PO PILLS. NO DIFFICULTY SWALLOWING. +FLATUS. DENIES NAUSEA.\n\nGU--FOLEY CATH PATENT DRAINING MIN AMTS OF YELLOW URINE <30CC HR HOWEVER, NOW PT HAS DIURESED 150 OVER LAST HR. IVF AT 80 CC HR.\n\nENDO--UNREMARKABLE AT PRESENT.\n\nSKIN--INTACT. R CEA SITE WITH STERI-STRIPS INTACT , NOT OOZING. BUTTOCKS AND BACK WITHOUT BREAKDOWN.\n\nID--AFEBRILE AT PRESENT.\n\nPAIN--AS NOTED IN EARLIER NOTE. SHE IS RECEIVING MSO4 AND ATIVAN PRN.\n\n HAS HUSBAND AND 2 DAUGHTERS. THEY HAVE VISITED . PHONE #'S ARE ON TOP OF GREEN CHART.\n\nA--STABLE AT PRESENT. IMPROVED SAO2 ,BP AND HR.\n\nP--CON'T TO MONITOR. NEURO CHECKS Q1HR. GIVE REST OF DILANTIN BOLUS.(SHE RECEIVED 500 MG PRIOR TO IT BEING D/CED). CHECK AGB'S. OFFER SUPPORT. MEDICATE AS NEEDED , ASSESS RELIEF. LABS DID NOT INTERFACE WITH COMPUTER.\n" }, { "category": "Nursing/other", "chartdate": "2154-01-03 00:00:00.000", "description": "Report", "row_id": 1434388, "text": "Respiratory Care:\nNeb tx's ordered today due to increased O2 requirement & diffuse wheezing throughout lung fields. Pt does benefit from Neb tx's with wheezing clearing. Plan to continue Nebs as ordered Q6prn.\n" }, { "category": "Nursing/other", "chartdate": "2154-01-03 00:00:00.000", "description": "Report", "row_id": 1434385, "text": "Nursing Progress Note MICU A\n\nPicked up pt in MRI and transferred up to MICU A. Pt admitted from OSH with right head bleed. Pt had CEA on , was discharged from hospital on . Last evening pt woke up with HA and could not sit up in bed. Left side flaccid. Rescue called and pt taken to OSH. Head Ct showed right bleed. Pt transferred to .\n\nNeuro: Alert and oriented x 3. PEARL, MAE R>L. Following all commands. Denies any pain.\n\nCV: NSR with no ectopy noted. HR 80's. NBP 88/53. Team notified of hypotension. 500cc NS Fluid bolus ordered. +palp pedal pulses, no edema.\n\nResp: LS clear,dim in bases, denies any SOB. On 6L O2 with o2 sats 93%.\n\nGI: Abd softly distended, non-tender, +bs. NPO.\n\nGu: Foley cath intact with clear yellow urine.\n\nAccess: 2 PIV's.\n\nSocial: Husband updated, waiting in waiting room until pt is settled in room.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2163-06-20 00:00:00.000", "description": "Report", "row_id": 1613713, "text": "Respiratory Care\nPt Device: pt is currently on NIV mask ventilation, was placed on this upon arrival in the ED, when pt was transported to floor she was placed on NC 4L and was tol well with SpO2 of 100%. Around 5AM pt had flash pulm edema and sats decreased, pt was placed back on mask ventilation of with 100% FiO2 . Pt tol these settings well with NARN.\n\nChest: BBS coarse crackles t/o.\n\nGas Exchange: No ABGS done, SpO2 100%\n\nPlan: monitor and support.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-20 00:00:00.000", "description": "Report", "row_id": 1613714, "text": "CCU NRSG ADMIT NOTE\n73yo with extensive past med hx. Briefly, she has ESRD with severe PVD>s/p bilateral BKA's, diastolic CHF with severe LVH and ? HOCM. Has had multiple admits to MICU for CHF. Admitted late eve with c/o acute SOB from her center. She was tx'd in ew with 1\" NTP and mask ventilation with improved sats and hemodynamics. She is transferred to CCU for further management.\n She was transferred on mask ventilation which was d/c for transfer to bed. It was noted that she was able to maintain her sats 99-100% with 4lnp therefore she cont on 4lnp. She was afebrile. Her Hr was 80's with bp 120-140's. She c/o being extremely hot, blood sugar checked which was in the 130's, temp was normal. She then c/o chest tightness, ekg done and team called, then she became acutely SOB. She was treated with a total of 15mg lopressor iv, morphine 4mg iv, iv ntg started and ^'d to 1.83mcg/kg/min and placed on mask ventilation again. Took approx 30 mins for resolution of acute symptoms. Approx 1 hour after symptoms started able to decrease in ntg to 1.10mcg/kg/min with pt looking visibly more comfortable. During SOB episode bp ^^ 200's/100's with hr in the 100's st. Currently Hr 70-80's with bp 130's. Lungs intially with crackles approx 1/3 up bilaterally, then sounding course throughout with SOB episode. She is oliguric but voided mod amt of urine. Abd is soft with (+) bowel sounds, she states her last bm was . She is neurally intact with no deficits noted. Her prosthesis are in the room, she uses walker. Her plan is to wean iv ntg as tolerated, maintaining bp > 130's and to have dialysis this am. ( She does admit to drinking too much this weekend due to the heat.)\n" }, { "category": "Nursing/other", "chartdate": "2163-06-20 00:00:00.000", "description": "Report", "row_id": 1613715, "text": "CCU NSG NOTE: ALT IN CV/RESP DISTRESS\nS: \"I feel tired, but much better.\"\nO: This 73y old woman, with long PMH including IDDM, bilateral BKA-walks with prosthesis and walker, arrthmias, htn, hocm hyperparathroid and RF with HD M-W-F, was at home in when she became acutely SOB and called EMTs who brought her to where she had crackes to apices, with bp 170/100 and hr 100-110. She was started on CPAP with sat up to 100% and she was feeling much more comfortable. Triple lumen inserted in L groin.No lasix given as she was anuric. She was transfered to CCU and came of CPAP, but again was acutely SOB ~0500,with low sats and HTN a few hour later and was RXd with lopressor, morphine and iv nitro and went back on cpap. Within and hour symptoms resolved. Plans were for dialysis.\nCV: Pt has had no further episodes of SOB and de-sating or hypertension. Hr has been in 70-80s with occ PVCs. BP has stayed in 120/60s. IV Nitroglycerine was d/c at 11:30 when dialysis began and has not been restarted. She received he usual lopressor in the am and diltiazem at the end of diaylsis. Her K+ in the am was 6.7 with no EKG changes. She received 1 amp D50 followed by 5units of regular insulin IV. He is due to lytes at .\nRESP: She came off CPAP at 0800 and was sating 98% on 4liters. She continued to have rales up ~, but felt comfortable. Post dialysis she is sating 99-100% on RA. She has BBR. She is on home 02 at 2L and should probably have it on at bedtime.\nRENAL: She received dialysis from 1130 to 1430 and had 3liters taken off. She tolerated it well. Dsg should be removed from L arm fistula at 1900.\nGI: Pt had light breakfast and then lunch at 1500. She did not feel like dinner at 1800. She had small G- golden stool. She co of indigestion and received maalox.\nENDO: She is on 4u NPH at home and has received half dose here as she is not eating much. FS in 150s.\nACCESS: Pt has triple lumen in L groin. Dsg changed. Pt will need this line pulled sometime tomorrow. Periferal access not possible, so she will either need PICC, or possible go home. PEVA knows of this decision and agrees.\nMS: PT A & O X 3, very pleasant, cooperative and knowledgeable about care. Family has called and will be in this evening.\nA: Episode pulmonary edema/resolved with CPAP and dialysis\nP: Monitor overnight for further episodes. Monitor sugars per protocol. Bloods due at . Decision re-access needs to be made tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-21 00:00:00.000", "description": "Report", "row_id": 1613716, "text": "CCU Nursing Progress Note 1900-0700\nS: \"I feel great now.\"\n\nO: Please see carevue for all objective data.\n\nNeuro- A&Ox3. Pleasant and cooperative w/ care. Denied pain.\n\nCV- HR 80s-90s NSR w/ rare PVCs, occasional APCs. NIBP labile 120s-160s/60s-70s. CCU team aware. Remains off IV nitro. On home doses of diltiazem and lopressor. Lytes @ 20:00 WNL, K=4.1 (Had been 6.7 on days).\n\nRESP- LS w/ rales 1/2 up bilat. Resp even and unlabored. SPO2 98-100% room air. Wears 2lNC O2 at noc at home, however SPO2>98% and pt comfortable so left off.\n\nGI- +BS x 4 quad. Abd soft, NT/ND. LBM guaiac negative.\n\nGU- Oliguric. ESRD on hemodialysis M,W,F. Last - removed 3 liters. Urine amber, clear.\n\nENDO- IDDM. FS HS 107, no coverage.\n\nACCESS- L groin TLC placed . L arm AV fistula for HD.\n\nSocial- Family involved. No calls overnight.\n\nA: 73 yo female w/ extensive cardiac PMH including 10 admissions this year for CHF exacerbations, presented to ED via EMS w/ CC: SOB. Tx'd w/ CPAP mask ventilation, IV nitro gtt and dialyzed for 3 Liters. Presently asymptomatic off IV nitro and on room air.\n\nPLAN: Continue to monitor for s/s resp distress. Monitor hemodynamics. BP still running high at times- team aware(concern for risk of flash pulm edema given poor EF). Monitor lytes- especially K+. FS QID. NPH and RISS coverage PRN. Plan to do extra dialysis on Fridays (including ultrafiltration) to avoid fluid overload over weekend where pt goes 2 days in a row without dialysis. Possible call out to floor or DC home if pt stable. Lives in Independent section of an facility. Active w/ VNA for Nsg and HHA services. DC planning and page 2 need to be finalized.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-21 00:00:00.000", "description": "Report", "row_id": 1613717, "text": "Nursing Note 7a-7p\nNeuro- A+Ox3, cooperative w/ care. No c/o c-pain/ sob.\nCV- SR rare PACs, HR 67-83. NBPs 96-150/50s-70s, restarted on Avapro () & ACE, conts on lopressor & dilt. L fem TLCL intact, to be d/c'd tomorrow. Plan for next HD tx @ 0730 in AM. L AVF +thrill/bruit.\nResp- LS w/ faint crackles bibasilary, sats >98% r/a.\nGI/GU- Abd soft +bs, no bm. Appetite good, conts on Na+ restriction. Oliguric, voided 180cc on bedpan.\nEndo- Sugars below RISS, conts on NPH.\nA/P- 73yo female admitted for CHF exacerbation. ESRD-> HD (M,W,F) Tx'd w/ CPAP, NTG gtt & dialyzed approx 3L. Stable, prob call out tomorrow p HD.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-22 00:00:00.000", "description": "Report", "row_id": 1613718, "text": "1900-0700\n\nNo significant events overnight.\n\nNeuro: AAO x3. MAE. Denies pain. Slept throughout the night; able to reposition self in bed independently.\nCV: HR 60-70/NSR/No ectopy. BP 120-140/60-70. Continue Lopressor and Diltiazem PO/ATC.\nResp: Lungs clear/diminished @ bases. Non-productive cough. SATs 98-100% on RA. 2Liters NC overnight per request of patient; 100%.\nGI/GU: ABD/SNT w/ +BS x4. Tolerating diet as ordered. Voiding 150cc on bedpan. Plan is for HD @ 0730.\nSkin: Intact.\nEndo: RISS; no coverage. FSBS 109 @ HS.\nDispo: HD in am; call out to floor when bed available.\n\n" }, { "category": "ECG", "chartdate": "2163-06-20 00:00:00.000", "description": "Report", "row_id": 297008, "text": "Sinus rhythm. The previously mentioned multiple abnormalities persist without\ndiagnostic interim change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2163-06-20 00:00:00.000", "description": "Report", "row_id": 297009, "text": "Sinus rhythm with slowing of the rate as compared with tracing of .\nLeft atrial enlargement. Left ventricular hypertrophy with ST-T wave change.\nCompared to the previous tracing of no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-06-19 00:00:00.000", "description": "Report", "row_id": 297010, "text": "Sinus rhythm. Left atrial enlargement. Left ventricular hypertrophy with\nST-T wave change. Baseline artifact. Compared to the previous tracing\nof it is apparent that the previous recording reflected misattachment\nof the limb leads. The present tracing is consistent with the tracing\nof and all previous with continued ST-T wave change and no diagnostic\ndifference. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-06-20 00:00:00.000", "description": "Report", "row_id": 297007, "text": "Sinus rhythm with slowing of the rate as compared with tracing of .\nThe previously mentioned multiple abnormalities persist without diagnostic\ninterim change.\nTRACING #4\n\n" } ]

[ { "category": "Radiology", "chartdate": "2195-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976281, "text": " 4:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pneumo? post chest tube film\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap; s/p chest tube removal\n\n REASON FOR THIS EXAMINATION:\n pneumo? post chest tube film\n ______________________________________________________________________________\n WET READ: 6:57 PM\n No PTX. sp removal of the right chest tube. PNEUMOPERITONEUM AS EXPECTED.\n bibasilar atelectasis and low lung volumes.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Gunshot wound to chest, status post exploratory laparotomy\n and chest tube removal. Question pneumothorax.\n\n STUDY: Portable frontal chest x-ray, upright.\n\n PRELIMINARY REPORT: No pneumothorax. Status post removal of right chest\n tube. Pneumoperitoneum as expected. Bibasilar atelectasis and low lung\n volumes. Dr .\n\n FINDINGS:\n\n Compared to at 15:24, left chest tube has been removed. No\n pneumothorax. Lung volumes are low and there is persistent opacity at the left\n lung base, likely laceration or hemorrhage from gunshot wound.\n Cardiomediastinal contour is normal. Pneumoperitoneum is present, not\n unexpected given recent surgery.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 976499, "text": " 8:26 AM\n CHEST (PA & LAT) Clip # \n Reason: Assess for ptx, lung re-expansion. Please do by 7 AM\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with stab wound, s/p diaphragm repair\n REASON FOR THIS EXAMINATION:\n Assess for ptx, lung re-expansion. Please do by 7 AM\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, \n\n CLINICAL INFORMATION: 15-year-old male with stab wound status post diaphragm\n repair, question pneumothorax.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n There are low lung volumes. There is atelectasis with patchy airspace opacity\n at the left lung base. No pneumothorax identified. The right lung is\n relatively clear. Cardiomediastinal silhouette is unremarkable. There are\n multiple air-filled colonic loops in the left upper quadrant.\n\n IMPRESSION:\n\n 1. Low lung volumes. Atelectasis left lower lobe, essentially unchanged.\n\n 2. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976147, "text": " 10:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 16-year-old male after traumatic accident.\n\n AP CHEST: There is a nasogastric tube terminating in the stomach. The heart\n size and cardiomediastinal contours are normal. There are low inspiratory\n lung volumes. There is no focal parenchymal consolidation or pneumothorax.\n Blunting of the left costophrenic sulcus may indicate a small left pleural\n effusion. No fracture is identified. No free gas is seen under the\n diaphragm.\n\n IMPRESSION: Possible small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 976618, "text": " 9:44 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for pneumothorax\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap; s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n please eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, FOUR VIEWS, , 09:47 HOURS\n\n CLINICAL INFORMATION: 16-year-old male, stab wound to the chest, chest tube\n removal, evaluate for pneumothorax.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n The costophrenic angles have been omitted from the study. There is a probable\n small left pleural effusion. There is probable atelectasis at the left lung\n base as well. The right lung and the left upper lung zone are clear. The\n heart and mediastinum are within normal limits.\n\n IMPRESSION:\n 1. Probable small left pleural effusion and left lower lobe atelectasis. It\n may be slightly improved since the prior study.\n 2. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-07-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976786, "text": " 4:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for cardiopulm process\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap & diaphragmatic repair, now\n requring non-rebreather\n REASON FOR THIS EXAMINATION:\n please evaluate for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post stab wound to chest with diaphragmatic rupture repair\n requiring increased O2 requirements.\n\n Comparison is made to and examinations.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n Left lower lobe atelectasis with elevation of left hemidiaphragm and adjacent\n effusion may be minimally improved since most recent radiograph with no new\n consolidations identified. Right costophrenic angle is not included on\n current film. There is unchanged gaseous prominence of the bowel which may\n suggest postoperative ileus.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976346, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for pneumothorax after CT d/c\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap; s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumothorax after CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Evaluate for pneumothorax.\n\n No pneumothorax is identified. Cardiac and mediastinal contours are stable\n allowing for technical differences between the studies. Worsening opacity in\n left lower lobe is likely due to atelectasis but aspiration should also be\n considered in the appropriate clinical setting. Relatively spherical\n component of an adjacent opacity could potentially represen focal pulmonary\n contusion given history of stab wound, but it was not present at the time of\n the initial presentation, favoring atelectasis. Small-to-moderate left\n pleural effusion has increased. Distention of bowel loops in the upper\n abdomen likely reflects postoperative ileus given recent abdominal surgery.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976266, "text": " 2:32 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for ptx, hemothorax\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap; chest tube to water seal at 0930\n\n REASON FOR THIS EXAMINATION:\n Eval for ptx, hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest trauma, status post ex lap.\n\n COMPARISON: at 22:15, at 2:35 a.m.\n\n PORTABLE UPRIGHT VIEW OF THE CHEST AT 2:35 P.M: The left chest tube remains\n in unchanged position, terminating at the left apex. There is no\n pneumothorax. There is no fluid accumulation. The left hemidiaphragm is\n elevated. There is a rounded hazy opacity in the left lower lobe that was\n likely present on the prior film in the region that was excluded from the\n exam. This could represent bleeding. There has been interval removal of an\n endotracheal tube and an NG tube.\n\n IMPRESSION: Elevated left hemidiaphragm. Left lower lobe hazy opacity\n possibly representing bleeding. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976164, "text": " 2:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct placement, confirm ETT placement\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap\n REASON FOR THIS EXAMINATION:\n s/p ct placement, confirm ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate ETT and chest tube placement, history of trauma, status\n post ex lap.\n\n Comparison is made to a film of approximately four hours earlier.\n\n PORTABLE SUPINE VIEW OF THE CHEST: The endotracheal tube terminates in\n satisfactory position approximately 3.5 cm above the carina. A left chest\n tube terminates in the left apex. The NG tube terminates below the diaphragm.\n\n Lung volumes are low, and the left costophrenic angle is excluded from this\n exam. There is no pleural effusion on the right. There is no pneumothorax on\n the right or visible in the left apex. The cardiomediastinal silhouette is\n normal and unchanged.\n\n IMPRESSION: ETT, NGT, and left chest tube all in satisfactory position. No\n pneumothorax is visible on this technically limited exam. No other interval\n change.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976708, "text": " 1:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval desaturation\n Admitting Diagnosis: S/P STAB WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man with SW to chest, s/p ex lap; s/p chest tube removal\n\n REASON FOR THIS EXAMINATION:\n eval desaturation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST SINGLE VIEW \n\n CLINICAL INFORMATION: Stab wound to the chest status post chest tube removal.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n Since the prior study, there has been mild volume loss in the left hemithorax.\n There is increased atelectasis in the left lung with a small left pleural\n effusion. Right lung is relatively clear. There are low lung volumes\n overall.\n\n There is gaseous distention of the colon and stomach. Heart and mediastinum\n are within normal limits.\n\n IMPRESSION:\n 1. Overall low lung volumes, but increased volume loss of the left\n hemithorax.\n 2. Increased atelectasis left lower lobe. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-07-27 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 976764, "text": " 11:51 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: CT abd and pelvis w/p.o. and IV contrast, please evaluate fo\n Admitting Diagnosis: S/P STAB WOUND\n Field of view: 43 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old man POD4 s/p L diaphragmatic laceration repair secondary to stab\n wound\n REASON FOR THIS EXAMINATION:\n CT abd and pelvis w/p.o. and IV contrast, please evaluate for intraabdominal\n injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT abdomen and pelvis.\n\n INDICATION: Status post stab wound to left upper quadrant. Evaluate for\n intra-abdominal injury.\n\n COMPARISON: No old CT available for comparison.\n\n TECHNIQUE: CT of abdomen and pelvis was performed with axial images taken\n from the lung bases to the symphysis pubis. Oral and IV contrast was\n administered. Reconstructions were performed in the coronal and sagittal\n planes.\n\n CT ABDOMEN FINDINGS: Some bowel is situated in the left hemithorax adjacent\n to the heart. Note is made of a left pleural effusion and associated\n atelectasis. Some right basilar atelectasis is also noted. The left\n hemidiaphragm is raised which may represent paresis in this patient status\n post left diaphragmatic rupture and repair.\n\n Within the abdomen, the liver is visualized and is normal. The gallbladder is\n normal. The spleen is visualized and is normal. The stomach is located\n anterior to the spleen and extends up close to the left ventricle. Some\n contrast is identified within the stomach. Just posterior to the\n stomach, there is some fluid which superiorly appear closely adherent to the\n stomach but inferiorly appears to represent a separate fluid collection\n containing some air. This is located just anterior to the inferior pole of\n the spleen. It measures approximately 8.6 cm in transverse x 2.2 cm in AP\n diameter. At this site, on series 2, image 9, it is technically very\n difficult to percutaneously drain this fluid. This fluid is situated just\n superior to the pancreas. Some peripancreatic fluid may be a postoperative\n result; serial monitoring of the amylase is advised.\n\n The adrenals and kidneys are normal. The pancreas is normal.\n\n There is a significant amount of free intraperitoneal air, which may be\n secondary to both the trauma of the stab wound and the surgery. The small\n bowel is diffusely dilated with some of the small bowel loops measuring up to\n 3.5 cm. There is no point of transition noted. The colon is also air filled.\n\n (Over)\n\n 11:51 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: CT abd and pelvis w/p.o. and IV contrast, please evaluate fo\n Admitting Diagnosis: S/P STAB WOUND\n Field of view: 43 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n No significant retroperitoneal lymphadenopathy. No significant\n intraperitoneal fluid.\n\n CT OF PELVIS FINDINGS: Some free fluid is seen in the pelvis. The bladder is\n normal.\n\n Bony windows show no definite fractures.\n\n Multiplanar reconstructions were essential in depicting the anatomy and\n identifying the pathology.\n\n IMPRESSION:\n 1. No evidence of any solid organ injury in a patient status post stab injury\n to left upper quadrant with status post repair of left diaphragmatic rupture.\n 2. Fluid collection located just superior to the pancreas; it is an difficult\n site of access for percutaneous drainage. If clinically indicated\n consideration to endoscopic transgastric drainage should be made.\n 3. Small bowel dilation consistent with ileus.\n 4. Free intraperitoneal air status post surgery.\n 5. Free fluid in the pelvis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-07-23 00:00:00.000", "description": "Report", "row_id": 1671554, "text": "T/SICU Nursing Admission / Progress\n16 year old male s/p single stab wound to left chest/flank with resulting diaphragmatic injury. Presents to T/SICU s/p exploratory laparotomy with diaphragmatic repair and chest tube placement. Patient has no past medical history except eye surgery for repair of disconjugate gaze. He takes no medications and has no known allergies.\n\nNeuro: Sedated now on 15mcg/kg/min of propofol. Resting comfortably but able to gesture & make his needs known. Moving all extremities purposefully and to command. +gag, cough, corneals.\n\nPain: Complaining of abdominal pain, pointing to incision, fentanyl gtt increased to 50mcg/hr with 25mcg bolus.\n\nResp: Lungs clear in all fields. SPO2 100%. ABG reveals mild metabolic acidosis with excellent oxygenation. Ventilated now on CPAP+PSV 5/5/40%, RSBI in the 20's. Left chest tube to 20cm suction, does fluctuate, no leak present, no crepitus at insertion site.\n\nCV: Sinus rhythm without ectopics. Vitals as charted in flowsheets. Palpable distal pulses. Skin warm & dry. Pneumoboots on. Serial hcts stable thus far.\n\nGI: Abdomen soft, appropriately tender at the incision. Bowel sounds faint. NPO. NGT to low wall suction sumping thick bilious liquid.\n\nGU: Foley to gravity draining clear yellow urine qs.\n\nEndo: RISS with coverage as ordered for FSBG in the 150's.\n\nLytes: Repleted magnesium.\n\nSkin: Midline incision with DSD, scant serosangueous output, intact. Left flank / chest stab wound covered by DSD, scant sanguenous output. Left chest tube dressing intact. Backside intact.\n\nSocial: Mother, aunt, cousin visited overnight, went home to rest briefly and return with patient's father. RN Police, circumstances of stabbing unclear and no suspect is in custody, so the patient remains in a safe bed.\n\nPlan: Maintain safety. Pain management. Ween to extubate. q4 hr hematocrits. Notify team of acute changes. Emotional / social support.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-23 00:00:00.000", "description": "Report", "row_id": 1671555, "text": "T/SICU Nursing Admission / Progress\nAddendum:\nExtubated to face mask at 0540 without difficulty.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-23 00:00:00.000", "description": "Report", "row_id": 1671553, "text": "Resp: pt from OR post op abdominal stabbing intubated with 7.5 ett, 23 @ lip. Placed on a/c 18/550/5+/50%. BS are clear bilaterally. Weaned to psv 10/5/40%. AM ABG 7.32/42/190/23. RSBI=36. Weaned psv to 5. Plan to extubate this am.\n" }, { "category": "ECG", "chartdate": "2195-07-28 00:00:00.000", "description": "Report", "row_id": 218695, "text": "Sinus tachycardia\nST-T wave changes are nonspecific\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Radiology", "chartdate": "2158-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 963440, "text": " 9:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate lung fields\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with continued temps, known infiltrate on CT.\n\n REASON FOR THIS EXAMINATION:\n Please evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old man with continued temperatures.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal, and hilar contours are stable status post\n median sternotomy. There is mild pulmonary vascular congestion. Rounded\n opacity in the right mid lung has increased in size. The retrocardiac opacity\n is similar in appearance. There are no pleural effusions. Osseous and soft\n tissue structures are unchanged.\n\n IMPRESSION: Increased right mid lung opacity and stable retrocardiac opacity.\n These findings could represent worsening pneumonia or aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 963993, "text": " 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: eval progression\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59M recovering from pneumosepsis.\n REASON FOR THIS EXAMINATION:\n eval progression\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and sepsis.\n\n PA AND LATERAL (THREE RADIOGRAPHS). The heart is enlarged with a prosthetic\n aortic valve. There is slight apical vascular plethora reflecting in part to\n lordotic positioning. Right PIC line with tip in mid SVC. No effusions. A\n vague focus of increased density in the right mid lung, lying above the minor\n fissure is of equivocal etiology and has markedly improved since last exam, .\n\n IMPRESSION: Improving apparent right upper lobe consolidation. Cardiomegaly\n with borderline vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 963057, "text": " 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? eval for pna\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 y/o M s/p renal txp , p/w fevers to 105, CXR with ? atelectasis vs pna\n REASON FOR THIS EXAMINATION:\n ? eval for pna\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever in a patient with status post renal\n transplantation in .\n\n COMPARISON: Chest radiograph from , , and chest\n CT from .\n\n TECHNIQUE: Unenhanced MDCT of the chest from thoracic inlet to upper abdomen\n was obtained with subsequent 1.25- and 5-mm collimation axial images reviewed\n in conjunction with coronal reformats.\n\n FINDINGS:\n\n New right upper lobe 10 x 13.5 mm nodule has discrete borders, 3:22. The\n right middle lobe subfissural nodule, 3:31, is 12 mm in diameter, surrounded\n by ground- glass opacity. A 6-cm diameter rounded consolidation in left lower\n lobe with air bronchograms is adjacent to areas of ground- glass and acinar\n opacities inferiorly extending to the pleural surface. Linear atelectasis in\n the right lower lobe, 3:35 is mild. All these findings are new compared to\n exams from and . There is no pleural effusion.\n\n The airways are patent to the level of segmental bronchi. Small mediastinal\n lymph nodes are not pathologically enlarged in the right and left lower\n paratracheal areas, but larger in the subcarinal location measuring up to 11\n mm. No hilar lymphadenopathy is present.\n\n The heart size is markedly enlarged especially the left ventricle, after\n aortic valve replacement and coronary bypass surgery. The native\n coronary arteries are heavily calcified. Mitral annulus valve calcifications\n are extensive. No pericardial effusion is demonstrated.\n\n The postoperative sternum is dehisced 5 mm at the level of manubrium, up to 8\n mm in the level of the body and up to 1\n cm at the level of xiphoid process. Although there is no fluid collection or\n bone sclerosis or destruction diagnostic of osteomyelitis, the presence of\n stranding in the surrounding subcutaneous fat and stranding and small areas of\n soft tissue density in the retrosternal fat, 2:28, are suspicious for\n infection.\n\n The imaged portion of the upper abdomen demonstrates small hiatal hernia and\n previous cholecystectomy and otherwise is unremarkable. No bone lesions\n (Over)\n\n 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? eval for pna\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n suspicious for malignancy are demonstrated.\n\n IMPRESSION:\n\n 1. Three parenchymal abnormalities new over six months, the largest in the\n left lower lobe and two in the right upper and right middle lobes. Given\n their nodular appearance and patient's symptoms of infection, Nocardia\n infection would be the most likely diagnosis, especially for the left lower\n lobe consolidation. Alternatively, the two, smaller right lung lesions could\n be PTLD.\n\n 2. Cardiomegaly. Status post aortic valve replacement and CABG. Sternal\n dehiscence with peristernal fat stranding and collections might represent\n osteomyelitis. If this diagnosis is plausible clinically, MRI or radionuclide\n scanning would be be helpful to confirm.\n\n 3. Small hiatal hernia.\n\n 4. Status post cholecystectomy.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 963463, "text": " 3:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with continued temps, known infiltrate on CT.\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old man with no infiltrates on CT and continued\n temperatures.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal, and hilar contours are stable. Pulmonary\n vasculature is unremarkable. The mid right lung opacity appears slightly\n improved compared to a prior examination. The retrocardiac opacity is similar\n in appearance. No new consolidations are identified. There may be a small\n left pleural effusion. Osseous and soft tissue structures are unchanged.\n\n IMPRESSION: Slight improvement in right mid lung opacity and similar\n appearance of left retrocardiac opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 963416, "text": " 5:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? evolving infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with continued temps, known infiltrate on CT.\n\n REASON FOR THIS EXAMINATION:\n ? evolving infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow up infiltrates in 59-year-old man status post renal\n transplant.\n\n Comparison is made to most recent radiograph and chest CT dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n Lung volumes remain low however there appears to be increased patchy\n consolidation projecting over the right mid hemithorax which may represent a\n worsening infection. Dense retrocardiac/left lower lobe opacity is not\n significantly changed with interval increase of left lower lobe basilar\n atelectasis. There is no evidence of pneumothorax, pleural effusion, or\n pulmonary edema.\n\n IMPRESSION:\n Probable progression of right upper lobe opacity with increased left lower\n lobe basilar atelectasis. Stable retrocardiac/left lower lobe opacity. \n suggest aspiration\n\n" }, { "category": "Radiology", "chartdate": "2158-06-19 00:00:00.000", "description": "PICC W/O PORT", "row_id": 963799, "text": " 7:48 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: place picc, right side only, left side has fistula\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with PNA, who needs long term abx. unable o get bedside picc\n (failed)\n REASON FOR THIS EXAMINATION:\n place picc, right side only, left side has fistula\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Receiving vancomycin and needs double-lumen PICC.\n\n FINDINGS/PROCEDURE: The risks and benefits of the procedure were explained to\n the patient and a preprocedural timeout was performed. Ultrasound was used to\n identify appropriate right upper extremity brachial vein and right upper\n extremity was prepped and draped in usual sterile fashion. 1% lidocaine was\n adminstered locally for anethesia. Using ultrasound guidance, a 19-gauge\n micropuncture set was used to access the right brachial vein and hard copy\n images were obtained before and after intravenous access. Microwire was then\n inserted through the needle and advanced under fluoroscopic guidance to the\n lower SVC. The needle was then replaced with peel-away microsheath and a\n double-lumen PICC was advanced to the lower SVC, measuring 40 cm. The wire\n and peel-away sheath were removed and the catheter was flushed and secured.\n The patient tolerated the procedure well without immediate complications.\n\n IMPRESSION: Successful double-lumen 40 cm right brachial vein PICC\n terminating in the lower SVC. The line is ready for use.\n\n Dr. performed the procedure and Dr. , the attending\n physician, .\n\n" }, { "category": "Radiology", "chartdate": "2158-06-16 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 963574, "text": " 3:46 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: renal u/s with post void residual in renal transplant patien\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man w/ ESRD s/p renal trasnplant in on immunosuppressants, AS\n s/p AVR, HTN, DM, HepC p/w recurrent high fevers\n REASON FOR THIS EXAMINATION:\n renal u/s with post void residual in renal transplant patient.\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND.\n\n INDICATION: End-stage renal disease, status post transplant. High fevers.\n\n FINDINGS: The transplant kidney in the left iliac fossa is identified and\n measures 12.6 cm in maximum diameter. There is normal renal cortical\n thickness. There is good blood flow. The resistive index measures 0.74 to\n 0.76. There is a normal waveform. There is some mild fullness of the\n collecting system, both before and after the catheter is unclamped. No\n evidence of any mass lesion and no evidence of any hydronephrosis.\n\n IMPRESSION: Unremarkable renal transplant in the left iliac fossa with some\n mild fullness of the collecting system, which is reduced when compared with\n the previous ultrasound from .\n\n" }, { "category": "Radiology", "chartdate": "2158-06-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 962980, "text": " 3:08 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please assess R Ij placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with new R IJ\n REASON FOR THIS EXAMINATION:\n please assess R Ij placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New right internal jugular catheter placement. Please assess\n line placement.\n\n FINDINGS: Single AP upright portable chest radiograph is reviewed and\n compared to . Right internal jugular approach central venous catheter\n is seen, with tip projecting over the cavoatrial junction. There has been\n prior median sternotomy and cardiac surgery. Lung volumes are low, and there\n is moderate bibasilar atelectasis. Underlying consolidation is difficult to\n exclude. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Right IJ central venous catheter with tip projecting over the\n cavoatrial junction. Moderate bibasilar atelectasis.\n\n" }, { "category": "Echo", "chartdate": "2158-06-16 00:00:00.000", "description": "Report", "row_id": 60036, "text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease.\nHeight: (in) 70\nWeight (lb): 218\nBSA (m2): 2.17 m2\nBP (mm Hg): 134/52\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 10:24\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>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. Mildly dilated aortic arch.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR\ngradient. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Mild functional MS due to MAC. Mild (1+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic arch is mildly dilated. A bioprosthetic aortic valve prosthesis is\npresent and appears well-seated. The transaortic gradient is normal for this\nprosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. There is mild functional mitral stenosis (mean gradient\n4 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nNo vegetation seen.\n\nCompared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n" }, { "category": "Echo", "chartdate": "2158-06-13 00:00:00.000", "description": "Report", "row_id": 60037, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. #21 - aortic valve prosthesis.\nHeight: (in) 70\nWeight (lb): 218\nBSA (m2): 2.17 m2\nBP (mm Hg): 121/47\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 14:43\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Dilated IVC (>2,5cm)\nwith <50% decrease during respiration (estimated RAP 16-20 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR\ngradient. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Minimally\nincreased gradient consistent with trivial MS. Mild (1+) MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left and right atrium are moderately dilated. The estimated right atrial\npressure is 16-20 mmHg. There is mild symmetric left ventricular hypertrophy\nwith normal cavity size and systolic function (LVEF>55%). Regional left\nventricular wall motion is normal. Right ventricular chamber size and free\nwall motion are normal. A bioprosthetic aortic valve prosthesis is present.\nThe transaortic gradient is top normal for this prosthesis. Trace aortic\nregurgitation is seen. The mitral valve leaflets and supporting structures are\nmoderately thickened. There is a minimally increased gradient consistent with\ntrivial mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Well seated aortic bioprosthesis with high-normal gradient and\ntrace aortic regurgitation. Pulmonary artery systolic hypertension. Mild\nmitral regurgitation.\nIf clinically indicated, a TEE would be better able to define a structural\nabnormality involving the aortic valve.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis IS recommended. Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-14 00:00:00.000", "description": "Report", "row_id": 1365145, "text": "NPN 7pm-7am\n59 yr old male admitted with high temps and hypotension (sepsis) Followed by Micu service.\n\nROS: See carevue for exact data\n\nShift Note: Uneventful\n\nN: Intact. Oriented x3. Pleasant appropriate. Denies all pain\n\nCV: HR 60-70 SR BP stable 120-138/30-50. Pt not requiring any pressor therapy, pt restarted on lopressor 25 mg , tolerated well. Pulses weakly palp. CVP 4-11. Pt with RIJ (precept cath) multi lumen. Ns @ KVO.\n\nResp: Pt doing well on r.a O2-->94-98% using I/s with little help. O2 back on for O2 overnoc. Pt on 2l with saturation in 99-100. LS clear anteriorly, posteriorly crackles to left base otherwise diminished bilat. RR 14-22.PT with positive LLL pna.\n\nGI: Abd soft, BS present, denies nausea, encouraging liquids overnoc\n\nGu: u/o adeq. Initially bloody, resident aware, clearing as night cont now slightly in color. Brief period overnoc pt autodiuresing lg amts 150-200 q30-1hr short lasting.\n\nSkin: Intact\n\nLytes/Hem-Pending\n\nEndo: Pt started on glargine fixed dose tonight. Reg insulin gtt cont's per resident at 8-10 per hour until bld sugar decreases . Initial blood sugars 200-300's. Insulin gtt on till 2400 then pt dropped bld sugar to 120 from 396. Insulin gtt off, and rechecked q 1/2 hr. Bld sugar stable at 140-160.\n\nSkin: Intact\n\nId: Pt afebrile, Cont on vanco/zosyn/bactrim\n\nPlan: Cont to monitor pt, ? transfer to floor status today.\n Enc cough and deep breathing, use of I/S.\n Monitor bld sugars, correct with sliding scale.\n Provide Emotional support, await final plan\n Will pass on to next Rn for cont coverage.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-14 00:00:00.000", "description": "Report", "row_id": 1365146, "text": "Nursing progress note (1430);\n\nROS:\n\nNeuro: Pt A&O x 3, following commands, pleasant/cooperative. MAE. Denies c/o pain.\n\nLS: LS Clear to apices w/ fine crackles to bilateral bases; non-productive cough. RR regular.. teens-20s. O2 sats 94-96% on 2L NC. Resp tx attempted to collect induced sputum, but unsuccessful. Bronchoscopy scheduled for tomorrow ..CXR showing ? infiltrates/nodules..possible Nocardia PNA.\n\nCV: VSS. NSR. HR 70s. No ectopy. Cont on po lopressor. Denies c/o CP, shortness of breath, or lightheadedness. + PP bilaterally. TTE yest- no vegetations noted.\n\nGI/GU; Abd soft, ND, NT. BS present. No BM this shift. Tolerating diet. Denies c/o nausea, - vomiting. Urine clear/yellow via foley. UOP adequate. Urine chem sample sent today. BUN/creat improving.\n\nEndo: Blood sugars 180s-300s. Cont on standing dose of lantus daily and RISS protocol.\n\nID: Afebrile. Cont on po bactrim and IV zosyn and vanco.\n\nAccess: RIJ TLC.\n\nAllergies: ciprofloxacin.\n\nCode status: full code.\n\nSocial: Pt has been speaking on phone w/ girlfriend today..updating her on POC.\n\nPlan: pt c/o to floor, bronchoscopy scheduled tomorrow, NPO after midnight, monitor BS, encourage CDB, OOB to chair.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-13 00:00:00.000", "description": "Report", "row_id": 1365143, "text": "Resp. Care note\nAttempted sputum induction for gm. stain and PCP as ordered. 3% hypertonic saline x30\" / aerosol but pt unable to produce sample. Sputum cup at bedside. Will reattempt.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-13 00:00:00.000", "description": "Report", "row_id": 1365144, "text": "Admit Note\n Pt presented to Hospital last evening with sudden onset fatigue, fever and overall feeling \"unwell\". Transferred to as he is followed by multiple disciples here including transplant. In EW temp 104.4, ST and SBP in 90s. Fluid resusitation with 2L NS and anbx given. Of note pt also hyperglycemic in 300s with elevated creatinine 2.2, flat WBCs with +bands on EW labs.\n\nAdmitted to MICU at 6am for close monitoring.\n\nPt has h/o DM, AV fistula x 2 in LUEs, Kidney tx , AVR, hiatal hernia, HTN, CAD, multiple toe amputation, s/p fem bypass.\n\n Neuro-Pt intact. OOB to wheelchair for CT scan and did well though feels physically weak.\n Resp-On 5lnc this am, weaned to 3lnc and sats 94-96%. Pt has clear lung anteriorly, posteriorly can hear coarse rhonchi and crackles in LLs. Attempted to obtain induced sputum sample without sucess, pt not c/o cough symptoms. CT scan of chest done and suspicious for pneumonia esp LLL. On broad spectrum anbx.\n CV- SR, no ectopy though freq changing reflection of QRS. BP has been stable 100-120s/50-70s. Afebrile. BC x 2 sent and lytes pending. Insulin gtt started this am and titrated to as high as 20 before BG started to decline. Able to wean gtt down to 10u/h. Pt and his fiancee mentioned wanting him to change present therapy of Humalin N at home prior to this event and consult called to start pt on lantus. Will start this evening and d/c gtt if BG remained better controlled. IVF TKO. Good UO. Started back on home meds.\n ECHO done to r/o endocarditis.\n GI/GU-Abd soft, +BS. Ate breakfast this am though complain food tasted horrible. Later when OOB to wheelchair became nauseated and vomited part of breakfast. Offered zofran but after emesis nausea subsided. In evening nauseated again (associated with dip in BG to 159 from 200s), zofran given with effect and pt able to eat dinner. PO fluids encouraged. Foley patent with adeq UO. After CT scan noted to occ have blood streaks. ? if foley pulled at some point in transfer though not seen to have done so nor did pt c/o it.\n Plan- Monitor overnight. Transistion to Lantus and SSIC. Cont anbx. Follow up with pending cx and close monitoring of Creat til returns to baseline.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-19 00:00:00.000", "description": "Report", "row_id": 1365155, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: Ciprofloxacin/Levaquin\n\nUneventful shift\n\nNeuro: Pt A&O x 3, pleasant, cooperative with care, follows commands. Able tp reposition self in bed. Bed to chair with one assist. Pt denies pain.\n\nCV: HR 60-80 NSR with no ectopy noted. NBP 140-150/50-70, pt responding well to increased dose Lopressor. Peripheral pulses palpable. PIV x 1, pt to IR today for PICC placement. Running low grade temps received PRN tylenol with good effect. Pt very difficult stick, unable to draw AM labs, team aware.\n\nResp: Received pt on RA, put on NC while sleeping for sat in high 80's. RR teens - 20s with sats >93%. Lung sounds clear in all fields. Pt with strong cough.\n\nGI: BS x 4, no stool this shift. Pt tolerating /carb consistent diet well.\n\nGU: Foley patent and draining large amounts of clear, yellow urine. UO 80-200cc/hr, pt appears to be autodiuresing.\n\nEndo: Continues on sliding scale humalog.\n\nID: Tmax 99.8, continues on ABX therapy, Bactrim/Vanco/Meropenum. Multiple cultures pending.\n\nSocial: Significant other in last night, updated on pt's condition and plan of care.\n\nPlan:\nmonitor temp, continue ABX\nto IR for PICC placement\nfollow up culture data\nc/o to floor?\nroutine ICU care and monitoring\nsupport to pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-19 00:00:00.000", "description": "Report", "row_id": 1365156, "text": "NSG 7AM-1800\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\n59 YR OLD WITH HX OF ESRD, S/P RENAL TRANSPLANT IN , (ON IMMUNOSSUPPRESSANTS)HTN, DM, TRANSFERED FROM OSH WITH FEVERS/FATIGUE/TEMP FROM OSH WAS 104/ ADMITTED AND TREATED IN THE ICU FOR POSS SEPSIS. CHEST XRAY SHOWS STERNAL OSTEOMYELITIS.\n\nPRESENTLY, PT A/OX3, FOLLOWS COMMANDS, MOVES ALL EXTREMITIES/ DENIES PAIN. OOB TO CHAIR WITH MINIMAL ASSIST. MAKES NEEDS KNOWN.\nAFEBRILE. TMAX:98.7/ REMAINS ON ANTBX: VANCO, MEROPENEM, BACTRIM. CBC PENDING.\nREMAINS ON SSI AND FIXED DOSE LANTUS AT HS.\n\nLUNG SOUNDS CLEAR IN UPPER AIRWAYS/ COARSE/DIMISHED AT BASES. MAINTAINS SATO2:94-98% ON RA.\n\nABD SOFT, POS BS/ NO BM. TOLERATES PO. NO N/V.\n\nFOLEY PATENT, DRAINING CLEAR YELLOW URINE/ 100-250CC/HR. CHEMISTRY SENT THIS PM/ PENDING.\n\nSKIN W/D/I\n\n18 GAUGE PIVX1, DUO LUMEN R PICC INSERTED ON . OLD LAV FISTULA WITH POS THRILL.\n\nC/O TO FLOOR\nCONT ANTBX.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-18 00:00:00.000", "description": "Report", "row_id": 1365152, "text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\n59M hx DM, htn, hep C, s/p renal transplant , AS s/p AVR , admitted to from OSH for recurring fever, came to MICU for hypotension/sepsis; currently on vancomycin, meropenum; TEE neg for vegetation;\n\nT max 99.4 this night, however did have sweats at approx 23:00/midnight as if he spiked a temp;\nb/p stable, hypertensive at times--on lopressor;\n\napprox 01:00 assisted up to bedside commode, had large amount soft formed stool, gu neg;\n\nvery good urine output, clear yellow; foley was kinked at approx 19:00, so pt leaked urine around foley--encourage pt to check his foley at times to make sure it is not kinked;\n\nPt very difficult IV access, left arm not usable d/t a-v fistula;\ntherefore keep open rate increased from 10 cc/hr to 20 cc/hr;\n\nRemains dependent on nasal cannula oxygen, at 5-6 l/min; will desat to approx 89% w/out oxygen;\n\nBlood sugars adequately controlled via lantus and humalog SSI;\n\nPLAN:\n1) monitor temps\n2) cont abx as ordered\n3) draw/check results a.m. labs\n4) OOB to chair today per pt request and activity orders\n5) ensure patency of flow of foley catheter\n" }, { "category": "Nursing/other", "chartdate": "2158-06-18 00:00:00.000", "description": "Report", "row_id": 1365153, "text": "06:55\n\nUnable to draw pt's labs;\ncall IV team;\n\nPt requested OOB to chair,\nassisted up w/ 1, pt tolerated well,\nstates feels well today.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-18 00:00:00.000", "description": "Report", "row_id": 1365154, "text": "Nursing note (0700-1900) 16:30.\n\nNeuro.\nPt is A+Ox3, no complaints of pain, in good spirits.\n\nResp.\nPt determined to stay off O2 if possible, SpO2 90-96% on RA, LS clear to UL's, diminshed bases. Pt does desat to 80's when transfering to chair.\n\nCVS.\nPt in NSR with no ectopy seen. Pt has been hypertensive, Lopressor increased to 37.5mg TID, with good effect.\nPts IV removed by IV nurse this am as site reddened, was assessed for PICC, and attempt made at placing. Unable to access vein despite US guidance. Pt currently has no IV access, team will place EJ with US guidance later today.\nPt with low grade temp, responded to Tylenol.\n\nGI/GU.\nPt tollerating good amounts of diet, +BS with no BM today as yet.\nUOP good amounbts of clear yellow urine via foley.\n\nEndo.\nFSG this am 43, given OJ and ate breakfast, then increased to 140.\n\nSocial.\nPt visited by sig other, updated as to plan.\n\nPlan.\nIV access.\nMonitor temps.\nPt will have PICC placed Monday in IR.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-14 00:00:00.000", "description": "Report", "row_id": 1365147, "text": "Resp. Care Note\nReattempted sputum induction for gm. stain and PCP as ordered. 3% hypertonic saline x20 min. Cough dry and nopn-prod. unalbe to obtain sputum. Pt to have bronch tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-16 00:00:00.000", "description": "Report", "row_id": 1365148, "text": "Nursing Admit Note 2200-0700\n\nBriefly this is a 59 year old male with PMH sig for ESRD s/p renal transplant, AS s/p AVR, DM2 who originally presented to an OSH for fever to 104 & fatigue. He was transferred to for ? sepsis. In our EW he was RX with Vanco/zoysn, IVF and a central line was placed. He was transferred to the ICU for further monitoring. His CXR showed some large nodules and he was called out with planned bronch scheduled for . Also of note there was a ? of sternal dehisence vs osteo on a chest CT done here, CT cleared sternal site. He was called out to the floor on and was doing well until the evening of , where he was noted to have a temp spike to 104.9, Hypertensive to 200, mild tachycardia to 110's and increased 02 requriments. He was given 1 GM tylenol and placed on a cooling blanket with little effect on his temp. BC/UA sent and he was started on Meropenum for ? Nocardia PNA. He was transferred to the ICU for further monitoring\n\nNeuro: A&Ox3, + rigors and chills upon arrival which has subsided since his temp normalized. He was given an additional dose of 650 mg of tylenol at midnoc and was on a cooling blanket until 3 am. He denies any pain, at baseline he is independent with all ADL's.\n\nResp: Lungs rhonchorous at bases. Sats 92-95 on 6 LNC, desats slightly when flat. RR 12-20. + dry non productive cough. Sputum sample needed. ? bronch later today\n\nCardiac: HR trending down over course of AM currently 60's NSR without ectopy. Hemodynamically stable, BP 120-140/50's. No edema + 1pt/dp bilaterally. BNP elevated to +. Echo to be repeated today\n\nGI: Currently NPO, Abdomen soft distended, + BS in 4 quadrents, No BM since admit\n\nRenal: Foley placed upon admission. UOP 40-60 cc/hr. FOley draining clear yellow urine. 10 mg IV lasix given at 0239, with 250 cc response. Old AV fistula to left lower extremitie with + bruit & thrill\n\nID: Temp normalized see carevue for details. Started on Meropenum this evening. Zoysn D/C'd On day 3 of vanco. Is on Bactrim for PCP . AM WBC 5.8\n\nSKin: Intact no current issues\n\nSocial: Girlfriend in to visit last evening. Full Code\n\nFEN: FS mildly elevated ? D/T steroids. Given 80 units of lantus at HS\n\nPlan:\n\n1. Monitor Cardiac status. ? need for additional lasix, echo today\n2. Monitor resp status, wean 02 as tolerated, ? bronch today\n3. Follow temp curve, culture data ANBX as ordered\n4. Routine ICU monitoring and care\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-16 00:00:00.000", "description": "Report", "row_id": 1365149, "text": "MICU Nurse Progress Note 0700-1900\nEvents: repeat TTE done this am. Bronch done at 1400, well,. Renal US at 1600. 02 weaned to 2l n/c with 02 sats 95-100%. at 1630pt began having chills, rigors, HR increased from the 60's to 100-110, 02 sat dropped to 80%'s. temp remained at 97.3. pt placed on 100% NRB and medicated with tylenol, demerol, and lasix. 02 sat improved to 95-98%, rigors and chills resolved, and HR decreased to 85-90. UOP following lasix 420ml. temp at 1800 spiked to 102.9, MD notified, will cont to monitor closely and send additional cultures if temp remains elevated.\n\nROS\n\nNeuro: pt A/O x3 pleasant, cooperative following commands well. All extremities strong/equal. pt medicated for bronchoscopy with fentanyl 100mcg and versed 2mg, returned to baseline immediately following bronch.\n\nPulm: pt currently on 02 5l n/s w/ 02 sat 93-97% LS upper lobes clear, lower lobes coarse bilat. Bronchoscopy done, bronch wash cultures sent. cardiac ECHO done, reults pending.\n\ncardiac: NSR HR60's to 70's at start of shift, increased with chills as above, currently 80's-90's. B/P 113-147/50's-60's increased to 153-177/ 52-99 with temp spike.\n\nGI: pt NPO this am for bronchoscopy, appetite good, taking PO's after bronch no s/s of aspiration. BS normal x 4 quads. No BM this shift.\n\nGU: foley patent draining clear yellow urine 25-80ml/hr, diuresed 420ml since lasix given at 17:00. Renal US done results pending.\n\nID: current temp 102.9, remains on Vanco/ Meropenum/ and bactrim.\n\nendo: FSBS 237 at 1200 and 114 at 1700, pt currently on diet and HISS.\n\nsocial: Fiancee in to see pt at 1700, asking appropriate questions, involved on pt care.\n\nplan: monitor temp closely, reculture, give tylenol, and adjust abx as needed.\nContinue close monitoring of 02 sat and adjust 02 accordingly.\nContinue supportive care and cardiac monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2158-06-17 00:00:00.000", "description": "Report", "row_id": 1365150, "text": "Nursing progressive notes\nreview carevue for all additional data\n\nNo significant events overnight\n\nNeuro; , oriented x3, following commands, MAE. Denies pain\n\nCv: NSR without ectopy, continued on po lopressor. SBP 130-160. Lt hand av fistula in place. Unable to draw blood for am labs, paged phlebotomy.\n\nResp: desats to 86-90% with o2 via nasal canula and started cool mist 60%. Bilateral lung sounds clear and diminished at the base. unproductive coug\n\nGi/Gu: tolerating diet, abd soft and Bs present and refused colace, no Bm this shift.\n\nEndo: insulin ss and fixed dose as per blood sugar\nid: t max 101.6, no cx sent, tylenol with good effect. continued vanco/meropanem/bactrim.\n\nSkin; intact\n\nPlan: F/U bronch from yesterday\n monitor tempcurve/ wbc\n Close monitoring of resp status\n F/U echo results\n\n" }, { "category": "Nursing/other", "chartdate": "2158-06-17 00:00:00.000", "description": "Report", "row_id": 1365151, "text": "0700-1900\nsee progress notes in green chart, careview down\n" }, { "category": "ECG", "chartdate": "2158-06-13 00:00:00.000", "description": "Report", "row_id": 109143, "text": "Sinus rhythm. Consider left ventricular hypertrophy by voltage. Non-specific\nST-T wave changes with prolonged QTc interval. Cannot exclude in part\ndrug/electrolyte/metabolic effect. Clinical correlation is suggested. Since the\nprevious tracing of no significant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2116-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165201, "text": " 9:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? etiology of hypotension\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with metastatic small cell lung cancer with persistent oxygen\n requirement and hypotension.\n REASON FOR THIS EXAMINATION:\n ? etiology of hypotension\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with persistent oxygen\n requirement and metastatic small cell lung cancer.\n\n Portable AP chest radiograph was compared to .\n\n The current study demonstrates no change in the cardiomediastinal contour.\n The right apical opacity seen on the CT torso is not well appreciated on the\n chest radiograph. The suprahilar right mass and the right hilar fullness are\n redemonstrated. Since the prior radiograph, there is no evidence of newly\n developed abnormality. Left retrocardiac opacity, most likely consistent with\n atelectasis, has been seen before. No pleural effusion or pneumothorax has\n been demonstrated. Pacemaker leads appears to be in unchanged, unremarkable\n position.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164379, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in LLL opacity and \n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with systolic CHF presents with SOB, increased sputum\n production and hypotension\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in LLL opacity and change in pulmonary\n edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath with increased sputum production.\n\n FINDINGS: In comparison with the study of , there are persistent low\n lung volumes. Enlargement of the cardiac silhouette persists with\n retrocardiac opacification consistent with volume loss in the left lower lobe\n and possible effusion. Elevation of the right hemidiaphragm is again seen\n with gas beneath it that could reflect either bowel or possible\n pneumoperitoneum. Again, the known masses in the right perihilar and upper\n lobe are not well appreciated on plain radiographs. Upper zones are clear.\n Pacemaker device remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-13 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1164453, "text": " 12:04 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Any signs of pneumoperitoneum?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with metastatic lung cancer found to have free air under\n diaphragm on admission CXR that resolved, but unclear source. Abd tender on\n exam.\n REASON FOR THIS EXAMINATION:\n Any signs of pneumoperitoneum?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 87-year-old man with metastatic lung cancer, thought to have\n free air on his admission chest x-ray, which subsequently resolved, query\n source.\n\n TECHNIQUE: Axial MDCT images were acquired from the thoracic inlet to the\n symphysis pubis without oral or intravenous contrast. Multiplanar\n reformations were produced and reviewed.\n\n COMPARISON: CT chest dated , and CT abdomen and pelvis dated\n .\n\n CT CHEST WITHOUT CONTRAST:\n\n Extensive vascular calcification noted in the thoracic aorta and coronary\n arteries. Pacemaker in situ, unchanged in position compared with the previous\n study. There are new small bilateral pleural effusions with associated\n compressive atelectasis. The right upper lobe mass has decreased in size from\n 2 x 1.7 cm to 1.9 x 0.8 cm. The bulky right paratracheal and right hilar\n lymphadenopathy has decreased in size, this previously measured approximately\n 2.3 x 4.1 cm but now measures 2.2 x 1.7 cm cyst. The right paratracheal\n lymphadenopathy is no longer appreciated.\n\n CT ABDOMEN WITHOUT IV CONTRAST:\n There is interposition of a large bowel loop between the liver and the\n diaphragm, known as Chilaiditi's syndrome. This may account for the\n appearance of a pneumoperitoneum on the chest x-ray. No pneumoperitoneum is\n demonstrated on today's study. Non-contrast examination of the liver, spleen,\n adrenal glands, and pancreas is unremarkable. Both kidneys are somewhat small\n although cortical thickness is difficult to assess on this non-contrast study.\n No retroperitoneal or mesenteric lymphadenopathy is seen. No free fluid.\n\n Calcification of the abdominal aorta noted with a 3.3 x 3.6 cm infrarenal\n aortic aneurysm seen. There is a second aneurysm of the right common iliac\n artery near its bifurcation, which measures 3.5 x 3.3 cm. These have both\n increased slightly in the interval since the previous study.\n\n CT PELVIS WITHOUT IV CONTRAST:\n (Over)\n\n 12:04 PM\n CT ABDOMEN W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Any signs of pneumoperitoneum?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There are numerous surgical clips seen along both pelvic sidewalls and the\n patient's prostate gland cannot be identified, presumed to be resected. The\n urinary bladder and rectum are unremarkable in appearance. Sigmoid\n diverticulosis without evidence of diverticulitis. No pelvic lymphadenopathy\n is seen. No free fluid. A fat-filled left inguinal hernia. Extensive\n calcification of the proximal femoral vessels noted.\n\n OSSEOUS STRUCTURES: Degenerative joint disease is noted throughout the lumbar\n spine with anterolisthesis of L5 on S1 and mild scoliosis convex to the left.\n No concerning lytic or sclerotic bony lesions seen.\n\n IMPRESSION:\n 1. Extensive vascular calcifications throughout the visualized aorta, common\n iliac and femoral vessels as well as the coronary vessels.\n 2. Interval decrease in size of the right upper lobe pulmonary mass.\n Interval decrease in size of the right suprahilar and mediastinal\n lymphadenopathy.\n 3. No pneumoperitoneum, large bowel loop extending anteriorly between the\n dome of the diaphragm and the liver, known as Chilaiditi's syndrome and a\n normal variant.\n 4. Infrarenal abdominal aortic aneurysm measuring 3.6 cm, right common iliac\n artery aneurysm measures 3.5 cm.\n 5. Sigmoid diverticulosis without evidence of diverticulitis.\n\n" }, { "category": "Radiology", "chartdate": "2116-10-20 00:00:00.000", "description": "PENILE ULTRASOUND", "row_id": 1165542, "text": " 9:39 AM\n PENILE ULTRASOUND Clip # \n Reason: definition of mass at base of penus ? Penile metas?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with Hx of prostate cancer, now at base of pinus\n REASON FOR THIS EXAMINATION:\n definition of mass at base of penus ? Penile metas?\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND SOFT TISSUE\n\n INDICATION: History of prostate CA with prostatectomy in . Now new soft\n tissue superficial lesion at base of penis.\n\n COMPARISON: CT Torso .\n\n FINDINGS:\n\n There is a hypoechoic 1.7 x 0.8 x 0.9 cm superficial soft tissue lesion\n identified at the base of the penis just to the left of the midline. It\n contains some internal echogenic material but no posterior shadowing is noted.\n No internal Doppler flow is identified. Multiple tattoos from previous\n radiotherapy are noted on the skin. Findings may represent either\n post-radiotherapy fibrous scar; however, penile metastases cannot fully be\n excluded.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164219, "text": " 10:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiopulm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with lung cancer, new cough\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior chest radiograph and PET CT scan from \n and respectively.\n\n CLINICAL HISTORY: 86-year-old man with lung cancer, new cough, question\n pneumonia.\n\n FINDINGS: Upright portable AP view of the chest is obtained. Dual-lead AICD\n device is again noted with lead tips extending into the right atrium and right\n ventricle. There is slight elevation of the right hemidiaphragm with lucency\n below the right hemidiaphragm, which could reflect air-filled bowel below the\n right hemidiaphragm, though pneumoperitoneum cannot be excluded. There is\n relative increased opacity at the left lung base, which could reflect\n atelectasis versus pneumonia. The known masses in the right perihilar and\n upper lobe are suboptimally assessed. No pneumothorax is present. Heart size\n appears grossly stable. Atherosclerotic calcifications along the thoracic\n aorta are noted. Bony structures appear demineralized.\n\n IMPRESSION:\n 1. Lucency below the right hemidiaphragm could reflect air-filled large bowel,\n though pneumoperitoneum cannot be excluded. Please correlate clinically and\n with left lateral decubitus views of the abdomen to further assess as\n indicated.\n 2. Increased opacity at the left lung base could represent atelectasis versus\n pneumonia. Known right-sided lung masses are poorly visualized.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2116-10-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1164308, "text": " 4:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: no mets?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with sclc may need anticoag\n REASON FOR THIS EXAMINATION:\n no mets?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of small cell lung cancer.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial MDCT-acquired images of the head were obtained\n without administration of intravenous contrast. Coronal and sagittal\n reformatted images were reviewed.\n\n FINDINGS: There is no hemorrhage or major acute vascular territorial\n infarction. There is no edema, mass effect or shift of normally midline\n structures. The ventricles and sulci are prominent in size and configuration,\n likely due to age-related global atrophy. Extensive periventricular white\n matter hypodensities are likely due to chronic small vessel ischemic disease.\n\n\n Bilateral calcified atherosclerosis are noted in the carotid siphons.\n\n The paranasal sinuses and mastoid air cells are clear.\n\n BONE WINDOWS: There is no concerning lesion for metastatic disease.\n\n IMPRESSION: No intracranial abnormality. In the setting of continued\n clinical concern, MRI is more sensitive for metastatic disease evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2116-10-12 00:00:00.000", "description": "CHEST (LAT DECUB ONLY)", "row_id": 1164307, "text": " 4:19 PM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: pls do left lat decub to eval for free air THIS IS AN ED PAT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with ? of free air\n REASON FOR THIS EXAMINATION:\n pls do left lat decub to eval for free air THIS IS AN ED PATIENT\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST PERFORMED ON .\n\n Comparison with CXR performed earlier today.\n\n CLINICAL HISTORY: Question of free air below the right hemidiaphragm.\n\n FINDINGS: Single left lateral decubitus view of the chest was provided.\n There is no definite sign of free air below the right hemidiaphragm. Right\n lung remains clear.\n\n IMPRESSION: No definite signs of free air below the right hemidiaphragm.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2116-10-13 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1164461, "text": " 12:29 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Anys sings on DVT?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with metastatic small cell lung cancer presented with weakness,\n chest pain and dyspnea discharged from hospital 1 day prior, comes back with\n hypotension and desaturation to the 70's, concern for PE, can't get CTA \n renal failure\n REASON FOR THIS EXAMINATION:\n Anys sings on DVT?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old with metastatic small cell cancer with weakness,\n chest pain and dyspnea, concern for PE. Evaluate for DVT.\n\n COMPARISON: .\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler examination of\n the right and left common femoral, superficial femoral, and popliteal veins\n were performed and demonstrate normal compressibility, augmentability and\n respiratory variation in flow. No intraluminal thrombus is identified.\n\n IMPRESSION: No deep venous thrombosis involving the right or left lower\n extremity.\n\n" }, { "category": "Echo", "chartdate": "2116-10-13 00:00:00.000", "description": "Report", "row_id": 61889, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function. Right ventricular function. Shortness of breath.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 124/56\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 12:14\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate global LV\nhypokinesis. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Frequent atrial\npremature beats.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate global left ventricular hypokinesis\n(LVEF = 35-40 %). Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and\nfree wall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened. There is mild aortic valve stenosis\n(valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is a very\nsmall pericardial effusion.\n\nIMPRESSION: Moderate left ventricular global hypokinesis. Mild aortic\nstenosis. Mild aortic regurgitation. Mild mitral regurgitation. Moderate\nestimated pulmonary artery systolic hypertension\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function has worsened.\n\n\n" }, { "category": "ECG", "chartdate": "2116-10-12 00:00:00.000", "description": "Report", "row_id": 112663, "text": "Baseline artifact. Irregularly irregular rhythm but with organized atrial\nactivity. Probable sinus rhythm with atrial and ventricular premature beats.\nLow limb lead voltage. Since the previous tracing of there is now\nventricular bigeminy.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2112-06-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 791895, "text": " 7:35 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FELL FROM CRIB\n Admitting Diagnosis: NEWBORN\n Field of view: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with fall from crib\n REASON FOR THIS EXAMINATION:\n r/o fracture or bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The following is the transcription report generated by\n , MD at the Medical Center.\n\n INDICATION: Fell out of basonnet.\n\n TECHNIQUE: Axial images of the brain without contrast.\n\n FINDINGS: The brain appears normally formed, normally myelinated and without\n structural abnormality, mass lesion or abnormal density. The CSF spaces\n appear normal. No acute definite hemorrhage is seen. Within the midline on\n axial images number 12 of series 2 there are two lucencies within the\n occipital bone, posteriorly, in the midline that raise the possibiity of a\n nondisplaced fracture. There is soft tissue swelling of the occipital region\n and vertex.\n\n IMPRESSION: Negative CT of the brain. Axial bone windows raise the\n possibility of a midline, nondisplaced occipital skull fracture, which could\n be confirmed with plain films if clinically indicated. These results were\n relayed to the referring practitioner Dr. and to \n from NICU.\n\n" }, { "category": "Radiology", "chartdate": "2112-06-30 00:00:00.000", "description": "P BABYGRAM (ABD ANY SGL VIEW) (74000) PORT", "row_id": 791929, "text": " 12:18 PM\n BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # \n Reason: evaluate bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with blood streaks in stool\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infant with blood streaks in stool.\n\n FINDINGS: Single frontal portable view of the abdomen was performed. There are\n several uniformly distended gas filled loops of bowel throughout the abdomen,\n without evidence for focal obstruction. No abnormal calcifications.\n Demonstrated osseous structures are intact. Lung bases are clear.\n\n" }, { "category": "Radiology", "chartdate": "2112-06-30 00:00:00.000", "description": "P SKULL (AP, TOWNES & LAT) TRAUMA PORT", "row_id": 791930, "text": " 12:51 PM\n SKULL (AP, & LAT) TRAUMA PORT Clip # \n Reason: r/o fracture\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n SKULL FILMS, \n\n CLINICAL INDICATION: Rule out fracture.\n\n FINDINGS: Frontal and lateral views of the skull reveal soft tissue\n thickening along the parietal-occipital region on the lateral view. This may\n represent a hematoma, given the patient's history. On the lateral view, there\n is a tiny linear density along the superolateral margin of the parietal skull,\n just deep to the soft tissue thickening. This may represent a small\n nondisplaced fracture. Please correlate with same day CT scan.\n\n" }, { "category": "Radiology", "chartdate": "2112-07-01 00:00:00.000", "description": "BABYGRAM (ABD ANY SGL VIEW) (74000)", "row_id": 792003, "text": " 8:00 AM\n BABYGRAM (ABD ANY SGL VIEW) () Clip # \n Reason: evaluate bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with blood streaks in stool\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE VIEW BABYGRAM \n\n HISTORY: Infant with blood streaks in stool. Evaluate bowel gas pattern.\n\n FINDINGS: There is slightly more gaseous distention than on the study of\n . There is no evidence of obstruction, pneumatosis or pneumoperitoneum.\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-01 00:00:00.000", "description": "Report", "row_id": 2022103, "text": "NPN 1900-2300\nBaby girl and active, awaking for feeds, VSS, pink and sl. jaundiced, well perfused. No resp distress noted. Bottled well 60cc Prosobee, no spits, small green seedy stool with sl. trace of blood in stool noted. Mom up and updated on infant's progress. No significant change in 4 hours.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-01 00:00:00.000", "description": "Report", "row_id": 2022099, "text": "Nursing progress note\n\n1 FEN\n2 Parenting\n3 Growth & dev\n\n#1 O: At start of shift, baby was feeding prosobee ad\nlib. Baby was having blood streaks in stool. Baby took \nfeeds well with no spits. DS 73. Abd soft with active bowel\nsounds & no loops. Baby was made NPO at 6AM d/t continuing\nblood streaked stools. IV started in L hand. A: Potential\nfor infection &/or feeding intol. P: Cont to assess. Abd\nfilm to be done.\n#2 O: No contact with . NNP spoke with when\nbay was made NPO. P: Support.\n#3 O: Remains on warmer with stable temp. Alert with cares.\nBaby feels sweaty at times. A: Stable. P: Cont to assess.\n\nREVISIONS TO PATHWAY:\n\n 1 FEN; added\n Start date: \n 2 Parenting; added\n Start date: \n 3 Growth & dev; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-01 00:00:00.000", "description": "Report", "row_id": 2022100, "text": "Neonatology\nRemains well in RA. Comfortable appearing.\n\nWt 3605 down 60. Abdomen benign. Several stools over night that had blood streaked mucous overnight, but this am is clearing. Kubs ahve been normal. ? rectal fissure. Will start feeds this am with Prosobee and monitor tolerance. ? swallowed blood vs rectal fissure as cause of bleeding.\n\nJaundiced this am. Bili 12 yesterday. Lytes bili and CBC to be checked with BC this am.\n\nNot on abx. Reconsider need based on clincial status.\nCT read as normal. Skull films normal. Neruo exam non-focal and age appropriate.\n\nWill discuss with family.\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-01 00:00:00.000", "description": "Report", "row_id": 2022101, "text": "NNP Physical Exam\n\nPE: pink, jaundiced, AFOF, sutures approximated, breath sounds clear/equal with easy WOB, no murmur, normal pulses, abd sfot, non distended, non tender, + bowel sounds, no rectal fissure noted on exam, active with normal tone and reflexes.\n\nUpdated Dr. on the phone.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-01 00:00:00.000", "description": "Report", "row_id": 2022102, "text": "NPN 1620\n\n\n#1 F/N: Baby Girl NPO this AM w/ IV D10 w/ lytes of\n infusing at 120cc/kg/d=18.7cc/hr. Infant w/ soft abd,\nactive bowel snds. Feeds started at 12pm; infant bottled\n45cc Prosobee w/ one projectile vomit, then bottled ~15cc\nmore w/o spitting. Infant then woke at 2pm and bottled 25cc\nw/o spitting. IV placed to heplock at 4pm. Stools are seedy\ngreen/yellow which are heme positive by guiac. One stool\ngrossly positive. Infant is voiding well. Lytes this PM:\n134/4.7/102/14.\nA: Stools continue heme positive. Infant now bottling\nProsobee w/o difficulty, occ. spit.\nP: Bottle infant ad lib. Monitor stools.\n#2 : Mom, , sibling up to visit at 4pm. Asking\nappropriate questions. Concerned about blood in stools.\n holding , pleased w/ baby. wishes to bottle\nfeed. Mom says she is starting to feel better; she may stay\nfor one more day and may receive another unit of PRBC's.\nA: Mother w/ difficult C/S and recovery. worried\nabout infant.\nP: Cont to updated and answer questions. Encourage\ninvolvement in care.\n#3 G/D: taken off the warmer and is now swaddled in an\nopen crib. Awake and alert w/ cares. Appropriate behavior\nfor term infant. Sucks vigorously on pacifier.\nA: AGA\nP: Cont dev. supports.\n#4 Bili: Bili now 14.4/0.3/14.1. Color mildly jaundiced.\nA: Hyperbili\nP: Begin lights today to provide as much exposure as\npossible prior to d/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-02 00:00:00.000", "description": "Report", "row_id": 2022104, "text": "npn 1900-0730\n\n\nFEN: BW=3745kg, CW= 3640kg ^ 35gms. Infant is an ad-lib\ndemand feeder on Prosobee20 bottling bwtn 45-70cc q\n3-4.5hrs. Infant tolerating feeds well. Had x1 lg emesis, np\naware. Abd benign, soft, no loops, +BS. Abd girth = 32cm.\nInfant voiding and stooling, trace positive for blood. P:\nContinue to encourage imcreased feeding volumes as\ntolerated.\n\nPAR: No contact from thus far, unable to assess\nfuther. P: Continue to update and suuport .\n\nDEV: Temp stable in an Air Controlled Isoleete. Infant \nand active with cares. Enjoys sucking on pacificer\nvigorously. Brings hands to face to comfort self. Wakes on\nown for feeds. Sleeps well in bwtn cares. Infant is\ncurrently under single phototherapy due to high bili levels.\nnfant jaundice and well perfused. AFSF. MAE. P: Continue to\nmonitor and support developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-02 00:00:00.000", "description": "Report", "row_id": 2022105, "text": "NICU Nursing Note\nI examined and agree with the above assessment. The infant requires frequent burping to avoid emesis. The stools continue to be trace positive, no fissure seen. Continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-02 00:00:00.000", "description": "Report", "row_id": 2022106, "text": "NICU nursing note\n\n\n1. FEN=O/Cont on adlib demand feeding schedule of Prosobee\n20cal. Waking Q4 hours. Abd benign. (Please refer to\nflowsheet for assessment and po amts.) Med spit x1.\nVoiding and stooling, heme (-). A/Tolerating current\nregime. P/Cont to monitor for feeding intolerance.\n\n2. =O/No contact with so far this shift.\nP/Cont to support and educate .\n\n3. G&D=O/Temp stable nested in air isolette. Cont on\nsingle phototx. and active with cares. Waking for\nfeeds. Sleeping well. A/Alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-02 00:00:00.000", "description": "Report", "row_id": 2022107, "text": "Neonatology Attending Progress Note:\n\nDOL #4\nRA, RR=30-60's\nno murmur, HR=130-160's. BP mean=56\nbili=14.4/0.3 yesterday\nwt=3645g (inc 35g). BM/prosobee\nfeeding well.\nstool heme negative today\nvoiding\n\nImp/Plan: FT infant with bloody stools with possible cow's milk allergy--improving on prosobee/BM\n--continue monitor abdominal exam\n--monitor all stools for heme\n--recheck bili in am\n--d/c planning\n" }, { "category": "Nursing/other", "chartdate": "2112-07-02 00:00:00.000", "description": "Report", "row_id": 2022108, "text": "PE: well appearing, AFOF, normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended. ext warm, well perfused. tone aga\n" }, { "category": "Nursing/other", "chartdate": "2112-06-30 00:00:00.000", "description": "Report", "row_id": 2022097, "text": "NPN 7a-7p\n\n\nAdmission note:\n\nInfant admitted from NBN s/p fall from crib. Infant is\nfullterm girl. Alert and crying with cares. Placed on\nradiant warmer. Vital signs stable see carevue. KUB\nobtained. Head xrays taken awating results. CBC sent. Dad\ncalled for update. Am stool x1 with bld streaks. Await plan\nper team\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-06-30 00:00:00.000", "description": "Report", "row_id": 2022098, "text": "Neonatology\\\nPatient is now 2 do term infant sent to NICU for evaluation of vomitting and h/o blood streaked stools by DR .\n\nPatient is 3.745 kg product of term gestation born to 35 yo G2P0 woman whose pregancy was notable for diet controlled GDM. c-section for CPD on . Apgars 9,9. DId well in DR transferred to NN.\n\nOn had admission PE that was unremarkable. AT that time was noted to have small amount of blood streaking in stool. Mother unable to Breast feed, and so infant changed to soy formula. COntinued with intermittent episodes of this. Last night was seen by Dr after episode in which baby's crib tipped over striking ground while baby was in it. baby remained in crib and had normal exam follwoing the spiode as documented in Dr note. A head CT was done this morning and by report from the CH Neuroradiologist shows no evidence of intracranial injury, bleed. The bone windows were not able to exclude an occipital fx so the CH neuroradiologist has suggested plain skull films which we have just done and are brinign to CH for .\n\nThis am seen by Dr who sent infant to NICU because of episode of projectile non-bilious vomitting.\n\nOn exam patient is pink active alert infant. Well perfused and saturated in rA. Skin w/o leisons. Mild parietooccipital caput. No evidence of fx on PE. HEENT wnl. Neck supple without tracts/sinuses/masses. Cor nl s1s2 w/o murmurs. Lungs clear.A bdomen soft benign. Genitalia nl term female. Neuro non-focal and age appropriate. Face symmetric good suck/root. Cry normal. Moves all ext well. No skeletal injury. Grasps x 4. EOMI. Pupils ERRL. Hips normal. Anus patent.\n\nKUB normal bowel gas pattern. No evidence of pneumotosis.\n\nA- Term infant with vomitting in setting of blood in stool. Abdominal exam is reassuring as is KUB. ? swallowed maternal blood as cause of blood in stool. Neuro exam and results of CT argue against neurological cause of vomitting.\nP Admit NICU\n Clinical and non-invasive monitoring of resp status.\n Follow abdominal exam. Further evaluation if abnl exam or contiued vomitting\n Allow feeds as tolerated.\n Repeat CBC sent and pending.\n Skull films to be reviewed by CH radiology team.\n Parents aware of status and plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-03 00:00:00.000", "description": "Report", "row_id": 2022109, "text": "NPN\n\n\n#1 O: has been waking for feeds taking 80-100cc\nBM/prosobee. Abd benign, soft, no loops or distention noted.\n+BS, lg stool, heme neg.vdg qs. Color sl jaundice, has been\nunder phototherapy for elevated bili, currently on bili\nblanket with eyes covered, in open crib, bili today\n13.1/0.3. A: feeding well. P: ? dc phototherapy, monitor\nstools, cont feeds.\n#2 Mom and here, baby to breast and did very well,\nlatched and fed for 20 min. both handle infant well.\nA: involved family P: cont to support and inform\n#3 is doing well in open crib, double wrapped with bili\nblanket on. waking for feeds, and sleeps between. sucks well\non pacifier. A: AGA P: cont to support development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-07-03 00:00:00.000", "description": "Report", "row_id": 2022110, "text": "NNP PHysical Exam\n\nPE: pink, jaundiced, AFOF, sutures approximated, breath sounds clear/equal with easy WOB, soft murmur audible LSB and left back when first auscultated for heart sounds that disappeared during exam, normal pulllllses, abd soft, non distended, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2112-07-03 00:00:00.000", "description": "Report", "row_id": 2022111, "text": "Neonatology Attending\n\nDay 5\n\nRemains in RA. No murmur. HR 140-150s. Pink, well-perfused. Bilirubin 13.1/0.3 on phototherapy. Weight down 20 gms. On ad lib demand ProSobee and breast milk. Taking 90-120 cc per feed. Passing heme negative stool. Small spits with feeds (minimal).\n\nDoing well. Feeding well. Tolerating feeds well. Adequate breathing control. Bilirubin now down to \"dischargeable\" level. Will send home and arrange for follow up bilirubin. Needs hearing screen. HBV already administered. Follow up care by Pediatrics. Will inform Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2112-07-03 00:00:00.000", "description": "Report", "row_id": 2022112, "text": "NICU nursing note\n\n\nPt pink/slightly jaundiced. and active. No resp\nissues. Vital signs stable. Waking Q3-4 hours to feed.\nBottlefeeding well BM20/Prosobee20. Bili blanket d/c'd.\nTemp stable in open crib. Discharge teaching/paperwork\ncompleted with . will contact their pedi \nam to make apt. Discharged home with at 1530 per\norder.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2190-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733092, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Patient remains ventillated pending arrival of family (possibly Good\n Friday). aware of patient for possible transfer once family gives\n approval. MAPs dropped overnight to 40s, but came up with repositioning\n patient - no pressors given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:52 AM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Morphine Sulfate - 2 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:41 AM\n Heparin Sodium (Prophylaxis) - 10:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.7\nC (98.1\n HR: 112 (91 - 112) bpm\n BP: 102/49(61) {78/38(47) - 160/94(98)} mmHg\n RR: 17 (13 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,245 mL\n 1,078 mL\n PO:\n TF:\n 1,325 mL\n 396 mL\n IVF:\n 905 mL\n 222 mL\n Blood products:\n Total out:\n 240 mL\n 45 mL\n Urine:\n 240 mL\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,005 mL\n 1,033 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 471 (306 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 47\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR without significant change\n without improvement on BiPAP. Now intubated with improved ventilation\n on ABG. BNP greater than assay is consistent with CHF. Put out well in\n the ED. Anticoagulated, so PE seems less likely. Mucous plugging seems\n like a likely component as well. Worsening of leukocytosis and\n persistent fever concerning for possible resistant organism.\n - Family meeting ; patient now DNR. Will likely extubate when\n family can gather.\n - Continuing /Vanco/Flagyl\n - Respiratory comfort while on vent, on morphine drip for comfort\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. Na continues to improve this morning at 144.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: DNR (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:29 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2190-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128024, "text": " 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for fluid\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with fluic overload\n REASON FOR THIS EXAMINATION:\n evaluate for fluid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fluid overload.\n\n FINDINGS: Comparison study of , there has been some decrease in the\n degree of pulmonary vascular congestion. Substantial layering effusion is\n seen on the left. The right costophrenic angle has been excluded from the\n image.\n\n The tip of the endotracheal tube now measures approximately 2.5 cm above the\n carina. Nasogastric tube extends to the upper stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128190, "text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with pneumonia.\n\n COMPARISON: .\n\n CHEST, AP: Mild interstitial edema, cardiomegaly, and moderate bilateral\n layering effusions are unchanged. The mediastinal and hilar contours are\n normal. Again seen is an endotracheal tube 3 cm from the carina, median\n sternotomy wires, gastrojejunostomy tube, and right humeral prosthesis.\n\n IMPRESSION: Mild volume overload.\n\n" }, { "category": "Radiology", "chartdate": "2190-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127696, "text": " 12:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for position\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with new ETT placement\n REASON FOR THIS EXAMINATION:\n eval for position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: New ET tube placement for position.\n\n One AP supine view. Comparison with the previous study done earlier the same\n day. Diffuse bilateral pulmonary infiltrates consistent with edema persist.\n There is evidence of bilateral pleural effusions before. The difference in\n the appearance of the chest is presumably due to differences in technique,\n improved lung volumes and redistribution of pleural fluid. Mediastinal\n structures are unchanged. An endotracheal tube has been inserted and\n terminates at the thoracic inlet. A nasogastric tube has been placed and\n terminates in the region of the stomach. A PICC line remains in place. A\n radiopaque catheter is recoiled in the abdomen, as before.\n\n IMPRESSION: Endotracheal tube and nasogastric tube in satisfactory position.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-03-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127874, "text": " 3:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with intubation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after intubation.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is low, approximately 2 cm above the carina. The NG tube tip\n is in the stomach although stomach continues to be significantly distended.\n The patient is after GJ tube insertion that appears to be unchanged. There is\n a bilateral large pleural effusion and extensive parenchymal opacities that\n might be consistent with interval worsening of pulmonary edema which\n demonstrated significant change since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127739, "text": " 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with chf, cad, cva presents with fluid overload now s/p\n intubation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Fluid overload.\n\n FINDINGS: Endotracheal tube terminates 2.4 cm above the carina and a\n nasogastric tube remains coiled in the stomach. Overall appearance of the\n chest is relatively similar to the prior study except for slight improvement\n in the degree of pulmonary edema. Small right and moderate left pleural\n effusions are unchanged.\n\n\n" }, { "category": "Physician ", "chartdate": "2190-03-26 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 733396, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.6\nF - 12:00 PM\n - Palliative care recs: order for SL morphine 5-10 mg SL q 15 minutes\n prn resp distress and Morphine supp 10-20 mg PR q2- 4 hours prn for\n longer acting coverage, and then use SL morphine for breakthrough,\n Levsin 0.125-0.25 mg SL q4 prn may be used for secretions, and ativan\n prn for agitation or restlessness.\n - Coughing up bilious fluid. NGT to suction returned several hundred cc\n bilious fluid. Tube feeds held O/N.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Vancomycin - 08:00 AM\n Meropenem - 08:24 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.2\nC (99\n HR: 104 (102 - 125) bpm\n BP: 85/48(56) {81/11(38) - 149/83(95)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,043 mL\n 106 mL\n PO:\n TF:\n 1,289 mL\n IVF:\n 894 mL\n 106 mL\n Blood products:\n Total out:\n 904 mL\n 180 mL\n Urine:\n 204 mL\n 80 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,139 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 695) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Intubated\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema. Plan to wait\n for family\ns arrival today and take patient off of ventilator, transfer\n to for supportive care.\n # Acute hypercarbic respiratory failure: Initial CXR without\n significant change or improvement on BiPAP. Now intubated with improved\n ventilation on ABG. BNP greater than assay is consistent with CHF. Put\n out well in the ED. Anticoagulated, so PE seems less likely. Mucous\n plugging seems like a likely component as well. Worsening of\n leukocytosis and persistent fever concerning for possible resistant\n organism. Per respiratory therapy notes, patient has increased amount\n and viscosity of secretions.\n - Family meeting ; patient now DNR. Will likely extubate today\n if family can gather.\n - Continuing /Vanco/Flagyl for HAP\n - Respiratory comfort while on vent, on morphine drip for comfort\n - Suction PRN\n - Will not check daily CXR\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload. Lasix drip did\n not increase urine output and was discontinued.\n - Will bolus gently if needed\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. No longer checking labs.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today, no longer checking labs.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Was previously in Afib in ED. Pt has been on anticoagulation\n for afib but Hct trending down. Concern for RP bleed but nothing on\n imaging. In sinus tach at this time.\n - No anticoagulation at this time\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs. No\n longer checking daily labs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: DNR (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD s/p CABG, CHF, recurrent aspiration\n pneumonia, pulmonary edema, respiratory failure.\n Exam notable for Tm 101.6 BP 125/86 HR 100 RR 18 with sat 100 on PSV\n 0.4. WD man, NAD on vent. Coarse BS B. RRR s1s2. Soft +BS. 2+\n edema. No labs.\n Plan of care d/w team and patient\ns family including his son, two\n daughters and two granddaughters. We will extubate Mr. after a\n visit from Pastoral Care to administer sacrament of the sick. Following\n extubation, he will receive morphine as needed to treat any respiratory\n discomfort. If he is stable in the AM, we will work to transfer him\n back to .\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:11 PM ------\n" }, { "category": "Physician ", "chartdate": "2190-03-27 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 733496, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:15 PM\n After family meeting and with family at bedside, patient made comfort\n measures only. Extubated and maintaining airway without distress.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Meropenem - 08:24 PM\n Vancomycin - 08:01 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged.\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100\n HR: 103 (97 - 121) bpm\n BP: 95/47(58) {78/44(36) - 132/75(86)} mmHg\n RR: 14 (11 - 45) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 791 mL\n 38 mL\n PO:\n TF:\n IVF:\n 491 mL\n 38 mL\n Blood products:\n Total out:\n 325 mL\n 30 mL\n Urine:\n 125 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 466 mL\n 8 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 601 (601 - 652) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 10 cmH2O\n SpO2: 93%\n ABG: ////\n Ve: 5 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Nasal cannula in place.\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema. Overall plan\n to return to today after patient was made CMO yesterday\n after family meeting.\n # Acute hypercarbic respiratory failure: Initial CXR without\n significant change or improvement on BiPAP. Now intubated with improved\n ventilation on ABG. BNP greater than assay is consistent with CHF. Put\n out well in the ED. Anticoagulated, so PE seems less likely. Mucous\n plugging seems like a likely component as well. Worsening of\n leukocytosis and persistent fever concerning for possible resistant\n organism. Per respiratory therapy notes, patient has increased amount\n and viscosity of secretions.\n - Family meeting ; patient now CMO. Patient was extubated and\n has been maintaining his airway with no evidence of respiratory\n distress.\n - discontinue /Vanco/Flagyl for HAP\n - Morphine prn for comfort\n - Suction PRN\n - Will not check daily CXR\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - CMO, pressures SBP 90s\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Discontinue antibiotics as above\n # Fluid Overload\n patient with total body overload. Lasix drip did\n not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. No longer checking labs.\n - CMO\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today, no longer checking labs.\n - d/c asa 325 mg daily\n - d/c high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Was previously in Afib in ED. Pt has been on anticoagulation\n for afib but Hct trending down. Concern for RP bleed but nothing on\n imaging. In sinus tach at this time.\n - No anticoagulation at this time\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs. No\n longer checking daily labs.\n - d/c PPI\n - no longer maintaining T and S\n # Dm: ISS\n # Dementia: discontinue mirtazapine\n # FEN: CMO\n # Prophylaxis: pneumoboots, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: CMO (discussed with HCP)\n # Disposition: Likely return to today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. Pt nonverbal, unable to\n review systems, histories with him and no family present.\n Resp failure due to aspiration pna.\n CMO management course decided yesterday.\n Extubated yesterday after family meeting.\n Resp status has remained stable except for upper airway secretions and\n rhonchorous breath sounds.\n Mental status declined overnight, not following commands as he was\n yesterday evening.\n On exam appears very comfortable. Sleeping, arousable. No apparent\n pain.\n Remainder of issues per Dr \ns note.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:56 ------\n" }, { "category": "Physician ", "chartdate": "2190-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733306, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.6\nF - 12:00 PM\n - Palliative care recs: order for SL morphine 5-10 mg SL q 15 minutes\n prn resp distress and Morphine supp 10-20 mg PR q2- 4 hours prn for\n longer acting coverage, and then use SL morphine for breakthrough,\n Levsin 0.125-0.25 mg SL q4 prn may be used for secretions, and ativan\n prn for agitation or restlessness.\n - Coughing up bilious fluid. NGT to suction returned several hundred cc\n bilious fluid. Tube feeds held O/N.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Vancomycin - 08:00 AM\n Meropenem - 08:24 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.2\nC (99\n HR: 104 (102 - 125) bpm\n BP: 85/48(56) {81/11(38) - 149/83(95)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,043 mL\n 106 mL\n PO:\n TF:\n 1,289 mL\n IVF:\n 894 mL\n 106 mL\n Blood products:\n Total out:\n 904 mL\n 180 mL\n Urine:\n 204 mL\n 80 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,139 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 695) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Intubated\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema. Plan to wait\n for family\ns arrival today and take patient off of ventilator, transfer\n to for supportive care.\n # Acute hypercarbic respiratory failure: Initial CXR without\n significant change or improvement on BiPAP. Now intubated with improved\n ventilation on ABG. BNP greater than assay is consistent with CHF. Put\n out well in the ED. Anticoagulated, so PE seems less likely. Mucous\n plugging seems like a likely component as well. Worsening of\n leukocytosis and persistent fever concerning for possible resistant\n organism. Per respiratory therapy notes, patient has increased amount\n and viscosity of secretions.\n - Family meeting ; patient now DNR. Will likely extubate today\n if family can gather.\n - Continuing /Vanco/Flagyl for HAP\n - Respiratory comfort while on vent, on morphine drip for comfort\n - Suction PRN\n - Will not check daily CXR\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload. Lasix drip did\n not increase urine output and was discontinued.\n - Will bolus gently if needed\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. No longer checking labs.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today, no longer checking labs.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Was previously in Afib in ED. Pt has been on anticoagulation\n for afib but Hct trending down. Concern for RP bleed but nothing on\n imaging. In sinus tach at this time.\n - No anticoagulation at this time\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs. No\n longer checking daily labs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: DNR (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733270, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.6\nF - 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Vancomycin - 08:00 AM\n Meropenem - 08:24 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.2\nC (99\n HR: 104 (102 - 125) bpm\n BP: 85/48(56) {81/11(38) - 149/83(95)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,043 mL\n 106 mL\n PO:\n TF:\n 1,289 mL\n IVF:\n 894 mL\n 106 mL\n Blood products:\n Total out:\n 904 mL\n 180 mL\n Urine:\n 204 mL\n 80 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,139 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 695) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 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 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n IMPAIRED SKIN INTEGRITY\n ANEMIA, OTHER\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n DIABETES MELLITUS (DM), TYPE I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733271, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.6\nF - 12:00 PM\n - Palliative care recs: order for SL morphine 5-10 mg SL q 15 minutes\n prn resp distress and Morphine supp 10-20 mg PR q2- 4 hours prn for\n longer acting coverage, and then use SL morphine for breakthrough,\n Levsin 0.125-0.25 mg SL q4 prn may be used for secretions, and ativan\n prn for agitation or restlessness.\n - Coughing up bilious fluid. NGT to suction returned several hundred cc\n biliois fluid. Tube feeds held O/N.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Vancomycin - 08:00 AM\n Meropenem - 08:24 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.2\nC (99\n HR: 104 (102 - 125) bpm\n BP: 85/48(56) {81/11(38) - 149/83(95)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,043 mL\n 106 mL\n PO:\n TF:\n 1,289 mL\n IVF:\n 894 mL\n 106 mL\n Blood products:\n Total out:\n 904 mL\n 180 mL\n Urine:\n 204 mL\n 80 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,139 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 695) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Intubated\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733274, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.6\nF - 12:00 PM\n - Palliative care recs: order for SL morphine 5-10 mg SL q 15 minutes\n prn resp distress and Morphine supp 10-20 mg PR q2- 4 hours prn for\n longer acting coverage, and then use SL morphine for breakthrough,\n Levsin 0.125-0.25 mg SL q4 prn may be used for secretions, and ativan\n prn for agitation or restlessness.\n - Coughing up bilious fluid. NGT to suction returned several hundred cc\n biliois fluid. Tube feeds held O/N.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Vancomycin - 08:00 AM\n Meropenem - 08:24 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 37.2\nC (99\n HR: 104 (102 - 125) bpm\n BP: 85/48(56) {81/11(38) - 149/83(95)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,043 mL\n 106 mL\n PO:\n TF:\n 1,289 mL\n IVF:\n 894 mL\n 106 mL\n Blood products:\n Total out:\n 904 mL\n 180 mL\n Urine:\n 204 mL\n 80 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,139 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 695) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Intubated\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema. Plan to wait\n for family\ns arrival today and take patient off of ventilator, transfer\n to for supportive care.\n # Acute hypercarbic respiratory failure: Initial CXR without\n significant change or improvement on BiPAP. Now intubated with improved\n ventilation on ABG. BNP greater than assay is consistent with CHF. Put\n out well in the ED. Anticoagulated, so PE seems less likely. Mucous\n plugging seems like a likely component as well. Worsening of\n leukocytosis and persistent fever concerning for possible resistant\n organism. Per respiratory therapy notes, patient has increased amount\n and viscosity of secretions.\n - Family meeting ; patient now DNR. Will likely extubate today\n if family can gather.\n - Continuing /Vanco/Flagyl for HAP\n - Respiratory comfort while on vent, on morphine drip for comfort\n - Suction PRN\n - Will not check daily CXR\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload. Lasix drip did\n not increase urine output and was discontinued.\n - Will bolus gently if needed\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. No longer checking labs.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today, no longer checking labs.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Was previously in Afib in ED. Pt has been on anticoagulation\n for afib but Hct trending down. Concern for RP bleed but nothing on\n imaging. In sinus tach at this time.\n - No anticoagulation at this time\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs. No\n longer checking daily labs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: DNR (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 733480, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-03-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 733483, "text": "Mr is a 78 y/o M with multiple medical problems including\n healthcare associated pneumonia, chronic aspiration, afib on coumadin,\n CVAs, and CAD who presents with hypoxia, consistent with pulmonary\n edema. He was intubated in EW and transferred to MICU for management.\n After family meeting yesterday decision made to place pt on comfort\n measures, pt subsequently extubated.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt resting comfortably, HR 102 normal sinus rhythm, bp 90\n 100 / 40\n 50, lung sounds , tube llq, + bowel sound, stage 2\n coccyx, + 4 pitting edema ble, responds to voice, non verbal.\n Action:\n Pt turned and repositioned q 2 hours, sacral area cleansed dressing\n changed, morphine 2mg prn q 4 hours for pain, fingersticks dc\nd, mouth\n care, frequent reorientation, Witnessed with House Officer DNR\n transfer orders with Son over phone.\n Response:\n Pt resting comfortably\n Plan:\n Transfer to extended care facility with hospice.\n" }, { "category": "Physician ", "chartdate": "2190-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733472, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:15 PM\n After family meeting and with family at bedside, patient made comfort\n measures only. Extubated and maintaining airway without distress.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Meropenem - 08:24 PM\n Vancomycin - 08:01 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged.\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100\n HR: 103 (97 - 121) bpm\n BP: 95/47(58) {78/44(36) - 132/75(86)} mmHg\n RR: 14 (11 - 45) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 791 mL\n 38 mL\n PO:\n TF:\n IVF:\n 491 mL\n 38 mL\n Blood products:\n Total out:\n 325 mL\n 30 mL\n Urine:\n 125 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 466 mL\n 8 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 601 (601 - 652) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 10 cmH2O\n SpO2: 93%\n ABG: ////\n Ve: 5 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Nasal cannula in place.\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema. Overall plan\n to return to today after patient was made CMO yesterday\n after family meeting.\n # Acute hypercarbic respiratory failure: Initial CXR without\n significant change or improvement on BiPAP. Now intubated with improved\n ventilation on ABG. BNP greater than assay is consistent with CHF. Put\n out well in the ED. Anticoagulated, so PE seems less likely. Mucous\n plugging seems like a likely component as well. Worsening of\n leukocytosis and persistent fever concerning for possible resistant\n organism. Per respiratory therapy notes, patient has increased amount\n and viscosity of secretions.\n - Family meeting ; patient now CMO. Patient was extubated and\n has been maintaining his airway with no evidence of respiratory\n distress.\n - discontinue /Vanco/Flagyl for HAP\n - Morphine prn for comfort\n - Suction PRN\n - Will not check daily CXR\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - CMO, pressures SBP 90s\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Discontinue antibiotics as above\n # Fluid Overload\n patient with total body overload. Lasix drip did\n not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. No longer checking labs.\n - CMO\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today, no longer checking labs.\n - d/c asa 325 mg daily\n - d/c high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Was previously in Afib in ED. Pt has been on anticoagulation\n for afib but Hct trending down. Concern for RP bleed but nothing on\n imaging. In sinus tach at this time.\n - No anticoagulation at this time\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs. No\n longer checking daily labs.\n - d/c PPI\n - no longer maintaining T and S\n # Dm: ISS\n # Dementia: discontinue mirtazapine\n # FEN: CMO\n # Prophylaxis: pneumoboots, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: CMO (discussed with HCP)\n # Disposition: Likely return to today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733453, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:15 PM\n After family meeting and with family at bedside, patient made comfort\n measures only. Extubated and maintaining airway without distress.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Meropenem - 08:24 PM\n Vancomycin - 08:01 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged.\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100\n HR: 103 (97 - 121) bpm\n BP: 95/47(58) {78/44(36) - 132/75(86)} mmHg\n RR: 14 (11 - 45) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 791 mL\n 38 mL\n PO:\n TF:\n IVF:\n 491 mL\n 38 mL\n Blood products:\n Total out:\n 325 mL\n 30 mL\n Urine:\n 125 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 466 mL\n 8 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 601 (601 - 652) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 10 cmH2O\n SpO2: 93%\n ABG: ////\n Ve: 5 L/min\n Physical Examination\n General: Patient flutters eyelids in response to voice, but unable to\n open eyes to command; no signs of pain/distress\n HEENT: Nasal cannula in place.\n CV: Tachycardic but regular, heart sounds overwhelmed by rhonchi\n Lungs: Diffuse rhonchi throughout lung fields, more pronounced at\n apices.\n Abdomen: Full/firm, no apparent tenderness, +BS present\n Extremities: Hands with contractures of fingers. Feet with amputation\n of toes at baseline, but warm/perfused.\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema. Overall plan\n to return to today after patient was made CMO yesterday\n after family meeting.\n # Acute hypercarbic respiratory failure: Initial CXR without\n significant change or improvement on BiPAP. Now intubated with improved\n ventilation on ABG. BNP greater than assay is consistent with CHF. Put\n out well in the ED. Anticoagulated, so PE seems less likely. Mucous\n plugging seems like a likely component as well. Worsening of\n leukocytosis and persistent fever concerning for possible resistant\n organism. Per respiratory therapy notes, patient has increased amount\n and viscosity of secretions.\n - Family meeting ; patient now CMO. Patient was extubated and\n has been maintaining his airway with no evidence of respiratory\n distress.\n - discontinue /Vanco/Flagyl for HAP\n - Morphine prn for comfort\n - Suction PRN\n - Will not check daily CXR\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - CMO, pressures SBP 90s\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Discontinue antibiotics as above\n # Fluid Overload\n patient with total body overload. Lasix drip did\n not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. No longer checking labs.\n - CMO\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today, no longer checking labs.\n - d/c asa 325 mg daily\n - d/c high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Was previously in Afib in ED. Pt has been on anticoagulation\n for afib but Hct trending down. Concern for RP bleed but nothing on\n imaging. In sinus tach at this time.\n - No anticoagulation at this time\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs. No\n longer checking daily labs.\n - d/c PPI\n - no longer maintaining T and S\n # Dm: ISS\n # Dementia: discontinue mirtazapine\n # FEN: CMO\n # Prophylaxis: pneumoboots, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: CMO (discussed with HCP)\n # Disposition: Likely return to today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733351, "text": "TITLE: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Pt. is DNR.\n UPDATE: Family meeting held today with son(HCP), dtrs and grand-dtrs\n today\n all kept up to date with POC/pt status. Family agreed that it\n was time to extubated pt and make comfort the goal of care. \n priest visited pt shortly thereafter and provided sacrament of\n the sick. Pt was subsequently extubated to RA @ 15:15 and is doing\n quite well with nl sats, RR and resp effort on bed rest. If pt cont\n to do well overnight he will be a candidate for transfer back to \n who have been contact and updated on pts care s/p extubation\n and are sending over a representative to facilitate transfer. A\n compassion cart was provided to the family. Currently the pt is in NAD\n but does not follow commands nor appear purposeful. The family has now\n gone home for the evening but will call this evening for updates. The\n pt is a DNR/DNI.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 5/5 with 40% FiO2 with nl sats, RR and resp\n effort. AM RSBI value of 27 noted. Pt sxn\ned for sm amounts of thick\n tan sec today. LS are clear s/p sxn\ning.\n Action:\n Pt sxn\ned today for sm amounts of thick tan sec per ETT today. Pt\n electively extubated to RA @ 15:15.\n Response:\n Pt doing well s/p extubation with nl sats, RR, HR and resp effort on\n RA.\n Plan:\n Will provide supplemental oxygen if necessary. Will provide IV\n Morphine for air hunger/dyspnea as needed. Will cont to monitor resp\n status/VS and adjust care to promote comfort accordingly.\n" }, { "category": "Nursing", "chartdate": "2190-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733426, "text": "Mr is a 78 y/o M with multiple medical problems including\n healthcare associated pneumonia, chronic aspiration, afib on coumadin,\n CVAs, and CAD who presents with hypoxia, consistent with pulmonary\n edema. He was intubated in EW and transferred to MICU for management.\n After family meeting yesterday decision made to place pt on comfort\n measures, pt subsequently extubated.\n" }, { "category": "Nursing", "chartdate": "2190-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733427, "text": "Mr is a 78 y/o M with multiple medical problems including\n healthcare associated pneumonia, chronic aspiration, afib on coumadin,\n CVAs, and CAD who presents with hypoxia, consistent with pulmonary\n edema. He was intubated in EW and transferred to MICU for management.\n After family meeting yesterday decision made to place pt on comfort\n measures, pt subsequently extubated.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt opens eyes to stimulation, not following commands, right side\n rigid. Lungs rhonchorous throughout. + upper airway secretions. HR\n 100-110\ns. RR high 20\ns. Sats 91-94 on2 LNC. BP 80-90\ns. T max 100.5\n axillary\n Action:\n Morphine 2 mg IV Q 4 hours PRN, Scopolamine patch placed, Tylenol given\n x 1 for fever\n Response:\n Pt appears comfortable RR low 20\ns, sleeping comfortably through the\n night\n Plan:\n ? transfer back to house today for hospice care\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 732567, "text": "TITLE: MICU Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n GEN: Intubated and sedated\n HEENT: NC/AT.\n PULM: Bilateral inspiratory rhonchi, left greater than right. Decreased\n breath sounds right base.\n CVS: RRR with normal S1+S2\n ABD: Hypoactive BS, soft, non-distended.\n Ext: 2+ Pitting edema bilaterally to halfway up shin.\n Neurologic: sedated\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n CT Abdomen/Pelvis without Contrast:\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with\n Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is\n recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared\n to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Worsening leukocytosis and fever concerning for possible\n resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - check vancomycin trough prior to PM dose\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin now trending down\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - hold coumadin for now, consider restarting in the near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD s/p CABG, CHF, recurrent aspiration\n pneumonia, pulmonary edema, respiratory failure. Passed SBT, awaiting\n family meeting re goals of care.\n Exam notable for Tm 98.8 BP 120/40 HR 79 RR 18 with sat 100 on PSV 5/5\n 0.4 7.37/38/66. WD man, NAD on vent. Coarse BS B. RRR s1s2. Soft +BS.\n 2+ edema. Labs notable for WBC 10K, HCT 28, K+ 3.6, Cr 1.5. CXR with B\n ASD.\n Agree with plan to manage recurrent respiratory failure with vanco /\n for possible pneumonia, lasix for volume removal if off pressors.\n For hypotension, hold propofol and wean levo off as able. AF -\n currently in NSR, hold coumadin for now. Hypernatremia - FWB via PEG.\n CRI - stable, follow vanco levels, RD meds. Will restart TFs today.\n Need to clarify goals of care with family; my understanding is that\n they are meeting with the team at to discuss this and\n will then contact the MICU team. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:43 PM ------\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732546, "text": "TITLE: MICU Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n GEN: Intubated and sedated\n HEENT: NC/AT.\n PULM: Bilateral inspiratory rhonchi, left greater than right. Decreased\n breath sounds right base.\n CVS: RRR with normal S1+S2\n ABD: Hypoactive BS, soft, non-distended.\n Ext: 2+ Pitting edema bilaterally to halfway up shin.\n Neurologic: sedated\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n CT Abdomen/Pelvis without Contrast:\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with\n Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is\n recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared\n to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Worsening leukocytosis and fever concerning for possible\n resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - check vancomycin trough prior to PM dose\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin now trending down\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - hold coumadin for now, consider restarting in the near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2190-03-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 732555, "text": "Subjective\n patient intubated- records Osmolite 1.5 @70mL/hr\n over 19 hours ( kcals)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 79 kg\n 25.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 98 per UBW%\n kg\n 71 Kg kg\n 111%\n Diagnosis: Hypoxia, CHF\n PMHx: Ogilvies Syndrome- Has frequent admissions for abdominal\n distention, with dilated colon on imaging, which resolves with rectal\n tube decompression.\n Chronic aspiration (Per PCP)\n CVA complicated by expressive aphagia, dysphagia\n Coronary artery disease, s/p CABG in , mild systolic regional\n hypokinesis with EF 55%\n HTN\n Hyperlipidemia\n GERD\n History of pancreatitis\n Type 2 diabetes c/b gastroparesis\n Anemia h/o intermittent heme+ stools\n Atrial fibrillation on coumadin\n Food allergies and intolerances: NKFA\n Pertinent medications: abx, SS insulin, multiviatmin, vitamin D,\n propofol drip, norepinephrine drip, lasix prn, others noted\n Labs:\n Value\n Date\n Glucose\n 100 mg/dL\n 02:24 AM\n Glucose Finger Stick\n 124\n 10:00 AM\n BUN\n 58 mg/dL\n 02:24 AM\n Creatinine\n 1.5 mg/dL\n 02:24 AM\n Sodium\n 145 mEq/L\n 02:24 AM\n Potassium\n 3.6 mEq/L\n 02:24 AM\n Chloride\n 117 mEq/L\n 02:24 AM\n TCO2\n 20 mEq/L\n 02:24 AM\n PO2 (arterial)\n 66 mm Hg\n 03:50 PM\n PCO2 (arterial)\n 38 mm Hg\n 03:50 PM\n pH (arterial)\n 7.37 units\n 03:50 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 03:50 PM\n Calcium non-ionized\n 7.9 mg/dL\n 02:24 AM\n Phosphorus\n 3.8 mg/dL\n 02:24 AM\n Magnesium\n 2.0 mg/dL\n 02:24 AM\n WBC\n 10.6 K/uL\n 02:24 AM\n Hgb\n 9.1 g/dL\n 02:24 AM\n Hematocrit\n 28.4 %\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, tube feed dependent\n Estimated Nutritional Needs\n Calories: 1775-2130 (25-30 cal/kg)\n Protein: 71-99 (1-1.4 g/kg)\n Fluid: per team\n Calculations based on: Usual body weight\n Specifics:\n 78 year old male re-admitted to MICU p/ discharge 10 hours previously\n form floor, w/ hypoxia and was subsequently intubated. Patient well\n known to nutrition services from admit. Patient is tube feed dependent\n at baseline, w/ plan to resume equivalent to home feeds. Will\n run over 24 hr while intubated in ICU. K repletion noted. To flush\n tube w/ 200mL H2O q4 hr while hypernatremia resolves.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: as ordered\n Start Isosource 1.5 @20mL/hr to increase by 10-20mL q4 hr to\n goal of 55mL/hr ( kcals/90 gr protein)\n No residuals w/ GJ tube, monitor tolerance via abd exam,\n bowel movements\n Lyte and glucose management as you are\n Adjust water flushes prn\n Following #\n 14:21\n" }, { "category": "Nutrition", "chartdate": "2190-03-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 732562, "text": "Subjective\n patient intubated- records Osmolite 1.5 @70mL/hr\n over 19 hours ( kcals)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 79 kg\n 25.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 98 per UBW%\n kg\n 71 Kg kg\n 111%\n Diagnosis: Hypoxia, CHF\n PMHx: Ogilvies Syndrome- Has frequent admissions for abdominal\n distention, with dilated colon on imaging, which resolves with rectal\n tube decompression.\n Chronic aspiration (Per PCP)\n CVA complicated by expressive aphagia, dysphagia\n Coronary artery disease, s/p CABG in , mild systolic regional\n hypokinesis with EF 55%\n HTN\n Hyperlipidemia\n GERD\n History of pancreatitis\n Type 2 diabetes c/b gastroparesis\n Anemia h/o intermittent heme+ stools\n Atrial fibrillation on coumadin\n Food allergies and intolerances: NKFA\n Pertinent medications: abx, SS insulin, multiviatmin, vitamin D,\n propofol drip, norepinephrine drip, lasix prn, others noted\n Labs:\n Value\n Date\n Glucose\n 100 mg/dL\n 02:24 AM\n Glucose Finger Stick\n 124\n 10:00 AM\n BUN\n 58 mg/dL\n 02:24 AM\n Creatinine\n 1.5 mg/dL\n 02:24 AM\n Sodium\n 145 mEq/L\n 02:24 AM\n Potassium\n 3.6 mEq/L\n 02:24 AM\n Chloride\n 117 mEq/L\n 02:24 AM\n TCO2\n 20 mEq/L\n 02:24 AM\n PO2 (arterial)\n 66 mm Hg\n 03:50 PM\n PCO2 (arterial)\n 38 mm Hg\n 03:50 PM\n pH (arterial)\n 7.37 units\n 03:50 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 03:50 PM\n Calcium non-ionized\n 7.9 mg/dL\n 02:24 AM\n Phosphorus\n 3.8 mg/dL\n 02:24 AM\n Magnesium\n 2.0 mg/dL\n 02:24 AM\n WBC\n 10.6 K/uL\n 02:24 AM\n Hgb\n 9.1 g/dL\n 02:24 AM\n Hematocrit\n 28.4 %\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, tube feed dependent\n Estimated Nutritional Needs\n Calories: 1775-2130 (25-30 cal/kg)\n Protein: 71-99 (1-1.4 g/kg)\n Fluid: per team\n Calculations based on: Usual body weight\n Specifics:\n 78 year old male re-admitted to MICU p/ discharge 10 hours previously\n form floor, w/ hypoxia and was subsequently intubated. Patient well\n known to nutrition services from admit. Patient is tube feed dependent\n at baseline, w/ plan to resume equivalent to home feeds. Will\n run over 24 hr while intubated in ICU. K repletion noted. To flush\n tube w/ 200mL H2O q4 hr while hypernatremia resolves.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: as ordered\n Start Isosource 1.5 @20mL/hr to increase by 10-20mL q4 hr to\n goal of 55mL/hr ( kcals/90 gr protein)\n No residuals w/ GJ tube, monitor tolerance via abd exam,\n bowel movements\n Lyte and glucose management as you are\n Adjust water flushes prn\n Following #\n 14:21\n ------ Protected Section ------\n Of note [patient receiving ~180 kcals/day form propofol- no need to\n adjust tube feed goal at this time, but will monitor closely. #\n ------ Protected Section Addendum Entered By: , RD, LDN,\n on: 14:32 ------\n 14:32\n" }, { "category": "Respiratory ", "chartdate": "2190-03-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732833, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Pt received on SBT 5/0 - pt\n tolerated well for 2 hours. Pt placed back on PSV 5/5 as noted. Pt\n became apneic this afternoon and was placed on AC for 2 hours. Pt\n placed on PSV and PS increased to 10cm secondary to low VT of 130-180\n on PS 5cm.\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: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2190-03-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732679, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done on 0 peep/ 5ips 50.\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: Will cont with SBT and monitor resp status for extubation.\n" }, { "category": "Nursing", "chartdate": "2190-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732892, "text": "HPI: Pt d/c\nd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 10/5. Sp02 100%. Mod amts of thin\n ETT and oropharyngeal secretions. LS rhonchi and dim. Pt had few\n periods of apnea. .WBC up to 15.0 from 10.3.\n Action:\n Admin abx for PNA: flagyl, vancomycin, meropenum.\n Response:\n Pt did not diurese to lasix gtt when given yesterday, UOP ml/hr,\n Plan:\n Cont abx, ? re-order scopalimine patch for increased secretions.\n Impaired Skin Integrity\n Assessment:\n Pt has stage II on coccyx and non-blancheable mark on R heel.\n Action:\n Freq reposition, mepilex to coccyx, elevate heels, TF running at goal.\n Response:\n Stable.\n Plan:\n Cont skin care.\n Anemia, other\n Assessment:\n Pt has hx of afib w/ anticoagulation w/ Coumadin. Pt has guiac\n positive stool this admission.\n Action:\n Hold anticoagulants and monitor H/H . Admin SC heparin.\n Response:\n H/H stable: Hct up to 30.2 and INR down to 1.5. this morning. Pt is\n in NSR 90-110.\n Plan:\n Cont to monitor H/H, monitor for signs of bleeding. Restart Coumadin\n before d/c to .\n" }, { "category": "Nursing", "chartdate": "2190-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732889, "text": "HPI: Pt d/c\nd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 5/5. Sp02 100%. Mod amts of thin\n ETT and oropharyngeal secretions. LS rhonchi and dim. Pt had few\n periods of apnea. .WBC 10.3.\n Action:\n Admin abx for PNA: flagyl, vancomycin, meropenum.\n Response:\n Pt did not diurese to lasix gtt when given yesterday, UOP ml/hr,\n Plan:\n Cont abx, ? re-order scopalimine patch for increased secretions.\n Impaired Skin Integrity\n Assessment:\n Pt has stage II on coccyx and non-blancheable mark on R heel.\n Action:\n Freq reposition, mepilex to coccyx, elevate heels, TF running at goal.\n Response:\n Stable.\n Plan:\n Cont skin care.\n Anemia, other\n Assessment:\n Pt has hx of afib w/ anticoagulation w/ Coumadin. Pt has guiac\n positive stool this admission.\n Action:\n Hold anticoagulants and monitor H/H . Admin SC heparin.\n Response:\n H/H stable: Hct 29.6 this PM, INR 1.7 this morning. Pt is in NSR\n 90-110.\n Plan:\n Cont to monitor H/H, monitor for signs of bleeding. Restart Coumadin\n before d/c to .\n" }, { "category": "Nursing", "chartdate": "2190-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733162, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on c-pap mode of ventilation with 5 peep\n Action:\n Suctioned periodically for small amts thick yellow secretions, both\n via et tube and orally\n Response:\n 02 sats 95-98%, generates tidal volumes of 650-670, remains with\n rhonchi\n Plan:\n Continue with pulmonary toileting and repositioning for optimal lung\n expansion\n Hypotension (not Shock)\n Assessment:\n Ptsys Bp 130\ns-frequently down to high 80\n Action:\n Morphine gtt decreased from 3 mgm- one mgm,presently off per order Micu\n team, and pt receiving ativan via g tube for vent comfort\n Response:\n Sys presently 140\ns, pt is sleeping at present but easily awakened,\n occas tracks speaker but frequently has anxious look, moves rt foot\n and rt hand very slightly on bed, moves left side better, does not\n follow commands consistently\n Plan:\n ? meeting with family tomorrow,? CMO measures to be discussed, goal is\n to keep pt comfortable at present and offer emotional support to pt and\n family\n pt\n ------ Protected Section ------\n Pt has had temp spike 101.6-101.2, medic with Tylenol, Dr. \n informed and pt not to have blood cultures at this point.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:05 ------\n" }, { "category": "Nursing", "chartdate": "2190-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733158, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on c-pap mode of ventilation with 5 peep\n Action:\n Suctioned periodically for small amts thick yellow secretions, both\n via et tube and orally\n Response:\n 02 sats 95-98%, generates tidal volumes of 650-670, remains with\n rhonchi\n Plan:\n Continue with pulmonary toileting and repositioning for optimal lung\n expansion\n Hypotension (not Shock)\n Assessment:\n Ptsys Bp 130\ns-frequently down to high 80\n Action:\n Morphine gtt decreased from 3 mgm- one mgm,presently off per order Micu\n team, and pt receiving ativan via g tube for vent comfort\n Response:\n Sys presently 140\ns, pt is sleeping at present but easily awakened,\n occas tracks speaker but frequently has anxious look, moves rt foot\n and rt hand very slightly on bed, moves left side better, does not\n follow commands consistently\n Plan:\n ? meeting with family tomorrow,? CMO measures to be discussed, goal is\n to keep pt comfortable at present and offer emotional support to pt and\n family\n pt\n" }, { "category": "Physician ", "chartdate": "2190-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732751, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n \n Patient off of vasopressors. Attempting gentle diuresis with lasix\n boluses. Got 40mg IV x3 with reasonable response.\n Plan for family meeting today at .\n Opens eyes and follows commands; otherwise non-verbal. No apparent\n distress/pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:57 PM\n Metronidazole - 01:15 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:57 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 96 (72 - 103) bpm\n BP: 129/69(83) {94/28(46) - 142/99(102)} mmHg\n RR: 26 (0 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,958 mL\n 506 mL\n PO:\n TF:\n 141 mL\n IVF:\n 1,453 mL\n 135 mL\n Blood products:\n Total out:\n 925 mL\n 485 mL\n Urine:\n 925 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,033 mL\n 21 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 426 (300 - 426) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 9.3 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 227 K/uL\n 9.5 g/dL\n 92 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 57 mg/dL\n 114 mEq/L\n 141 mEq/L\n 29.7 %\n 10.3 K/uL\n [image002.jpg]\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n Hct\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n Plt\n 255\n 208\n 186\n 227\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 20\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n Other labs: PT / PTT / INR:18.3/36.9/1.7, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Worsening leukocytosis and fever concerning for possible\n resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above\n - follow cultures (NGTD)\n - f/u vanco trough with AM labs (pending)\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - hold coumadin for now, consider restarting in the near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732936, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 04:00 AM\n Patient remains off vasopressors. Was on lasix drip, did not increase\n his UOP (averaging 30-45 ml/hour). Patient DNR after family meeting at\n - likely extubation when family can gather.\n Overnight spiked fever to 101.3 and received tylenol.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 113 (88 - 113) bpm\n BP: 127/68(81) {101/51(64) - 139/72(84)} mmHg\n RR: 30 (0 - 32) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 1,845 mL\n 881 mL\n PO:\n TF:\n 868 mL\n 349 mL\n IVF:\n 356 mL\n 132 mL\n Blood products:\n Total out:\n 892 mL\n 67 mL\n Urine:\n 892 mL\n 67 mL\n NG:\n Stool:\n Drains:\n Balance:\n 953 mL\n 815 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): 354 (328 - 457) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 10.7 L/min\n Physical Examination\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Initial worsening of leukocytosis and fever concerning for\n possible resistant organism.\n - Family meeting yesterday; patient now DNR. Will likely extubate when\n family can gather.\n - Pressure support trial on 5/0\n - Continuing /Vanco/Flagyl\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses followed by levophed\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:23 AM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732940, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 04:00 AM\n Patient remains off vasopressors. Was on lasix drip, did not increase\n his UOP (averaging 30-45 ml/hour). Patient DNR after family meeting at\n - likely extubation when family can gather.\n Overnight spiked fever to 101.3 and received tylenol.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 113 (88 - 113) bpm\n BP: 127/68(81) {101/51(64) - 139/72(84)} mmHg\n RR: 30 (0 - 32) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 1,845 mL\n 881 mL\n PO:\n TF:\n 868 mL\n 349 mL\n IVF:\n 356 mL\n 132 mL\n Blood products:\n Total out:\n 892 mL\n 67 mL\n Urine:\n 892 mL\n 67 mL\n NG:\n Stool:\n Drains:\n Balance:\n 953 mL\n 815 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): 354 (328 - 457) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 10.7 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR without significant change\n without improvement on BiPAP. Now intubated with improved ventilation\n on ABG. BNP greater than assay is consistent with CHF. Put out well in\n the ED. Anticoagulated, so PE seems less likely. Mucous plugging seems\n like a likely component as well. Worsening of leukocytosis and\n persistent fever concerning for possible resistant organism.\n - Family meeting yesterday; patient now DNR. Will likely extubate when\n family can gather.\n - Continuing /Vanco/Flagyl\n - Respiratory comfort while on vent, consider morphine\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:23 AM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-25 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 733154, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Patient remains ventillated pending arrival of family (possibly Good\n Friday). aware of patient for possible transfer once family gives\n approval. MAPs dropped overnight to 40s, but came up with repositioning\n patient - no pressors given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:52 AM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Morphine Sulfate - 2 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:41 AM\n Heparin Sodium (Prophylaxis) - 10:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.7\nC (98.1\n HR: 112 (91 - 112) bpm\n BP: 102/49(61) {78/38(47) - 160/94(98)} mmHg\n RR: 17 (13 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,245 mL\n 1,078 mL\n PO:\n TF:\n 1,325 mL\n 396 mL\n IVF:\n 905 mL\n 222 mL\n Blood products:\n Total out:\n 240 mL\n 45 mL\n Urine:\n 240 mL\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,005 mL\n 1,033 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 471 (306 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 47\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR without significant change\n without improvement on BiPAP. Now intubated with improved ventilation\n on ABG. BNP greater than assay is consistent with CHF. Put out well in\n the ED. Anticoagulated, so PE seems less likely. Mucous plugging seems\n like a likely component as well. Worsening of leukocytosis and\n persistent fever concerning for possible resistant organism.\n - Family meeting ; patient now DNR. Will likely extubate when\n family can gather.\n - Continuing /Vanco/Flagyl\n - Respiratory comfort while on vent, on morphine drip for comfort\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. Na continues to improve this morning at 144.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: DNR (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:29 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD s/p CABG, CHF, recurrent aspiration\n pneumonia, pulmonary edema, respiratory failure. No response to lasix,\n febrile, RSBI worse, awaiting family.\n Exam notable for Tm 100.3 BP 100/60 HR 96 RR 26 with sat 100 on PSV. WD\n man, NAD on vent. Coarse BS B. RRR s1s2. Soft +BS. 2+ edema. No labs.\n Agree with plan to manage recurrent respiratory failure with vanco /\n for progressive pneumonia / sepsis, and will continue remainder of\n current regimen, no labs / CXR. Would bolus for hypotension and will\n add morphine for respiratory discomfort / pain. Awaiting arrival of\n family prior to transitioning to CMO, Palliative care team following,\n available for Hospice care if needed. Remainder of plan\n as outlined above.\n Total time: 15 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:23 PM ------\n" }, { "category": "Physician ", "chartdate": "2190-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732348, "text": "24 Hour Events:\n Pt. remained intubated. He was diuresed, but remained hypotensive.\n Started on levophed and propofol was weaned down. EKG showed first\n degree block.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:07 PM\n Meropenem - 04:07 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 07:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.4\n HR: 78 (75 - 100) bpm\n BP: 112/62(73) {72/46(51) - 126/76(85)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,351 mL\n 573 mL\n PO:\n TF:\n IVF:\n 601 mL\n 233 mL\n Blood products:\n Total out:\n 236 mL\n 190 mL\n Urine:\n 236 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 600) mL\n Vt (Spontaneous): 411 (411 - 411) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.41/31/155/20/-3\n Ve: 8.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General: Sedated, intubated, opens eyes and grimaces to sternal rub\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not assessible, no LAD\n Lungs: clear anteriorly, good airmovement\n CV: RRR. Nl S1 and S2.\n Abdomen: soft, ABS. slightly distended from edema. nontender. tube in\n place.\n GU: foley in place. brown urine in foley bag.\n Ext: 2+ LE edema to knees\n Labs / Radiology\n 255 K/uL\n 8.4 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.3 mEq/L\n 61 mg/dL\n 120 mEq/L\n 149 mEq/L\n 26.5 %\n 11.4 K/uL\n [image002.jpg]\n 11:48 AM\n 02:28 PM\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n WBC\n 11.4\n Hct\n 26.1\n 24.3\n 26.5\n Plt\n 255\n Cr\n 1.4\n 1.4\n TropT\n 1.38\n 1.39\n TCO2\n 24\n 22\n 18\n 20\n Glucose\n 135\n 92\n Other labs: PT / PTT / INR:22.2/41.7/2.1, CK / CKMB /\n Troponin-T:148/21/1.39, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course today.\n Worsening leukocytosis and fever concerning for possible resistant\n organism.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n would have DC\nd today, but will keep\n him on these for now\n - Repeat TTE\n # Hypotension: pt. hypotensive with diuresis overnight, started on\n levophed overnight\n - consider CVL\n - decrease PEEP\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 149 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin still trending up\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down.\n - Hold Coumadin today in setting of ?bleed\n - Rate control as above\n - Repeat EKG in AM\n # Anemia: 5 point Hct drop in the setting of diuresis is concerning.\n Mild tachycardia, but patient is betablocked at baseline.\n - guaiac stools\n - continue PPI\n - T and S , transfuse 2 units PRBCs with lasix\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: hold coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Events: Hypotensive, propofol d/c\nd and started on levophed. PICC team\n informed of ?malposition of line on CXR, per their records, line has\n not moved and ? of whether tip is lost in mediastinal shadow. Given\n lasix but I/O positive.\n Tm99.8, P70-100s 112/60, RR 11-20.\n PSV 10/5/40% TV 500\n I/O: +1.5L\n Exam this AM: intubated, NAD. Grimaces, withdraws to pain. RRR S1\n S2. Coarse BS B/L. Abd soft +BS. 1+ LE edema.\n WBC 20.3 -> 11.4, Hct 32 -> 26, Plt 255, INR 2.1\n Chem-7: Na 149, K 3.3, HCO3 20, BUN69/Cr1.4\n Trop: 1.39 <- 1.2 but prior to that 1.8\n CXR: ?improved b/l infiltrates, b/l effusions\n Meds include: Vanc, meropenem, RISS, coumadin, MVI, Vit D, flagyl PO,\n levophed, simvastatin, free H2O bolus.\n 78 y/o man with multiple medical problems including , chronic\n aspiration, EF 40%, CVA, CAD, DM, Afib on coumdin admitted from after recent d/c from () admitted with recurrent\n hypoxemic respiratory failure, CHF (BNP of >70K) vs aspiration (h/o\n same, WBC 20).\n While doing better from resp status unclear how well underlying CHF has\n been treated, remains an aspiration risk, and would want to clarify\n code status as discussion re: DNR/DNI is pending. Will continue\n treatment for HAP.\n Hypotensive in setting of Hct trending down\n transfuse, guaiac stool,\n Vit K, d/c coumadin and give FFP; will give CT abd if continues as\n bleed of unclear origin at prior admission. Ddx for hypotension\n includes sepsis, cardiogenic; latter seems less likely given overall\n trend down in Trop, but will follow.\n Access an issue\n apparently required fem line in past; PICC is new\n from , though may be in great vessel and not SVC. Will defer for\n now given risk / benefit unless pressor requirement persistent.\n Remainder of plan as above, pt is critically ill.\n CC time 40 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:08 ------\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732602, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 5/5. ABG 7.37/38/66. LS very\n rhonchorous bilat. Sp02 100%. Copious amts thin bronchial secretions\n via ETT as well as oropharyngeal secretions. Sputum cx this admission\n is pending. Pt is afebrile, WBC 10.6. Bilat pleural effusion on CXR.\n RSBI this morning 80. Pt moves LUE only, does not follow commands,\n PERRL, no gag, weak cough.\n Action:\n Admin abx as dir: vanc, , flagyl. VAP care / oral care. Attempt\n diuresis w/ 40 mg lasix this afternoon. Refrain from extubation today\n d/t increased secretions.\n Response:\n Min response to lasix. WBC this afternoon 8.8.\n Plan:\n Cont abx therapy, attempt further diuresis renal function allows. ?\n lasix gtt.\n Hypotension (not Shock)\n Assessment:\n Received pt on propofol 15 mcgs/kg/min for light sedation and low dose\n levophed at 0.03 mcg/kg/min for BP support. NBPs as low as 98/39.\n Action:\n Stop propofol and levo.\n Response:\n NBPs increased to 123/57\n 141/47. UOP still low at 15-30 ml/hr and\n disappointing response to lasix (40 mg).\n Plan:\n Anemia, other\n Assessment:\n Pt has hx of Afib w/ anticoagulation. INR >2 on admission w/ Hct of\n 26, guiac positive stool. Troponin up to 1.39 this admission. Pt\n received PRBCs this admission, FFP, and Vit K. CT abdomen neg for RP\n bleed.\n Action:\n Hold anticoagulants. Monitor for bleeding, labs (H/H).\n Response:\n INR this AM 1.8. H/H stable this afternoon at 29/9.2.\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732605, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 5/5. ABG 7.37/38/66. LS very\n rhonchorous bilat. Sp02 100%. Copious amts thin bronchial secretions\n via ETT as well as oropharyngeal secretions. Sputum cx this admission\n is pending. Pt is afebrile, WBC 10.6. Bilat pleural effusion on CXR.\n RSBI this morning 80. Pt moves LUE only, does not follow commands,\n PERRL, no gag, weak cough.\n Action:\n Admin abx as dir: vanc, , flagyl. VAP care / oral care. Attempt\n diuresis w/ 40 mg lasix this afternoon. Refrain from extubation today\n d/t increased secretions.\n Response:\n Min response to lasix. WBC this afternoon 8.8.\n Plan:\n Cont abx therapy, attempt further diuresis renal function allows. ?\n lasix gtt.\n Hypotension (not Shock)\n Assessment:\n Received pt on propofol 15 mcgs/kg/min for light sedation and low dose\n levophed at 0.03 mcg/kg/min for BP support. NBPs as low as 98/39.\n Action:\n Stop propofol and levo.\n Response:\n NBPs increased to 123/57\n 141/47. UOP still low at 15-30 ml/hr and\n disappointing response to lasix (40 mg).\n Plan:\n Anemia, other\n Assessment:\n Pt has hx of Afib w/ anticoagulation. INR >2 on admission w/ falling\n Hct of 26, guiac positive stool, low BPs. Troponin up to 1.39 this\n admission. Pt received PRBCs this admission, FFP, and Vit K. CT\n abdomen neg for RP bleed.\n Action:\n Hold anticoagulants. Monitor for bleeding, labs (H/H).\n Response:\n INR this AM 1.8. H/H stable this afternoon at 29/9.2. BP improving\n once off propofol.\n Plan:\n Cont to monitor hemodynamics, oxygenation, and labs.\n Impaired Skin Integrity\n Assessment:\n Pt has minimum of stage II decubitus ulcer on coccyx. Also\n nonblanchable area on proximal R heel.\n Action:\n Wound care consult, monitor pressure ulcers, keep mepilex on coccyx and\n keep heels off bed. Nutrition consult and begin TFs today.\n Response:\n Stable.\n Plan:\n Cont plan of care.\n" }, { "category": "Nursing", "chartdate": "2190-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732722, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd pt on 40%/.LS rhonchorous.Copious amount of thin frothy pink\n secretions through ET and copious amount of oral secretions.\n Action:\n IV Abx vanco/meropenem/ 40mg iv lasix.Scopilamine patch\n applied.\n Response:\n Pt is pos 1000cc for past 24 hrs.Secretion reduced compared to start of\n the shift.RSBI this am 50\n Plan:\n Cont abx therapy, attempt further diuresis renal function allows.\n Anemia, other\n Assessment:\n Guiac pos BM x1.\n Action:\n Hold anticoagulants. Monitor for bleeding, labs (H/H).\n Response:\n Hct stable this am.\n Plan:\n Cont to monitor hemodynamics, oxygenation, and labs.\n Impaired Skin Integrity\n Assessment:\n Pt has minimum of stage II decubitus ulcer on coccyx. Also\n nonblanchable area on proximal R heel.\n Action:\n Dressing to coccyx renewed.Frequent position changes.TF started.\n Response:\n Tf at 30cc/hr.Goal 55cc.\n Plan:\n Cont plan of care.\n Hypernatremia (high sodium)\n Assessment:\n PM sodium 146.\n Action:\n FWB through TF 200cc q4hrs.\n Response:\n Awaiting am labs.\n Plan:\n Cont to monitor.\n" }, { "category": "Physician ", "chartdate": "2190-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732728, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n \n Patient off of vasopressors. Attempting gentle diuresis with lasix\n boluses. Got 40mg IV x3 with reasonable response.\n Plan for family meeting today at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:57 PM\n Metronidazole - 01:15 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:57 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 96 (72 - 103) bpm\n BP: 129/69(83) {94/28(46) - 142/99(102)} mmHg\n RR: 26 (0 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,958 mL\n 506 mL\n PO:\n TF:\n 141 mL\n IVF:\n 1,453 mL\n 135 mL\n Blood products:\n Total out:\n 925 mL\n 485 mL\n Urine:\n 925 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,033 mL\n 21 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 426 (300 - 426) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 9.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 227 K/uL\n 9.5 g/dL\n 92 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 57 mg/dL\n 114 mEq/L\n 141 mEq/L\n 29.7 %\n 10.3 K/uL\n [image002.jpg]\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n Hct\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n Plt\n 255\n 208\n 186\n 227\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 20\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n Other labs: PT / PTT / INR:18.3/36.9/1.7, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732729, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n \n Patient off of vasopressors. Attempting gentle diuresis with lasix\n boluses. Got 40mg IV x3 with reasonable response.\n Plan for family meeting today at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:57 PM\n Metronidazole - 01:15 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:57 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 96 (72 - 103) bpm\n BP: 129/69(83) {94/28(46) - 142/99(102)} mmHg\n RR: 26 (0 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,958 mL\n 506 mL\n PO:\n TF:\n 141 mL\n IVF:\n 1,453 mL\n 135 mL\n Blood products:\n Total out:\n 925 mL\n 485 mL\n Urine:\n 925 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,033 mL\n 21 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 426 (300 - 426) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 9.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 227 K/uL\n 9.5 g/dL\n 92 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 57 mg/dL\n 114 mEq/L\n 141 mEq/L\n 29.7 %\n 10.3 K/uL\n [image002.jpg]\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n Hct\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n Plt\n 255\n 208\n 186\n 227\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 20\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n Other labs: PT / PTT / INR:18.3/36.9/1.7, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Worsening leukocytosis and fever concerning for possible\n resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - check vancomycin trough prior to PM dose\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin now trending down\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - hold coumadin for now, consider restarting in the near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 733125, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Patient remains ventillated pending arrival of family (possibly Good\n Friday). aware of patient for possible transfer once family gives\n approval. MAPs dropped overnight to 40s, but came up with repositioning\n patient - no pressors given.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:52 AM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Morphine Sulfate - 2 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:41 AM\n Heparin Sodium (Prophylaxis) - 10:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.7\nC (98.1\n HR: 112 (91 - 112) bpm\n BP: 102/49(61) {78/38(47) - 160/94(98)} mmHg\n RR: 17 (13 - 36) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 3,245 mL\n 1,078 mL\n PO:\n TF:\n 1,325 mL\n 396 mL\n IVF:\n 905 mL\n 222 mL\n Blood products:\n Total out:\n 240 mL\n 45 mL\n Urine:\n 240 mL\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,005 mL\n 1,033 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 471 (306 - 471) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 47\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.2 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR without significant change\n without improvement on BiPAP. Now intubated with improved ventilation\n on ABG. BNP greater than assay is consistent with CHF. Put out well in\n the ED. Anticoagulated, so PE seems less likely. Mucous plugging seems\n like a likely component as well. Worsening of leukocytosis and\n persistent fever concerning for possible resistant organism.\n - Family meeting ; patient now DNR. Will likely extubate when\n family can gather.\n - Continuing /Vanco/Flagyl\n - Respiratory comfort while on vent, on morphine drip for comfort\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. Na continues to improve this morning at 144.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, will stop subQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: DNR (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:29 PM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2190-03-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 733128, "text": "Objective\n Pertinent medications: Morphine drip, Normal saline @ 15ml/hr, ABX,\n RISS, Flagyl, Lansoprazole, Heparin, Vitamin D, Multi-vitamin\n Labs:\n Value\n Date\n Glucose\n 86 mg/dL\n 04:52 AM\n Glucose Finger Stick\n 151\n 10:00 AM\n BUN\n 59 mg/dL\n 04:52 AM\n Creatinine\n 1.7 mg/dL\n 04:52 AM\n Sodium\n 144 mEq/L\n 04:52 AM\n Potassium\n 3.7 mEq/L\n 04:52 AM\n Chloride\n 116 mEq/L\n 04:52 AM\n TCO2\n 18 mEq/L\n 04:52 AM\n PO2 (arterial)\n 66 mm Hg\n 03:50 PM\n PCO2 (arterial)\n 38 mm Hg\n 03:50 PM\n pH (arterial)\n 7.37 units\n 03:50 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 03:50 PM\n Calcium non-ionized\n 7.9 mg/dL\n 04:52 AM\n Phosphorus\n 4.1 mg/dL\n 04:52 AM\n Magnesium\n 1.9 mg/dL\n 04:52 AM\n WBC\n 15.0 K/uL\n 04:52 AM\n Hgb\n 9.4 g/dL\n 04:52 AM\n Hematocrit\n 30.2 %\n 04:52 AM\n Current diet order / nutrition support: Diet : NPO\n Tube feed : Isosource 1.5 @ 55ml/ht; 200ml water every 6 hours\n GI: soft/distended, positive bowel sounds, negative flatus\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Patient presented with hypoxia, consistent with pulmonary edema.\n Remains intubated. Tube feed running at goal via GJ tube to provide\n calories and 90g protein. Noted code changed to DNR. Awaiting\n family to extubate patient, possible transfer back to skilled nursing\n facility. BS well controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate:\n o Continue tube feed at goal while within plan of care\n Multivitamin / Mineral supplement: continue current\n Will follow to check plan, page if questions *\n 11:06\n" }, { "category": "Nursing", "chartdate": "2190-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732846, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 5/5. Sp02 100%. Mod amts of thin\n ETT and oropharyngeal secretions. LS clear and dim. Pt had periods of\n apnea today. WBC 10.3.\n Action:\n Pt put on AC for approx 1-2 hr today. Admin abx for PNA: flagyl,\n vancomycin, meropenum. Pt placed on lasix gtt for diuresis.\n Response:\n Pt placed back on rate and is ventilating well, SRR 20, MV 6.5 L. Sp02\n 100%. Pt did not diurese to lasix gtt, UOP 17-40 ml/hr, lasix gtt\n stopped and lytes being repleted.\n Plan:\n Cont abx, ? re-order scopalimine patch for increased secretions\n tonight.\n Impaired Skin Integrity\n Assessment:\n Pt has stage II on coccyx and non-blancheable mark on R heel.\n Action:\n Freq reposition, mepilex to coccyx, elevate heels, TF running at goal.\n Response:\n Stable.\n Plan:\n Cont skin care.\n Anemia, other\n Assessment:\n Pt has hx of afib w/ anticoagulation w/ Coumadin. Pt has guiac\n positive stool this admission.\n Action:\n Hold anticoagulants and monitor H/H . Admin SC heparin.\n Response:\n H/H stable: Hct 29.6 this PM, INR 1.7 this morning. Pt is in NSR\n 90-100 w/ PVCs.\n Plan:\n Cont to monitor H/H, monitor for signs of bleeding. Restart Coumadin\n before d/c to .\n" }, { "category": "Physician ", "chartdate": "2190-03-23 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 732849, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n \n Patient off of vasopressors. Attempting gentle diuresis with lasix\n boluses. Got 40mg IV x3 with reasonable response.\n Plan for family meeting today at .\n Opens eyes and follows commands; otherwise non-verbal. No apparent\n distress/pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:57 PM\n Metronidazole - 01:15 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:57 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 96 (72 - 103) bpm\n BP: 129/69(83) {94/28(46) - 142/99(102)} mmHg\n RR: 26 (0 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,958 mL\n 506 mL\n PO:\n TF:\n 141 mL\n IVF:\n 1,453 mL\n 135 mL\n Blood products:\n Total out:\n 925 mL\n 485 mL\n Urine:\n 925 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,033 mL\n 21 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 426 (300 - 426) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 9.3 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 227 K/uL\n 9.5 g/dL\n 92 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 57 mg/dL\n 114 mEq/L\n 141 mEq/L\n 29.7 %\n 10.3 K/uL\n [image002.jpg]\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n Hct\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n Plt\n 255\n 208\n 186\n 227\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 20\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n Other labs: PT / PTT / INR:18.3/36.9/1.7, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Initial worsening of leukocytosis and fever concerning for\n possible resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Today)\n - Pressure support trial on 5/0\n - Continuing /Vanco/Flagyl\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses followed by levophed\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - change vancomycin to 1gm q 24 hours\n - repeat sputum\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD s/p CABG, CHF, recurrent aspiration\n pneumonia, pulmonary edema, respiratory failure. Passed SBT, awaiting\n family meeting re goals of care. Off pressors, minimal response to\n lasix IV.\n Exam notable for Tm 98.8 BP 130/60 HR 96 RR 26 with sat 100 on PSV 5/5\n 0.4. WD man, NAD on vent. Coarse BS B. RRR s1s2. Soft +BS. 2+ edema.\n Labs notable for WBC 10K, HCT 29, K+ 3.4, Cr 1.6. CXR with B ASD.\n Agree with plan to manage recurrent respiratory failure with vanco /\n for possible pneumonia (to end Sunday), minimal response to lasix\n challenge - start lasix gtt, check PM lytes. AF - currently in NSR,\n hold coumadin for now. Hypernatremia - FWB via PEG, can decrease to\n 200q6. CRI - stable, follow vanco levels, RD meds. CAD / NSTEMI - ASA /\n statin. Will continue TFs. Need to clarify goals of care with family;\n my understanding is that they are meeting with the team at \n today to discuss this and will then contact the MICU team.\n Remainder of plan as outlined above.\n ADDENDUM\n Situation reviewed with RN from .\n After d/w son today, Mr. was made DNR with a plan to\n focus further efforts on comfort. I have spoke to and confirmed\n that his father will be DNR, and we are awaiting the DNR form from\n , which is to be faxed this PM. I\nve discussed with \n the timing of extubation, and he would like to speak to family members\n about coming in to the ICU tomorrow, with a plan for extubation\n followed by transport to SH when stable.\n Patient is critically ill\n Total time: 90 min\n ------ Protected Section Addendum Entered By: , MD\n on: 06:57 PM ------\n" }, { "category": "Physician ", "chartdate": "2190-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732908, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 04:00 AM\n Patient remains off vasopressors. Was on lasix drip, did not increase\n his UOP (averaging 30-45 ml/hour). Patient DNR after family meeting at\n - likely extubation when family can gather.\n Overnight spiked fever to 101.3 and received tylenol.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 113 (88 - 113) bpm\n BP: 127/68(81) {101/51(64) - 139/72(84)} mmHg\n RR: 30 (0 - 32) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 1,845 mL\n 881 mL\n PO:\n TF:\n 868 mL\n 349 mL\n IVF:\n 356 mL\n 132 mL\n Blood products:\n Total out:\n 892 mL\n 67 mL\n Urine:\n 892 mL\n 67 mL\n NG:\n Stool:\n Drains:\n Balance:\n 953 mL\n 815 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): 354 (328 - 457) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 10.7 L/min\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) Overweight / Obese,\n No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva pale, No(t)\n Sclera edema\n Head, Ears, Nose, Throat: No(t) Poor dentition, No(t) NG tube, No(t) OG\n tube\n Lymphatic: No(t) Cervical adenopathy\n Cardiovascular: (S1: No(t) Absent), (S2: No(t) Distant, No(t) Loud,\n No(t) Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,\n (Murmur: No(t) Systolic, 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: No(t) Paradoxical), (Percussion: No(t)\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n No(t) Clear : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished:\n , No(t) Absent : )\n Abdominal: No(t) Distended, No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed, No(t)\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Initial worsening of leukocytosis and fever concerning for\n possible resistant organism.\n - Family meeting yesterday; patient now DNR. Will likely extubate when\n family can gather.\n - Pressure support trial on 5/0\n - Continuing /Vanco/Flagyl\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses followed by levophed\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:23 AM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-24 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 732996, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 04:00 AM\n Patient remains off vasopressors. Was on lasix drip, did not increase\n his UOP (averaging 30-45 ml/hour). Patient DNR after family meeting at\n - likely extubation when family can gather.\n Overnight spiked fever to 101.3 and received tylenol.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 113 (88 - 113) bpm\n BP: 127/68(81) {101/51(64) - 139/72(84)} mmHg\n RR: 30 (0 - 32) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 1,845 mL\n 881 mL\n PO:\n TF:\n 868 mL\n 349 mL\n IVF:\n 356 mL\n 132 mL\n Blood products:\n Total out:\n 892 mL\n 67 mL\n Urine:\n 892 mL\n 67 mL\n NG:\n Stool:\n Drains:\n Balance:\n 953 mL\n 815 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): 354 (328 - 457) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 10.7 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR without significant change\n without improvement on BiPAP. Now intubated with improved ventilation\n on ABG. BNP greater than assay is consistent with CHF. Put out well in\n the ED. Anticoagulated, so PE seems less likely. Mucous plugging seems\n like a likely component as well. Worsening of leukocytosis and\n persistent fever concerning for possible resistant organism.\n - Family meeting yesterday; patient now DNR. Will likely extubate when\n family can gather.\n - Continuing /Vanco/Flagyl\n - Respiratory comfort while on vent, consider morphine\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - changed vancomycin to 1gm q 24 hours, obtain trough\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip did not increase urine output and was discontinued.\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:23 AM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD s/p CABG, CHF, recurrent aspiration\n pneumonia, pulmonary edema, respiratory failure. No response to lasix,\n febrile, RSBI worse, awaiting family.\n Exam notable for Tm 101.3 BP 100/60 HR 96 RR 26 with sat 100 on PSV\n 0.4 RSBI 105. WD man, NAD on vent. Coarse BS B. RRR s1s2. Soft\n +BS. 2+ edema. Labs notable for WBC 15K from 10K, HCT 30, K+ 3.7,\n Cr 1.7. CXR with B ASD / effusions.\n Agree with plan to manage recurrent respiratory failure with vanco /\n for progressive pneumonia / sepsis, and will continue remainder of\n current regimen, no labs / CXR. Would bolus for hypotension and will\n add morphine for respiratory discomfort / pain. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:04 PM ------\n" }, { "category": "Nursing", "chartdate": "2190-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732696, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd pt on 40%/.LS rhonchorous.Copious amount of thin frothy pink\n secretions through ET and copious amount of oral secretions.\n Action:\n IV Abx vanco/meropenem/ 40mg iv lasix.Scopilamine patch\n applied.\n Response:\n Pt is pos 1000cc for past 24 hrs.Secretion reduced compared to start of\n the shift.RSBI this am 50\n Plan:\n Cont abx therapy, attempt further diuresis renal function allows.\n Anemia, other\n Assessment:\n Action:\n Hold anticoagulants. Monitor for bleeding, labs (H/H).\n Response:\n Plan:\n Cont to monitor hemodynamics, oxygenation, and labs.\n Impaired Skin Integrity\n Assessment:\n Pt has minimum of stage II decubitus ulcer on coccyx. Also\n nonblanchable area on proximal R heel.\n Action:\n Dressing to coccyx renewed.Frequent position changes.TF started.\n Response:\n Tf at 30cc/hr.Goal 55cc.\n Plan:\n Cont plan of care.\n Hypernatremia (high sodium)\n Assessment:\n Na this am.\n Action:\n FWB through TF 200cc q4hrs.\n Response:\n Na this PM 146.\n Plan:\n Cont to monitor.\n" }, { "category": "Respiratory ", "chartdate": "2190-03-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 733001, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Pt received on SBT 5/0 - pt\n tachypneic with a RR of 41 and VT ranges 250-280. Pt placed on PSV 10/5\n as noted as a result. Pt's RR 34 after change with VT's mid 300's. Pt\n seems more comfortable.\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: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2190-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733003, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on SBT PS 0/+5/40%, with RR to 40\ns but maintaining O2 sat\n 100%. RSBI 105. Lung snds clear after ETT sxn\nd. Pt with eyes wide\n open, squeezing L hand on command, appearing anxious. Tmax 100.7po,\n presently 98.1po.\n Action:\n Pt returned to present vent settings PS 10/+5/40%. Morphine qtt started\n @ 2mg/hr for pt comfort.\n Response:\n RR now 21 and regular. Pt cont to have mod-lg amt of thin white\n secretions via ETT, as well as excessive clear oral secretions.\n Plan:\n Cont present med tx including Vanco, Meropenem, Flagyl. Morphine qtt\n for pt comfort. Awaiting son/proxy for extubation\ncomfort care.\n Hypotension (not Shock)\n Assessment:\n Generally, HR 110->91SR without VEA, BP 92/40-118/59. However @ 0715\n SBP dropped to 70\ns after pt turned STS.\n Action:\n Fluid bolus started for low BP, but stopped when BP spont retuned to\n baseline.\n Response:\n Stable @ present\n Plan:\n Cont telemetry. Fluid bolus rather than pressor if pt drops BP.\n" }, { "category": "Nursing", "chartdate": "2190-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733078, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on CPAP 10/5 40%, with RR to 30\ns but maintaining O2 sat 100%.\n Lung snds exhibit rhonchi/dim but this clears after ETT sxn\nd. Pt with\n eyes wide open, squeezing L hand on command, appearing anxious. Tmax\n 98.9.\n Action:\n Pt. continues on PS 10/+5/40%. Morphine qtt started @ 2mg/hr for pt\n comfort.\n Response:\n RR now 21 and regular. Pt cont to have mod-lg amt of thin white\n secretions via ETT, as well as excessive clear oral secretions.\n Plan:\n Cont present med tx including Vanco, Meropenem, Flagyl. Morphine qtt\n for pt comfort. Awaiting son/proxy for extubation\ncomfort care.\n Hypotension (not Shock)\n Assessment:\n Generally, HR 110->91SR without VEA, BP 82/40-117/59.\n Action:\n Fluid bolus started for low BP, but stopped when BP soon retuned to\n baseline.\n Response:\n Stable @ present\n Plan:\n Cont telemetry. Fluid bolus rather than pressor if pt drops BP\n" }, { "category": "Physician ", "chartdate": "2190-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732901, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 04:00 AM\n Patient remains off vasopressors. Was on lasix drip, did not increase\n his UOP (averaging 30-45 ml/hour). Patient DNR after family meeting at\n - likely extubation when family can gather.\n Overnight spiked fever to 101.3 and received tylenol.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:57 PM\n Metronidazole - 12:00 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 113 (88 - 113) bpm\n BP: 127/68(81) {101/51(64) - 139/72(84)} mmHg\n RR: 30 (0 - 32) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n Total In:\n 1,845 mL\n 881 mL\n PO:\n TF:\n 868 mL\n 349 mL\n IVF:\n 356 mL\n 132 mL\n Blood products:\n Total out:\n 892 mL\n 67 mL\n Urine:\n 892 mL\n 67 mL\n NG:\n Stool:\n Drains:\n Balance:\n 953 mL\n 815 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): 354 (328 - 457) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 10.7 L/min\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) Overweight / Obese,\n No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva pale, No(t)\n Sclera edema\n Head, Ears, Nose, Throat: No(t) Poor dentition, No(t) NG tube, No(t) OG\n tube\n Lymphatic: No(t) Cervical adenopathy\n Cardiovascular: (S1: No(t) Absent), (S2: No(t) Distant, No(t) Loud,\n No(t) Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,\n (Murmur: No(t) Systolic, 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: No(t) Paradoxical), (Percussion: No(t)\n Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds:\n No(t) Clear : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished:\n , No(t) Absent : )\n Abdominal: No(t) Distended, No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed, No(t)\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 258 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 116 mEq/L\n 144 mEq/L\n 30.2 %\n 15.0 K/uL\n [image002.jpg]\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n 04:40 PM\n 04:52 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n 15.0\n Hct\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n 29.6\n 30.2\n Plt\n 255\n 208\n 186\n 227\n 258\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n 1.6\n 1.7\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n 129\n 86\n Other labs: PT / PTT / INR:17.1/37.4/1.5, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:23 AM 55 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733069, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on SBT PS 0/+5/40%, with RR to 40\ns but maintaining O2 sat\n 100%. RSBI 105. Lung snds clear after ETT sxn\nd. Pt with eyes wide\n open, squeezing L hand on command, appearing anxious. Tmax 100.7po,\n presently 98.1po.\n Action:\n Pt returned to present vent settings PS 10/+5/40%. Morphine qtt started\n @ 2mg/hr for pt comfort.\n Response:\n RR now 21 and regular. Pt cont to have mod-lg amt of thin white\n secretions via ETT, as well as excessive clear oral secretions.\n Plan:\n Cont present med tx including Vanco, Meropenem, Flagyl. Morphine qtt\n for pt comfort. Awaiting son/proxy for extubation\ncomfort care.\n Hypotension (not Shock)\n Assessment:\n Generally, HR 110->91SR without VEA, BP 92/40-118/59. However @ 0715\n SBP dropped to 70\ns after pt turned STS.\n Action:\n Fluid bolus started for low BP, but stopped when BP spont retuned to\n baseline.\n Response:\n Stable @ present\n Plan:\n Cont telemetry. Fluid bolus rather than pressor if pt drops BP\n" }, { "category": "Nursing", "chartdate": "2190-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733071, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on CPAP 10/5 40%, with RR to 30\ns but maintaining O2 sat 100%.\n Lung snds exhibit rhonchi/dim but this clears after ETT sxn\nd. Pt with\n eyes wide open, squeezing L hand on command, appearing anxious. Tmax\n 98.9.\n Action:\n Pt. continues on PS 10/+5/40%. Morphine qtt started @ 2mg/hr for pt\n comfort.\n Response:\n RR now 21 and regular. Pt cont to have mod-lg amt of thin white\n secretions via ETT, as well as excessive clear oral secretions.\n Plan:\n Cont present med tx including Vanco, Meropenem, Flagyl. Morphine qtt\n for pt comfort. Awaiting son/proxy for extubation\ncomfort care.\n Hypotension (not Shock)\n Assessment:\n Generally, HR 110->91SR without VEA, BP 82/40-117/59.\n Action:\n Fluid bolus started for low BP, but stopped when BP soon retuned to\n baseline.\n Response:\n Stable @ present\n Plan:\n Cont telemetry. Fluid bolus rather than pressor if pt drops BP\n" }, { "category": "Respiratory ", "chartdate": "2190-03-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 733063, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\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 Comments: RSBI done on 0 peep/ 5 ips 47.\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: Will cont to monitor resp status.\n" }, { "category": "Respiratory ", "chartdate": "2190-03-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 733171, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Brown / Frothy\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\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: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2190-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733228, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Pt. is DNR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout .\n Action:\n Sx\nd for thick tan-greenish secretions in large amts.\n Response:\n Continues with large amts of secretions.\n Plan:\n Plan to ?extubate and send back to house in am.\n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact to coccyx wound. Right heel red with small scab on\n outer aspect.\n Action:\n Repositioned side to side.\n Response:\n Tolerating turning well.\n Plan:\n Continue to reposition side to side. ? need waffle boot to R foot due\n to reddened heel.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Abd. distended with hypoactive bowel sounds. Glucose <150.\n Action:\n TF shut off around 12am due to high residuals (700cc from OGT\n suctioned).\n Response:\n OGT clamped. GT clamped.\n Plan:\n Monitor abd. and possibly restart TF in am.\n" }, { "category": "Nursing", "chartdate": "2190-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733225, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Pt. is DNR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout .\n Action:\n Sx\nd for thick tan-greenish secretions in large amts.\n Response:\n Continues with large amts of secretions.\n Plan:\n Plan to ?extubate and send back to house in am.\n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact to coccyx wound. Right heel red with small scab on\n outer aspect.\n Action:\n Repositioned side to side.\n Response:\n Tolerating turning well.\n Plan:\n Continue to reposition side to side. ? need waffle boot to R foot due\n to reddened heel.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Abd. distended with hypoactive bowel sounds. Glucose <150.\n Action:\n TF shut off around 12am due to high residuals.\n Response:\n OGT clamped. GT clamped.\n Plan:\n Monitor abd. and possibly restart TF in am.\n" }, { "category": "Respiratory ", "chartdate": "2190-03-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732160, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Bloody / 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 Invasive ventilation assessment:\n Trigger work assessment: Not triggering, 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: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Bedside Procedures:\n ABG puncture\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732238, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 14, +5, 40%. Breath sounds rhonchorous, clear with\n suction. Suctioned x 3 for mod thick brown (old blood) secretions. Sats\n 100%. Overbreathing set RR 1-2 breaths occ when awake. Tv ~ 500. VERY\n impaired gag and cough, which is pt\ns baseline. Propofol gtt for\n sedation. ABG 7/41/31/155/20\n Action:\n Sputum specimen sent. Pulmonary hygiene. Orally suctioned for large amt\n thick brown secretions, same as from ETT. Continues on antibx for PNA.\n Lasix 40 mg IVP x 1. AM CXR pending. Propofol gtt off d/t hypotension.\n Surveillance BC sent this AM\n Response:\n Response from lasix fair, however UOP has ^^ over the course of the\n night ( be from levophed). Pt is comfortable off of sedation, RR 14\n when sleeping.\n Plan:\n Pulmonary hygiene. Continue antibx regime. Folow Cx data.\n Hypotension (not Shock)\n Assessment:\n NBP cuff is on right thigh d/t right arm edema and PICC in left arm.\n NBP gradually decreasing last evening from 110s->>low 70s/, MAP 50. NSR\n 70s-80s. Physical exam unchanged from previous admission\nright hand is\n cool, + radial pulse. Bil feet cool, dopplerable pulses. Left hand\n warm.\n Action:\n Levophed gtt started in setting of volume overload. Titrated to MAP>60.\n Attempted to wean levophed off unsuccessful. Currently @ 0.05 mcg.\n Response:\n Small dose levophed gtt required to keep MAP>60, SBP>90/.\n Plan:\n Wean levophed gtt s tolerated. Goal MAP>60\n Anemia, other\n Assessment:\n Hct on admission 31, rechecked @ 1600 ->26 in setting of diuresis. No\n S/S active bleeding. Secretions brown (old blood). INR 2.4\n Action:\n Repeat Hct sent @ 2200 with T&S. Coumadin held yesterday. Increased\n lansoprazole to \n Response:\n Hct @ 2200 24.3. AM Hct 26.5. No S/S active bleeding.\n Plan:\n Follow Hct. Monitor for S/S bleeding. Goal Hct>21.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcer on coccyx 3cm x 2 cm. Base is pink, surrounding skin is\n dark purple\n Action:\n Douderm gel and Mepilex placed, same treatment as recommended by wound\n care RN on initial admission and assessment on . Turned side->\n side. NPO for now d/t possible extubation today\n Response:\n Pressure ulcer looks a little worse than initial presentation .\n Plan:\n Duoderm gel with mepilex. Turn side to side, keep off of coccyx.\n Restart tube feeds when able. ? needs re-eval by wound care RN\n" }, { "category": "Nursing", "chartdate": "2190-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 733223, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2190-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732234, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 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: 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:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: Pt remains intubated with no sedation, breathing on mandatory\n rate on the vent. Pt has clear lunf sounds, but moderate thick brown\n secretions. Pt has no sedation on board but still very difficult to\n arouse. Pt to scored a strong RSBI score of 76 showing good\n spontaneous drive. Pt to continue current support.\n BEDSIDE RSBI- 76\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732223, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 18, +5, 40%. Breath sounds rhonchorous, clear with\n suction. Suctioned x 3 for mod thick brown (old blood) secretions. Sats\n 100%. Overbreathing set RR 1-2 breaths occ. VERY impaired gag and\n cough, which is pt\ns baseline. Propofol gtt for sedation. ABG\n 7/41/31/155/20\n Action:\n Sputum specimen sent. Pulmonary hygiene. Orally suctioned for large amt\n thick brown secretions, same as from ETT. Continues on antibx for PNA.\n Lasix 40 mg IVP x 1. AM CXR pending. Propofol gtt off d/t hypotension.\n Decreased RR from 18->14. Surveillance BC sent this AM\n Response:\n Response from lasix fair, however UOP has ^^ over the course of the\n night ( be from levophed). Pt is comfortable off of sedation, RR 14\n when sleeping.\n Plan:\n Pulmonary hygiene. Continue antibx regime. Folow Cx data.\n Hypotension (not Shock)\n Assessment:\n NBP cuff is on right thigh d/t right arm edema and PICC in left arm.\n NBP gradually decreasing last evening from 110s->>low 70s/, MAP 50. NSR\n 70s-80s. Physical exam unchanged from previous admission\nright hand is\n cool, + radial pulse. Bil feet cool, dopplerable pulses. Left hand\n warm.\n Action:\n Levophed gtt started in setting of volume overload. Titrated to MAP>60.\n Attempted to wean levophed off unsuccessful. Currently @ 0.05 mcg.\n Response:\n Small dose levophed gtt required to keep MAP>60, SBP>90/.\n Plan:\n Wean levophed gtt s tolerated. Goal MAP>60\n Anemia, other\n Assessment:\n Hct on admission 31, rechecked @ 1600 ->26 in setting of diuresis. No\n S/S active bleeding. Secretions brown (old blood). INR 2.4\n Action:\n Repeat Hct sent @ 2200 with T&S. Coumadin held yesterday. Increased\n lansoprazole to \n Response:\n Hct @ 2200 24.3. AM Hct 26.5. No S/S active bleeding.\n Plan:\n Follow Hct. Monitor for S/S bleeding. Goal Hct>21.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcer on coccyx 3cm x 2 cm. Base is ppink, surrounding skin is\n dark purple\n Action:\n Douderm gel and Mepilex placed, same treatment as recommended by wound\n care RN on initial admission and assessment on . Turned side->\n side. NPO for now d/t possible extubation today\n Response:\n Pressure ulcer looks a little worse than initial presentation .\n Plan:\n Duoderm gel with mepilex. Turn side to side, keep off of coccyx.\n Restart tube feeds when able. ? needs re-eval by wound care RN\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732224, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 18, +5, 40%. Breath sounds rhonchorous, clear with\n suction. Suctioned x 3 for mod thick brown (old blood) secretions. Sats\n 100%. Overbreathing set RR 1-2 breaths occ. VERY impaired gag and\n cough, which is pt\ns baseline. Propofol gtt for sedation. ABG\n 7/41/31/155/20\n Action:\n Sputum specimen sent. Pulmonary hygiene. Orally suctioned for large amt\n thick brown secretions, same as from ETT. Continues on antibx for PNA.\n Lasix 40 mg IVP x 1. AM CXR pending. Propofol gtt off d/t hypotension.\n Decreased RR from 18->14. Surveillance BC sent this AM\n Response:\n Response from lasix fair, however UOP has ^^ over the course of the\n night ( be from levophed). Pt is comfortable off of sedation, RR 14\n when sleeping.\n Plan:\n Pulmonary hygiene. Continue antibx regime. Folow Cx data.\n Hypotension (not Shock)\n Assessment:\n NBP cuff is on right thigh d/t right arm edema and PICC in left arm.\n NBP gradually decreasing last evening from 110s->>low 70s/, MAP 50. NSR\n 70s-80s. Physical exam unchanged from previous admission\nright hand is\n cool, + radial pulse. Bil feet cool, dopplerable pulses. Left hand\n warm.\n Action:\n Levophed gtt started in setting of volume overload. Titrated to MAP>60.\n Attempted to wean levophed off unsuccessful. Currently @ 0.05 mcg.\n Response:\n Small dose levophed gtt required to keep MAP>60, SBP>90/.\n Plan:\n Wean levophed gtt s tolerated. Goal MAP>60\n Anemia, other\n Assessment:\n Hct on admission 31, rechecked @ 1600 ->26 in setting of diuresis. No\n S/S active bleeding. Secretions brown (old blood). INR 2.4\n Action:\n Repeat Hct sent @ 2200 with T&S. Coumadin held yesterday. Increased\n lansoprazole to \n Response:\n Hct @ 2200 24.3. AM Hct 26.5. No S/S active bleeding.\n Plan:\n Follow Hct. Monitor for S/S bleeding. Goal Hct>21.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcer on coccyx 3cm x 2 cm. Base is ppink, surrounding skin is\n dark purple\n Action:\n Douderm gel and Mepilex placed, same treatment as recommended by wound\n care RN on initial admission and assessment on . Turned side->\n side. NPO for now d/t possible extubation today\n Response:\n Pressure ulcer looks a little worse than initial presentation .\n Plan:\n Duoderm gel with mepilex. Turn side to side, keep off of coccyx.\n Restart tube feeds when able. ? needs re-eval by wound care RN\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732225, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 14, +5, 40%. Breath sounds rhonchorous, clear with\n suction. Suctioned x 3 for mod thick brown (old blood) secretions. Sats\n 100%. Overbreathing set RR 1-2 breaths occ when awake. Tv ~ 500. VERY\n impaired gag and cough, which is pt\ns baseline. Propofol gtt for\n sedation. ABG 7/41/31/155/20\n Action:\n Sputum specimen sent. Pulmonary hygiene. Orally suctioned for large amt\n thick brown secretions, same as from ETT. Continues on antibx for PNA.\n Lasix 40 mg IVP x 1. AM CXR pending. Propofol gtt off d/t hypotension.\n Surveillance BC sent this AM\n Response:\n Response from lasix fair, however UOP has ^^ over the course of the\n night ( be from levophed). Pt is comfortable off of sedation, RR 14\n when sleeping.\n Plan:\n Pulmonary hygiene. Continue antibx regime. Folow Cx data.\n Hypotension (not Shock)\n Assessment:\n NBP cuff is on right thigh d/t right arm edema and PICC in left arm.\n NBP gradually decreasing last evening from 110s->>low 70s/, MAP 50. NSR\n 70s-80s. Physical exam unchanged from previous admission\nright hand is\n cool, + radial pulse. Bil feet cool, dopplerable pulses. Left hand\n warm.\n Action:\n Levophed gtt started in setting of volume overload. Titrated to MAP>60.\n Attempted to wean levophed off unsuccessful. Currently @ 0.05 mcg.\n Response:\n Small dose levophed gtt required to keep MAP>60, SBP>90/.\n Plan:\n Wean levophed gtt s tolerated. Goal MAP>60\n Anemia, other\n Assessment:\n Hct on admission 31, rechecked @ 1600 ->26 in setting of diuresis. No\n S/S active bleeding. Secretions brown (old blood). INR 2.4\n Action:\n Repeat Hct sent @ 2200 with T&S. Coumadin held yesterday. Increased\n lansoprazole to \n Response:\n Hct @ 2200 24.3. AM Hct 26.5. No S/S active bleeding.\n Plan:\n Follow Hct. Monitor for S/S bleeding. Goal Hct>21.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcer on coccyx 3cm x 2 cm. Base is ppink, surrounding skin is\n dark purple\n Action:\n Douderm gel and Mepilex placed, same treatment as recommended by wound\n care RN on initial admission and assessment on . Turned side->\n side. NPO for now d/t possible extubation today\n Response:\n Pressure ulcer looks a little worse than initial presentation .\n Plan:\n Duoderm gel with mepilex. Turn side to side, keep off of coccyx.\n Restart tube feeds when able. ? needs re-eval by wound care RN\n" }, { "category": "Physician ", "chartdate": "2190-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732312, "text": "24 Hour Events:\n Pt. remained intubated. He was diuresed, but remained hypotensive.\n Started on levophed and propofol was weaned down. EKG showed first\n degree block.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:07 PM\n Meropenem - 04:07 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 07:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.4\n HR: 78 (75 - 100) bpm\n BP: 112/62(73) {72/46(51) - 126/76(85)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,351 mL\n 573 mL\n PO:\n TF:\n IVF:\n 601 mL\n 233 mL\n Blood products:\n Total out:\n 236 mL\n 190 mL\n Urine:\n 236 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 600) mL\n Vt (Spontaneous): 411 (411 - 411) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.41/31/155/20/-3\n Ve: 8.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General: Sedated, intubated, opens eyes and grimaces to sternal rub\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not assessible, no LAD\n Lungs: clear anteriorly, good airmovement\n CV: RRR. Nl S1 and S2.\n Abdomen: soft, ABS. slightly distended from edema. nontender. tube in\n place.\n GU: foley in place. brown urine in foley bag.\n Ext: 2+ LE edema to knees\n Labs / Radiology\n 255 K/uL\n 8.4 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.3 mEq/L\n 61 mg/dL\n 120 mEq/L\n 149 mEq/L\n 26.5 %\n 11.4 K/uL\n [image002.jpg]\n 11:48 AM\n 02:28 PM\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n WBC\n 11.4\n Hct\n 26.1\n 24.3\n 26.5\n Plt\n 255\n Cr\n 1.4\n 1.4\n TropT\n 1.38\n 1.39\n TCO2\n 24\n 22\n 18\n 20\n Glucose\n 135\n 92\n Other labs: PT / PTT / INR:22.2/41.7/2.1, CK / CKMB /\n Troponin-T:148/21/1.39, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course today.\n Worsening leukocytosis and fever concerning for possible resistant\n organism.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n would have DC\nd today, but will keep\n him on these for now\n - Repeat TTE\n # Hypotension: pt. hypotensive with diuresis overnight, started on\n levophed overnight\n - consider CVL\n - decrease PEEP\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 149 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin still trending up\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down.\n - Hold Coumadin today in setting of ?bleed\n - Rate control as above\n - Repeat EKG in AM\n # Anemia: 5 point Hct drop in the setting of diuresis is concerning.\n Mild tachycardia, but patient is betablocked at baseline.\n - guaiac stools\n - continue PPI\n - T and S , transfuse 2 units PRBCs with lasix\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: hold coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732404, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 5/5 40%. Breath sounds a liitle rhonchorous, clear\n with suctioning. RR 20-24. Awake, chewing on ETT, frowning and looking\n distressed. Copious oral secretions.\n Action:\n Propofol gtt restarted , titrated to comfort. Pulmonary hygiene.\n Suctioned for thick yellow secretions. Orally suctioned for copious\n clear secretions with a little old blood, much less than yesterday.\n Antibx\n Response:\n Tolerating CPAP setting but needs propofol gtt tonight for comfort\n Plan:\n Antibx, pulmonary hygiene. RSBI in AM. Wean vent toward extubation.\n Team will clarify with pts son whether pt is for re-intubation.\n Pt is full code at this time.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732405, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 5/5 40%. Breath sounds a liitle rhonchorous, clear\n with suctioning. RR 20-24. Awake, chewing on ETT, frowning and looking\n distressed. Copious oral secretions.\n Action:\n Propofol gtt restarted , titrated to comfort. Pulmonary hygiene.\n Suctioned for thick yellow secretions. Orally suctioned for copious\n clear secretions with a little old blood, much less than yesterday.\n Antibx\n Response:\n Tolerating CPAP setting but needs propofol gtt tonight for comfort\n Plan:\n Antibx, pulmonary hygiene. RSBI in AM. Wean vent toward extubation.\n Team will clarify with pts son whether pt is for re-intubation.\n Pt is full code at this time.\n Hypotension (not Shock)\n Assessment:\n NBP cuff on right thigh. BP 110s-130s/, NSR 70s-80s. Levophed gtt on.\n Action:\n Levophed gtt titrated to MAP>60, gtt on/off, unable to wean levophed\n gtt off.\n Response:\n Requires low dose levophed gtt to keep MAP>60\n Plan:\n Monitor VS, levophed gtt titrated to MAP>60\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2190-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732420, "text": "Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\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 / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains orally intubated on PSV; was clearly agitated at\n beginning of shift, RN started propofol and pt appeared much more\n comfortable; remained on +5PSV/+5PEEP overnoc w/ Vt ~400s RR low 20s,\n maintaining Ve ~8L/M. RSBI = 80, but pt has many barriers to\n extubation including copious amounts of secretions\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: family meeting planned for tuesday to discuss goals of care;\n maintain support; pulmonary toilet\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732423, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 5/5 40%. Breath sounds a little rhonchorous, clear\n with suctioning. RR 20-24. Awake, chewing on ETT, frowning and looking\n distressed. Copious oral secretions.\n Action:\n Propofol gtt restarted , titrated to comfort. Pulmonary hygiene.\n Suctioned for several times for mod amt thick yellow secretions. Orally\n suctioned for copious clear secretions with a little old blood, much\n less than yesterday. Antibx for HCAP. Lasix 40 mg x 1. AM RSBI 80\n Response:\n Tolerating CPAP setting but needs propofol gtt tonight for comfort.\n Small increase in UOP from lasix. K repleted this AM.\n Plan:\n Antibx, pulmonary hygiene. Wean vent toward extubation. Team will\n clarify with pts son whether pt is for re-intubation. Pt is\n full code at this time. Family meeting Tuesday\n Hypotension (not Shock)\n Assessment:\n NBP cuff on right thigh. BP 110s-130s/, NSR 70s-80s. Levophed gtt on.\n Action:\n Levophed gtt titrated to MAP>60, gtt on/off. Attempted to wean levophed\n gtt off but SBP drops to 70s/..\n Response:\n Requires low dose levophed gtt to keep MAP>60\n Plan:\n Monitor VS, levophed gtt titrated to MAP>60\n Impaired Skin Integrity\n Assessment:\n Sacral decubitus ulcer unchanged from yesterday. ? stage.\n Action:\n Mepilex and duoderm gel as previously directed by wound care nurse.\n Turned side->side off of coccyx\n Response:\n No change in wound\n Plan:\n Dressing as above. Keep off of coccyx. Needs to be seen by wound care.\n Anemia, other\n Assessment:\n Incontinent small loose brown stool, trace OB +. No other S/S bleeding.\n No aspirate from PEG.\n Action:\n AM Hct 28.4 (28). Previcid \n Response:\n Stable Hct.\n Plan:\n Monitor for further S/S bleeding\n" }, { "category": "Physician ", "chartdate": "2190-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732279, "text": "24 Hour Events:\n Pt. remained intubated. He was diuresed, but remained hypotensive.\n Started on levophed and propofol was weaned down. EKG showed first\n degree block.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:07 PM\n Meropenem - 04:07 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 07:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.4\n HR: 78 (75 - 100) bpm\n BP: 112/62(73) {72/46(51) - 126/76(85)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,351 mL\n 573 mL\n PO:\n TF:\n IVF:\n 601 mL\n 233 mL\n Blood products:\n Total out:\n 236 mL\n 190 mL\n Urine:\n 236 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 600) mL\n Vt (Spontaneous): 411 (411 - 411) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.41/31/155/20/-3\n Ve: 8.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n Labs / Radiology\n 255 K/uL\n 8.4 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.3 mEq/L\n 61 mg/dL\n 120 mEq/L\n 149 mEq/L\n 26.5 %\n 11.4 K/uL\n [image002.jpg]\n 11:48 AM\n 02:28 PM\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n WBC\n 11.4\n Hct\n 26.1\n 24.3\n 26.5\n Plt\n 255\n Cr\n 1.4\n 1.4\n TropT\n 1.38\n 1.39\n TCO2\n 24\n 22\n 18\n 20\n Glucose\n 135\n 92\n Other labs: PT / PTT / INR:22.2/41.7/2.1, CK / CKMB /\n Troponin-T:148/21/1.39, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732282, "text": "24 Hour Events:\n Pt. remained intubated. He was diuresed, but remained hypotensive.\n Started on levophed and propofol was weaned down. EKG showed first\n degree block.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:07 PM\n Meropenem - 04:07 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 07:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.4\n HR: 78 (75 - 100) bpm\n BP: 112/62(73) {72/46(51) - 126/76(85)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,351 mL\n 573 mL\n PO:\n TF:\n IVF:\n 601 mL\n 233 mL\n Blood products:\n Total out:\n 236 mL\n 190 mL\n Urine:\n 236 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 600) mL\n Vt (Spontaneous): 411 (411 - 411) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.41/31/155/20/-3\n Ve: 8.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General: Sedated, intubated, minimal grimace to sternal rub\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not assessible, no LAD\n Lungs: rhonchorous, good airmovement\n CV: RRR. Nl S1 and S2.\n Abdomen: soft, ABS. slightly distended from edema. nontender. tube in\n place.\n GU: foley in place. brown urine in foley bag.\n Ext: 2+ LE edema to knees\n Labs / Radiology\n 255 K/uL\n 8.4 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.3 mEq/L\n 61 mg/dL\n 120 mEq/L\n 149 mEq/L\n 26.5 %\n 11.4 K/uL\n [image002.jpg]\n 11:48 AM\n 02:28 PM\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n WBC\n 11.4\n Hct\n 26.1\n 24.3\n 26.5\n Plt\n 255\n Cr\n 1.4\n 1.4\n TropT\n 1.38\n 1.39\n TCO2\n 24\n 22\n 18\n 20\n Glucose\n 135\n 92\n Other labs: PT / PTT / INR:22.2/41.7/2.1, CK / CKMB /\n Troponin-T:148/21/1.39, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n .\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course\n tommorow. Worsening leukocytosis and fever concerning for possible\n resistant organism.\n - Continue Ventilation now, but reduce set rate given worsening\n alkalosis over\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n - consider additional diuresis this afternoon as BP allows\n - repeat CXR in AM\n - Change sedation to propafol for hopeful extubation in AM\n .\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n .\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 149 this AM.\n - FW flushes through tube 250cc x4\n -\n .\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin still trending up\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n .\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib with stable hct for the past\n few days.\n - Continue coumadin\n - Rate control as above\n - Repeat EKG in AM\n .\n # Anemia: 5 point Hct drop in the setting of diuresis is concerning.\n Mild tachycardia, but patient is betablocked at baseline.\n - guaiac stools\n - continue PPI\n - T and S\n - Maintain 2 PIVs\n .\n # Dm: ISS\n .\n # Dementia: Continue mirtazapine\n .\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: On coumadin, PPI\n # Access: peripherals\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732286, "text": "24 Hour Events:\n Pt. remained intubated. He was diuresed, but remained hypotensive.\n Started on levophed and propofol was weaned down. EKG showed first\n degree block.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:07 PM\n Meropenem - 04:07 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 07:49 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.9\nC (98.4\n HR: 78 (75 - 100) bpm\n BP: 112/62(73) {72/46(51) - 126/76(85)} mmHg\n RR: 11 (11 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,351 mL\n 573 mL\n PO:\n TF:\n IVF:\n 601 mL\n 233 mL\n Blood products:\n Total out:\n 236 mL\n 190 mL\n Urine:\n 236 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 383 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 600) mL\n Vt (Spontaneous): 411 (411 - 411) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.41/31/155/20/-3\n Ve: 8.8 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General: Sedated, intubated, opens eyes and grimaces to sternal rub\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not assessible, no LAD\n Lungs: clear anteriorly, good airmovement\n CV: RRR. Nl S1 and S2.\n Abdomen: soft, ABS. slightly distended from edema. nontender. tube in\n place.\n GU: foley in place. brown urine in foley bag.\n Ext: 2+ LE edema to knees\n Labs / Radiology\n 255 K/uL\n 8.4 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.3 mEq/L\n 61 mg/dL\n 120 mEq/L\n 149 mEq/L\n 26.5 %\n 11.4 K/uL\n [image002.jpg]\n 11:48 AM\n 02:28 PM\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n WBC\n 11.4\n Hct\n 26.1\n 24.3\n 26.5\n Plt\n 255\n Cr\n 1.4\n 1.4\n TropT\n 1.38\n 1.39\n TCO2\n 24\n 22\n 18\n 20\n Glucose\n 135\n 92\n Other labs: PT / PTT / INR:22.2/41.7/2.1, CK / CKMB /\n Troponin-T:148/21/1.39, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n .\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course\n tommorow. Worsening leukocytosis and fever concerning for possible\n resistant organism.\n - Continue Ventilation now, but can attempt to extubate later this AM\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n - Change sedation to propafol for hopeful extubation in AM\n .\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n .\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 149 this AM.\n - FW flushes through tube 250cc x4\n -\n .\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin still trending up\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n .\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib with stable hct for the past\n few days.\n - Continue coumadin\n - Rate control as above\n - Repeat EKG in AM\n .\n # Anemia: 5 point Hct drop in the setting of diuresis is concerning.\n Mild tachycardia, but patient is betablocked at baseline.\n - guaiac stools\n - continue PPI\n - T and S\n - Maintain 2 PIVs\n .\n # Dm: ISS\n .\n # Dementia: Continue mirtazapine\n .\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: On coumadin, PPI\n # Access: peripherals\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732390, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732392, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd on vent settings CPAP/PS 7/+5/40% with SRR 16-23 and regular.\n O2 sat 100%. Lungs snds intermit rhonchorous in upper airways, clearing\n with suctioning of mod amts thin white secretions.\n Action:\n Vent settings weaned down to PS 5/+5/40%, then extended SBT 0/0/40%.\n Response:\n RR remained unchanged on SBT with O2 sat 100%, however SBP inc\nd to\n 130-140\ns. ABG 7.37/38/66. Pt cont to have significant secretions via\n ETT/oral and son/proxy unavailable to discuss post extubation plan\n (?reintubation), so pt returned to PS 5/+5/40% overnight.\n Plan:\n Cont aggressive pulm toilet. Attempt extubation tomorrow after\n discussion with son re ? reintubation. Family mtg Tuesday.\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt on Levophed @ .08mcg/kg/min. BP\n 87/51(sleeping)-136/57(awake/agitated), with HR 72-81SR without VEA. AM\n Hct 26.5, INR 2.1.\n Action:\n Pt to abd/pelvis CT without contrast for ? bleed. Pt rec\nd 1 bag FFP\n and Vit K 10mg via GT, as well as 1 unit PRBC\n Response:\n Levo weaned off for 3hrs, but then restarted for SBP in 70\n Plan:\n Guiaic stool when available. Cont to wean Levo as tolerated, with goal\n MAP>60.\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732393, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt rec\nd on vent settings CPAP/PS 7/+5/40% with SRR 16-23 and regular.\n O2 sat 100%. Lungs snds intermit rhonchorous in upper airways, clearing\n with suctioning of mod amts thin white secretions.\n Action:\n Vent settings weaned down to PS 5/+5/40%, then extended SBT 0/0/40%.\n Response:\n RR remained unchanged on SBT with O2 sat 100%, however SBP inc\nd to\n 130-140\ns. ABG 7.37/38/66. Pt cont to have significant secretions via\n ETT/oral and son/proxy unavailable to discuss post extubation plan\n (?reintubation), so pt returned to PS 5/+5/40% overnight.\n Plan:\n Cont aggressive pulm toilet. Attempt extubation tomorrow after\n discussion with son re ? reintubation. Family mtg Tuesday.\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt on Levophed @ .08mcg/kg/min. BP\n 87/51(sleeping)-136/57(awake/agitated), with HR 72-81SR without VEA. AM\n Hct 26.5, INR 2.1.\n Action:\n Pt to abd/pelvis CT without contrast for ? bleed. Pt rec\nd 1 bag FFP\n and Vit K 10mg via GT, as well as 1 unit PRBC\n Response:\n Levo weaned off for 3hrs, but then restarted for SBP in 70\ns. Repeat\n Hct 28.1.\n Plan:\n Guiaic stool when available. Cont to wean Levo as tolerated, with goal\n MAP>60.\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732535, "text": "TITLE: MICU Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n GEN: Intubated and sedated\n HEENT: NC/AT.\n PULM: Bilateral inspiratory rhonchi, left greater than right. Decreased\n breath sounds right base.\n CVS: RRR with normal S1+S2\n ABD: Hypoactive BS, soft, non-distended.\n Ext: 2+ Pitting edema bilaterally to halfway up shin.\n Neurologic: sedated\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n CT Abdomen/Pelvis without Contrast:\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with\n Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is\n recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared\n to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Worsening leukocytosis and fever concerning for possible\n resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - check vancomycin trough prior to PM dose\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin now trending down\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - hold coumadin for now, consider restarting in the near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732399, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732199, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Hypoxemia\n Assessment:\n Pt rec\nd from ED on vent settings CMV/AC 100%/20 X 600/+5 with no\n overbreathing rate. O2 sat 100%. Lung snds clear throughout. Pt sedated\n on Fentanyl and Versed.\n Action:\n ABG 7.47/29/336, and vent settings changed to 40%/18 X 600/+5. Pt\n suctioned for mod amts thick blood tinged secretions. EKG done. Nasal\n swab sent for ? MRSA. Sedation changed to Propofol in anticipation of\n short intubation. Pt spont opening eyes, but unresponsive to commands.\n Soft wrist restraints in place bilat for pt safety.\n Response:\n O2 sat has remained 100% with rare over-breathing of set rate.\n Plan:\n Cont aggressive pulm toilet. Monitor temp.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2190-03-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 732200, "text": "Chief Complaint: Increased work of breathing\n HPI: 78 yo M with multiple medical problems including ,\n Chronic aspiration, CVA, CAD, DM, Afib on coumdin presents from rehab\n after routine Vitals this Am noted an oxygen saturation of 69% on RA.\n He was suctioned twice with thick white secretions. He appeared to\n demonstrate increased work of breathing at that time. Oxygen saturation\n improved to 96% on 4L.\n .\n In the ED, initial vitals were 100.7, 104/54, 124, 35, 99 NRB. On exam,\n he was noted to be minimally responsive. He was noted to have coarse\n breath sounds, and appeared to have evidence of volume overload on\n exam. EKG showed afib. He was given lasix 40 mg IVx1. Initial VBG\n showed 7.35 / 39 / 43 / 22. Bipap was initiated and ABG showed\n 7.19/59/217/24. Based on worsening ABG, patient was intubated and\n started on fentanyl/versed for sedation. He received Vancomycin 1g\n IVx1, and Zosyn 4.5 g x1, as well as tylenol 650 mg pr x1. On\n transfer, VS were 117/59, 102, ac 100 FiO2, 600 cc, 20, Peep 5 on fent\n 25 mcg.\n .\n In the ICU, patient appears comfortable but is unresponsive to sternal\n rub.\n .\n Of note, patient was admitted though at with\n pneumonia. He was initially intubated and briefly on pressors, and\n later extubated on . Course was also complicated by NSTEMI that was\n felt to be demand, and anemia requiring 4 U PRBC. Antibiotics included\n Vanco/Cefepime/Flagyl for planned course through for total 12 day\n course. On , patient was retransferred to the MICU for respiratory\n distress that improved with bipap and diuresis. He was transferred to\n the floor and back to house the same day. Multiple family\n meetings were help regarding code status, but HCP and son \n , and decision was made to keep patient FULL CODE for now until\n the family could come to a complete consensus.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n # Aspirin 81 mg daily\n # Lisinopril 20 mg daily\n # Lansoprazole 30 mg \n # Furosemide 20 mg daily\n # Metoprolol Tartrate 25 mg \n # Isosorbide Dinitrate 10 mg TID\n # Mirtazapine 30 mg QHS\n # Coumadin 1 mg Tablet daily\n # Simvastatin 80 mg daily\n # Multivitamin daily\n # Vitamin D 400 daily\n # Prednisolone Acetate 1 % Drops, Suspension Sig: 1-2 drops\n Ophthalmic twice a day: right eye.\n # Bacitracin 500 unit/g Ointment Sig: One (1) application\n Ophthalmic twice a day.\n # Nitroglycerin 0.3 mg prn\n # Metronidazole 500 mg po Q8H\n # Vancomycin 750 mg Recon Soln Sig: Seven y (750)\n mg Intravenous every twelve (12) hours: last day .\n # Cefepime 2 gram Recon Soln Sig: Two (2) gm Intravenous every\n twenty-four(24) hours: last day .\n # ISS\n Past medical history:\n Family history:\n Social History:\n #. Ogilvies Syndrome- Has frequent admissions for abdominal\n distention, with dilated colon on imaging, which resolves with\n rectal tube decompression.\n #. Chronic aspiration (Per PCP)\n #. CVA complicated by expressive aphagia, dysphagia\n #. Coronary artery disease, s/p CABG in , mild systolic\n regional hypokinesis with EF 55%\n #. HTN\n #. Hyperlipidemia\n #. GERD\n #. History of pancreatitis\n #. Type 2 diabetes c/b gastroparesis\n #. Anemia h/o intermittent heme+ stools\n #. Atrial fibrillation on coumadin\n NC\n Living at nursing home since stroke in , wife passed\n away 5 years ago, no tobacco or ETOH use.\n Review of systems:\n Not assessed\n Flowsheet Data as of 07:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.4\nC (97.6\n HR: 100 (88 - 100) bpm\n BP: 121/75(85) {79/49(55) - 121/75(85)} mmHg\n RR: 18 (18 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 688 mL\n PO:\n TF:\n IVF:\n 188 mL\n Blood products:\n Total out:\n 0 mL\n 76 mL\n Urine:\n 76 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 612 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n SpO2: 100%\n ABG: 7.47/29/336/20/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 840\n Physical Examination\n T: 99.8 BP: 105/65 P: R: 21 18 O2: FiO2 40 AC 500 x 15 PEEP 5\n General: Sedated, intubated, minimal grimace to sternal rub\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not assessible, no LAD\n Lungs: rhonchorous, good airmovement\n CV: RRR. Nl S1 and S2.\n Abdomen: soft, ABS. slightly distended from edema. nontender. tube in\n place.\n GU: foley in place. brown urine in foley bag.\n Ext: 2+ LE edema to knees\n Labs / Radiology\n 135 mg/dL\n 1.4 mg/dL\n 60 mg/dL\n 20 mEq/L\n 121 mEq/L\n 3.7 mEq/L\n 150 mEq/L\n 26.1 %\n [image002.jpg]\n \n 2:33 A3/27/ 11:48 AM\n \n 10:20 P3/27/ 02:28 PM\n \n 1:20 P3/27/ 05:30 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 26.1\n Cr\n 1.4\n TropT\n 1.38\n TC02\n 24\n 22\n Glucose\n 135\n Other labs: CK / CKMB / Troponin-T:184/22/1.38, Lactic Acid:1.7 mmol/L,\n Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPOXEMIA\n DIABETES MELLITUS (DM), TYPE I\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n .\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course\n tommorow. Worsening leukocytosis and fever concerning for possible\n resistant organism.\n - Continue Ventilation now, but reduce set rate given worsening\n alkalosis over\n - Broaden coverage to /Vanco/Flagyl\n - Repeat TTE\n - consider additional diuresis this afternoon as BP allows\n - repeat CXR in AM\n - Change sedation to propafol for hopeful extubation in AM\n .\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n .\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above.\n - FW flushes through tube 250cc x4\n - Recheck NA in 4 hours\n .\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads.\n - cycle enzymes\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n .\n # Afib: Currently in sinus tachycardia, but was previously in Afib in\n ED. Pt has been on anticoagulation for afib with stable hct for the\n past few days.\n - Continue coumadin\n - Rate control as above\n - Repeat EKG in AM\n .\n # Anemia: 5 point Hct drop in the setting of diuresis is concerning.\n Mild tachycardia, but patient is betablocked at baseline.\n - guaiac stools\n - continue PPI\n - T and S\n - Maintain 2 PIVs\n .\n # Dm: ISS\n .\n # Dementia: Continue mirtazapine\n .\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: On coumadin, PPI\n # Access: peripherals\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT: Coumadin, INR therapeutic\n Stress ulcer: ppi\n VAP: hob elevation, chlorhexadine\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2190-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732201, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Hypoxemia\n Assessment:\n Pt rec\nd from ED on vent settings CMV/AC 100%/20 X 600/+5 with no\n overbreathing rate. O2 sat 100%. Lung snds clear throughout. Pt sedated\n on Fentanyl and Versed. VS HR 88-100SR without VEA, BP 79/49-121/75. T\n max 99.8R. Extremeties cool, especially R hand which is also more\n swollen than L.\n Action:\n ABG 7.47/29/336, and vent settings changed to 40%/18 X 600/+5. Pt\n suctioned for mod amts thick blood tinged secretions. EKG done. Nasal\n swab sent for ? MRSA. Sedation changed to Propofol in anticipation of\n short intubation. Pt spont opening eyes, but unresponsive to commands.\n Soft wrist restraints in place bilat for pt safety.\n Response:\n O2 sat has remained 100% with rare over-breathing of set rate.\n Plan:\n Cont aggressive pulm toilet, abx. Monitor temp.\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSG 170\n135. Pt NPO with OGT and PEG clamped. Abd soft/distended with +\n BS, no stool.\n Action:\n Pt rec\nd 2units Regular insulin per sliding scale.\n Response:\n Approp decrease in FSG.\n Plan:\n Cont insulin sliding scale routine.\n" }, { "category": "Nursing", "chartdate": "2190-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732211, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2190-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732795, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n \n Patient off of vasopressors. Attempting gentle diuresis with lasix\n boluses. Got 40mg IV x3 with reasonable response.\n Plan for family meeting today at .\n Opens eyes and follows commands; otherwise non-verbal. No apparent\n distress/pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:57 PM\n Metronidazole - 01:15 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:57 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 96 (72 - 103) bpm\n BP: 129/69(83) {94/28(46) - 142/99(102)} mmHg\n RR: 26 (0 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,958 mL\n 506 mL\n PO:\n TF:\n 141 mL\n IVF:\n 1,453 mL\n 135 mL\n Blood products:\n Total out:\n 925 mL\n 485 mL\n Urine:\n 925 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,033 mL\n 21 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 426 (300 - 426) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 9.3 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 227 K/uL\n 9.5 g/dL\n 92 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 57 mg/dL\n 114 mEq/L\n 141 mEq/L\n 29.7 %\n 10.3 K/uL\n [image002.jpg]\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n Hct\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n Plt\n 255\n 208\n 186\n 227\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 20\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n Other labs: PT / PTT / INR:18.3/36.9/1.7, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Initial worsening of leukocytosis and fever concerning for\n possible resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Today)\n - Pressure support trial on 5/0\n - Continuing /Vanco/Flagyl\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses followed by levophed\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above (last day Sunday )\n - follow cultures (NGTD)\n - change vancomycin to 1gm q 24 hours\n - repeat sputum\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x Q6h\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI, SQ heparin\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732796, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2190-03-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732885, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\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: 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 Comments: RSBI done on 0 peep/ 5 ips 105. Pt having increased amts of\n thick secretions.\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: Will cont to monitor resp status.\n" }, { "category": "Physician ", "chartdate": "2190-03-20 00:00:00.000", "description": "Weekend Intensivist Addendum", "row_id": 732195, "text": "TITLE: MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with Dr.\n for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 78 y/o man with multiple medical problems including , chronic\n aspiration, EF 40%, CVA, CAD, DM, Afib on coumdin admitted from after recent d/c from () here with hypoxemic\n respiratory failure. This AM, thick secretions suctioned, T 100.7.\n Initially felt to have CHF, received lasix and NTP and put on BiPap;\n however, worsening ABG, was intubated, given Vanc / Zosyn, Fentanyl,\n Versed, and sent to ICU.\n Of note, recent hospitalization for CHF, aspiration, pna requiring\n intubations. Discussion about code status had been held with plans for\n rediscussion .\n PMHx as above\n NKDA\n Meds reviewed\n VS notable for Tm 99.8, BP 80s-90s/50s, MAP60\n A/C 500x18(0)/5/40%\n Exam notable for PER, lungs with coarse BS, RRR S1 S2, abd soft, 2+\n edema, no rashes.\n Labs notable for WBC 20.3 from 13.3, Hct 32, Plt 350, INR 2.4, Cr 1.3,\n Na 148, Bicarb 19, CK 195, BNP > 70,000.\n Trop 1.2. Lactate 2.3 to 1.7.\n ABG 7.47/29/336 from 7.19/59/217\n CXR with diffuse b/l infiltrates\nc/w pulm edema\n, L PICC (from )\n ?in subclavian.\n EKG sinus tach IVCD LBBB pattern, new downsloping ST changes laterally.\n 78 y/o with recurrent hypoxemic respiratory failure due to CHF vs\n aspiration. Volume status difficult as likely in some chronic CHF,\n hypernatremic but BNP higher. Agree with treatment for HAP (will\n broaden\nmeropenem), diuresis as tolerated by BP for CHF, cycle\n enzymes, follow EKG, and consider repeat echo. Currently\n hyperventilating, will decrease minute ventilation by decreasing TV.\n If hemodynamics borderline, will first consider d/c\ning propofol, if\n persists, may need CVL, and check ScvO2. Free water repletion. Goals\n of care discussions have been in progress, and will need to be\n readdressed, but currently confirmed full code.\n Remainder of plan as above.\n Pt is critically ill CC time 60 minutes.\n" }, { "category": "Nursing", "chartdate": "2190-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732197, "text": "Pt D/C'd to rehab from , but returned less\n than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. Pt intubated in transfered to MICU.\n Brother/proxy now says goal is to pt up to allow return to \n where he will be made comfort measures.\n PMH: CVA with dysphagia, recurrent PNA, aspiration, CHF, NSTEMI, AFib\n on coumadin, HTN, GERD, hypertension, anemia, pancreatitis, great R\n toes amp. He has lived @ the last 5 years.\n Pt is presently a FULL CODE per son/proxy, .\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2190-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732765, "text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n \n Patient off of vasopressors. Attempting gentle diuresis with lasix\n boluses. Got 40mg IV x3 with reasonable response.\n Plan for family meeting today at .\n Opens eyes and follows commands; otherwise non-verbal. No apparent\n distress/pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Vancomycin - 08:57 PM\n Metronidazole - 01:15 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:57 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 96 (72 - 103) bpm\n BP: 129/69(83) {94/28(46) - 142/99(102)} mmHg\n RR: 26 (0 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,958 mL\n 506 mL\n PO:\n TF:\n 141 mL\n IVF:\n 1,453 mL\n 135 mL\n Blood products:\n Total out:\n 925 mL\n 485 mL\n Urine:\n 925 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,033 mL\n 21 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 426 (300 - 426) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 50\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: ///18/\n Ve: 9.3 L/min\n Physical Examination\n General: Patient opens eyes and orients to voice; no apparent distress;\n follows commands to open eyes, squeeze hands\n HEENT: Intubated\n CV: Regular rate/rhythm, nl s1 s2\n Lungs: Soft diffuse rhonchi, crackles at left base\n Abdomen: Soft, no apparent tenderness to palpation, +NABS\n Extremities: Toes of left foot amputated, great toe of right foot\n amputated. Significant edema in feet prevents palpation of DP pulses,\n but feet appear warm/well-perfused.\n Skin: Sacral lesion noted by nursing not examined at this time\n Labs / Radiology\n 227 K/uL\n 9.5 g/dL\n 92 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 57 mg/dL\n 114 mEq/L\n 141 mEq/L\n 29.7 %\n 10.3 K/uL\n [image002.jpg]\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n 03:16 PM\n 05:46 AM\n WBC\n 11.4\n 10.6\n 8.8\n 10.3\n Hct\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n 29.0\n 29.7\n Plt\n 255\n 208\n 186\n 227\n Cr\n 1.4\n 1.5\n 1.5\n 1.5\n 1.6\n TropT\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 20\n 23\n Glucose\n 92\n 111\n 100\n 87\n 92\n Other labs: PT / PTT / INR:18.3/36.9/1.7, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Worsening leukocytosis and fever concerning for possible\n resistant organism. CXR today with worsening infiltrates.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 5/0\n - Continuing /Vanco/Flagyl\n # Hypotension: Pt normotensive now off of vasopressors for 24 hours.\n - continue to monitor; if becomes hypotensive will attempt gentle\n boluses followed by levophed\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - Continue antibiotics as above\n - follow cultures (NGTD)\n - change vancomycin to 1gm q 24 hours\n - repeat sputum\n - will complete 8 day course of Meropenem (last dose Sunday, )\n # Fluid Overload\n patient with total body overload.\n - check PM lytes, replete electrolytes as needed\n - Lasix drip\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na continues to improve this morning at 141.\n - Continue FW flushes through tube 200cc x 4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin not re-checked today.\n - asa 325 mg daily\n - high dose statin\n - d/c beta blocker\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down. Concern\n for RP bleed but nothing on imaging.\n - continue to hold Coumadin, but consider low dose in near future\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: IV boluses as needed, replete electrolytes, TF\n # Prophylaxis: pneumoboots, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2190-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732965, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years.\n Code Status: DNR Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on SBT PS 0/+5/40%, with RR to 40\ns but maintaining O2 sat\n 100%. Lung snds clear after ETT sxn\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732470, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732473, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course today.\n Worsening leukocytosis and fever concerning for possible resistant\n organism.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n would have DC\nd today, but will keep\n him on these for now\n - Repeat TTE\n # Hypotension: pt. hypotensive with diuresis overnight, started on\n levophed overnight\n - consider CVL\n - decrease PEEP\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 149 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin still trending up\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down.\n - Hold Coumadin today in setting of ?bleed\n - Rate control as above\n - Repeat EKG in AM\n # Anemia: 5 point Hct drop in the setting of diuresis is concerning.\n Mild tachycardia, but patient is betablocked at baseline.\n - guaiac stools\n - continue PPI\n - T and S , transfuse 2 units PRBCs with lasix\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: hold coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732489, "text": "TITLE: MICU Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n GEN: Intubated and sedated\n HEENT: NC/AT.\n PULM: Bilateral inspiratory rhonchi, left greater than right. Decreased\n breath sounds right base.\n CVS: RRR with normal S1+S2\n ABD: Hypoactive BS, soft, non-distended.\n Neurologic: sedated\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n CT Abdomen/Pelvis without Contrast:\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with\n Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is\n recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared\n to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course today.\n Worsening leukocytosis and fever concerning for possible resistant\n organism.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n would have DC\nd today, but will keep\n him on these for now\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin now trending down\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down.\n - restart coumadin\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 732490, "text": "TITLE: MICU Progress Note\n Chief Complaint:\n 24 Hour Events:\n Pt remained intubated. Spoke w/ son who says that goal is for family\n meeting on Tuesday at where family will discuss goals of\n care with staff. Indicated that they may move towards do\n not hospitalize, CMO. Did well on SBT but remained intubated through\n the day for concern of need for re-intubation. Transfused 1 unit PRBCs.\n INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd\n obtained for concern of RP bleed, did not show evidence of RP bleed,\n but did show anasarca, pleural effusions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:14 PM\n Metronidazole - 04:06 PM\n Vancomycin - 08:00 PM\n Meropenem - 04:05 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:07 AM\n Furosemide (Lasix) - 02:41 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 06:57 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: 37.1\nC (98.8\n HR: 81 (68 - 89) bpm\n BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg\n RR: 24 (13 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,956 mL\n 552 mL\n PO:\n TF:\n IVF:\n 1,707 mL\n 522 mL\n Blood products:\n 639 mL\n Total out:\n 795 mL\n 215 mL\n Urine:\n 795 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,161 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 499 (317 - 499) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 80\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.37/38/66/20/-2\n Ve: 11.9 L/min\n PaO2 / FiO2: 165\n Physical Examination\n GEN: Intubated and sedated\n HEENT: NC/AT.\n PULM: Bilateral inspiratory rhonchi, left greater than right. Decreased\n breath sounds right base.\n CVS: RRR with normal S1+S2\n ABD: Hypoactive BS, soft, non-distended.\n Ext: 2+ Pitting edema bilaterally to halfway up shin.\n Neurologic: sedated\n Labs / Radiology\n 208 K/uL\n 9.1 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 58 mg/dL\n 117 mEq/L\n 145 mEq/L\n 28.4 %\n 10.6 K/uL\n [image002.jpg]\n 05:30 PM\n 08:56 PM\n 10:15 PM\n 10:41 PM\n 02:28 AM\n 12:40 PM\n 03:50 PM\n 05:50 PM\n 11:19 PM\n 02:24 AM\n WBC\n 11.4\n 10.6\n Hct\n 26.1\n 24.3\n 26.5\n 26.7\n 28.1\n 28.4\n Plt\n 255\n 208\n Cr\n 1.4\n 1.4\n 1.5\n 1.5\n TropT\n 1.38\n 1.39\n 1.28\n 1.26\n 1.28\n TCO2\n 18\n 20\n 23\n Glucose\n 135\n 92\n 111\n 100\n Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /\n Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,\n Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:3.8 mg/dL\n CT Abdomen/Pelvis without Contrast:\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with\n Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is\n recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared\n to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n Assessment and Plan\n 78 y/o M with multiple medical problems including healthcare associated\n pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who\n presents with hypoxia, consistent with pulmonary edema.\n # Acute hypercarbic respiratory failure: CXR with increased volume and\n patient did not improve with Bipap in the ED. Now intubated with\n improved ventilation on ABG. BNP greater than assay is markedly\n consistent with CHF. Put out well in the ED. Anticoagulated, so PE\n seems less likely. Mucous plugging seems like a likely component as\n well. Already on HAP treatment, and schedule to complete course today.\n Worsening leukocytosis and fever concerning for possible resistant\n organism.\n - Continue Ventilation now and talk with family about possible\n extubation (family meeting scheduled for Tuesday)\n - Pressure support trial on 0/0\n - Continuing /Vanco/Flagyl\n would have DC\nd today, but will keep\n him on these for now\n - Repeat TTE\n # Hypotension: pt. intermittently hypotensive with diuresis, continues\n on levophed\n - consider CVL\n - attempt to wean pressor\n # Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on\n admission on . Piperacillin-tazobactam was changed to cefepime on\n . Metronidazole was added on due to persistent fevers.\n - broaden as above\n - follow cultures\n - repeat sputum\n # Hypernatremia: be do to poor po intake, but patient total body\n overloaded. 2.5 L deficit at this time. Do not want to fluid bolus\n given CHF as above. Na 145 this AM. FWD about 2L\n - Continue FW flushes through tube 250cc x4\n # NSTEMI: Troponin elevated but flat CK, could be consistent with\n resolving infarct on last admission. EKG with signs of demand in\n lateral leads. Troponin now trending down\n - cycle enzymes to peak\n - asa 325 mg daily\n - high dose statin\n - Betablocker with holding parameters\n - hold ace-i in setting of acute CHF\n # Afib: Sinus tachycardia has resolved, was previously in Afib in ED.\n Pt has been on anticoagulation for afib but Hct trending down.\n - restart coumadin after guaiac negative\n - Rate control as above\n - Repeat EKG this morning\n # Anemia: HCT appears stable after transfusion of 1 unit pRBCs.\n - continue PPI\n - T and S\n - Maintain 2 PIVs , PICC\n # Dm: ISS\n # Dementia: Continue mirtazapine\n # FEN: Gentle D5 IVF, replete electrolytes, NPO for now\n # Prophylaxis: restart coumadin, PPI\n # Access: peripheral\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n # Communication: has two daughters and son; is HCP, work\n no: . Email: . , daughter\n .\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n I\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:45 PM\n 18 Gauge - 01:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2190-03-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732361, "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: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n :\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\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 / 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 :\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, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1130\n none\n Bedside Procedures:\n ABG puncture (1600)\n Comments:\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732610, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 5/5. ABG 7.37/38/66. LS very\n rhonchorous bilat. Sp02 100%. Copious amts thin bronchial secretions\n via ETT as well as oropharyngeal secretions. Sputum cx this admission\n is pending. Pt is afebrile, WBC 10.6. Bilat pleural effusion on CXR.\n RSBI this morning 80. Pt moves LUE only, does not follow commands,\n PERRL, no gag, weak cough.\n Action:\n Admin abx as dir: vanc, , flagyl. VAP care / oral care. Attempt\n diuresis w/ 40 mg lasix this afternoon. Refrain from extubation today\n d/t increased secretions.\n Response:\n Min response to lasix. WBC this afternoon 8.8.\n Plan:\n Cont abx therapy, attempt further diuresis renal function allows. ?\n lasix gtt.\n Hypotension (not Shock)\n Assessment:\n Received pt on propofol 15 mcgs/kg/min for light sedation and low dose\n levophed at 0.03 mcg/kg/min for BP support. NBPs as low as 98/39.\n Action:\n Stop propofol and levo.\n Response:\n NBPs increased to 123/57\n 141/47. UOP still low at 15-30 ml/hr and\n disappointing response to lasix (40 mg). Occ bronchospastic episodes\n now that sedation is off.\n Plan:\n Cont to monitor BPs and ? bolus sedation for comfort.\n Anemia, other\n Assessment:\n Pt has hx of Afib w/ anticoagulation. INR >2 on admission w/ falling\n Hct of 26, guiac positive stool, low BPs. Troponin up to 1.39 this\n admission. Pt received PRBCs this admission, FFP, and Vit K. CT\n abdomen neg for RP bleed.\n Action:\n Hold anticoagulants. Monitor for bleeding, labs (H/H).\n Response:\n INR this AM 1.8. H/H stable this afternoon at 29/9.2. BP improving\n once off propofol.\n Plan:\n Cont to monitor hemodynamics, oxygenation, and labs.\n Impaired Skin Integrity\n Assessment:\n Pt has minimum of stage II decubitus ulcer on coccyx. Also\n nonblanchable area on proximal R heel.\n Action:\n Wound care consult, monitor pressure ulcers, keep mepilex on coccyx and\n keep heels off bed. Nutrition consult and begin TFs today.\n Response:\n Stable.\n Plan:\n Cont plan of care.\n" }, { "category": "Nursing", "chartdate": "2190-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 732612, "text": "HPI: Pt D/C'd to rehab from , but returned\n less than 24hrs later with C/O inc'd WOB, O2 sat 69% on RA, inc'd\n secretions, and temp. He also had hyperglycemic episode in am with FSG\n 348 and diaphoretic. In ED, ABG 7.19/59/217 on masked ventilation so pt\n intubated. Temp 102.8R tx\nd with Tylenol, and rec\nd Vancomycin and\n Zosyn. Pt then transferred to MICU. Brother/proxy now says goal is to\n pt up to allow return to where he will be made\n comfort measures. PMH: CVA with dysphagia, recurrent PNA, aspiration,\n CHF, NSTEMI, AFib on coumadin, HTN, GERD, hypertension, anemia,\n pancreatitis, great R toes amp. He has lived @ the last 5\n years. Code Status: Pt is presently a FULL CODE per son/proxy,\n . Allergy: NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on CPAP 40% 5/5. ABG 7.37/38/66. LS very\n rhonchorous bilat. Sp02 100%. Copious amts thin bronchial secretions\n via ETT as well as oropharyngeal secretions. Sputum cx this admission\n is pending. Pt is afebrile, WBC 10.6. Bilat pleural effusion on CXR.\n RSBI this morning 80. Pt moves LUE only, does not follow commands,\n PERRL, no gag, weak cough.\n Action:\n Admin abx as dir: vanc, , flagyl. VAP care / oral care. Attempt\n diuresis w/ 40 mg lasix this afternoon. Refrain from extubation today\n d/t increased secretions.\n Response:\n Min response to lasix. WBC this afternoon 8.8.\n Plan:\n Cont abx therapy, attempt further diuresis renal function allows. ?\n lasix gtt.\n Hypotension (not Shock)\n Assessment:\n Received pt on propofol 15 mcgs/kg/min for light sedation and low dose\n levophed at 0.03 mcg/kg/min for BP support. NBPs as low as 98/39.\n Action:\n Stop propofol and levo.\n Response:\n NBPs increased to 123/57\n 141/47. UOP still low at 15-30 ml/hr and\n disappointing response to lasix (40 mg). Occ bronchospastic episodes\n now that sedation is off.\n Plan:\n Cont to monitor BPs and ? bolus sedation for comfort.\n Anemia, other\n Assessment:\n Pt has hx of Afib w/ anticoagulation. INR >2 on admission w/ falling\n Hct of 26, guiac positive stool, low BPs. Troponin up to 1.39 this\n admission. Pt received PRBCs this admission, FFP, and Vit K. CT\n abdomen neg for RP bleed.\n Action:\n Hold anticoagulants. Monitor for bleeding, labs (H/H).\n Response:\n INR this AM 1.8. H/H stable this afternoon at 29/9.2. BP improving\n once off propofol.\n Plan:\n Cont to monitor hemodynamics, oxygenation, and labs.\n Impaired Skin Integrity\n Assessment:\n Pt has minimum of stage II decubitus ulcer on coccyx. Also\n nonblanchable area on proximal R heel.\n Action:\n Wound care consult, monitor pressure ulcers, keep mepilex on coccyx and\n keep heels off bed. Nutrition consult and begin TFs today.\n Response:\n Stable.\n Plan:\n Cont plan of care.\n Hypernatremia (high sodium)\n Assessment:\n Na this AM 145 and has been elevated this admission to 149.\n Action:\n Pt completed 1 L D5W this AM, cont KVO w/ D5. Admin FWB as dir.\n Response:\n Na this PM 146.\n Plan:\n Cont to monitor.\n" }, { "category": "Respiratory ", "chartdate": "2190-03-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 732614, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n 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: White / Frothy\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Occasional periods of tachypnea\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: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n" }, { "category": "Respiratory ", "chartdate": "2190-03-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 733237, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Frothy\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Comfort measures only; Comments: Family meeting today\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Radiology", "chartdate": "2190-03-21 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1127793, "text": ", MED MICU 11:51 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please assess for RP bleed, non con\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 yom, hypotensive, dropping Hct, no clear source of bleeding, on coumadin,\n prior fem line\n REASON FOR THIS EXAMINATION:\n please assess for RP bleed, non con\n CONTRAINDICATIONS for IV CONTRAST:\n changing renal function\n ______________________________________________________________________________\n PFI REPORT\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n\n" }, { "category": "Radiology", "chartdate": "2190-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127687, "text": " 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n FINAL ADDENDUM\n Left PICC tip appears to have been withdrawn, terminating within the left\n subclavian vein.\n\n DFDdp\n\n\n 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man with hypoxia. Evaluate for infiltrate.\n\n COMPARISON: Multiple prior chest radiographs, with the latest on and .\n\n SINGLE FRONTAL CHEST RADIOGRAPH: Compared to the study on , there is\n interval increase of pulmonary markings in the right lung, compatible with\n interval increase of pulmonary edema. Small bilateral pleural effusions are\n present. Bibasilar atelectasis persists. There is no pneumothorax. The\n cardiomediastinal silhouette is grossly normal and unchanged. Multiple median\n sternotomy wires are unchanged. The right shoulder arthroplasty is unchanged.\n Moderate degenerative disease is noted in the left shoulder. Abdominal drains\n are partially imaged.\n\n IMPRESSION: Mild-to-moderate pulmonary edema, worse in the interval, with\n small bilateral pleural effusions and bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2190-03-21 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 1127792, "text": " 11:51 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please assess for RP bleed, non con\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 yom, hypotensive, dropping Hct, no clear source of bleeding, on coumadin,\n prior fem line\n REASON FOR THIS EXAMINATION:\n please assess for RP bleed, non con\n CONTRAINDICATIONS for IV CONTRAST:\n changing renal function\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SUN 12:55 PM\n 1. No definite evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is recommended.\n 3. Large bilateral pleural effusions, slightly increased when compared to\n prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\n\n COMPARISON: .\n\n HISTORY: Hypotensive with dropping hematocrit, no clear source of bleeding.\n\n TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were\n obtained. IV contrast was not administered.\n\n FINDINGS: There are large bilateral pleural effusions, similar when compared\n to prior exam. There is no pericardial effusion. Calcifications of the\n aortic valve are noted. NG tube is identified terminating within the stomach.\n GJ-tube is also identified terminating within the proximal jejunum. Within\n the limitation of a non-contrast exam, the spleen, liver, adrenal glands,\n pancreas, and kidneys are unremarkable. Calcifications of the splenic artery,\n descending aorta and its branches are noted. Small bowel loops are normal in\n caliber and without focal wall thickening. There is no free fluid or free\n air. There is no mesenteric or retroperitoneal lymphadenopathy. There is no\n evidence of large retroperitoneal bleed identified.\n\n CT OF THE PELVIS: Extensive streak artifact from bilateral hip prosthesis\n limits evaluation of the pelvis. The bladder contains a Foley catheter, with\n small foci of air, likely due to recent catheterization. Large amount of air\n and fluid within the sigmoid colon and rectum are noted. The fluid appears\n hyperdense and distends the lumen of the colon. Correlation with Hemoccult\n test is recommended. There is no definite pelvic or inguinal lymphadenopathy.\n There is diffuse anasarca.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n (Over)\n\n 11:51 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please assess for RP bleed, non con\n Admitting Diagnosis: HYPOXIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multilevel degenerative changes are unchanged.\n\n IMPRESSION:\n 1. No evidence of retroperitoneal bleeding.\n 2. Hyperdense fluid within the sigmoid colon. Correlation with Hemoccult is\n recommended to exclude blood within the colon. Alternately, this may\n represent oral contrast. Correlation with clinical history is recommended.\n 3. Large bilateral pleural effusions, similar when compared to prior exam.\n 4. Vascular calcifications.\n 5. Diffuse anasarca.\n\n Findings discussed with Dr. via telephone.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2176-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207089, "text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute pathology\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with acute pathology\n REASON FOR THIS EXAMINATION:\n acute pathology\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Look for pathology.\n\n TECHNIQUE: AP upright portable radiograph of the chest.\n\n No prior chest radiographs are available for comparison.\n\n IMPRESSION: Patient is status post median sternotomy with intact sternotomy\n sutures. Both lungs are clear without lung consolidation. Pleural effusion,\n if any, is minimal on the left side. Heart size, mediastinal and hilar\n contours are normal. Mild atherosclerotic calcification seen in the aortic\n arch.\n\n" }, { "category": "Echo", "chartdate": "2176-08-13 00:00:00.000", "description": "Report", "row_id": 91898, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function.\nStatus: Inpatient\nDate/Time: at 22:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal. A\nbioprosthetic aortic valve prosthesis is present. The mitral valve leaflets\nare mildly thickened. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Limited emergency study. Grossly preserved biventricular systolic\nfunction.\n\n\n" }, { "category": "ECG", "chartdate": "2176-08-16 00:00:00.000", "description": "Report", "row_id": 250732, "text": "Sinus rhythm. Minimal ST segment elevation in the inferior and anterolateral\nleads. Low voltage in the limb leads. Compared to the previous tracing\nof ST segment elevation is less.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-08-13 00:00:00.000", "description": "Report", "row_id": 250733, "text": "Artifact is present. Sinus rhythm. ST segment elevation in the inferior and\nanterolateral leads consistent with acute myocardial infarction. Clinical\ncorrelation is advised. Compared to the previous tracing of the same day\nST segment elevation is slightly more diffuse.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2176-08-15 00:00:00.000", "description": "Report", "row_id": 250962, "text": "Sinus rhythm with atrial premature beats. Otherwise, the findings are the same\nas on tracing #2 without change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2176-08-14 00:00:00.000", "description": "Report", "row_id": 250963, "text": "Sinus rhythm. Compared to tracing #1 the findings are the same without change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-08-14 00:00:00.000", "description": "Report", "row_id": 250964, "text": "Sinus rhythm. Right atrial abnormality. Possible inferior ST segment\nelevations raising concern for acute myocardial ischemia in inferior and\nlateral walls. Compared to the previous tracing of the findings are\nsimilar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2176-08-13 00:00:00.000", "description": "Report", "row_id": 250965, "text": "Moderate baseline artifact. Normal sinus rhythm. ST segment elevation\nin leads II, III, aVF and V6. No previous tracing available for comparison.\nConsider acute inferolateral ischemia.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2130-10-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1160724, "text": " 2:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with ETT\n REASON FOR THIS EXAMINATION:\n ?ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old female with ET tube placement. Question position.\n\n COMPARISON: None available.\n\n FINDINGS: Single portable AP chest radiograph demonstrates an ET tube with\n tip in the proximal right main bronchus approximately 5 mm past the carina. A\n feeding tube traverses inferiorly out of view with side port along the greater\n curvature of stomach. The lungs appear clear. There is no evidence of\n pulmonary vascular congestion, collapse, or pneumothorax. Trace linear\n atelectasis may be present in the left base. A radiopaque foreign body\n projecting over the upper trachea is incompletely imaged, and likely\n represents a pendant, although aspiration into the airway cannot be excluded.\n\n IMPRESSION:\n 1. Right mainstem stem bronchus intubation. Recommend retraction of ETT by\n at least 4 cm.\n 2. Radiopaque foreign body projects over upper trachea, incompletely imaged.\n Please correlate clinically to exclude aspiration.\n\n ETT position reported to Dr. on . Final report\n findings discussed with Dr. on .\n\n" }, { "category": "Radiology", "chartdate": "2130-10-02 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1160812, "text": " 12:16 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ETT placement\n Admitting Diagnosis: EPIGLOTTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with epiglottitis, recent arrest\n REASON FOR THIS EXAMINATION:\n please eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:38 P.M. :\n\n HISTORY: Recent cardiac arrest.\n\n IMPRESSION: AP chest compared to , 6:26 a.m.:\n\n Tip of the endotracheal tube, less than 2 cm from the carina, is 2.5 cm below\n optimal placement. Lungs are clear aside from plate-like atelectasis on the\n left. Heart size top normal. No pleural abnormality. Nasogastric tube ends\n in the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1160928, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change in acute cardiopulmonary pro\n Admitting Diagnosis: EPIGLOTTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with likely epiglottitis, now intubated\n REASON FOR THIS EXAMINATION:\n please eval for interval change in acute cardiopulmonary processes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Epiglottitis with intubation, to assess for acute abnormality.\n\n FINDINGS:\n\n In comparison with the study of , the endotracheal and nasogastric tubes\n have been removed. The atelectatic streak in the left mid zone has cleared.\n\n At the current time, there is no evidence of acute pneumonia or vascular\n congestion or pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-10-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1160753, "text": " 6:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please assess ETT placement\n Admitting Diagnosis: EPIGLOTTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with recent intubation, ETT pulled back\n REASON FOR THIS EXAMINATION:\n please assess ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Radiographs dating back to and most recently .\n\n INDICATION: Recent intubation, repositioned endotracheal tube, evaluate for\n position.\n\n FINDINGS: The endotracheal tube is now in satisfactory position with its\n distal tip at the inferior margin of the clavicles approximately 3 cm from the\n carina. The nasogastric tube is in satisfactory position with its side hole\n projected over the left upper quadrant and the distal tip not visualized on\n the radiograph but well below the diaphragm. The lungs are normal in\n appearance. The cardiac size is normal.\n\n IMPRESSION:\n Satisfactory position of endotracheal tube after repositioning.\n\n" }, { "category": "ECG", "chartdate": "2130-10-02 00:00:00.000", "description": "Report", "row_id": 236609, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nsinus rate is slower. The other findings are similar.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2197-08-14 00:00:00.000", "description": "Report", "row_id": 1278728, "text": "NPN MICU 7PM-7AM:\nNeuro: Pt initially awake and alert, cooperative and asking how long she has been here and why etc. Pt was forgetful and asked same questions frequently, needing to be reassured she would be going home soon. Also states she wants to get off the drugs and lead a more normal life. Her boyfriend was present at the beginning of the shift. He was a calming influence on her at that time. He also has a drug abuse problem and was asking how to get help. I recommended talking to his PCP and getting referral to rehab/detox etc. He left because he felt withdrawal symptoms coming on. I recommended going to the ER if he felft acutely ill but he opted to go home. Pt's precedex stopped at 2100 due to pt doing so well and the valium was switched to PO from IV. She required the 30mg Q2hrs as ordered. Her behaviour deteriorated, having periods of agitation/diaphoresis and feeling like she had bugs crawling over her body and by midnight pt had become acutely agitated, paranoid, calling out frequently and required restarting the precedex drip at .1 which was increased to .2 and the valium was continued 30mg IV Q2hrs but switched back to IV. She had failed the attempts to switch to PO and d/c the precedex. Team aware.\n\nShe contineus to have periods of paranoid ideations, requires frequent reassurance that we are not trying to kill her. Her mood is very labile, crying one minute alt w/ smiling and laughing the next.\n\nCV: HR 80 at rest up to 100 with agitation. BP 90-100 Occasional periods of diaphoresis.\n\nResp: Lungs clear on RA with good sats. RR 18-20.\n\nGI: Diet as tolerated in small amts.\n\nGU: Foley in place draining well, large amts urine.\n\nID: Afebrile.\n\nSkin: INtact. Pt given two baths tonight.\n\nIV: One peripheral IV in place #20 right AC working well but painful due to it being in the AC space. Pt's arm put on armboard.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-14 00:00:00.000", "description": "Report", "row_id": 1278729, "text": "MICU NPN Update:\nBy 3AM pt was very paranoid and uncooperative, calling out and agitated, pulling off O2 sat monitor and BP cuff. Precedex increased at that time to .5 and pt fell asleep. Pt remained asleep at 4AM and valium held. Precedex slowly decreased to .2 again and pt still sleeping at 6AM but wakes when stimulated and falls right back to sleep. BP at this time running only 85-90 so valium held until pt more awake and BP improves. HR 60's. BP 90. Temp 97 axillary. RR 20 and O2 sat 93%-96% on RA. Team aware of two doses of valium not given. Plan to consult additions services today and develope aggressive plan to stop the precedex infusion. Pt remains with 1:1 sitters for safety.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-15 00:00:00.000", "description": "Report", "row_id": 1278731, "text": "NPN 7P-7A\nNeuro:> Pt 3. Remains w/ labile mood, weepy about being away from boyfriend and when asked about social/family hx. Boyfriend reportedly on 12, repeated phone calls btw the two of them. Pt is requesting to be placed on same floor as boyfriend transfer. Pt w/ hx of GHB use, and occ cocaine use \"on weekends\". Pt voiced concern about not being able to sleep with out GHB as she took it Q2-3/hrs to help w/ sleeping and to prevent panic/anxious feelings. Pt on Diazepam Q3/hrs and and IV Haldol . Noted to have slight nystagmus in RT eye. Forgetful at times, repeating same questions over and over. Reports wanting to get sober, but also having twin sister and mother who abuse, father in prison. MAE, follows commands. Cooperative w/ care. Seen by psych and SW today, both w/ cont to follow.\nCV: HR 80's NSR. sbp 80-90's. no ectopy noted. +pp.\nResp: on RA, sats 97-100%. no cough noted, no c/o sob. LS CTA\nGI/GU: house diet, also requested fruit for snack, well tolerated. No BM. + flatulus. Foley dc'd to Pt c/o discomfort,voiding well w/ bedpan. clear, yellow urine,adeq. amounts.\nSkin: w/d/i\nID: afebrile.no issues.\nA/P: Cont to wean Diazepam and Haldol as tol, consider working up anxiety/panic feelings for more longterm med solution. Cont to provide emotional/supportive care. Cont to have SW and psych follow. Probable c/o to med. floor.\n" }, { "category": "Echo", "chartdate": "2197-08-15 00:00:00.000", "description": "Report", "row_id": 79281, "text": "PATIENT/TEST INFORMATION:\nIndication: Murmur.\nHeight: (in) 63\nWeight (lb): 125\nBSA (m2): 1.59 m2\nBP (mm Hg): 132/78\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 880498, "text": " 3:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumonia\n Admitting Diagnosis: OVERDOSE;CHANGE IN MENTAL STATUS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with altered mental status, fever, elev wbc\n\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW, PORTABLE.\n\n INDICATION: 21-year-old woman with altered mental status.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n with the previous study of yesterday.\n\n The lungs are clear. The heart and mediastinum are within normal limits.\n\n IMPRESSION: No active lung disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 880462, "text": " 6:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with altered mental status, fever, elev wbc\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, fever and elevated white count.\n\n COMPARISON: None.\n\n FINDINGS: AP semi upright bedside exam demonstrates normal cardiac and\n mediastinal contours. There is slight increased density in the right lower\n lung zone. No focal infiltrate, pleural effusion, or pneumothorax is noted.\n The soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Question of infiltrate in the right lower lung zone. Dedicated\n PA and lateral chest recommended for complete evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2197-08-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 880451, "text": " 5:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for edema, shift\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with altered mental status, hyperthermic\n REASON FOR THIS EXAMINATION:\n assess for edema, shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:46 PM\n no intracranial hemorrhage or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, hyperthermic.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intraparenchymal or extraaxial hemorrhage. There is no\n shift of normally midline structures, mass effect or hydrocephalus. The\n ventricles, sulci and cisterns are within normal limits. Note is made of\n slight motion artifact. The visualized maxillary sinuses demonstrate a small\n amount of rounded mucosal thickening and a mucous retention cyst within the\n left maxillary sinus. The osseous structures are unremarkable.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-10 00:00:00.000", "description": "LP WRIST(3 + VIEWS) LEFT PORT", "row_id": 880481, "text": " 9:55 PM\n WRIST(3 + VIEWS) LEFT PORT Clip # \n Reason: eval for fracture\n Admitting Diagnosis: OVERDOSE;CHANGE IN MENTAL STATUS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21F brought in for cocaine o/d, now w/ erythema of L wrist,? abuse.\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old female with history of cocaine overdose, now with\n erythema of the left wrist. Evaluate for fracture.\n\n THREE VIEWS OF THE LEFT WRIST:\n\n There is no evidence of fracture or dislocation. The joint spaces of the\n carpal bones and hand are well preserved. There is normal bone\n mineralization. The soft tissues are unremarkable.\n\n IMPRESSION:\n\n Normal-appearing radiograph of the left wrist.\n\n\n" }, { "category": "ECG", "chartdate": "2197-08-10 00:00:00.000", "description": "Report", "row_id": 211312, "text": "Sinus tachycardia. Non-specific ST-T wave changes. No previous tracing\navailable for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2197-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881567, "text": " 5:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Cardiopulmonary infiltrate. spiked new fever\n Admitting Diagnosis: OVERDOSE;CHANGE IN MENTAL STATUS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with altered mental status, fever, elev wbc\n\n REASON FOR THIS EXAMINATION:\n Cardiopulmonary infiltrate. spiked new fever\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: New fever.\n\n REFERENCE EXAM: .\n\n FINDINGS: This is an AP upright view of the chest and is slightly lordotic.\n The lungs are clear without infiltrate or effusion. The cardiac silhouette is\n normal. The bony thorax appears normal.\n\n IMPRESSION: Normal chest.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-12 00:00:00.000", "description": "Report", "row_id": 1278724, "text": "NURSING PROGRESS NOTE:\nNEURO: PT AWAKE AND CONFUSED ABOUT WHERE SHE IS. SHE KNOWS NAME AND A CLOSE APPOX OF THE DATE. KNOWS YEAR AND MONTH AT TIMES. HALLUCINATING ALL NIGHT. STATE SHE HER BOYFRIEND IN THE ROOM AND HAS CONVERSATIONS WITH HIM. PT SCREAMS OUT OFTEN, SEEMS TO BE AFRAID OF THE SITTER. PT THINKS AT HOME MOST OF THE TIME. PT TALKS , FREQ UNABLE TO FORMULATE WORDS. PT C/O BEING VERY TIRED BUT UNABLE TO SLEEP. PT HAS BEEN MED Q /HRS WITH VALIUM 20MG IV AND ATIVAN 4MG IV PRN THROUGHOUT THE NIGHT. MEDS HELP PT SETTLE DOWN FOR SHORT PERIOD OF TIME BUT NOT COMPLETELY OR FOR LONG.\n\nCV: PT'S HR IN NSR TO ST WITH RATES IN THE 80'S TO 130'S. NO ECTOPY NOTED. BLOOD PRESSURE WITHIN ACCEPTABLE RANGE DESPITE LRG AMT'S OF VALIUM AND ATIVAN. PT BECOMES TACHYPNEIC AT TIMES WITH RR IN THE HIGH 30'S BUT WILL COME DOWN AS LOW AS THE TEENS. O2 SAT'S IN MID 90'S ON ROOM AIR.\n\nRESP: LUNG SOUNDS CLEAR.\n\nGI: OCC ABLE TO TAKE SIPS OF WATER AND GINGERALE WITHOUT DIFF. NO C/O N/V. ABD SOFT, POS BOWEL SOUNDS. NO STOOL AT THIS TIME.\n\nGU: FOLEY CATH PRESENT DRAINING MOD AMT'S OF PINK TINGED URINE. PT NOTED TO HAVE SOME BROWNISH DRAINAGE FROM VAGINA.\n\nSKIN: INTACT.\n\nENDO: HAS NOT REQUIRED SSRI.\n\nPT CONT TO BE IN 3 POINT RESTRAINT, AND WAIST RESTRAINT TO KEEP PT IN BED. OCC LUNGES FORWARD BUT UNABLE TO GET OUT OF RESTRAINTS. PT HAS 1:1 SITTER. PSYCH NEEDS TO COME BACK AND RE EVALUATE WHEN MORE ALERT AND ABLE TO ANSWER QUESTIONS. PT IS FULL CODE. MOTHER CALLED TO CHECK UP ON PT WILL BE IN TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-12 00:00:00.000", "description": "Report", "row_id": 1278725, "text": "NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: PATIENT AWAKE DISORIENTED TO TIME AND PLACE, KNOWS MONTH AND YEAR AT TIMES. CONTINUES WITH HALLUCINATING ABOUT SEEING AND TALKING TO BOYFRIEND \"\". PERRLA, MAEW, FOLLOWS COMMANDS WELL AT TIMES BECOMING AGITATED REQUIRING MEDICATION OF VALIUM INCREASED TO 30MG PO Q1-3 HOURS, ATIVAN 2-4MG GIVEN IV Q1-3 HOURS. CIWA SCALE BETWEEN . REMAINS IN 4 POINT SOFT RESTRAINTS WITH WAIST BAND RESTRAINT. SITTER PRESENT AT PATIENTS BEDSIDE THOUGHOUT SHIFT.\nC/V: NSR RATE 88-103, BP 90-125/48-62.\nRESP: LUNG SOUNDS CLEAR, O2 SAT 94-100%.\nGI: ABD SOFT NONTENDER, POSITIVE BOWEL SOUNDS, NO FLATUS OR STOOL THIS SHIFT. TAKING CLEAR LIQUIDS WELL THIS SHIFT INCREASE DIET TO REGULAR AS TOLERATED.\nGU: FOLEY PATIENT DRAINING PINK CLEARED CLEAR URINE. PATIENT FREQUENTLY FOUND PULLING AT CATHETER.\nID: TMAX 98.8 VANCOMYCIN AND CEFTRIAXONE D/CD TODAY.\nACCESS: #20 INFILTRATED RIGHT FA, WARM SOAKS APPLIED, #18 RESTARTED LEFT FA PATIENT D/CD. #20 RESTARTED AGAIN PLEASE SEE FLOWSHEET FOR DETAILS.\nENDO: INSULIN SCALE DISCONTINUED.\nSOCIAL: PATIENTS TWO SISTERS AND BOYFRIEND INTO VISIT, PATIENT ABLE TO CONVERSE WITH VISITORS. MOTHER CALLED WILL BE INTO VISIT TONIGHT.\nPLAN: CONTINUE TO MONITOR PATIENTS NEURO STATUS ON CIWA SCALE, MEDICATE APPROPRIATELY. TRANSFER TO FLOOR WHEN PATIENT MORE STABLE ALSONG WITH SITTER.\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-11 00:00:00.000", "description": "Report", "row_id": 1278723, "text": "21 yo with withdrawal symptoms (most likely GHB per family) and +cocaine per urine tox screen.\n\nneuro: pt awake and agitated throughout shift...remains delerious and delusional (+visual hallucinations). pt on ciwa scale and medicated as ordered. pt had received total of 50 mg ativan and 30 mg valium iv with minimal improvement in behavior. toxicology consult in place and psych rn consulted. cont to attempt to climb oob and self d/c all medical equipment (pt has infiltrated 2 piv's this shift from thrashing around in bed). pt is in waist restraint as well as soft restraints x3 extremites for safety. 1:1 sitter at all times for safety.\ncv: monitor shows persistent st throughout shift with no ectopy noted.\nresp: lscta diminshed bibasilar. no sob or resp distress noted. 94-100 on ra.\ngi: abd soft and nontender. +bs noted. no stools this shift.\ngu: foley intact and patent draining yellow urine with no sedimenatation noted.\nskin: d+i with no open areas noted. l wrist xray with -fx per preliminary report. ace wrap intact with +csm noted.\ni-d: low grade temps. remains on vanco and ceftriaxone (prophylactic treatment for meningitis...unable to lp at this time severe agitation and uncooperative). wbc trending down.\nheme: k low and repleted with 40 meq IV this shift.\npsy-soc: mother has been identified as the spokesperson...if twin sister or boyfriend calls for info/update please refer to mother for update (both currently using GBH per mother...sister had overdosed on \"liquid G\" in the past x3). mother has severe anxiety and emotional support provided (see social work consult note). social work consult in place. remains full code on micu service. mother updated on status and poc by this rn and dr . sister called in afternoon and referred to mother as spokesperson for update.\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-15 00:00:00.000", "description": "Report", "row_id": 1278732, "text": "NURSING PROGRESS NOTE 0700-1900 HOURS:\n** FULL CODE\n\n** NKDA\n\n** RIGHT HAND PIV\n\nNEURO: PT COOPERATIVE WITH CARE-NO LONGER IN RESTRAINTS. FEW MOMENTS OF AGITATION-SWEARING AND EXPRESSING DISLIKE FOR PLAN OF CARE (EX. HAVING A BLOOD PRESSURE CUFF ON, GETTING LABS DRAWN)BUT EASILY CALMED. HAS A 1:1 SITTER. HAS NOT ATTEMPTED TO GET OOB. EMOTIONALLY LABILE WITH PERIODS OF LAUGHING AND SMILING AND THEN HYSTERICALLY CRYING IN PARTICULAR WHEN SPEAKS TO BOYFRIEND ON THE PHONE. ABLE TO FOLLOW ALL COMMANDS AND EXPRESS CONCERNS. NYSTAGMUS-PSYCH BELIEVES TO BE VALIUM OD.\n\nCARDIAC: NSR WITH HR IN 70'S. SBP >110. ECHO DONE TODAY WITH RESULTS PENDING. DOES AT TIMES C/O CHEST HEAVINESS WITH INSP/EXPIRATION-SEEMS PLEURITIC IN NATURE.\n\nRESP: LUNGS CLEAR. SATS >06%. NO SOB OR DISTRESS. RR IN 20'S.\n\nGI/GU: TOL HOUSE DIET WITHOUT ISSUE. MAKING REQUESTS FOR EXTRA SNACKS-WITH FAIR APPETITE. URINATING ON BEDPAN ADEQUATE AMTS-CLEAR, YELLOW.\n\nID: AFEBRILE. WBC THIS AM OF 7.1.\n\nSKIN: INTACT-NO BREAKDOWN. PT WITH C/O SORENESS FROM AREAS OF PREVIOUS BLOOD-DRAWS\n\nPSYCHOSOCIAL: PT SPEAKS WITH BOYFRIEND ON THE PHONE (LIVES WITH BOYFRIEND)-MOTHER CALLED TWICE AND VERBALIZED THAT SHE PLANS ON COMING IN. TWIN SISTER CAME IN TO VISIT-THEY SEEMED TO GET ALONG WELL.\n\nDISPO: PSYCH INVOLVED, ADDICTION CONSULT INVOLVED-PLAN TO TX TO MEDICAL FLOOR FOR FURTHER WORK-UP.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-11 00:00:00.000", "description": "Report", "row_id": 1278722, "text": "1900-0700 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ADMIT FROM ER AT APPROX 2130 W/ 1:1 SITTER R/T AGITATION AND CONFUSION. ADMIT DX OF ALTERED MENTAL STATUS, POSSIBLE OVERDOSE, ELEVATED WBC, FEVER. URINE TOX SCREEN POSITIVE FOR COCAINE. WBC ON ADMIT= 26.9, REPEAT THIS AM= 16.0, IV VANCO AND CEFTRIAXONE GIVEN IN ER. CXR RESULTS PENDING. BLD CX RESULTS PENDING. TEMP MAX IN ER= 101.7 RECTALLY. PRELIM HEAD CT NEGATIVE. TREATED W/ LARGE DOSES OF ATIVAN, RESTRAINTS, AND 1:1 SITTER IN ER.\n\nPT ALERT, OPENS SPONTANEOUSLY, RESPONDS TO NAME. CONFUSED AND MUMBLING INCOMPREHEND WORDS FOR MOST OF SHIFT. BUT ORIENTED TO SELF AND TIME THIS AM, AND LESS SLURRING OF WORDS NOTED. HOWEVER STILL DOES NOT FOLLOW COMMANDS. WRIST RESTRAINTS OFF AT THIS TIME R/T POSSIBLE R/O LEFT FOREARM FRACTURE. XRAY PENDING. 1:1 SITTER AT BEDSIDE AT ALL TIMES, SUICIDE PRECAUTIONS VS WITHDRAWAL. TEAM INITIATE CIWA SCALE. AT THIS TIME, ATIVAN ORDERED @ 4HRS PRN. MEDICATED W/ ATIVAN 2MG IV AT 0200 W/ FAIR EFFECTS. PT DOZING BETWEEN BOUTS OF AGITATION. PT DOES NOT APPEAR TO BE IN PAIN. MAE, PERLA. LEFT FOREARM NOTED TO HAVE SWELLING AND SLIGHT DISFIGUREMENT. MICU TEAM MADE AWARE, ACE WRAP APPLIED. NSR TO ST @ 97-126, NO ECTOPY NOTED. CK=253, MB=3, TROP=<0.01. NBP=120-148/55-101. LS=CLEAR/DIM. 02 SAT 95-100% ON RA. NO RESP DISTRESS NOTED. RR=18-34. ABD SOFT, PRESENT BS. NPO STATUS MAINTAINED. FOLEY CATH D/S/P DRAINING LG AMTS CLEAR YELLOW URINE 120-380CC/HR. PIV X2 #18G LEFT ANTECUB AND RIGHT FOREARM. LR @ 150CC/HR X 3 LITERS. LACTATE IN ER= 3.5, AM LEVEL PENDING. PER ER REPORT, RN PULLED OUT TAMPONS X2. NO MENSES NOTED ON FLOOR. MICU TEAM MADE AWARE. FULL CODE. INQUIRIES MADE BY PT'S MOTHER, SISTER, AND OTHER- ALL TO VISIT IN AM. EMOTIONAL SUPPORT PROVIDED.\n\nPLAN- ASSESS FOR AIRWAY PROTECTION. ADMIN ATIVAN AS NEEDED FOR AGITATION. CONTINUE 1:1 SITTER AS ORDERED. MONITOR WBC LEVEL AND CONTINUE IV ABX- R/O SOURCE. FOLLOW UP ON XRAY AND CULTURES. ADMIN IVF AS ORDERED AND MONITOR LACTATE. MAINTAIN SAFE ENVIRONMENT AND CONTINUE ICU SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-13 00:00:00.000", "description": "Report", "row_id": 1278726, "text": "NEURO: ALERT, ORIENTED TO SELF ONLY. AUDITORY HALLUCINATIONS, HAVING CONVERSATIONS WITH AND . HALLUCINATING THAT SHE IS RIDING IN A CAR. SEES AND IN ROOM. VALIUM 30MG IV X 3, ATIVAN 4MG IV X 4 WITHOUT DECREASE IN AGITATION. COMBATIVE, PINCHING AT TIMES. SCREAMING OUT, SHAKING SIDE RAILS, ATTEMPTING TO GET OOB, KICK AND PINCH. HR UP TO 120'S. PRECEDEX GTT STARTED AFTER 54MCG BOLUS WITH EFFECT. PSYCH EVAL DONE FOR APPROPRIATE MED MANAGEMENT. CIWA SCALE > 17.\n\n\nPULM: LUNGS CLEAR. RA SATS >98%. EUPNEIC DESPITE MASSIVE AMTS VALIUM ABD ATIVAN.\n\nCV: NSR-ST WITHOUT ECTOPY. SEE CAREVE FOR VS AND ASSESSMENTS. + PEDAL PULSES. # 20 INSYTE PLACED R ANTECUBUTAL AFTER L PERIPHERAL IV INFILTRATED L HAND\n\nGI: ABD SOFT, + BS.\n\nGU; FOLEY TO CD DRAINING BLD TINGED URIEN FOR PULLING ON CATHETER.\n\n\nSOCIAL: NO VISITORS OR PHONE CALLS.\n\nPLAN: 1:1 SITTER AT ALL TIMES UNTIL MENTALLY CLEAR AND SAFE. FOUR POINT RESTRAINTS AND WAIST RESTRAINT UNTIL PT A&O X 3 FOR SAFETY. ONCE MENTALLY CLEARER NEEDS INPT PSYCH STAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-13 00:00:00.000", "description": "Report", "row_id": 1278727, "text": "NURSING NOTE 7A-7P Review of Systems:\nNEURO: Arouses to voice continues on Precedex drip at change of shift. PERRLA, MAEW, remains in 4 point soft wrist restaints as well as waist belt most of the day. Wrist and Ankle restaints removed while family present. No hallucinations this shift, appropriate asking questions such as \"What happpened? How long have I been here?\" Precedex weaned off then restarted at low dose currently at .1mcg/kg/hr. Continues with 1:1 Sitter. Psychiatry Consult obtained today recommends changing meds and possible EEG to rule out seizure activity last evening.\nC/V: NSR rate 61-94 without ectopy, BP 90-106/40-54. Positive pulses.\nRESP: Continues on RA, lung sounds clear, Sat= 95-100%.\nGI: Taking PO diet well, very hungery this evening ate ice cream, fruit salad cups, Italian Ice drowsy during dinner tray left inside room.\nGU: Foley patent draining well clear yellow urine.\nSOCIAL: Patients mother, sisters and boyfriend into visit.\nPLAN: Continue with monitoring CIWA scale, medicated with Valium Q 3 hour and PRN as Needed.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-14 00:00:00.000", "description": "Report", "row_id": 1278730, "text": "NPN 0700-1500;\n\nRECEIVED PT WITH I.V PRECEDEX RUNNING .PT ASLEEP BUT EASILY AROUSABLE.\nI.V INFILTRATED . PT OFF DRIP SINCE 9AM. TOLERATING I.V VALIUM SWITCHED TO PO WITH HALDOL 2 MGS I.V. . AND PRN. SOME NYSTAGMUS IN RT EYE NOTED.\nPT AWAKE AND COOPERATIVE MOOD LABILE. CRYING AND DESPONDENT AT ONE MOMENT, ASKING FOR SOMETHING TO EAT THE NEXT. VERY TEARFUL AND AGITATED WITH THOUGHT OF I.V REPLACEMENT BUT TOLERATED 2ND I.V. BETTER. SITTER 1;1 CONTINUES.\nRESP; LUNGS CLEARS SATS 95-96% ON RA.\n\nCVS; TMAX 98 PO.BP DOOWN TO 84/42 WHEN SLEEPING BUT RUNNING 102-110/79.\n\nGU; PASSING GOOD AMOUNTS CLEAR URINE VIA FOLEY .C/O OF DISCOMFORT.\n\nGI; TAKING MOD AMOUNT HOUSE DIET WITHOUT PROBLEMS. BELLY SOFT PASSING FLAYUS. N SOOL/\n\nSOC; FRIENDS AND SISTER INTO VISIT, BOY FRIEND HAS CHECKED SELF INTO HOSPITAL FOR DETOX. AND IS IN 12 RIESMANN.\n\nA/P IMPROVING MENTAL CONDITION, PLAN TO TRANSITION TO PO VALIUM AND HALDOL TRANSFER TO FLOOR IN AM.\n\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2197-01-19 00:00:00.000", "description": "Report", "row_id": 1330144, "text": "SOCIAL WORK NOTE:\nThis pt, who is well-known to staff and this SW, returned to this morning via the ED from due to seizures. Pt is a 26 year old single man who had been living in with his family prior to his on . Pt had a long course of care here on the CTIC/SICU prior to his d/c to rehab in early . Pt's , Sr. and \"\", and his sister, , and his cousin, , have been present since this morning. They are an extremely involved family and are well-known to staff here. This SW met with them in the ED this morning after pt arrived there and then again this afternoon in the ICU Waiting Room. I will remain involved to offer continued support to family and pt as needed. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2197-01-19 00:00:00.000", "description": "Report", "row_id": 1330145, "text": "CTIC/SICU ADMIT NOTE\nPT AT PER FAMILY PT HAD C/O N/V WITH INTERMITTENT DIZZINESSS FOR 1 1/2 WEEKS. TRACHEOSTOMY SITE CAPPED X SEVERAL DAYS AS WELL. THIS AM PT WITH A GENERALIZED TONIC CLONIC SEIZURE X1 AT . PT TRANSFERRED TO EW WHERE PT EXPERIENCED 4 TIMES. PT FEBRILE TO 104.0 IN EW EXAM WAS SIGNIFICANT FOR ENCEPHALOPATHY AND PT TREATED WITH ROCEPHIN AND VANCO. HEAD CT WAS NEGATIVE. PT WAS INTUBATED FOR INCREASED AGITATION POST EACH SEIZURE ALONG WITH RESP. DISTESS.\n\nPMH: S/P RESULTED IN LIVER LAC, TRANSECTED AORTA REPARIED , ORIF L RADIUS, L EAR AVULSION, ARDS, PULMONARY CONTUSIONS. PEG PLACEMENT AND IVC FILTER PLACEMENT.\n\nALLERGIES: PCN\n\nMEDS: PAXIL, LABETALOL, CLONIDINE, LOVENOX, ENALAPRIL, MOTRIN, FENTANYL PATCH, LOPRESSOR, SERAX,\n\nNEURO: UPON ARRIVAL TO SICU, PT SEDATED, STARTED ON PROPOFOL INFUSION, WHEN LIGHTENED MOVES ALL EXTREMITIES PURPOSEFULLY, PERLA. PT FOLLOWED BY NEURO MED. EEG PERFORMED RESULTS PENDING.\n\nCV: ON ARRIVAL PT WAS IN AT ST 120'S WITH 1L BOLUS OF NS X 2, HR DECREASED TO 105. PT STARTED ON LABETALOL TO MAINTAIN A SBP<120. DISTAL PULSES PALP., SKIN, WARM AND DRY.\n\nRESP: PT FULLY VENTED, ABG WNL FOR ADEQUATE VENTILATION AND OXYGENATION, LS CTA, 02SATS 100%, PT SUCTIONED FOR THICK, BLOOD TINGED SECRETIONS, SPUTUM CULTURE SENT.\n\nGI: NPO, NS WITH 20MEQKCL INFUSING AT 75CC/HR, OGT TO CLWS, G-TUBE CLAMPED AT THIS TIME, SITE WITHOUT SIGNS OF INFECTION\n\nGU: FOLEY PATENT FOR ADEQUATE AMOUNTS OF CLEAR, YELLOW URINE.\n\nID: TEMP SPIKE TO 104. IN EW, PERIPHERAL BLOOD CX'S SENT UPON ARRIVAL TO THE UNIT, SPUTUM SENT AS WELL AND AN LP WAS DONE AT THE BEDSIDE. TEMPERATURE NOW DOWN TO 100.3\n\nENDO: GLUCOSE WNL\n\nHEME: HCT 40'S, INR 1.4\n\nLYTES: K 3.4 TREATED WITH 40MEQKCL, NOW 3.2 WILL TREATE AGAIN WITH ANOTHER 40MEQ KCL. MAGNESIUM AND CALCIUM ALSO REPLETED.\n\nSKIN: INTACT\n\nSOCIAL: COUSIN'S AT BEDSIDE, PT'S FATHER ALSO UPDATED BY THIS RN AND DR.. SOCIAL WORKER ALSO MEETING WITH FAMILY TO OFFER SUPPORT DURING THIS READMISSION.\n\nA.STABLE\nP. PT TO REMAIN INTUBATED AND SEDATED OVERNIGHT, FOLLOW AS PER PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-20 00:00:00.000", "description": "Report", "row_id": 1330146, "text": "CTIC/SICU NURSING NOTE\n\nN-> PERRLA. MAE WITH STRENGTH AND EQUALITY. INCONSISTENTLY FC. OPENS EYES SPONTANEOUSLY AND TRACKS. NO SZ ACTIVITY. DILANTIN ATC AFTER LOAD YESTERDAY. LEVEL PENDING. EEG PRELIMINARY READ REPORTEDLY NEG. LP RESULTS NEGATIVE FOR MENNINGITIS. FOLLOWING PT.\n\nCV-> HR SR 90'S NO VEA. BP GOAL <120 SYSTOLIC MAINTAINED WITH LOW DOSE IV LABETOLOL. CVP (PRIOR TO CL DC) . PALP PEDAL PULSES\n\nRESP-> AC MODE ON VENT WITH NOTED MILD METABOLIC ACIDOSIS. LS CTA, DIM BASES. CXR REPORTED NO INFILTRATES OR EFFUSIONS. PLAN TO WEAN AS NEURO EXAM IMPROVES. NOTED TO BE A DIFFICULT AIRWAY PER ANESTHESIA.\n\nRENAL-> U/O ADEQUATE. IVF NS IWTH 40MEQ KCL AT 75CCHR. PT RECEIVING KCL REPLACEMENT VIA PERIPH ACCESS TO CORRECT K+ 3.1-3.3. MAG REPLACED. CALCIUM NORMAL. RENAL PROFILE NORMAL.\n\nGI-> NPO. JEJ TUBE TO GRAVITY COLLECTION WITH >400CC BILIOUS DRAINAGE OUT OVERNGIHT. OGT (PER TEAM) CLAMPED. ABD SOFT. +BS. PROTONIXS QD.\n\nHEME-> HCT STABLE. INR 1.5. NO TX PER CTIC/SICU TEAM. PNEUMOBOOTS. IVC FILTER.\n\nENDO-> BS 100\n\nID-> TMAX 104., CURRENTLY 99. PAN CXS YESTERDAY. CL TIP SENT FOR CXS LAST NIGHT. WBC 5. RECEIVED ONE TIME VANCO/CEFTAZ IN ED YESTERDAY.\n\nSKIN-> OLD INCISIONS WELL HEALED. BACK INTACT. AM CARE PROVIDED.\n\nSOC-> THIS RN SPOKE WITH LAST EVENING. SUPPORT PROVIDED. PTS FAMILY UNDERSTANDABLY UPSET WITH PT ADMISSION AND EVENTS LEADING UP TO THIS ADMISSION AS DOCUMENTED. SW, MCCLUCTHON, INVOLVED WITH FAMILY ISSUES AND WELL KNOWN TO THIS FAMILY. PLAN TO START PT WHEN PT MEDICALLY IMPROVED.\n\n***********************************************\nA: PT IMPROVING OVERNIGHT AS NOTED WITH NO SZ ACTIVITY S/P TOTAL OF 6 TONIC/CLONIC SZS YESTERDAY (2AT , AND 4 AT ED). HEMODYNAMICALLY STABLE ON LOW DOSE LABETOLOL FOR BP SUPPORT.\nP: CONTINUE TO CLOSELY FOLLOW NEURO EXAMS, WATCH FOR SZ ACTIVITY, AND F/U FORMAL EEG/LP READS FROM YESTERDAY. WEAN VENT AS TOLERATED. SUPPORT FAMILY AND PT AT THIS TIME. START REHAB PROCESS.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-20 00:00:00.000", "description": "Report", "row_id": 1330147, "text": "Respiratory Care Note\nPatient is intubated with 7.5 oral et tube taped at 23cm. Sedated and ventilated on assist/control 600 x 10 40% 5 of peep. ABGs within nrml limits. Clear, bilateral breath sounds.Plan is to leave sedated on propafol, hopefully extubate later today.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-22 00:00:00.000", "description": "Report", "row_id": 1330153, "text": "SICU/CTIC TRANSFER NOTE\nPT IS A 26YR OLD MALE ADMITTED FROM S/P 1 SEIZURE, THEN WHILE IN THE EW PT 4 MORE SEIZURES, PT LOADED WITH DILANTIN, MEDICATED WITH PHENOBARB AND ATIVAN, PT INTUBATED FOR RESPIRATORY DISTRESS, ON ADMISSION PT'S MAGNESIUM LEVEL AND POTASSIUM LEVEL WERE EXTREMELY LOW, PT HAD ONE WEEK HX OF VOMITTING AT PRIOR TO ADMISSION. EEG, HEAD CT, MENINGITIS WORK-UP WAS NEGATIVE. PT AN MRI ON AND THE RESULTS ARE PENDING. PT EXTUBATED ON .\n\nPMH: S/P WHICH RESULTED IN LIVER LAC, REQUIRING SURGICAL REPAIR, AORTIC TEAR REQUIRING GRAFT PLACEMENT, ORIF OF L RADIUS, ARDS AND PULMONARY CONTUSIONS REQUIRING LONGTERM INTUBATION AND SEDATION.\n\nALLERGIES: NKA\n\nNEURO: A/A/0X 3, MAE, FC'S, PAIN CONTROLLED WITH A FENTANYL PATCH, PT WITH 2 PERSON ASSIST REQUIRING STAND AND PIVOT.\n\nCV: TELE NSR 90'S AT REST WITH ACTIVITY ST 110'S, BP STABLE, GOAL IS TO MAINTAIN SBP<150.\n\nRESP: PT ON RA, 02SATS 97%, LS CTA, PT COUGHING UP THICK, YELLOW SECREIONS, RR IN THE MID 20'S PT DENIES C/O SOB.\n\nGI: PT RESTARTED ON TF'S IMPACT WITH FIBER WITH GOAL OF 40CC/HR, PRESENTLY INFUSING AT 20CC/HR, PT STARTED ON SOFT SOLIDS TODAY, ADVANCING SLOWLY. PT TOLERATED ALL OF OATMEAL THIS AM WITHOUT EPISODE OF ASPIRATION, PT ALSO TOLERATED APPLESAUCE THIS AFTERNOON. PT ALSO TAKING IN ADEQUATE CLEARS, IVF'S KVO. PT WITH 3 EPISODES OF LOOSE, BROWN STOOL. STOOL SENT FOR CDIFF. ABD SOFT, NT, ND.\n\nGU: FOLEY PATENT FOR CLEAR, YELLOW URINE ADEQUATE AMOUNTS.\n\nENDO: GLUCOSE WNL THIS AM\n\nHEME: HCT FROM 30\n\nSKIN: COCCYX AREA WITH STAGE 1 ULCER, PROTECTIVE BARRIER APPLIED.\n\nID: CENTRAL LINE WHICH HAS BEEN D/C'D CULTURE RETURNED POSITIVE ALSO ONE SET OF BLOOD POSITIVE PT ON VANCO.\n\nA. STABLE\nP. CONTINUE SEIZURE WORKUP, PULMONARY TOILET, RESCREEN FOR TRANSFER TO THE FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-21 00:00:00.000", "description": "Report", "row_id": 1330150, "text": "resp care\n\npt tx w/o incident to mri. ambu 100% o2 to/from. pt extubated shortly after return to unit. pt comfortable, nard.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-21 00:00:00.000", "description": "Report", "row_id": 1330151, "text": "CTIC/SICU NURSING PROGRESS NOTE\nNEURO: PT OFF SEDATION, A/A/0 X 3, MAE, FC'S, DENIES C/O PAIN. OOB-CHAIR WITH 2PERSON ASSIST, WEAK BUT ABLE TO STAND AND PIVOT. PT TEARFUL AT TIMES, STATING \" I WANT TO GO BACK TO NOW\", FEELS THAT THIS ADMISSION IS A SETBACK. EMOTIONAL SUPPORT PROVIDED, PT ENCOURAGED TO CONTINUE TO EXPRESS HIS FEELINGS.\n\nCV: TELE NSR 90'S, BP WELL CONTROLLED ON PO LABETALOL, ALL EXTREMITIES ARE WARM TO TOUCH.\n\nRESP: PT WEANED AND EXTUBATED ON NC 4L, 02SATS 99%, LS COARSE IN THE UPPER LOBES OTHERWISE CLEAR, PT WITH A STRONG COUGH FOR THICK, YELLOW SECRETIONS. RR MID 20'S, DENIES C/O SOB.\n\nGI: PT ALLOWED TO TAKE IN SIPS, NS WITH 40MEQ KCL INFUSING AT 75CC/HR, ABD SOFT, DIST. BS'S PRESENT. PT PASSING LOOSE BROWN STOOL AT TIMES. PEG REMAINS CLAMPED.\n\nGU: FOLEY PATENT FOR CLEAR , YELLOW URINE QS.\n\nENDO: GLUCOSE WNL\n\nLYTES: REPLETED.\n\nSKIN: INTACT, COCCYX AREA WITH STAGE 2 OTA, CDI.\n\nSOCIAL: COUSIN UPDATED, THEY ARE EXPECTED TO VISIT THIS EVENING.\n\nA. STABLE\nP. PULMONARY TOILET, PLAN FOR A REPEAT EEG, AWAIT RESULTS OF MRI, CONT. TO PROVIDE EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-22 00:00:00.000", "description": "Report", "row_id": 1330152, "text": "T/SICU- NPN 7P-7A\nS-\"WHEN CAN I GET SOMETHING TO EAT,I'M STARVING?\"\nO-NEURO-PT A+O X 2.5-3,MAE'S,FOLLOWS COMMANDS,CALM AND APPROPRIATE,STRONG COUGH,PERRLA 3-4MM,NO SEIZURE ACTIVITY NOTED.\nCV-PT SBP 110'S-140'S,OCCAS TRANSIENT SBP'S IN 160'S RESOLVING W/O INTERVENTION.CONT ON LABETELOL VIA PEG,HR 80'S-100'S NSR-ST,NO VEA NOTED.3+ DP/PT .AFEBRILE\nRESP-PT LS CTA DECREASED @ BASES BILAT-RR 20'S-30.NARD.STRONG PROD COUGH,SPUTUM THICK YELLOW AMTS PT SELF .\nGI/GU-PT ABD SOFTLY DIST + HYPOACTIVE BS,SIPS CLEARS CURRENT DIET,SL NAUSEA X 1 RESOLVED W/O INTERVENTION.U/O BRISK VIA FOLEY U/O /2HRS,URINE CLEAR LIGHT YELLOW VIA FOLEY.\nSKIN-NO NEW ACUTE ISSUES.\nID- AFEBRILE,CONT ON VANCO IV.\n SISTER PHONED X 1 OVER .\nA-HEMODYNAMICALLY STABLE\nP-CONT VS MONITORING,I+O,O2 PRN,IV ABX/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2197-01-20 00:00:00.000", "description": "Report", "row_id": 1330148, "text": "NSG NOTE\n\nNEURO:PT AWAKE AND BASICALLY COOPERATIVE WHEN OFF PROPOFOL.HAD PERIODS OF AGITATION AND ANGER.HE DOESN'T REMEMBER HAVING SEIZURES AND BEING REINTUBATED.HE MOVES ALL EXTREMETIES.HE HAS BEEN OFF PROPOFOL TWICE FOR ATTEMPTED WEANING.HE BECAME QUITE RESTLESS,DIAPHORETIC AND ANXIIOUS.HIS RR WAS IN THE 40'S WITH VT 400.HIS ABGS WERE ACCETPTABLE BUT IT WAS DECEIDED TO RESEDATE HIM AND LEAVE HIM ON PSV 5 UNTIL THE AM.HE WAS STARTED ON ATIVAN ATC AND A FENTANYL PATCH WAS ADDED.\n\nCV:HE WAS ON A LABETOLOL QTT THIS AM.HIS BP CAN BE UP TO 150.HE HAS BEEN STARTED ON LABETOLOL HIS GT AND THE QTT IS OFF AT PRESENT.HE REMAINS IN SR.HIS T MAX WAS 100.4.\nHIS UO IS ADEQUATE.HE IS ON MAINT IVF AT 75CC HR AND HIS K HAS BEEN REPLETED WITH 40 KCL IN 500 NS AT 125CC HR.HE WAS RESTARTED ON VANCO IV .\n\n GI:HE REMAINS NPO X FOR MEDS.THE GT AND OGT ARE CLAMPED.\n\n RESP:HE WAS CHANGED TO PSV AT 5 WITH 5 .HIS RR WHEN OF THE PROPOFOL WAS IN THE 40'S WITH VT 400.HIS ABG'S WERE ACCEPTABLE BUT HE WAS AGITATED,ANGRY,DIAPHORETIC.HE WAS SX FOR CLEAR THIN LARGE AMT SECRETIONS.DR WASN'T COMFORTABLE WITH EXTU=BATING SO HE WAS PUT BACK ON THE PROPOFOL AND ATIVAN ATC.HE WAS ALSO GIVEN A FENTANYL PATCH.HIS RR IS NOW 22 WITH VT 380-400.HE APPEARS MORE COMFORTABLE.\n\nFAMILY: CALLED EARLIER,THEY BE IN TONIGHT.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-01-21 00:00:00.000", "description": "Report", "row_id": 1330149, "text": "sicu/citic nsg progress note\n>> 1900>>0700\n\nno significant changes overnight- remains on propofol 50>80mcg/kg/min.\nneuro status unchanged. will c/o pain in throat (?ett) and nods 'yes' that he is frustrated. re-oriented pt to time,place,events of re-admission. tylenol given for discomfort.\ndialntin increased for low level>>13.1 today.\n\nstable cvs with bp within desired range ..labeatalol @ 400mg pgt q8/hrs. one drop in bp which responded to 250cc fluid bolus.\nadequate u/o; ivf at 75/hr with periphral k+ repletion increasing iv intake\n\nrsp- ventilation with abg's revealing met acidosis...total co2 20>>17. breath sounds are clear/diminished bases with diminished left lung areas this am. sats wnl rr remains 30>42 with tidal vlumes of 380>>500cc. secretions small amts thick light yellow sputum.\n\nid- afebrile; restarted vancomycin- one of four blood culture bottles with gr + cocci..final results pnd.\n\nheme- stable\n\ngi- no enteral feedings yet; abs soft/distended w/no stool and absent bowel sounds. ogt and peg with minimal residuals.\n..protonix\n\nsocial- family called x2..informed of current status; cont supportive but worrried and upset over recent events precipitating readmission.\n\na/p- seizure of ??etiology ? altered blood chenistry>>seizures c/b resp distress requiring intubation and sedation for agitation.\n\n will evaluate tor readiness to wean from vent.\n" }, { "category": "Radiology", "chartdate": "2197-01-21 00:00:00.000", "description": "MR RECONSTRUCTION IMAGING", "row_id": 749005, "text": " 1:44 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: hx seizures, r/o abscess. r/o venous sinous thrombosis.\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with s/p mva with traumatic aortic dissection. now with\n fevers, seizures. MRI head with gadolinium. MRV to rule out venous sinus\n thrombosis.\n REASON FOR THIS :\n hx seizures, r/o abscess. r/o venous sinous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with hx of traumatic aortic dissection now with fever and\n seizures for further evaluation.\n\n MR HEAD:\n\n TECHNIQUE: T-1 sagittal and axial, and flair T-2 images of the brain in\n inversion recovery coronal images of the temporal lobes are obtained before\n Gadolinium. T-1 axial and coronal images were obtained following Gadolinium.\n In addition, 2D TOF MRV of the brain was obtained.\n\n FINDINGS: The is limited due to motion. In particular, the flair\n and T-2 weighted images were twice repeated and are limited by motion.\n\n BRAIN MRI: There is apparent signal increase in the posterior portion of both\n occipital regions on flair images which could be artifactual. However, in\n view of the patient's clinical history of seizures, it is suggested that the\n patient should have a repeat under sedation for better evaluation\n by flair and diffusion images.\n\n Following the administration of Gadolinium, there is no evidence of abnormal\n parenchymal, vascular or meningeal enhancement identified. There is no\n evidence of brain abscess or abnormal leptomeningeal enhancement.\n\n IMPRESSION: Limited . Flair images are limited and although\n increased signal is seen posteriorly in both parietal occipital regions, it is\n unclear whether if that is due to technical reason and repeat with\n flair imaging and diffusion imaging is recommended. No evidence of abnormal\n enhancement is seen.\n\n MRV OF THE HEAD: The MR of the dural sinuses\n demonstrate no evidence of venous sinus thrombosus.\n\n IMPRESSION: Normal MRV of the head.\n\n\n\n (Over)\n\n 1:44 PM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: hx seizures, r/o abscess. r/o venous sinous thrombosis.\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2197-01-24 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 749170, "text": " 2:09 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: please check placement l basilac picc for long term abx, pt.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with seizures,s/p head trauma\n REASON FOR THIS :\n please check placement l basilac picc for long term abx\n pt. may travel by wheelchair. call beeper with wet read\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26 year old man with seizures status post head trauma, evaluate\n placement of left PICC line.\n\n AP portable radiograph of the chest dated is compared with prior AP\n portable dated .\n\n FINDINGS: The cardiomediastinal and hilar contours are stable in appearance.\n The right lung is clear. There is no pulmonary vascular congestion. There is\n increased hazy opacification and obscuration of the left hemidiaphragm.\n Surgical clips are seen overlying the upper left border of the mediastinum and\n the left lateral chest wall. A left PICC line is seen with its tip\n terminating at the junction of the distal SVC and right atrium. There has\n been interval extubation of the patient. Rib fractures are seen in the\n posterior left fourth and fifth ribs. There is what appears to be an osseous\n fragment in the region of the right shoulder with no apparent donor site.\n There is no pneumothorax.\n\n IMPRESSION:\n 1. Increasing retrocardiac left lower lobe consolidation/collapse.\n 2. PICC line in satisfactory position.\n 3. Left posterior rib fractures.\n 4. Osseous structure in the right shoulder, of uncertain significance.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-19 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 748825, "text": " 8:01 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o PNA vs pulmonary process,\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with seizure (1st time) tonic clonic. Pt w/ long hospital stay\n in for trauma (had orbital fx and aortic dissection).\n\n Eval for changes.\n REASON FOR THIS EXAMINATION:\n r/o PNA vs pulmonary process\n\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizures.\n\n SINGLE PORTABLE CHEST RADIOGRAPH compared to a prior study dated .\n\n The cardiomediastinal contours are unremarkable. There is blunting of the left\n costophrenic angle which may represent pleural effusion and/or thickening.\n There are no focal infiltrates or pneumothorax. There are clips within the\n left lateral soft tissues as well as the left apex probably post surgical in\n nature from patient's previous aortic dissection. There are also old rib\n resections, as well. There is a right subclavian line in the appropriate\n position. There is a tube that appears to be overlying the left shoulder and\n does not take the usual course for subclavian line and probably is above or\n below the patient. Clinical correlation is recommended. There is calcification\n of the coracoclavicular ligament on the right.\n\n IMPRESSION: No acute pulmonary disease.\n\n There is a tube overlying the left shoulder and heart, which is of uncertain\n position. Clinical correlation is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2197-01-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 748826, "text": " 8:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracerebral process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with seizure (1st time) tonic clonic. Pt w/ long hospital stay\n in for trauma (had orbital fx and aortic dissection).\n\n Eval for intracerebral changes.\n REASON FOR THIS EXAMINATION:\n r/o intracerebral process\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Seizures.\n\n TECHNIQUE: Non-contrast axial head CT of brain.\n\n FINDINGS: Comparison is made to study of . There is prominence of the\n temporal horns, unchanged from the previous study. Subdural fluid collections\n anterior to the frontal lobes have resolved. There is no extra-axial or axial\n hemorrhage or shift of normally midline structures. Bone windows show normal\n osseous structures.\n\n IMPRESSION: Resolution of subdural fluid collections. Mild atrophic changes.\n No hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 748849, "text": " 11:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with MVA with s/p aortic transection repair. seizures and high\n fever\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Check ETT placement.\n\n SINGLE VIEW CHEST: Compared to an earlier exam performed at 9:30 a.m. this\n morning. The ETT is in the appropriate position. The right subclavian line is\n in the SVC. This has slightly changed position in comparison to the prior\n examination. The cardiomediastinal contours are stable. There is motion\n artifact limiting the evaluation of the lung parenchyma. There are no focal\n infiltrates or large pneumothorax. The left costophrenic angle is not\n identified. There is vascular redistributaion suggesting congestive failure.\n\n IMPRESSION: Appropriately positioned ETT.\n Mild congestive failure.\n\n" }, { "category": "Radiology", "chartdate": "2197-01-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 748951, "text": " 1:45 PM\n PORTABLE ABDOMEN Clip # \n Reason: nausea, abd pain, fevers\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hx mva, aortic transsection, multiple pneumonias, with new\n seizures, fevers, nausea\n REASON FOR THIS EXAMINATION:\n nausea, abd pain, fevers\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: _____, fever and nausea. Patient s/p MVA and pneumonia.\n\n NG-tube is in distal antrum. IVC filter is at L2/3 level. Distribution of\n bowel gas is unremarkable. G tube overlies left upper quadrant.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-01-23 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 749119, "text": " 2:32 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: 26 M with MRI on which showed question of parieto-occi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with s/p mva with traumatic aortic dissection.\n REASON FOR THIS :\n 26 M with MRI on which showed question of parieto-occipital lesions,\n which may be real or may be artifactual. Would like repeat scan to further\n assess, patient may need sedation.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: 26 y/o man status post MVA with traumatic aortic dissection.\n Question parieto-occipital lesion on prior MRI scan.\n\n MR HEAD:\n\n TECHNIQUE: Multiplanar T1 and T2 weighted sequences are performed without\n intravenous contrast. Comparison is made to a prior study of .\n\n FINDINGS: On FLAIR images there are foci of high signal intensity at the\n grey/white matter junction in the parietal lobes bilaterally as well as in the\n right frontal lobe. These areas are of low signal intensity on the T1\n weighted and high signal intensity on the T2 weighted images. The right\n frontal lesion demonstrates susceptibility artifact. A tiny septated cyst is\n seen in the posterior nasopharyngeal soft tissues. There is high T2 signal\n intensity in the mastoid air cells bilaterally. On the prior MR \n of there was no abnormal enhancement in the identified lesions in the\n parietal lobe and right frontal lobe. On diffusion weighted images there are\n no areas of restricted diffusion.\n\n IMPRESSION: 1) Signal abnormalities in the parietal lobes bilaterally and\n the right frontal lobe. These can be traumatic in origin and represent\n diffuse axonal injury. The lesion in the right frontal lobe is consistent\n with an area of chronic hemorrhage. Differential diagnosis for these lesions\n includes ischemia in the watershed areas possibly due to hypotension from the\n previous traumatic episode.\n\n 2) Septated Tornwaldt cyst. This might affect the drainage of the mastoid\n cells bilaterally which are fluid filled, perhaps secondary to obstruction by\n the cyst.\n\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2114-04-02 00:00:00.000", "description": "Report", "row_id": 97591, "text": "PATIENT/TEST INFORMATION:\nIndication: effusion f/u\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nStatus: Inpatient\nDate/Time: at 16:41\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. Effusion\necho dense, c/w blood, inflammation or other cellular elements. No\nechocardiographic signs of tamponade. Echocardiographic signs of tamponade may\nbe absent in the presence of elevated right sided pressures.\n\nConclusions:\nThere is a small pericardial effusion. The effusion appears circumferential.\nThe effusion is echo dense, consistent with blood, inflammation or other\ncellular elements. There are no echocardiographic signs of tamponade.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nCompared with the findings of the prior study (tape reviewed) of , no major change is evident. The prior study may have alightly\nunderestimated the size of effusion due to technically suboptimal images.\n\n\n" }, { "category": "Echo", "chartdate": "2114-04-02 00:00:00.000", "description": "Report", "row_id": 97592, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 126/71\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 10:26\nTest: Portable TTE (Focused views)\nDoppler: Limited doppler and no color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Dilated IVC (>2.5 cm).\n\nRIGHT VENTRICLE: RV hypertrophy. Markedly dilated RV cavity. Severe global RV\nfree wall hypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nMITRAL VALVE: Moderate (2+) MR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. Effusion echo dense,\nc/w blood, inflammation or other cellular elements. No echocardiographic signs\nof tamponade.\n\nConclusions:\nThe right atrium is markedly dilated. The inferior vena cava is dilated (>2.5\ncm). The right ventricular free wall is hypertrophied. The right ventricular\ncavity is markedly dilated. There is severe global right ventricular free wall\nhypokinesis. There is abnormal septal motion/position consistent with right\nventricular pressure/volume overload. Moderate (2+) mitral regurgitation is\nseen. There is a trivial/physiologic pericardial effusion. The effusion is\necho dense, consistent with blood, inflammation or other cellular elements.\nThere are no echocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (tape reviewed) of ,\nthe pericardial effusion is smaller.\n\n\n" }, { "category": "Echo", "chartdate": "2114-04-04 00:00:00.000", "description": "Report", "row_id": 98140, "text": "PATIENT/TEST INFORMATION:\nIndication: f/u pericardial effusion. S/p pericardiocentesis.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 108/62\nStatus: Inpatient\nDate/Time: at 09:28\nTest: Portable TTE (Focused views)\nDoppler: Color doppler only\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nA right atrial band is noted\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Dilated IVC (>2.5 cm).\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\nAbnormal septal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] TR.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo RA or RV diastolic collapse. Echocardiographic signs of tamponade may be\nabsent in the presence of elevated right sided pressures.\n\nGENERAL COMMENTS: Ascites.\n\nConclusions:\nThe left atrium is normal in size. The right atrium is markedly dilated. The\ninferior vena cava is dilated (>2.5 cm). The right ventricular cavity is\ndilated with severe 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. The mitral valve leaflets\nare mildly thickened. The tricuspid valve leaflets are mildly thickened.\nSevere [4+] tricuspid regurgitation is seen. There is a small to moderate\n(0.5-1cm) sized circumferential pericardial effusion. No right atrial or right\nventricular diastolic collapse is seen. Echocardiographic signs of tamponade\nmay be absent in the presence of elevated right sided pressures.\n\nCompared with the prior study (tape reviewed) of , the pericardial\neffusion is slightly larger.\n\n\n" }, { "category": "Echo", "chartdate": "2114-03-30 00:00:00.000", "description": "Report", "row_id": 98141, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate residual effusion s/p pericardial tap of 450 cc,\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 133/90\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 13:55\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Dilated IVC (>2.5 cm).\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. Severe global RV free wall\nhypokinesis. Abnormal diastolic septal motion/position consistent with RV\nvolume overload.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] TR.\n\nPERICARDIUM: Moderate pericardial effusion.\n\nGENERAL COMMENTS: Compared with the findings of the prior study, the size of\nthe pericardial effusion has decreased.\n\nConclusions:\n1. The left atrium is mildly dilated. The right atrium is markedly dilated.\nThe inferior vena cava is dilated.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. The right ventricular cavity is markedly dilated. There is severe global\nright ventricular free wall hypokinesis. There is abnormal diastolic septal\nmotion/position consistent with right ventricular volume overload.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n6. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid\nregurgitation is seen.\n7. There is a moderate sized pericardial effusion.\n8. Compared with the findings of the prior study of , the size of the\npericardial effusion has decreased.\n\n\n" }, { "category": "Echo", "chartdate": "2114-03-30 00:00:00.000", "description": "Report", "row_id": 98142, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 167/90\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 10:15\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Dilated IVC (>2.5 cm).\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. Severe global RV free wall\nhypokinesis. Abnormal diastolic septal motion/position consistent with RV\nvolume overload.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate thickening of\nmitral valve chordae. Moderate (2+) MR.\n\nTRICUSPID VALVE: Severe [4+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Large pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\n1. The left atrium is mildly dilated. The right atrium is markedly dilated.\nThe inferior vena cava is dilated.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. The right ventricular cavity is markedly dilated. There is severe global\nright ventricular free wall hypokinesis. There is abnormal diastolic septal\nmotion/position (D-shaped) consistent with right ventricular volume overload.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. The mitral valve leaflets are mildly thickened. There is moderate\nthickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is\nseen.\n6. The tricuspid valve leaflets are opened, thickened and fixed in position.\nSevere [4+] tricuspid regurgitation is seen.\n7. There is a large pericardial effusion. No clear sign of tamponade seen.\n\nConclusion: These finding are consistent with carcinoid syndrome.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2114-04-03 00:00:00.000", "description": "Report", "row_id": 1374216, "text": "CCU NPN 7p-7a\nS: \"What are you doing in my house...Get away from me.\"\n\nO: Please see careview for VS and additional data.\n\nNeuro: Pt continues to be confused, oriented to self only. Pt cooperative with care at times while family was present earlier this eve. Pt pulled out PIV this eve, IV therapy replaced-pt pulled out that PIV at approx 0430-PIV replaced. Pt with sitter at bedside once family left throughout shift. Pt refusing to have PIV placed, combative towards staff, pt reoriented, pt yelling for daughter-pt restating that she was in her home. Pt MAE. Pt received Haldol 3 mg IV x 1 with minimal effect. Pt slept for brief periods throughout night. Pt OOB to commode x 1 with assist.\n\nCV: Pt remains in afib HR 71-103 with rare to occ PVC's noted, pt HR noted as high as 120's with agitation-HR decreases with decreased stimulation. NBP 95-146/49-80. Pt received Metoprolol 25 mg PO at 2200 for dose due at midnoc-pt refused dose at 1600-pt BP to 95 systolic. Pt had echo during prior shift, please see report-sm/trivial pericardial effusion present. Dsg on old drain site CDI.\n\nResp: Pt O2 sats 95-100% on room air, RR 12-26-pt with audible wheezes when agitated, wheezes stop once pt settles and stimulus removed. Pt LS clear to coarse/fine crackles at bases.\n\nGI/GU: Pt voided amber colored urine x 2, approx 325 out for shift. Pt sm formed stool x 1. +BS, abd soft. Pt took eve pills with family at bedside.\n\nSocial: Pt daughter arrived from this eve-two daughters and son/?son-in-law in at bedside this eve. Pt appeared to recognize and respond appropriately to family members. Daughter from CA states she wants to speak with MD in am.\n\nA/P: 82 y/o female with pmh hx asthma, afib, HTN admitted on after pt experienced SOB at opthamologist and sent to ED. Pt found to have pericardial effusion, pericardial drain placed-drain removed yesterday afternoon. Pt confused, pulling at lines and combative at times with staff-pt sitter at bedside for pt safety. Continue to monitor pt MS. Continue to monitor pt hemodynamics and resp status. Continue to provide emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2114-04-02 00:00:00.000", "description": "Report", "row_id": 1374214, "text": "FULL CODE Universal Precautions NKDA\n\nPt had afternnon echo and post procedure became agitated, combative, refusing meds. There is no reasoning w/ her as she is insistant that she is home and cannot understand why we won't let her \"go upstairs to her room\" (home). She is becoming beligerent and striking at personell, calling out for \"Security\" and wanting a knife to cut the posey. Pt requires 1:1 sitter. Daughter is due in from this evening and daughter is picking her at airport. It's hopeful once family arrives, pt will settle down. The dementia and confusion is a constant state as noted above, she doesn't retain any information given to her - i.e that she's in the hospital, she had the pericardial drain, etc. Haldol 5mg IVP given w/ little effect.\n" }, { "category": "Nursing/other", "chartdate": "2114-04-02 00:00:00.000", "description": "Report", "row_id": 1374215, "text": "Neuro: Awake, alert, but very confused/disoriented. No short-term memory - pt forgets info just as soon as you tell it to her. She had to be convinced that she was in the hospital, and despite days of explaining that she had the pericardial drain, every time it was like it was the first time she heard that info! OOB to chair/commode w/ assistance, but she is fairly steady on her feet. She does require a sitter for safety because she is constantly trying to get out of the bed or the chair.\n\nCV: HR=80-90s, afib w/ no ectopy. Lopressor 25mg tid. BP=110-120s/70s. Weak pedal pulses, no edema, extrems a bit cool.\n\nResp: R/A w/ 02sat 99-100%, lungs occ wheeze in upper airways and crackles in bases bilat. Occ cough - dry, non-productive. RR=18-24.\n\nGI/GU: abd soft, +BS, no BM. Taking soft diet well. Voiding dark, conc amber urine - 100cc since 7am. Occ incont.\n\nPain: No c/o discomfort\n\nAccess: RFA PIV d/c'd - couldn't flush line. LAC intact\n\nID: afebrile - started on cefazolin\n\nProcedures: Cardiac echo done at bedside. Percardial drain removed by MD this afternoon - There was only 25cc drainage since 7am.\n\nSocial: Daughter and her fiance in to see pt. , SW spoke w/ family. Daughter will coming in the evening from .\n" }, { "category": "Nursing/other", "chartdate": "2114-04-01 00:00:00.000", "description": "Report", "row_id": 1374212, "text": "AFIB 80S TO 100 ,BP OVER 100 SYS,LOPRESSER CHANGED TO TID,CAPTOPRIL DC .PERICARDIAL DRAIN SEROUS C RARE BLOOD TINGE,DRAINING LESSER AMTS INTO0 BAG,IRRIGATES EASILY BUT DOES NOT ASPIRATE .pt afebrile\n\nDOE C WHEEZES, NEBS PRN BS CL WHEN AT REST,SAT OVER 95 ON RM AIR .\n\nDRINKS FLUID AND MANAGES PUREED FOOD WELL ANYTHING WITH TEXTURE IS CHEWED BUT NOT SWALLOWED .\n\nONLY VOIDED 160 CC CONCENTRATED URINE X1 ,IV FLUIDS HAVE BEEN DC NEED REORDER .\n\nPT ALERT,ORIENTED TO PERSON NOT SURE OF PLACE OR TIME BUT CONVERSES APPROPRIATELY AND ACCEPTS EXPLANATIONS,COOPERATIVE.NO RESTRAINTS,BED ALARM ON ,SIDERAILS UP,NO SITTER AS OF 7AM.PT STATED HER DAUGHTER TAKES CARE OF HER,HER SON \"cannot take care of himself,he's a boozer.\" PT SPOKE C DAUGHTER IN BY PHONE .\n\nPERICARDIAL DRAINAGE DECREASING .URINE OUTPUT LOW NEED MORE FLUID\n" }, { "category": "Nursing/other", "chartdate": "2114-04-02 00:00:00.000", "description": "Report", "row_id": 1374213, "text": "CCU NPN\nS: \" Aren't I in your home....who are all those men in your house?\"\nO: See vs/objective data per care vue. Afebrile\nHr 100's afib with no vea noted, tolerating increased lopressor to tid well. Bp 100-140's. Pericardial drain intact with significantly decreased amts of drng. Flushing cath but unable to aspirate flush. Drain has had out approx 100cc for past 12 hours.\nLungs with exp wheezes at times, rec'ing alb/atr neb. Sats remain in the upper 90's on room air. ^^ bronchospasm and dyspneic with exertion.\nFoley drng dk yellow urine. Pt very agitated over foley placement. Stating that she had to urinate, attempting multiple times to get oob also. Approx 12am foley removed. Drinking fluids without any difficulty. Abd soft with good bowel sounds, no bm.\nShe was initially oriented x 2 but as night progressed only oriented to self. Conts to have short term memory deficit. Does not know why she is here after being explained multiple times. Also repeatedly attempting to get oob for many reasons (ie bathroom, thirsty.) Reoriented and explained necessity to stay in bed. Hands have remained unrestrained. Not pulling at ivs, but must watch drain and drainage bag. Nursing has sat by the window to her room most of shift to ensure pt safety. Daughter (from CA) called, she will be in tonight sometime after 6pm.\nA: pericardial effusion resolving\n dementia with severe short term memory deficit\n hemodyamically stable\nP: ? drain removal today\n cont to reorient and provide safety (may need a sitter if close observation can not be maintained)\n" }, { "category": "ECG", "chartdate": "2114-04-06 00:00:00.000", "description": "Report", "row_id": 266593, "text": "Atrial fibrillation\nRight axis deviation\nConduction defect of RBBB type\nInferior/lateral ST-T changes cannot exclude myocardial ischemia\nLow QRS voltages in limb leads\nConsider prior anteroseptal myocardial infarction\nQ waves in leads l, aVL - consider also lateral myocardial infarction, or\nchronic pulmonary disease\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2114-04-03 00:00:00.000", "description": "Report", "row_id": 266594, "text": "Atrial fibrillation\nRightward axis\nLow QRS voltage\nRight bundle branch block\nPoor R wave progression - is nonspecific but consider anterior (and ? lateral)\nmyocardial infarct, age indeterminate\nConsider also chronic pulmonary disease or RV overload\nDiffuse nonspecific ST-T wave changes\nClinical correlation is suggested\nSince previous tracing of , ST-T wave changes more prominent\n\n" }, { "category": "ECG", "chartdate": "2114-03-30 00:00:00.000", "description": "Report", "row_id": 266834, "text": "Atrial fibrillation. Right axis deviation. Right bundle-branch block. Q waves\nin leads VI-V2 consistent with pulmonary disease or prior anterior myocardial\ninfarction. Compared to the previous tracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2114-03-29 00:00:00.000", "description": "Report", "row_id": 266835, "text": "Atrial fibrillation. Right axis deviation. Right bundle-branch block with\nQRS duration 120 milliseconds. Q waves in leads VI-V2 consistent with pulmonary\ndisease or prior anterior myocardial infarction. The QRS voltages are low in\nthe precordial leads. T wave inversions in leads III and aVF. Compared to the\nprevious tracing of these findings are new.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2114-03-30 00:00:00.000", "description": "Report", "row_id": 1374207, "text": " \"B\" Nsg Progress Note:\n\nPt arrived from after a visit to opthamologist where she was c/o increasing SOB. Echo showed large Pericardial effusion. She is NPO for Pericardiocentesis this AM. Hct 24 on admit received 2 units PRBC's. PMH: Pt states 2MI's,asthma,hypercholesterolemia,HTN,anemia. Unable to locate old records or med lists tonight, sending for records from other hospitals today. Son, wishes to become HCP and has been trying to get this pt placed in a Nursing Home without success and plans to get legal guardianship now.\n\nCVS: Afebrile. HR=73-122 afib with rt BBB, rare PVC's noted. SBP=120-166. Pulses difficult to palpate.\n\nResp: O2 3l nc, Sats=97-100%, Lung sounds diminished and exp wheezes noted when pt agitated, neb RX given with good effect. No desaturation noted with SOB. SOB with slight exertion.\n\nGI: NPO for Pericardiocentesis today. +BS, Passing flatus.\n\nGU: Pt pulled out 2 foley catheters and cannot comprehend the fact that the catheter is for her urine, she has been instructed about this about every 15 minutes all night long without any sign of comprehending this. Urine therefore is now red and amt is 20cc/h.\n\nSkin: No open areas noted. Edema noted of legs.\n\nNeuro: Pt moves all extremities. She usually walks with a cane. She is completely disoriented and does not orient at all. She has been told where she is and why and what she is going to have done today. She cannot tell you even two minutes later where she is or why. She knows her name and that of her children but does not even acknowledge being in the hospital at times. She pulled out her IV and her foleys and climbed over the siderails and to the bottom of the bed multiple times. She received Haldol as ordered with very little effect. Wrist restraints had to be applied for pt safety.\n\nPlan: Pericardiocentesis today, longterm goal is placement.\n" }, { "category": "Nursing/other", "chartdate": "2114-03-30 00:00:00.000", "description": "Report", "row_id": 1374208, "text": "CCU NSG NOTE: ALT IN CV/PERICARDIAL EFFUSION\nS: \"I feel better I think. My memory is not too good.\"\nO: For complete VS see CCU flow sheet.\nCV: Pt had echo in am which again documented huge pericardial effusion of ~2liters, and near wide open tricuspid regurg with hugely dilated RA, RV and SVC. She went to cath lab at noon for drainage of effusion. SHe tolerated proceedure well without any addition sedation. 450cc of bloody fluid was removed, but there was more loculated behind the heart. Drain was left in place and should be flushed per protocol. HR was in 90-1-teens a-fib early in day, now down to 70-80s a-fib with no ectopy. BP has been stable in 140/70s, though it occasionally goes up to 170s. She was replaced with 3amp magnesium So4 today.\nRESP: Pt had just crackles at the bases this am, but just prior to going to cath lab she became acutely bronchospastic. She responded well and had no wheezes upon returning.\nGI: Pt has been NPO today. SHe did take pills without problem and seemed to have no trouble swallowing.\nRENAL: Foley draining pink to red urine in small amts. If pericardial drainage is not counted pt is ~800cc pos for the day, due to blood products.\nMS: Pt has been occasionally aggitated, but easily calmed. SHe took 2mg po haldol at 9pm. SHe has remained cooperative, though disoriented with difficulty asking questions and inconsistently following commands.\nSOCIAL: Pt son was in and signed the consent. He stated he had one sister who had \"abused the pt financially and emotionally\". He wanted to obtain power of attorney. His sister called today and stated she is in fact the one who consistently cares for the pt and that her brother is not reliable. There is also a third sister who is flying out from Calif. THe case manager has been informed of this conflict and not decisions as to proxy etc will be made before more investigation of pts situation has been done. Case manager and social work will both be involved.\nA: Drainage of pericardial effusion/Contd confusion/less aggitation\nP: Follow drain protocol. Monitor VS for changes. Keep careful I & O and ensure team knows of poor pt output. Assist pt eating.\n" }, { "category": "Nursing/other", "chartdate": "2114-03-31 00:00:00.000", "description": "Report", "row_id": 1374209, "text": "NPN\nCCU\nS/P PERICARDIAL EFFUSION/DRAIN\nRECEIVED THE PATIENT AGITATED AND COMBATIVE ..BUT DESPITE WRIST RESTRAINTS AND SITTER AT BEDSIDE ..PT AT GREAT RISK FOR PULLING OUT PERICARDIAL DRAIN.. CONFUSION AND AGITATION BECOING WORSE WITH PHYSICAL RESTRAINTS ..NO RESPONSE TO HALDOL 3 MG IV TIMES 2 ..GIVEN .5 MG OF IV ATIVAN ..AND PT SLEPT THROUGHOUT NIGHT ..\nPERICARDIAL DRAIN ASPIRATED Q2 ..45-60 CC SEROSANG FLUID\nHR 80-90'S AFIB ..SBP 100-120'S/50-60'S...\nRESP ..INTIALLY DIFFUSE EXP WHEEZES ..GIVEN ALB NEBS TIMES 2 WITH SOME AFFECT ...ON 100% NRB..RR 18-28..\nGU MINIMAL URINE OUTPUT PER FOLEY\nAGITATION AND CONFUSION RESPONDING WELL TO SMALL DOSE OF ATIVAN\n" }, { "category": "Nursing/other", "chartdate": "2114-03-31 00:00:00.000", "description": "Report", "row_id": 1374210, "text": "82 YR OLD CONFUSED FEMALE C PERICARDIAL DRAIN .\n\nCONTINUES IN AFIB RATE 90 TO 101 .RECEIVED PO LOPRESSER ,BP 90 TO 105 SYS.CAPTOPRIL HELD. PERICARDIAL DRAI SITE C/D,DRAIN SEROUS C RARE CLOT,IRRIGATED X1 PER PROTOCOL .160CC DRAIN .BAG CHANGED .DRAIN ASP BETTER WHEN PT FLAT TOWARD L SIDE .\n\nSAT 98 RM AIR ,BS CLEAR,NEB X1.\n\nTAKING FLUIDS WELL BUT DOES NOT SWALLOW CHEWED MEAT ,WILL STICK TO SOFT SOLIDS FOR NOW .POS BS.NO STOOL.\n\nHUO 10 TO 25 CC COUDY AMBER URINE ,SPEC SENT .\n\nPT P .5 ATIVAN AT 1AM,BUT GRADUALLY AWAKENING ,FOLLOWS SIMPLE COMMANDS BUT TRIES TO GET OOB ,PICKS AT LINES ,SOFT RESTAINTS IN PLACE,SITTER AT BEDSIDE.STARTED ON ZYPREXIA.DAUGHTER IN LAW TO SEE PT,CALLS FROM SON AND 2 DAUGHTERS .\n\nDRAINAGE CONTINUES BUT LESS ,RESP SATUS IMPROVED .LESS AGITATED BUT STILL PULLS AT LINES IF UNRESTRAINED .\n\nMONITOR PERICARDIAL DRAIN\nGENTLE REHYDRATION FOR LOW URINE OUTPUT .\nMAINTAIN PT \n\n\n" }, { "category": "Nursing/other", "chartdate": "2114-04-01 00:00:00.000", "description": "Report", "row_id": 1374211, "text": "CCU NPN\nS: \" I was better without you here....you are not here to help me.\"\nO: See vs/objective data per care vue. Low grade temp.\nHr 90-100's afib with no vea noted. Bp 90-110's, rec'd lopressor 25mg but held captopril due to low bp. Pericardial drain intact, drng serosang fluid. Fluid is drng into bag, most of the time unable to aspirate any further fluid with syringe, even after insilling. She is drng approx 25cc/hr. Line flushed easily and what is flushed normally is retreived.\nLungs with exp wheezes, rec'd alb/atr neb with improvement. Also, has crackles at the bases. No o2 with sats in the upper 90's. (+) DOE, becomes bronchospastic but once she is left alone and settles done breathing returns to baseline.\nC/O having to urinate,after rec'ing 500cc NS bolus. Bladder palpated but no urine coming from foley. Foley cath flushed easily but unable to retrieve fluid. Urinated around foley, therefore foley dc'd. She is incontinent of urine, med amts. Able to take meds without difficulty.\nShe is oriented x 1 only. Has severe short term memory problems. Does not remember things that are just told to her. Her wrists have remained unrestrained because sitter is available. No attempts to pull out ivs. Having periods of agitation but she is mostly cooperative. Slept on/off throughout night. Daughter in CA called wants to be made aware of any changes in her condition.\nA: pericardial drain with approx 25cc/hr out\n confusion improved with meds\n incontinent of urine\nP: cont with drain protocol\n cont with emotional support and reorient as needed\n" } ]

[ { "category": "Radiology", "chartdate": "2167-11-07 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1158382, "text": " 9:13 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for obstruction, acute process\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with hx of bowel resection, dulafoys, GI bleeds, presenting\n with acute bloating, inability to pass gas\n REASON FOR THIS EXAMINATION:\n eval for obstruction, acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of bowel resection, Dieulafoy's GI bleed, presenting with\n acute bloating, inability to pass gas, rule out obstruction, acute process.\n\n ABDOMEN, TWO VIEWS\n\n Bowel gas pattern is nonspecific. Gas and stool are seen throughout the\n colon. Scattered gas is seen in loops of small bowel, but no dilated air-\n filled loops of bowel or distinct fluid levels are identified. No free air is\n seen beneath the diaphragms. An IVC filter is present. There is an unusual\n appearance extending along the upper abdomen at the level of the thoracolumbar\n junction, question heterotopic ossification of some kind, not fully evaluated\n on this film. The ddx includes extravasated, ingested or iatrogenic material,\n but this is considered much less likely.\n\n There is incomplete visualization of a focal sclerotic lesion in the left\n intertrochanteric femur, not fully evaluated on this view. Differential\n diagnosis includes a calcified chondroid bone lesion. In the appropriate\n clinical setting, a sclerotic metastasis might also account for this\n appearance. Mild degenerative changes of both hips noted.\n\n IMPRESSION:\n\n 1. Nonspecific bowel gas pattern without evidence of obstruction. Unusual\n appearance in the upper abdomen with dense material, question heterotopic\n ossification iatrogenic material. Clinical correlation is requested. If\n there is no prior imaging through this area, then a CT scan would be\n recommended for further assessment.\n\n 2. Focal bone lesion in the left proximal femur. Dedicated left proximal\n femur radiographs are recommended for further assessment.\n\n Findings submitted to critical results dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2167-11-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1158430, "text": " 5:13 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with new onset fever\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n WET READ: DLrc SAT 6:03 PM\n Elevation of the right hemidiaphragm. No evidence of focal pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New-onset fever, question acute process.\n\n CHEST, TWO VIEWS.\n\n The right hemidiaphragm is elevated. Allowing for this, heart size is\n borderline. The aorta is minimally unfolded and slightly calcified. No CHF,\n focal infiltrate, or effusion is identified.\n\n" }, { "category": "Radiology", "chartdate": "2167-11-07 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1158426, "text": " 4:35 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with hx of bowel resection presenting with abdominal pain,\n melena, distention, and new onset fever\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Background of bowel resection after motorcycle accident in ,\n patient told at that time of abnormal calcification in his abdomen. Presents\n with abdominal pain, melena, distention and new onset fever.\n\n COMPARISON: No prior CT available for comparison. Radiographs earlier the\n same day.\n\n TECHNIQUE: Multidetector volumetric CT acquisition of the abdomen was\n performed after the administration of intravenous contrast. Images are\n presented in the axial plane at 5-mm collimation. Multiplanar reformation\n images are also submitted for review.\n\n FINDINGS: Ossified material arising from the sternum and the costochondral\n junctions of the lower ribs traverses the upper abdominal wall and extends in\n thin appendages into the abdominal cavity (2a:37, 35). The large bowel is\n immediately adjacent to this osseous material at the level of the cecum\n (2a:40). The distal ileum is not distended. Multiple loops of small bowel,\n likely mid and distal ileum appear matted to the anterior abdominal wall where\n there is a midline defect, surgical clip, and high-density material, possibly\n representing further ossification or possibly a hernia repair mesh (2a:58-73).\n There is marked divarication of the recti associated with this abdominal\n defect. There is no evidence of large or small bowel dilation.\n\n The gallbladder contains multiple calcified dependent gallstones without\n evidence of cholecystitis. A sliding hiatus hernia is small. Three right\n renal low-attenuation lesions measure 17 x 11, 37 x 38 and 7 x 12 mm, and are\n of fluid attenuation. There is focal cortical thinning of the left lower\n renal pole (300b:40). An infrarenal inferior vena cava filter is stable in\n position; the struts of the filter appear to extend outside the lumen of the\n inferior vena cava (2a:41). The adrenals, spleen, liver and pancreas appear\n normal.\n\n The visualized lung bases are normal.\n\n A well-corticated multiloculated lucent proximal femoral lesion is included on\n the inferior margins of the field of view, there is no evidence of associated\n cortical erosion or expansion to suggest malignancy, its location is most in\n keeping with a fibrous dysplasia, correlation with prior radiographs would be\n of value to ensure stability.\n (Over)\n\n 4:35 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Abnormal ossification involving the anterior abdominal wall communicating\n with the costochondral junctions of the lower ribs and sternum is in keeping\n with heterotopic ossification after either surgery or trauma.\n 2. No evidence of small or large bowel obstruction.\n 3. Multiple matted small bowel loops abutting the lower anterior abdominal\n wall suggests adhesions.\n Case discussed with Dr , clinical team member, at 1700 hours .\n\n" }, { "category": "ECG", "chartdate": "2167-11-05 00:00:00.000", "description": "Report", "row_id": 236936, "text": "Sinus rhythm. There is an early transition which is non-specific. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2162-08-15 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1148068, "text": " 5:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: LEUKOCYTOSIS, ASSESS FOR INFECTIOUS SOURCE\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: There is suggestion of a tract, which interrupts a line of staples,\n connecting the right side of the rectal pouch and the right sided peritoneal\n collection which contains locules of gas. These findings are suspicious for\n breakdown at the staple line. This finding is best seen on series 2 (axial),\n images 78-80, and series 300 (coronal), images 22-26. If confirmation of\n breakdown is desired, a contrast enema could be considered to assess for\n communication with the right sided collection.\n\n This was discussed by Dr. with Dr. at 9:15 AM, .\n\n\n 5:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: LEUKOCYTOSIS, ASSESS FOR INFECTIOUS SOURCE\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with new onset leukocytosis, tachycardia, 12 days s/p sub-total\n colectomy, ileostomy, repair of anastamotic leakPO and IV contrast\n REASON FOR THIS EXAMINATION:\n assess for infectious sourcePO and IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 8:05 PM\n -No small bowel obstruction, contrast seen up to ileostomy.\n -Anastomosis post ileostomy, unable to asses for leak.\n -Dominant perihepatic fluid collection with air fluid level, and fluid along\n left peritoneum with multiple foci of air, extending in pelvis, with\n enhancement of peritoneum, could be post-surgical; however in patient with\n leukocytosis, cannot exclude superinfection.\n -Bilateral effusion and atalectasis, worse on right\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old man with new onset of leukocytosis and tachycardia with\n 12-day status post subtotal colectomy, ileostomy and repair of anastomotic\n leak.\n\n TECHNIQUE: CT abdomen and pelvis with coronal and sagittal reformats. IV\n contrast was administered. Gastrografin was administrated through the NG\n tube.\n\n COMPARISON: CT abdomen and pelvis, .\n\n FINDINGS:\n\n LUNG BASES: There are bilateral small-to-moderate pleural effusions, worse on\n the right, with adjacent atelectasis. There is no pericardial effusion.\n There are calcifications of the coronary arteries. The ascending aorta\n measures 4.1 cm.\n\n CT ABDOMEN: The liver enhances homogeneously, and there is no evidence of\n extra- or intra-hepatic biliary duct dilatation. The gallbladder is\n unremarkable. Spleen is normal. The kidneys enhance symmetrically, and\n excrete contrast symmetrically with no evidence of hydronephrosis. Left\n adrenal gland is normal. There is minimal thickening of the lateral limb of\n the right adrenal gland, (2:41). The abdominal aorta is of normal caliber,\n with atherosclerotic changes. There are few punctate calcifications in the\n pancreas, and there is calcification of the splenic artery, (2:32).\n\n The patient is status post sub-total colectomy. There is ileostomy at the\n right lower abdominal quadrant. Gastrografin is seen through the loops of\n small bowel and exiting through the ileostomy, with no evidence of bowel\n obstruction up to the ileostomy. Beyond the ileostomy, loops of bowel are not\n (Over)\n\n 5:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: LEUKOCYTOSIS, ASSESS FOR INFECTIOUS SOURCE\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n filled with contrast, and we cannot evaluate for anastomotic leak, since the\n anastomosis is beyond ileostomy. There are no pathologically enlarged lymph\n nodes in the retroperitoneum, or mesentery. There are few scattered lymph\n nodes in the mesentery, which are small.\n\n There is free fluid in the abdomen surounding the liver. In addition, free\n fluid in the left abdomen, tracking into the pelvis and to the right lower\n pelvis, demonstrates enhancement of the peritoneum. Air locules are seen in\n these lobulations of free fluid; his finding could be post-surgical given the\n setting of recent surgery and anastomotic leak; however, in a patient with\n leukocytosis, we cannot exclude superinfection of the peritoneal fluid.\n\n CT PELVIS: There is a Foley catheter in the urinary bladder and urinary\n bladder is collapsed. There is focus of air within the urinary bladder,\n likely from a placement of Foley. The distal ureters are unremarkable.\n Anastomosis is seen in the lower pelvis, (2:82) and as described previously we\n cannot comment on anastomotic leak due to lack of contrast at this level.\n Free fluid is seen extending into the pelvis, with enhancement of the\n peritoneum, as described above.\n\n OSSEOUS STRUCTURES: There are sclerotic lesions within T12, L4, S1 and left\n pubic symphysis as on prior study, concerning for osseous metastasis.\n Degenerative changes are seen in bilateral hips. No evidence of fracture.\n\n IMPRESSION:\n\n 1. Dominant perihepatic (ascitic) fluid adjacent to the liver has a large\n locule of air; peritoneal enhancement and peritoneal fluid in the left\n abdomen, and communicating via multiple lobulations of fluid into the mid\n pelvis and the right pelvis has multiple smaller loculations of air.\n\n In a patient with recent surgery and recent anastomotic leak, the air may be\n postoperative in nature and the peritoneal enhancement from inflammation and\n post-surgical changes; however, in a patient with leukocytosis, we cannot rule\n out superinfection. Lab analysis of the peritoneal fluid is recommended (may\n be aspirated under ultrasound or CT guidance) which may be feasible via a\n targeted paracentesis. If appearing infected, they would be amenable for\n drainage.\n\n 2. No extraluminal oral contrast, no evidence of small-bowel obstruction up\n to the level of ileostomy.\n\n 3. Due to lack of oral contrast beyond the ileostomy, our sensitivity for\n detecting anastomotic leak is significantly decreased.\n\n (Over)\n\n 5:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: LEUKOCYTOSIS, ASSESS FOR INFECTIOUS SOURCE\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Bilateral pleural effusion, with adjacent atelectasis, worse on the right.\n\n 5. Multiple sclerotic osseous lesion concerning for metastatic disease as\n described on prior CT. No clear primary.\n\n Findings were discussed with Dr. from surgery, surgical intern,\n which will communicate the finding with her chief resident.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-08-05 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1146658, "text": " 3:32 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new PICC\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with colostomy\n REASON FOR THIS EXAMINATION:\n new PICC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old male with colostomy and new PICC placement.\n\n COMPARISON: Chest radiograph from earlier on the same day at 02:13 p.m.\n\n PORTABLE SUPINE CHEST RADIOGRAPH: A new left upper extremity PICC tip is seen\n likely in the top of the right atrium; withdrawal by at least 1 cm is\n recommended to place the catheter tip in the lower SVC. These findings were\n discussed with the IV nurse, , upon completion of the study.\n\n The remainder of the study is not changed from 1.5 hours earlier.\n\n" }, { "category": "Radiology", "chartdate": "2162-08-23 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1149178, "text": " 4:43 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Are there signs of performation or infection that migth expl\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ? intrabdominal infectious process, free air under R\n diaphram\n REASON FOR THIS EXAMINATION:\n Are there signs of performation or infection that migth explain the free air\n under the right diaphram\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa MON 6:50 PM\n 1. Overall interval decrease of three largest abscess collection, with an\n indwelling pigtail catheter in the left lower quadrant.\n 2. Decreased amount of free air in the right subdiaphragmatic region.\n 3. Fluid redistribution, now with apparent increase of fluid in the left\n subdiaphragmatic region.\n 4. Slightly increased pleural effusions, more pronounced in the right side.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old man with history of subtotal colectomy with ileostomy,\n complicated by intra-abdominal abscesses requiring drainage. Now evaluate for\n the progression of free air and upper abdominal abscess.\n\n COMPARISON: Multiple prior studies with the latest CT abdomen and pelvis on\n .\n\n TECHNIQUE: MDCT images were acquired from the lung bases to the pubic\n symphysis after administration of IV contrast. Multiplanar reformatted images\n were obtained for evaluation.\n\n CT ABDOMEN WITH IV CONTRAST: In the visualized lung bases, there are\n bilateral pleural effusions, right greater than left, with apparent mild\n interval increase in the right. There is adjacent passive atelectasis\n bilaterally. The abdomen is again noted with a large amount of ascites with\n apparent re-distribution of fluid, slightly increased in the left upper\n quadrant. A pocket of free air in the right upper quadrant has interval\n decreased in size.\n\n The liver is normal without focal lesions. The spleen, pancreas, gall\n bladder, adrenal glands and kidneys are grossly normal, allowing for the\n limitation from the underlying ascites. There is no hydronephrosis,\n hydroureter or evidence of renal stone. The stomach, duodenum and loops of\n small bowel are grossly unremarkable.\n\n Again noted are multiple collections, compatible with abscess. The largest\n three abscesses all appear to have decreased in size, with the one in the\n lower right anterior pelvis now measuring 20 mm in thickness compared to 26\n mm, the one in the right mid quadrant measures 31 mm compared to 52 mm, and\n the one with an indwelling pigtail catheter measures 33 mm compared to the\n (Over)\n\n 4:43 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Are there signs of performation or infection that migth expl\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pre-drained size of 54 mm.\n\n CT PELVIS WITH IV CONTRAST: There is a distended rectal stump with hyperdense\n material layering in the dependent portion. The urinary bladder is mostly\n collapsed with an indwelling Foley catheter with a pocket of intraluminal air,\n likely from recent instrumentation. There is no bowel obstruction. The\n ostomy in the mid-to-right pelvis is grossly intact. Multiple small metallic\n densities in the right inguinal area are compatible with prior right inguinal\n hernia repair.\n\n BONE WINDOW: There are unchanged sclerotic lesions within T12, L4, S1 and\n left pubic symphysis, concerning for osseous metastasis. Degenerative changes\n are moderate-to-severe in the hips.\n\n IMPRESSION:\n 1. Overall interval decrease of three largest abscess collections. An\n indwelling pigtail catheter in the left lower quadrant.\n 2. Decreased amount of free air in the right subdiaphragmatic region.\n 3. Redistribution of fluid, now with apparent increased fluid in the left\n subdiaphragmatic region likely shifted from the right upper quadrant where\n the fluid is decreased\n 4. Slightly increased pleural effusions, more pronounced in the right side.\n\n Dr. has discussed the findings with the primary team at the time of\n the initial interpretation at 5:30 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-08-23 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1149131, "text": " 12:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change, last film did not show R side CPA\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with hypercap resp failure\n REASON FOR THIS EXAMINATION:\n interval change, last film did not show R side CPA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb MON 2:57 PM\n 1. Right lung base opacity, could reflect a combination of atelectasis,\n effusion, and/or superimposed pneumonia.\n\n 2. Persistant Rounded lucency projected over the right upper abdomen, reduced\n but persistant since CT from , which demonstrated free air.\n This could be residual pneumoperitoneum however given persistance, further\n evaluation with CT as permitted by clinical status should be considered. Paged\n Dr. to discuss.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypercapnia and respiratory failure interval change. Please\n evaluate for right-sided costophrenic angle, not included in the field of view\n of the prior study.\n\n COMPARISON: at 5:14 a.m.\n\n AP UPRIGHT RADIOGRAPH OF THE CHEST: The right costophrenic angle is not\n included in the field of view. There is a consolidation in the right lung\n base, this could reflect a combination of atelectasis, effusion, and\n superimposed pneumonia is not excluded. A rounded lucency is seen in the\n right upper abdomen, reduced but peristant since the CT from , which\n demonstrated free air. Given persistance for over a week, further evaluation\n with CT is recommended, as permitted by patient's clinical status.\n\n Midline staples from patient's recent laparotomy are present. The right\n hemidiaphragm is also elevated, slightly more than the study from and could be partly due to volume loss in the right lung base.\n\n IMPRESSION:\n 1. Right lung base opacity, could reflect a combination of atelectasis,\n effusion, and/or superimposed pneumonia.\n\n 2. Persistant Rounded lucency projected over the right upper abdomen, reduced\n but persistant since CT from , which demonstrated free air.\n This could be residual pneumoperitoneum however given lack of\n redistribution/resorption over a week, further evaluation with CT as permitted\n by clinical status should be considered. This was discussed with Dr.\n .\n (Over)\n\n 12:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change, last film did not show R side CPA\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-08-23 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1149132, "text": ", A. 12:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change, last film did not show R side CPA\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with hypercap resp failure\n REASON FOR THIS EXAMINATION:\n interval change, last film did not show R side CPA\n ______________________________________________________________________________\n PFI REPORT\n 1. Right lung base opacity, could reflect a combination of atelectasis,\n effusion, and/or superimposed pneumonia.\n\n 2. Persistant Rounded lucency projected over the right upper abdomen, reduced\n but persistant since CT from , which demonstrated free air.\n This could be residual pneumoperitoneum however given persistance, further\n evaluation with CT as permitted by clinical status should be considered. Paged\n Dr. to discuss.\n\n" }, { "category": "Radiology", "chartdate": "2162-08-24 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1149234, "text": " 5:12 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? Interval change in pleural effusion\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with L sided pleural effsion and recent extubation\n REASON FOR THIS EXAMINATION:\n ? Interval change in pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of left-sided pleural effusion and recent\n extubation. Study is obtained to assess for the size of left pleural\n effusion.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n The left hemithorax demonstrates interval development of diffuse\n opacification. This finding is likely due to the redistribution of the\n moderate left pleural effusion noted on study secondary to\n patient's change in position. The right costophrenic angle is obscured,\n suggestive of right-sided pleural effusion. The right hemithorax also\n demonstrates increased opacification. The pulmonary vasculature appears more\n prominent when compared to prior exam, suggestive of increased pulmonary\n venous pressure. The hilar and mediastinal silhouettes appear stable. The\n heart size is difficult to assess given the surrounding opacities. No\n pneumothorax is visualized.\n\n The left PICC line terminates at low superior vena cava.\n\n Previously described abdominal air pocket is not well visualized on the\n current study, which may also be related to patient's change in position.\n\n The bony structures appear unremarkable.\n\n IMPRESSION:\n\n 1. Interval increase in opacification of the left hemithorax, which is most\n likely due to redistribution of the left pleural effusion secondary to\n patient's change in position. Similarly, right hemithorax demonstrates\n increase in opacification and right pleural effusion is demonstrated on\n current exam.\n\n 2. Bilateral prominence of the pulmonary vasculature, increased since prior\n exam.\n\n 3. Previously described abdominal air pocket is poorly visualized on the\n current study, which may also be related to patient's change in position.\n (Over)\n\n 5:12 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? Interval change in pleural effusion\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-07-10 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1142719, "text": " 12:59 AM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval obs\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with now with increasing abdominal distention.\n REASON FOR THIS EXAMINATION:\n pls eval obs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: now with increasing abdominal distention.\n\n ABDOMEN, SINGLE VIEW.\n\n The diaphragms and right and left lateral abdominal walls are not included on\n this film. The technologist's note indicates \"okayed by the doctor \ne was obtained due to patient inability to position for decubitus.\"\n\n Tubing overlying the rectum. There are multiple markedly dilated air-\n filled loops of bowel. There appears to have been some decrease in the degree\n of dilatation of the proximal transverse colon which measured 15.2 cm on\n and measures 11.2 cm on today's examination. However, as noted, there\n is still considerable bowel distention. There is limited assessment for free\n air, but no obvious free air or mural thickening is detected.\n\n Severe degenerative changes of both hips and degenerative changes in the lower\n lumbar spine are incidentally noted.\n\n" }, { "category": "Radiology", "chartdate": "2162-07-06 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1142080, "text": " 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?obstruction vs. ileus\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with abdominal distention and bowel distention on KUB\n REASON FOR THIS EXAMINATION:\n ?obstruction vs. ileus\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc TUE 7:41 PM\n Massive diffuse dilation of the entire colon and rectum filled with fluid and\n fecal material. The rectal contrast id diluted and cannot be seen proximal to\n the sigmoid colon. No evidence of obstruction or volvulus. These are\n suggestive of syndrome.The rectal catheter was placed in the rectum\n and a distal rectal/anal lesions cannot be excluded in this study. No free\n air.\n Sclerotic lesions in T12 and L1 are noted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man with abdominal distention, bowel distention on\n KUB radiograph.\n\n COMPARISON: Abdomen radiograph .\n\n TECHNIQUE: MDCT images were acquired through the abdomen and pelvis after\n administration of rectal and intravenous contrast. Sagittal and coronal\n reformats were generated and reviewed.\n\n FINDINGS: The visualized lung bases demonstrate subsegmental atelectasis.\n There are no pleural effusions or suspicious pulmonary nodules in the\n visualized portion of the lungs. The visualized portion of the heart and\n pericardium appears unremarkable except for moderate atherosclerotic\n calcification of the coronary arteries.\n\n There is massive distention of the entire large bowel and rectum, filled with\n air, fecal material and fluid. The administered rectal contrast gets diluted\n and is not seen beyond the level of the rectosigmoid junction. No obstructing\n masses or large bowel volvulus is detected. There is mild dilation of the\n distal small bowel loops, secondary to back pressure. The proximal small\n bowel loops and the stomach are decompressed. There is no free air or\n pneumatosis to suggest acute complications. There is a small amount of free\n fluid in the left inguinal hernia.\n\n The distended bowel exerts mass effect on all the intraperitoneal organs. The\n liver and spleen are compressed secondary to the distended bowel. The liver\n otherwise appears unremarkable without focal lesions or biliary dilatation.\n The gallbladder appears unremarkable. Both kidneys show symmetric\n opacification and excretion of contrast without hydronephrosis or concerning\n renal masses. The adrenals are not definitely visualized. The abdominal\n aorta demonstrates mild atherosclerotic calcification without aneurysmal\n dilation. No significant retroperitoneal or mesenteric lymphadenopathy is\n (Over)\n\n 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?obstruction vs. ileus\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n detected.\n\n The urinary bladder is decompressed. The distal ureters appear unremarkable.\n The prostate is moderately enlarged. No significant pelvic lymphadenopathy is\n detected.\n\n OSSEOUS STRUCTURES AND SOFT TISSUES: Multiple sclerotic bone lesions are\n detected in the left pubic symphysis (2:102), lateral aspect of the body of\n T12 vertebra, and the mid body of L4 and S1 vertebrae. These lesions are\n concerning for osseous metastatic disease. Bilateral severe degenerative\n disease of the hip joints noted.\n\n IMPRESSION:\n 1. Massive distention of the large bowel without evidence of obstructing mass\n or volvulus, suggests the possibility of syndrome. The anus is not\n included in the study and anal lesion cannot be excluded in this study. Mild\n secondary dilation of the distal small bowel.\n\n 2. Multiple sclerotic osseous lesions, concerning for metastatic disease.\n Recommened further evaluation with bone scintigraphy, and correlation with any\n history of malignancy.\n\n 3. Moderately enlarged prostate gland.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2162-07-28 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1145461, "text": " 4:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: reposition PICC\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with PICC placed needs repositioned under fluoroscopy\n REASON FOR THIS EXAMINATION:\n reposition PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Request for single lumen PICC line reposition/exchange.\n\n OPERATORS: Dr. and Dr. . The attending, Dr. \n , was present and supervising during the entire procedure.\n\n PROCEDURE: After obtaining informed consent, the patient was brought to the\n angiography suite and placed supine on the angiography table. Usual timeout\n and huddle were performed as per protocol. The right arm around the\n existing catheter was prepped and draped in the usual sterile fashion. A\n scout image showed the tip of the existing catheter in the right axillary\n vein. A 0.018 wire was then advanced through the existing catheter into the\n inferior vena cava. The catheter was pulled back and removed. The wire was\n then slowly withdrawn and after the desired position in the SVC and\n appropriate measurements were made, an equal length of a new PICC line,\n measuring 39 cm was cut and placed over the wire into the SVC, through a peel\n away sheath. The wire and the peel away sheaths were removed.The PICC line\n was saline flushed and capped. The patient withstood the procedure well and\n had no immediate complications.\n\n Local anesthesia around the entry site of the catheter was administered using\n 1% lidocaine.\n\n IMPRESSION: Uncomplicated exchange of right arm single lumen PICC line with\n tip in the SVC. This line is ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2162-07-12 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1143020, "text": " 11:14 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate pelvic lucency seen on KUB. If required used rectal\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Field of view: 45 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with probable olgilvies syndrome, with expanding lucency on KUB\n in rectal/pelvic area. Radiology attending requests CT, with no oral contrast\n but after initial film, rectal contrast as needed\n REASON FOR THIS EXAMINATION:\n evaluate pelvic lucency seen on KUB. If required used rectal contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy MON 12:23 PM\n 1. redemonstration of massively dilated colon and rectum, without obstructing\n mass or volvulus. this likely accounts for radiographic finding of lucency in\n the pelvis. no abdominopelvic fluid/air collection identified.\n 2. acute PE in left lower lobar and lingular arteries. additional\n subsegmental clot burden seen in RLL. note that the entire chest was not\n evaluated.\n 3. multiple sclerotic bone lesions again concerning for malignancy, as on\n prior study.\n 4. atherosclerosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with probable syndrome. CT is\n requested to evaluate expanding lucency in the pelvic area seen on KUB.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed following the\n administration of 130 cc of Optiray contrast. No enteric contrast was\n administered. Multiplanar reformats are provided and reviewed.\n\n FINDINGS\n\n CT ABDOMEN:\n\n There are acute pulmonary emboli seen in the left lingular and lower lobe\n pulmonary arteries (2:5, 2:9, and 2:15, for example). Filling defect in the\n right lower lobe pulmonary artery at the subsegmental level (2:18) likely\n represents additional acute embolus. These findings are new from .\n\n The main pulmonary artery is normal in caliber. The aorta is normal in\n caliber. There are coronary calcifications. There is no pleural or\n pericardial effusion. Plate-like atelectasis is seen at the bilateral lung\n bases. The hemidiaphragms are elevated secondary to distended viscus in the\n abdomen.\n\n There is again massive distention of the entire large bowel and rectum. A\n rectal tube is seen in standard position. Gas within this distended rectum\n (Over)\n\n 11:14 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate pelvic lucency seen on KUB. If required used rectal\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Field of view: 45 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and sigmoid likely accounts for the lucency seen on radiograph. There is no\n obstructing mass lesion identified. There is no pelvic fluid/air-containing\n collection. There is no bowel wall thickening and pneumatosis identified.\n There is no evidence for volvulus. The small bowel is not dilated. There is\n no free air identified in the abdomen. Small amount of fluid is again seen in\n the left inguinal hernia, as on prior study.\n\n The liver, spleen, adrenal glands, kidneys, and pancreas are again displaced\n by the massively distended viscus. There is no acute abnormality involving\n these solid organs. There is no biliary dilation. There is no\n hydronephrosis. There are no mass lesions. There is no apparent mesenteric\n or retroperitoneal adenopathy. The aorta is normal in caliber, with mild\n atherosclerotic calcification.\n\n CT PELVIS: The urinary bladder is compressed by distended viscus. Distal\n ureters appear unremarkable. There is no pelvic or inguinal adenopathy.\n Atherosclerotic calcification of the iliofemoral vessels is noted. There is\n evidence of prior right inguinal hernia repair. A small left inguinal hernia\n persists.\n\n BONE WINDOWS:\n\n Sclerotic lesions are again identified within T12, L4, S1, and the left pubic\n symphysis, as on prior study. These remain concerning for osseous metastatic\n disease.\n\n There is degenerative change in the bilateral hips and in the lumbosacral\n spine. There are no fractures identified.\n\n IMPRESSION:\n\n 1. Redemonstration of massively dilated large bowel extending to the rectum,\n without evidence for obstructing mass or volvulus. Findings are consistent\n with syndrome. There is no evidence for complication, including no\n pneumatosis or free air. There are no abdominopelvic fluid collections.\n\n 2. Redemonstration of multiple sclerotic osseous lesions, again concerning\n for metastatic disease, for which further evaluation with bone scan is\n recommended. Correlation with more remote prior imaging, if available, would\n also be helpful.\n\n 3. Acute pulmonary emboli, as detailed above.\n\n 4. Compressive atelectasis of the bilateral lung bases.\n\n (Over)\n\n 11:14 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate pelvic lucency seen on KUB. If required used rectal\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n Field of view: 45 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Aortic and coronary atherosclerosis.\n\n These findings were discussed with Dr. at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2162-07-17 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1143899, "text": " 5:12 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: eval for change compared to prior KUB\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with Ogilve's syndrome. S/p decompression\n REASON FOR THIS EXAMINATION:\n eval for change compared to prior KUB\n ______________________________________________________________________________\n WET READ: ENYa SAT 10:06 PM\n Rectal tube tip likely in sigmoid/descenidng colon. Unchanged diffusely gas-\n dilated colon. No pneumoperitoneum. Bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN \n\n CLINICAL INFORMATION: syndrome.\n\n Status post decompression, evaluate for change.\n\n FINDINGS:\n\n Two views of the abdomen are compared to the prior study of 09:42 hours of\n . A rectal tube has been placed and there has been significant\n decompression of the colon since the prior study. Whereas on the prior study\n the cecum measured approximately 18 cm in maximal dimension, it now measures\n approximately 12 cm. Transverse colon had measured approximately 15 cm and\n now measures approximately 12 cm.\n\n IMPRESSION:\n\n Significant reduction in colonic distention since rectal tube has been placed.\n Continued observation recommended.\n\n" }, { "category": "Echo", "chartdate": "2162-08-09 00:00:00.000", "description": "Report", "row_id": 99203, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Atrial fibrillation.\nHeight: (in) 71\nWeight (lb): 200\nBSA (m2): 2.11 m2\nBP (mm Hg): 134/84\nHR (bpm): 89\nStatus: Outpatient\nDate/Time: at 11:07\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Low normal LVEF. No resting LVOT gradient. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Moderately dilated 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. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect is seen by 2D\nor color Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is low normal (LVEF\n50-55%). There is no ventricular septal defect. Right ventricular chamber size\nand free wall motion are normal. The ascending aorta is moderately dilated.\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 no mitral valve prolapse. Mild to moderate (+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2162-09-07 00:00:00.000", "description": "Report", "row_id": 287434, "text": "Sinus rhythm. Left atrial abnormality. Delayed R wave progression is\nnon-specific and probably within normal limits. Since the previous tracing of\nsame date there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2162-09-07 00:00:00.000", "description": "Report", "row_id": 287435, "text": "Sinus rhythm. Left atrial abnormality. Delayed R wave progression is\nnon-specific, probably within normal limits. Since the previous tracing\nof atrial ectopy is absent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2162-08-25 00:00:00.000", "description": "Report", "row_id": 287436, "text": "Sinus rhythm with supraventricular and ventricular premature depolarizations.\nNon-diagnostic repolarization abnormalities. Compared to the previous tracing\nof there is no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2162-08-22 00:00:00.000", "description": "Report", "row_id": 287437, "text": "Sinus tachycardia with atrial premature beat. Low limb lead QRS voltage. Modest\nlow amplitude anterolateral lead T wave changes. Findings are non-specific.\nSince the previous tracing of there is probably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2162-08-21 00:00:00.000", "description": "Report", "row_id": 287438, "text": "Sinus rhythm with atrial premature beats and probable ventricular premature\nbeat. Delayed R wave progression with late precordial QRS transition. Modest\nlow amplitude T wave changes. Findings are non-specific. Since the previous\ntracing of the rate is lower. Otherwise, there may be no significant\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2162-08-14 00:00:00.000", "description": "Report", "row_id": 287439, "text": "Atrial fibrillation with rapid ventricular rate. Low limb voltage. Consider\ncardiomyopathy or volume overload. Compared to the previous tracing of \nfindings are generally similar.\n\n" }, { "category": "ECG", "chartdate": "2162-08-09 00:00:00.000", "description": "Report", "row_id": 287440, "text": "Sinus rhythm and frequent atrial ectopy, wandering atrial pacemaker. Low limb\nlead voltage. Diffuse non-specific ST-T wave changes. Compared to the previous\ntracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2162-08-07 00:00:00.000", "description": "Report", "row_id": 287441, "text": "Probable wandering atrial pacemaker with ventricular premature beats. Diffuse\nnon-specific ST-T wave abnormalities. Compared to the previous tracing\nof tracing is now more suggestive of wandering atrial pacemaker.\nSuggest clinical correlation and repeat tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2162-08-06 00:00:00.000", "description": "Report", "row_id": 287647, "text": "Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing of rhythm\nappearance is now more consistent with atrial fibrillation than wandering\natrial pacemaker.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2162-08-04 00:00:00.000", "description": "Report", "row_id": 287648, "text": "Wandering atrial pacemaker. Compared to the previous tracing of there\nis no change.\n\n" }, { "category": "ECG", "chartdate": "2162-08-02 00:00:00.000", "description": "Report", "row_id": 287649, "text": "Baseline artifact. Sinus rhythm with atrial premature beats. T wave\nabnormalities. Since the previous tracing of the rate is faster. Atrial\nectopy is new. T wave abnormalities may be less prominent. Clinical correlation\nis suggested.\n\n" }, { "category": "ECG", "chartdate": "2162-07-11 00:00:00.000", "description": "Report", "row_id": 287650, "text": "Sinus rhythm. Early R wave progression. ST-T wave abnormalities. Since the\nprevious tracing of no significant change in previously noted findings.\n\n" }, { "category": "ECG", "chartdate": "2162-07-06 00:00:00.000", "description": "Report", "row_id": 287651, "text": "Sinus rhythm. Left atrial abnormality. Consider prior inferoposterior\nmyocardial infarction, although it is non-diagnostic. Diffuse ST-T wave\nabnormalities. Prominent U waves. Findings are non-specific but cannot\nexclude drug/electrolyte/metabolic effect. Clinical correlation is suggested.\nSince the previous tracing of the rate is slower, ventricular ectopy\nis not seen. Inferior lead Q waves are more prominent. Further ST-T wave\nchanges are present.\n\n" }, { "category": "Radiology", "chartdate": "2162-08-16 00:00:00.000", "description": "GUIDANCE FOR ABSCESS (75989)", "row_id": 1148123, "text": " 10:13 AM\n PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # \n Reason: please place a drain in the abscess\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ********************************* CPT Codes ********************************\n * PERITONEAL ABSCESS DRAINAGE US GUIDANCE FOR ABSCESS () *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with suspected right anterior abdominal abscess\n REASON FOR THIS EXAMINATION:\n please place a drain in the abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND-GUIDED DRAINAGE OF ABDOMINAL COLLECTION\n\n INDICATION: 75-year-old man with suspected abdominal abscess, for drainage.\n\n PROCEDURE/FINDINGS:\n\n Following discussion of the risks, benefits and alternatives to the procedure,\n informed written patient consent was obtained.\n\n Complex fluid seen within the right subdiaphragmatic spaces and throughout the\n abdomen, with larger collections seen in the pelvis. All visualized pockets\n of fluid contained innumerable internal septations.\n\n A preprocedure timeout was performed using three patient identifiers.\n Moderate conscious sedation was provided by the nursing staff and the patient\n received 2 mg of midazolam and 100 mcg of fentanyl for a total in service time\n of approximately 50 minutes.\n\n The left lower quadrant was selected for drainage and was prepped and draped\n in the usual sterile fashion. 1% lidocaine buffered with sodium bicarbonate\n was instilled into the subcutaneous tissues to provide local anesthesia.\n Using ultrasound guidance, an 8 French pigtail catheter was advanced\n into the largest pocket of fluid seen in the left lower quadrant.\n Approximately 50 cc of predominantly clear yellow fluid was aspirated. In one\n loculation, purulent fluid was aspirated. This was sent to the microbiology\n lab for culture and sensitivity. It was not considered feasible to breakdown\n all of the internal septations. The 8 French catheter was pigtailed\n and left in situ, secured with external fixation device.\n\n Dr. the attending radiologist and he was present throughout the\n procedure.\n\n IMPRESSION: Technically successful insertion of 8 Fr drainage catheter into\n the left pelvic fluid collection. Multiple loculations and complex fluid\n prohibit adequate drainage. Right abdominal and superior hepatic collections\n have a similar appearance and, therefore, their draiange was not attempted.\n (Over)\n\n 10:13 AM\n PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # \n Reason: please place a drain in the abscess\n Admitting Diagnosis: NON-SURGICAL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2138-07-03 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 965258, "text": " 10:17 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: ASTHMA,DYSPNEA ,TACHYCARDIA ,EVAL FOR DVT\n Admitting Diagnosis: ASTHMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with asthma, increasing tachypnea & tachycaria, relatively\n sedentary.\n REASON FOR THIS EXAMINATION:\n Evidence of DVT?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Asthma, increasing tachypnea and tachycardia. Relatively\n sedentary. Assess for DVT.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Using linear probe, scale\n and color Doppler son of the common femoral, superficial femoral, and\n popliteal vessels were performed bilaterally. Study is limited by large body\n habitus. Allowing for limitations, there is no intraluminal thrombus. Vessels\n demonstrate normal flow, compressibility, respiratory variability, and\n augmentation.\n\n IMPRESSION: No evidence of DVT. Study limited by large body habitus.\n\n DR. \n" }, { "category": "Nursing/other", "chartdate": "2138-07-04 00:00:00.000", "description": "Report", "row_id": 1601659, "text": "resp care\nPt given unit dose alb/atr via microneb. BS bil with tight insp wheeze.RR generally mid 20's and slightly labored but will have episodes of inc rr 40 that slows with encouragement.Peak flow on eves 180 that improved to 240 after the neb. HR about 100. Will cont to follow with frequent nebs.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-04 00:00:00.000", "description": "Report", "row_id": 1601660, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report.\n\nROS:\n\nNeuro: Pt legally blind. Alert, oriented x 3. MAE, assists w/ turns in bed. C/O headache last eve; + relief w/ Motrin.\n\nResp: LS very diminished w/ inspiratory wheezes throughout. Pt is receiving Nebs ~ q 3 hrs. +NP. RR 20's-30's, sats mid 90's on 2 liters O2 via NC. Now on PO steroids.\n\nCV: HR 80's-100's, SR-ST, no ectopy noted. NIBP stable.\n\nGI/GU: Abd obese, NT, +BS, no bm overnight. Voiding via bedpan.\n\nPlan: C/O to floor; awaiting available bed; monitor resp status; continue Nebs/steroids; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-04 00:00:00.000", "description": "Report", "row_id": 1601661, "text": "07:00-19:00 on \n\nEVENTS:NO SIGNIFICANT EVENTS TO BE REPORTED.\n\nPT IS ALERT AND ORIENTED,TRANSFER WITH ONE NURSE FROM BED TO CHAIR.SAT OUT ON CHAIR FOR SHORT PERIODS.\n\nON 2L O2 VIA NC.SAO2>95%.RR 15-35/MIN.SLIGHT EXP WHEEZE,ATROVENT NEBS GIVEN 6 HRLY.\n\nCVS:IN ST MOSTLY.BP STABLE,NO ECTOPY.\n\nGI/GU:POS BS,NO BOWEL MOVEMENT THIS SHIFT.ON REGULAR DIET.PASSING URINE IN BEDPAN.\n\nID:AFEBRILE,ON AMPICILLIN ORALLY FOR SINUSITIS.\n\nENDO:ON SLIDING SCALE INSULIN.BLD SUGAR 227 THIS AFTERNOON.\n\nSOCAL: BY FRIEND.\n\nPLAN:A/W BED ON THE FLOOR,MONITOR RESP STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-05 00:00:00.000", "description": "Report", "row_id": 1601662, "text": "7p-7a MICU Nursing Progress Note\n\nEvents: No significant events to report overnight.\n\nROS:\n\nNeuro: Pt alert, oriented x 3. MAE, follows commands. C/O headaches, + relief w/ Motrin.\n\nResp: LS very diminished, w/ wheezes throughout. Pt c/o SOB @ times. Receiving Alb/Atr nebs ~ q 4 hrs o/n. O2 maintained @ 2 liters via NC. Sats mid 90's. RR 20's-30's. Pt continues on PO steroids for asthma exac.\n\nCV: HR 80's-100's, SR-ST, no ectopy noted. NIBP stable.\n\nGI/GU: Abd obese, NT, +BS. No bm overnight. Voiding via bedpan.\n\nPlan: Pt still awaiting tx to the floor; monitor resp status and continue nebs; encourage activity; routine ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-05 00:00:00.000", "description": "Report", "row_id": 1601663, "text": "07:00-19:00 ON \n\nPT IS ALERT AND ORIENTED,LEGALLY BLIND.TRANSFER UNDER SUPERVISION FROM BED TO CHAIR.\n\nRECIEVING O2 2L VIA NC.SAO2>95%.DESATS TO 90-91 WHEN ON RA.INSPIRATORY WHEEZE OCCASIONALLY,ATROVENT NEBS GIVEN AS PER CHART.RR 20-30.HAS GOT WEAK COUGH.\n\nCVS:IN NSR WITH NO ECTOPY.BP WNL.\n\nGU/GI:ON NORMAL DIET. SOFT BOWEL SOUND POS BOWEL MOVEMENT TWICE THIS SHIFT.VOIDING SELF.\n\nENDO:BLOOD SUGAR 133 THIS AFTERNOON.NO COVERAGE.\n\nID:AFEBRILE.ON AMOXICILLIN FOR SINUSITIS.\n\nSOCIAL: BY FRIEND.\n\nPLAN:A/W PRIVATE ROOM SO THAT PT CAN BRING GUIDE DOG IN.MONITOR RESP STATUS,CONTINUE NEBS.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2138-07-06 00:00:00.000", "description": "Report", "row_id": 1601664, "text": "Stable overnight given nebs as ordered lungs with diminished BS throughout improves after neb. On prednisone qd. VSS. Plan to floor when private room is available\n" }, { "category": "Nursing/other", "chartdate": "2138-07-03 00:00:00.000", "description": "Report", "row_id": 1601655, "text": "RESP CARE: Pt admitted from ED on Heliox with 5.0mg albuterol running at 9lpm/NRB at 9lpm and nasal 02 at 2lpm. Lungs good aeration bilat apices, more dim on R than L, few wheezes noted RLL. Pt able to speak though is tachypneic with RR 40s, HR 144. ABG-7.49/16/110/13/-7.Will continue and re-assess frequently.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-03 00:00:00.000", "description": "Report", "row_id": 1601656, "text": "Nursing Progress Note-0500-0700 hours:\nPt admit to micu at 5a. Please see adm hx for data. Pt with HR 130-150's, rr high 30's-50. MD evaluated; lungs wheezey and tight-receiving nebs and heliox by RT. Given ativan 0.5mg iv with fair effect. Able to help pt calm breathing with encouragement. Attempted foley placement but pt was extremely anxious, upset and unable to lie flat-had a lot of difficulty relaxing for the procedure. At 6a-pt voided on bedpan. Md verbalized need for UA with next void. See carevue for head to toe assessment. Cont to assess.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-03 00:00:00.000", "description": "Report", "row_id": 1601657, "text": "Resp. Care Note\nPt followed this shift for Albuterol and Atrovent nebs. Able to wean Rx freq to q3-4 today. Pt with decreased air movement, occas high pitched insp wheeze esp over L. Tachypneic to 40 at times but able to slow RR with encouragment. Peak flow 300 now and pt states baseline is 360. Improving resp status, cont to follow. Pt called out ot floors.\n" }, { "category": "Nursing/other", "chartdate": "2138-07-03 00:00:00.000", "description": "Report", "row_id": 1601658, "text": "NSG 7AM-7PM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\n29 YR OLD FEMALE WITH HX OF ASTHMA, ICU ADMISSIONSX2, PRESENTS WITH ASTHMA EXACERBATION, ASTHMA FLARE BE TRIGGERED BY ENVIRONMENTAL ALLERGIES.\n\nPT RECEIVED ANXIOUS, TACHYPNEIC RR:30S, TACHYCARDIC:110-130S. LUNG SOUNDS DIMINISHED WITH DIFFUSED WHEEZES THROUGHOUT. POOR RESP EFFORT. MULTIPLE NEB TX WITH POS OUTCOME. PRESENTLY, LUNGS CLEAR IN UPPER AIRWAYS/DIMINISHED AT BASES. LESS TACHYPNEIC RR:26/ TACHYCARDIC:90S-110S.\nAFEBRILE. TMAX 98.0\nREMAINS ON STEROIDS/ CHANGE TO PO. MONITOR BLOOD SUGAR WITH SSI.\nVOIDS LARGE AMOUNT OF URINE.\n\nA/OX3, ANXIOUS AT TIME/ ATIVAN 0.5 MG IV GIVEN WITH POS EFFECT. PT ABLE TO REST IN LUNG NAPS. MAE. ABLE TO MAKE NEEDS KNOWN. USE CALL LIGHT APPROPRIATELY.\n\nABD SOFT, POS BS. NO BM. TOLERATES PO INTAKE. NO N/V.\nSKIN W/D. REPOS SELF.\n\n FRIEND . INQUIRES APPROPRIATELY.\n\nC/O TO FLOOR\nCONT NEB TX AS ORDERED\nMONITOR HR\n\n\n" }, { "category": "Radiology", "chartdate": "2138-07-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 965208, "text": " 12:40 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with sob.\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old with shortness of breath, please evaluate.\n\n COMPARISON: .\n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST:\n\n Low lung volumes are present. The lungs are clear and pleural surfaces are\n smooth with no effusion or pneumothorax. Heart size is top normal, though\n this may be due to low lung volumes. Hilar contours are normal.\n\n IMPRESSION:\n\n No acute pulmonary process.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228005, "text": " 5:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p chest tube removal, please assess for any acute change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with pleural effusions with left sided chest tube, now\n removed\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal, please assess for any acute change\n ______________________________________________________________________________\n WET READ: MXAk TUE 6:16 PM\n Status post left chest tube removal with a tiny left apical pneumothorax\n persisting. Otherwise, little change compared to prior study from today.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:15 P.M. ON \n\n HISTORY: An 89-year-old woman with pleural effusion and a left chest tube,\n now removed.\n\n IMPRESSION: AP chest compared to through 14 at 2:57 p.m.:\n\n Small left apical pneumothorax is slightly larger, increasing from the level\n of the third posterior interspace to the bottom of the fourth posterior rib,\n although some of the change could be due to difference in level of\n inspiration. Moderate right pleural effusion is stable. There may also have\n been an increase in volume of left pleural effusion which is difficult to\n assess because of a substantial increase in left basal atelectasis. Moderate\n cardiomegaly is more severe and mild pulmonary edema is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-13 00:00:00.000", "description": "LO ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.", "row_id": 1227472, "text": " 2:30 PM\n ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: LEFT ANKLE ORIF\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n WET READ: GMSj FRI 9:00 PM\n Intraoperative fluoroscopic spot films from left ankle ORIF. Metallic plates\n and fixation screws appear intact. Pls see operative note for details.\n GSenapati \n ______________________________________________________________________________\n FINAL REPORT\n ANKLE, \n\n HISTORY: Left ankle ORIF.\n\n IMPRESSION:\n\n Fluoroscopic spot films of the left ankle are submitted for documentation of\n an invasive procedure performed with imaging guidance and no radiologist in\n attendance.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1227192, "text": " 6:17 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: ? traumatic injury, please eval thighs for bleeding\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with fall from 7 ft., rib fx on cxr, hip fx, dropping crit\n from osh\n REASON FOR THIS EXAMINATION:\n ? traumatic injury, please eval thighs for bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:07 AM\n 1. Hemorrhagic material within the left anterior and posterior pararenal\n spaces, tracking into the pelvis. No definite active extravasation.\n\n 2. Large left iliacus muscle hematoma.\n\n 3. Extensively comminuted fracture involving the left acetabulum with\n additional bilateral minimally displaced inferior pubic rami fractures.\n Non-displaced fractures through the left posterolateral eighth and likely\n ninth ribs.\n\n 4. Indistinctness of a gluteal branch of the left internal iliac artery at\n the level of the sciatic notch is of doubtful clinical significance, although\n a tiny pseudoaneurysm cannot be completely excluded.\n\n 5. 4-mm pulmonary nodules in the left lower lobe and lingula should be\n followed up with CT in one year.\n\n 7. Small to moderate hiatal hernia with a dilated predominantly air-filled\n esophagus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall from 7 feet on , with known rib\n fracture and hip fracture from outside hospital radiographs. Please evaluate\n for traumatic injury. Please include the thighs to assess for bleeding.\n\n TECHNIQUE: MDCT axial images were acquired from the thoracic inlet through\n the mid thighs following the administration of 100 cc of intravenous contrast\n material. Subsequently, delayed phase images were acquired through the\n pelvis. Multiplanar reformations were performed.\n\n COMPARISON: Outside hospital chest and pelvis radiographs from .\n\n CHEST CT: There is biapical pleural parenchymal thickening with associated\n pleural calcifications, possibly related to prior infection. Centrilobular\n emphysema is mild-to-moderate. A 4 mm right lower lobe pulmonary nodule is\n noted (2:33). There is also a 4-mm nodule in the lingula (2:25). An ovoid 11\n x 5 mm structure along the minor fissure is consistent with a fissural lymph\n node (2:29). There is minimal bibasilar dependent atelectasis with likely\n (Over)\n\n 6:17 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: ? traumatic injury, please eval thighs for bleeding\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n scarring. The lungs are otherwise clear. The airways are patent to the\n subsegmental levels bilaterally. Calcification of the tracheobronchial tree\n is noted. There is no pneumothorax. No pleural effusions are seen.\n\n A calcification is noted in the right lobe of the thyroid. The visualized\n portion of the thyroid gland is otherwise unremarkable. The thoracic aorta is\n normal in caliber. Dense calcifications are seen throughout the thoracic\n aorta. The right main pulmonary artery is enlarged, measuring up to 2.9 cm.\n There is massive dilatation of both atria. Overall, the heart is severely\n enlarged. There is no pericardial effusion. No pathologically enlarged\n mediastinal, hilar, or axillary lymph nodes are seen. The esophagus is\n dilated and predominantly air filled. No esophageal wall thickening is seen.\n There is a small to moderate hiatal hernia.\n\n ABDOMEN CT: A 6-mm hypodensity within hepatic segment VI (2:56) is too small\n to characterize but is statistically a hamartoma or simple cyst. No\n additional focal liver lesions are identified. There is no intrahepatic\n biliary duct dilatation. The portal vein is patent. The gallbladder, spleen,\n and right adrenal gland are grossly normal. The left adrenal gland is\n thickened, but no discrete nodule is identified. The main pancreatic duct is\n prominent throughout its course, measuring up to 3 mm. The common duct is\n slightly prominent, measuring 8 mm, not unexpected in a patient of this age.\n The pancreas is otherwise unremarkable. Tiny bilateral renal hypodensities\n are too small to characterize but are statistically simple cysts. The kidneys\n are otherwise grossly normal. Aside from the aforementioned hiatal hernia,\n the stomach is grossly unremarkable. The small bowel is normal in appearance.\n There are scattered colonic diverticula without evidence of diverticulitis.\n The appendix is not well visualized. The abdominal aorta is normal in\n caliber. There are extensive abdominal aortic calcifications as well as\n calcifications in the bilateral iliac arteries and their branches. There is\n no free air in the abdomen. No pathologically enlarged abdominal lymph nodes\n are seen.\n\n There is a moderate quantity of retroperitoneal hematoma seen within both\n within the anterior and posterior pararenal spaces as well as tracking into\n the pelvis. There is no definite active extravasation, although evaluation is\n slightly limited by streak artifact from bony fragments related to extensive\n pelvic fractures. Irregularity of a gluteal branch of the left internal iliac\n artery at the level of the sciatic notch (2:97) is of doubtful clinical\n significance, although a tiny pseudoaneurysm cannot be completely excluded.\n There is a large left iliacus muscle hematoma measuring up to 8.7 x 4.6 x 11.7\n cm. There is also asymmetric thickening of several of the muscles about the\n left pelvic girdle, particularly the obturator internus, likely related to\n intramuscular hematomas.\n\n (Over)\n\n 6:17 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n CT 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: ? traumatic injury, please eval thighs for bleeding\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n PELVIS CT: A Foley catheter is seen within the collapsed bladder. Evaluation\n of the bladder is limited secondary to both its collapsed state and streak\n artifact from a right hip prosthesis. Previously mentioned high-density fluid\n in the pelvis is consistent with hemorrhagic content. The uterus is not well\n visualized. There are no pathologically enlarged pelvic lymph nodes.\n\n BONE WINDOW: There is a non-displaced fracture of the posterolateral aspect\n of the left eighth rib as well as a possible non-displaced fracture of the\n posterolateral aspect of the left ninth rib. There is an extensively\n comminuted fracture of the left acetabulum with components involving the left\n iliac bone and superior pubic ramus. Bilateral minimally displaced fractures\n through both inferior pubic rami are also seen. Deformity of right shoulder\n likely relates to remote trauma. Note is made of a total right hip\n arthroplasty. No hardware complications. Marked dextroscoliosis of the\n thoracolumbar spine is seen. There are also multilevel degenerative changes\n of the thoracolumbar spine, including grade I anterolisthesis of L4 on L5.\n\n IMPRESSION:\n\n 1. Large left retroperitoneal/pelvic hematoma, left iliacus hematoma\n secondary to extensive left pelvic fractures. No definite active\n extravasation. ndistinctness of a gluteal branch of the left internal iliac\n artery at the level of the sciatic notch is of doubtful clinical significance,\n although a tiny pseudoaneurysm cannot be completely excluded.\n\n 2. Extensively comminuted fracture involving the left acetabulum with\n additional bilateral minimally displaced inferior pubic rami fractures.\n Non-displaced fractures through the left posterolateral eighth and likely\n ninth ribs.\n\n 3. 4-mm pulmonary nodules in the left lower lobe and lingula should be\n followed up with CT in one year.\n\n 4. Small to moderate hiatal hernia with a dilated predominantly air-filled\n esophagus.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1227193, "text": " 6:18 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with fall from 7 ft., rib fx on cxr, hip fx, dropping crit\n from osh\n REASON FOR THIS EXAMINATION:\n ? fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 6:43 PM\n No acute fracture or malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall from 7 feet with known rib fractures seen on chest\n radiograph as well as a known hip fracture. Now with dropping hematocrit.\n Transferred from outside hospital. Evaluate for fracture or malalignment.\n\n TECHNIQUE: MDCT axial images were acquired through the cervical spine without\n the administration of intravenous contrast material. Multiplanar reformations\n were performed.\n\n COMPARISON: None.\n\n FINDINGS: There is no acute fracture or malalignment. Multilevel\n degenerative changes of the cervical spine are seen. There is marked\n sclerosis at C1-2 with associated subchondral cystic change in the dens and\n thickening of the transverse ligament. Multilevel disc space narrowing is\n most prominent at C6-7 where there is severe narrowing. Large anterior\n osteophytes are seen at several levels. There are also posterior\n disc-osteophyte complexes at multiple levels causing spinal canal narrowing\n that is most severe at C6-7 where there is mild-to-moderate narrowing of the\n spinal canal. Uncovertebral and facet joint hypertrophy cause neural\n foraminal narrowing at multiple levels, most severe on the right at C3-4.\n\n There is no prevertebral soft tissue edema or hematoma. No pathologically\n enlarged cervical lymph nodes are seen. Bilateral carotid artery\n calcifications are noted. There is a course calcification in the right lobe\n of the thyroid. Pleural calcifications and pleuroparenchymal\n scarring/thickening are seen at both lung apices. The aerodigestive tract is\n grossly unremarkable.\n\n IMPRESSION:\n\n 1. No acute fracture or malalignment.\n\n 2. Marked multilevel degenerative changes of the cervical spine, including\n multilevel posterior disc osteophyte complexes that cause spinal canal\n narrowing that is most prominent at C6-7, where there is moderate narrowing of\n the canal. Narrowing of the spinal canal may predispose to spinal cord injury\n in the setting of trauma. MR is more sensitive than CT for detection of\n spinal cord injury.\n (Over)\n\n 6:18 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2150-03-11 00:00:00.000", "description": "L ANKLE (AP, MORTISE & LAT) LEFT", "row_id": 1227190, "text": " 5:56 PM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Patient with fall from feet, with pain, sweliing L ankle and foreshortened\n rotated LLe\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n LEFT ANKLE RADIOGRAPH PERFORMED ON \n\n Comparison with an outside hospital ankle radiograph from earlier today.\n\n CLINICAL HISTORY: Status post fall from 6 to 7 feet with left ankle swelling\n and pain with outside hospital radiograph demonstrating fractures.\n\n FINDINGS: Three views of the left ankle were provided. Acute fractures are\n seen involving the distal fibula extending to the syndesmosis compatible with\n a B fracture. Also noted is a slightly comminuted medial malleolar\n fracture. Widening of the ankle mortise is noted medially. Posterior\n malleolus is difficult to clearly assess and the possibility of a\n non-displaced fracture cannot be entirely excluded. Soft tissue swelling is\n noted. Vascular calcifications are present. The bones are diffusely\n demineralized.\n\n IMPRESSION: Acute fractures involving the medial malleolus, distal fibula\n ( B) with syndesmotic disruption and widened medial mortise.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2150-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227988, "text": " 3:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with chest tube\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube, to assess for interval change.\n\n FINDINGS: In comparison with the earlier study of this date, the left\n pneumothorax has substantially decreased. Otherwise, little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227849, "text": " 6:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? CT kinked (pulled back 3-4cm)\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 F s/p adjustment of left CT\n REASON FOR THIS EXAMINATION:\n ? CT kinked (pulled back 3-4cm)\n ______________________________________________________________________________\n WET READ: MXAk MON 7:43 PM\n Small left pneumothorax, decreased compared to prior study from the same day.\n Small left pleural effusion, stable. Small right pleural effusion, minimally\n decreased. New atelectasis of the left upper lung. Left chest tube appears\n retracted but in place.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Adjustment of the left chest tube.\n\n Portable AP radiograph of the chest was compared to prior study obtained the\n same day earlier.\n\n The left chest tube appears to be re-adjusted with the tip being projecting\n superiorly as compared to the prior examination. The widespread parenchymal\n consolidations and bilateral pleural effusion appear to be unchanged. There is\n evidence of left apical pneumothorax, small, better appreciated on the current\n radiograph as compared to prior examination.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-18 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1228126, "text": " 2:26 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: swallow eval\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with s/p pelvis and ankle ORIF\n REASON FOR THIS EXAMINATION:\n swallow eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swallow evaluation.\n\n FINDINGS: Swallowing videofluoroscopy was performed in conjunction with\n speech and swallow division. Multiple consistencies of barium were\n administered orally. Deep penetration was seen with nectar-thickened and thin\n liquids as well as with a cracker. Trace aspiration was seen with thin\n liquids.\n\n IMPRESSION: Trace aspiration with thin liquids and penetration with all other\n consistencies.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-18 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 1228143, "text": " 5:21 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: ? DVT please do not remove bivalve cast if possible\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with wound infection s/p ORIF ankle\n REASON FOR THIS EXAMINATION:\n ? DVT please do not remove bivalve cast if possible\n ______________________________________________________________________________\n WET READ: JEKh WED 5:45 PM\n calf veins not examined b/c of cast; no dvt in visualized veins; cyst.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89-year-old female with recent open reduction/internal fixation of\n the ankle, now with wound infection and lower extremity swelling on the left.\n\n STUDY: Left lower extremity venous ultrasound.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler son imaging was performed of\n bilateral common femoral, left superficial femoral, left popliteal, left\n posterior tibial, and left peroneal veins. Normal compressibility, flow and\n augmentation demonstrated. A 4.3 cm fluid collection in the popliteal fossa\n is compatible with cyst.\n\n IMPRESSION: No DVT; cyst.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227932, "text": " 9:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with chest tube\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 89-year-old female patient with chest tube interval change.\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 on , 18:27 hours. The previously described\n findings are unaltered, and the left apical pneumothorax measuring 2-3 cm in\n width in the apical area persists. The position of the left-sided chest tube\n is unaltered and so are the previously described densities.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227745, "text": " 9:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pulm edema\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with desat\n REASON FOR THIS EXAMINATION:\n ?pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:19 AM, \n\n HISTORY: Desaturation.\n\n IMPRESSION: AP chest compared to :\n\n The inferior two-thirds of the left hemithorax is opacified, probably by a\n combination of pleural effusion, moderate-to-large, and large scale\n consolidation in the left lung. Whether this is pneumonia or only atelectasis\n is radiographically indeterminate. Small right pleural effusion is new.\n Heart is moderately-to-severely enlarged, but heart size cannot be assessed\n because heart borders are obscured by pleural and parenchymal abnormalities.\n Thoracic aorta is heavily calcified and tortuous, but not focally aneurysmal.\n Dr. was paged to report these findings at the time of dictation.\n\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228054, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with chest tube\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:01 A.M. \n\n HISTORY: Evaluate interval pleural changes.\n\n IMPRESSION: AP chest compared to , 5:17 p.m.:\n\n Because this study is performed with the patient supine, assessing the volume\n of pleural air and fluid compared to preceding upright radiograph is dubious.\n Pleural effusions are small to moderate, and left pneumothorax is also small.\n Moderate-to-severe cardiomegaly is stable. Mild pulmonary edema may have\n increased slightly.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-16 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 1227826, "text": " 3:32 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: postop XR, interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with pelvic fx s/p ORIF\n REASON FOR THIS EXAMINATION:\n postop XR, interval change\n ______________________________________________________________________________\n WET READ: MXAk MON 7:55 PM\n Post ORIF changes of the left hip with no evidence of hardware failure. Right\n hip prosthesis again noted. Nonspecific bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL RADIOGRAPH OF THE PELVIS\n\n CLINICAL INDICATION: 89-year-old woman with pelvic fracture status post ORIF,\n postoperative evaluation for assessment of interval changes.\n\n COMPARISON: reference pelvis radiographs and CT torso with\n contrast from .\n\n FINDINGS:\n\n Again demonstrated are changes of a prior right hip hemiarthroplasty with\n orthopedic hardware in place and intact. Again seen is an extensive\n comminuted fracture involving the left acetabulum with also minimally\n displaced fractures involving the inferior pubic rami and superior pubic rami\n with surgical staples overlying the level of the pubic symphysis. Screw\n fixation with four total screws is seen to the level of the left acetabulum\n superiorly and fixation through known left anterior column posterior\n hemitransverse acetabular fracture. Multilevel incompletely seen degenerative\n changes in the lower lumbar spine. Surgical staples overlying the proximal\n lateral left thigh. Interval improvement in acetabular protrusio.\n\n IMPRESSION:\n\n 1. Interval ORIF changes with screw fixation through known left anterior\n column posterior hemitransverse acetabular fracture without signs of\n orthopedic hardware complication.\n 2. Changes of prior right hemiarthroplasty with orthopedic hardware in place\n and intact.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1227733, "text": " 8:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o ICH\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman s/p fall with acute mental status change\n REASON FOR THIS EXAMINATION:\n r/o ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with acute mental status changes. Evaluate for\n ICH.\n\n COMPARISONS: CT head, .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without the administration of IV contrast.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or\n new large vascular territory infarction. An area of cystic encephalomalacia\n is present in the right temporoparietal region, most likely from a prior MCA\n infarct. Confluent periventricular white matter hypodensities are consistent\n with moderate chronic small vessel ischemic disease. Vascular calcifications\n are noted in the internal carotid and vertebral arteries.\n\n Mild prominence of the ventricles and sulci suggest age-related atrophy. The\n basal cisterns are patent. No fracture is identified. The visualized\n paranasal sinuses, mastoid air cells, and middle ear cavities are clear.\n There is evidence of prior lens replacement surgery.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. Unchanged evidence of chronic small vessel ischemic disease and an old\n prior right MCA infarct.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1228241, "text": " 10:42 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 42cm iv \n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r picc 42cm iv \n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n right-sided PICC line. The line is malpositioned, crossing the midline and\n terminating in the contralateral subclavian vein. The line needs to be\n re-positioned. There is no evidence of complications such as pneumothorax.\n The PICC line nurse for notification at the time of dictation, 1138,\n on .\n\n The radiograph is otherwise unchanged, with constant appearance of the heart\n and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1228266, "text": " 1:39 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Right arm PICC repositioned. ? PICC tip location\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with right arm PICC repositioned. ? PICC tip now\n REASON FOR THIS EXAMINATION:\n Right arm PICC repositioned. ? PICC tip location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old female with new right-sided PICC.\n\n COMPARISON: Multiple chest radiographs dating back to , most\n recently \n\n TECHNIQUE: Portable upright AP chest radiograph.\n\n FINDINGS: New right-sided PICC is seen entering the subclavian and\n terminating within the low SVC with no evidence of pneumothorax. There has\n been interval decrease in pulmonary edema and bilateral pleural effusion\n remains essentially unchanged. Cardiomediastinal silhouette is stably\n enlarged.\n\n IMPRESSION: Successful placement of right-sided PICC. Interval improvement\n in pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-13 00:00:00.000", "description": "LO HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT IN O.R.", "row_id": 1227493, "text": " 5:07 PM\n HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: LEFT ORIF ACUTABULAR FX\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n WET READ: GMSj FRI 9:02 PM\n Intraoperative fluoroscopic spot films from left acetabular ORIF. Pls see\n operative note for details. Total fluoro time: 292.6 seconds. GSenapati\n \n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: LEFT HIP.\n\n Fluoroscopic spot films of the left hip are submitted for documentation of an\n operative procedure performed with imaging guidance and no radiologist in\n attendance.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-11 00:00:00.000", "description": "LP ANKLE (2 VIEWS) LEFT PORT", "row_id": 1227220, "text": " 11:08 PM\n ANKLE (2 VIEWS) LEFT PORT Clip # \n Reason: s/p splint placement, assess alignment.AP and lateral, PORTA\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman s/p fall with left ankle fx s/p splint placement\n REASON FOR THIS EXAMINATION:\n s/p splint placement, assess alignment.AP and lateral, PORTABLE please\n ______________________________________________________________________________\n FINAL REPORT\n LEFT ANKLE RADIOGRAPHS DATED \n\n CLINICAL INDICATION: 89-year-old woman status post fall with left ankle\n fracture, status post splint placement. Assess alignment.\n\n COMPARISON: Left ankle radiographs from same date, .\n\n FINDINGS:\n\n Frontal and lateral radiographs of the left ankle again demonstrate acute\n fractures involving the distal fibula extending to the syndesmosis compatible\n with B-type fractures and comminuted medial malleolar fracture with now\n near normal anatomic alignment in the interim. Fine bony trabecular detail is\n obscured by overlying external splint artifact. Ankle mortise appears\n preserved. Calcified atherosclerotic vascular disease of the lower extremity.\n\n IMPRESSION:\n\n Distal fibula and medial malleolus fractures, with now near normal anatomic\n alignment in the interim with external fixation artifact from overlying\n splint.\n\n" }, { "category": "Radiology", "chartdate": "2150-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1227798, "text": " 1:44 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: tube placement? lung re-expansion?\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with hypoxia s/p new L chest tube (300cc removed)\n REASON FOR THIS EXAMINATION:\n tube placement? lung re-expansion?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old female with new chest tube.\n\n COMPARISON: Semi-upright portable AP chest radiograph taken earlier the same\n day.\n\n TECHNIQUE: Portable semi-upright AP chest radiograph.\n\n FINDINGS: There is new moderate-sized left apical pneumothorax with no\n evidence of tension. There has been marked reduction in the quantity of left\n pleural effusion with small residual left pleural effusion noted. There has\n been interval increase in the right pleural effusion with associated right\n lower lung atelectasis. There is moderate cardiomegaly. The pleural surfaces\n are unremarkable.\n\n IMPRESSION: Moderate-sized right apical pneumothorax. Decrease in left\n pleural effusion. Increase in right pleural effusion and right lower lung\n atelectasis.\n\n These findings were reported to Dr. at 2:05 p.m. via phone by \n .\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-11 00:00:00.000", "description": "L HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT", "row_id": 1227189, "text": " 5:55 PM\n HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Patient with fall from feet, with pain, sweliing L ankle and foreshortened\n rotated LLe\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS AND LEFT HIP RADIOGRAPH PERFORMED ON \n\n Comparison with an outside hospital pelvis radiograph from earlier today.\n\n CLINICAL HISTORY: Status post fall with left hip pain, assess fracture.\n\n FINDINGS: Three views were provided including an AP view of the pelvis and\n two views of the left hip. There is an acute fracture involving the left\n acetabulum with a protrusio defect of the left humeral head medially.\n Additionally noted are fractures involving the right superior and inferior\n pubic ramus and the left inferior pubic ramus. Right hip replacement is\n noted. Degenerative changes and dextroscoliosis partially imaged in the lower\n lumbar spine.\n\n IMPRESSION: Multiple pelvic fractures detailed above including right superior\n and inferior pubic ramus fractures, left acetabular fracture with protrusio\n defect and left inferior pubic ramus fractures. Please refer to subsequently\n performed CT of the torso for further details.\n\n\n" }, { "category": "ECG", "chartdate": "2150-03-11 00:00:00.000", "description": "Report", "row_id": 244021, "text": "Atrial fibrillation with slowing of the rate as compared to the previous\ntracing of . There is frequent ventricular ectopy. Right axis deviation.\nPrior anteroseptal myocardial infarction. Left ventricular hypertrophy with\nST-wave change. Compared to the previous tracing, in the context of slowing of\nthe rate, there is variation in precordial lead placement but the ST-T wave\nchanges may be less prominent. Ventricular ectopy has appeared. Followup and\nclinical correlation are suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2150-03-11 00:00:00.000", "description": "Report", "row_id": 244022, "text": "Atrial fibrillation with rapid ventricular response. Right axis deviation.\nLeft ventricular hypertrophy with ST-T wave changes. QS deflection in\nleads V1-V3 consistent with prior anteroseptal myocardial infarction. Compared\nto the previous tracing of the rate has increased. Otherwise, no\ndiagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2150-03-11 00:00:00.000", "description": "Report", "row_id": 244023, "text": "Atrial fibrillation with rapid ventricular response. Left ventricular\nhypertrophy with ST-T wave changes. QS deflection in leads V1-V3 consistent\nwith prior anteroseptal myocardial infarction. There is right axis deviation.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2150-03-16 00:00:00.000", "description": "Report", "row_id": 244019, "text": "Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nST-T wave abnormality. Left and right arm lead reversal. Delayed R wave\nprogression suggesting possible remote anterior wall myocardial infarction.\nCompared to the previous tracing of limb lead reversal is again noted.\nThe ventricular response rate has slightly decreased.\n\n" }, { "category": "ECG", "chartdate": "2150-03-14 00:00:00.000", "description": "Report", "row_id": 244020, "text": "Possible arm lead reversal. Atrial fibrillation, average ventricular rate 99,\nwith diffuse non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of there is no diagnostic change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2136-09-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1206126, "text": " 12:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed, fx\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with fall, hit head\n REASON FOR THIS EXAMINATION:\n eval for bleed, fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AMLw WED 1:06 PM\n 1. No acute pathology.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT PERFORMED ON \n\n CLINICAL HISTORY: Status post fall with head trauma, question ICH or\n fracture.\n\n TECHNIQUE: Non-contrast MDCT with axial, coronal, sagittal reformations.\n\n FINDINGS: Evaluation is slightly limited due to motion artifact in the lower\n cuts. There is no intra-axial or extra-axial hemorrhage, edema, shift of\n normally midline structures, or evidence of acute major vascular territorial\n infarction. The ventricles and sulci appear stable and mildly prominent\n likely related to mild atrophy. Basilar cisterns are patent. Mild\n periventricular white matter hypodensity likely related to chronic\n microvascular ischemic disease. Paranasal sinuses are notable for minimal\n mucosal thickening. Mastoid air cells and middle ear cavities are well\n aerated. Bony calvarium is intact.\n\n IMPRESSION: No acute intracranial process.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2136-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206387, "text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx of DM, CAD, CKD, HTN, Fourniers gangreen with Upper GI\n bleed. Now intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Upper GI bleed.\n\n FINDINGS: In comparison with the study of , there is continued extensive\n opacification bilaterally that may have progressed further on the left.\n Findings suggest a combination of diffuse pneumonia and elevated pulmonary\n venous pressure. Monitoring and support devices remain in place. Multiple\n broken sternal wires are again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206208, "text": " 11:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for volume overload or any other process\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with increased O2 requirement & respiratory rate.\n REASON FOR THIS EXAMINATION:\n Please eval for volume overload or any other process\n ______________________________________________________________________________\n WET READ: 11:33 AM\n Findings consistent with multifocal pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with increased O2 requirement and respiratory\n rate.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: Dense consolidative opacity in the left mid hemithorax appears\n similar to minimally increased on this examination. Additionally, right peri\n and infrahilar opacities have become more confluent. There is likely a degree\n of volume overload; however, the appearnce is most consistent with multifocal\n pneumonia. No pneumothorax is seen. No significant pleural effusion. The\n heart size is mildly enlarged and there is pulmonary vascular congestion.\n\n Median sternotomy wires appear similar with fracture of the first and third\n wire from the top.\n\n IMRESSION: Findings consistent with multifocal pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206224, "text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pulmonary process.\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ugib, like eval regarding potential pulmonary process.\n REASON FOR THIS EXAMINATION:\n please eval for pulmonary process.\n ______________________________________________________________________________\n WET READ: 11:36 AM\n Interval worsening of multifocal pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with upper GI bleed. Interval evaluation of the\n chest.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: Dense consolidative opacities in the left hemithorax and right\n lower and mid hemithorax appear progressed on this examination. Aeration in\n the left hemithorax is decreasing. The consolidation extending from the right\n peri- and infrahilar region is also extending. Findings concerning for\n pneumonia. Additional vascular congestion may be present. The heart size is\n enlarged, however, unchanged. Again note is made of median sternotomy wires\n with fracture of the first and third wires from the top.\n\n IMPRESSION: Interval worsening of multifocal pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206245, "text": " 5:53 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval et tube location\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with intubation, eval for tube location\n REASON FOR THIS EXAMINATION:\n eval et tube location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old male with multifocal pneumonia. Evaluation after\n endotracheal tube placement.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated ,\n obtained approximately two hours prior.\n\n FINDINGS: In the interval from the prior examination, an endotracheal tube\n has been placed in satisfactory position with tip approximately 4.3 cm above\n the carina. An esophageal catheter coursing inferior to the diaphragm with\n tip out of view of the radiograph is unchanged. Median sternotomy wires and\n mediastinal clips appear unchanged.\n\n Again seen are bilateral multifocal dense consolidative opacities consistent\n with multifocal pneumonia. As compared to the prior examination obtained\n approximately two hours prior, there is no significant interval change.\n Pulmonary vascular congestion is not significantly different. No pneumothorax\n is seen. No significant pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1206116, "text": " 10:33 AM\n CHEST (PA & LAT) Clip # \n Reason: free air chest pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n free air chest pain\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: .\n\n CLINICAL HISTORY: Chest pain, assess for free air.\n\n FINDINGS: AP upright and lateral views of the chest were obtained. Midline\n sternotomy wires and mediastinal clips are again noted. There is diffuse\n pulmonary vascular congestion with trace pleural fluid along the fissural\n surfaces noted on lateral view. There is a more confluent opacity in the left\n mid lung posteriorly which is concerning for pneumonia. Subtle air\n bronchograms are noted within this confluent opacity. There is no\n pneumothorax. No free air is seen below the right hemidiaphragm. Bony\n structures appear intact.\n\n IMPRESSION: Congestive heart failure with superimposed pneumonia in the\n superior segment of left lower lobe. Recommend followup to resolution.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2136-09-24 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1206730, "text": " 12:20 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please peform nonIV contrast study with po contrast: eval ri\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with pna and intubated with new abd pain and rising WBC, on\n vanco/zosyn.\n REASON FOR THIS EXAMINATION:\n Please peform nonIV contrast study with po contrast: eval rising WBC,\n persistent fever for intra-abd/chest fluid collections or colitis\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n WET READ: PBec MON 2:58 AM\n 1. DIFFUSE PATHCY OPACIFICATIONS T/O RIGHT LUNG, PARTICULARLY RLL WITH AREAS\n OF MORE FOCAL CONSOLIDATION CONSCENRING FOR MULTI-FOCAL PNA.\n 2. NEAR COMPLETE COLLAPSE OF LLL AND MAJORITY OF LUL- LIKELY ATELECTASIS BUT\n CANNOT EXLCLUDE SUPERIMPOSED INFECTION.\n 3. BILATERAL SMALL PLEURAL EFFUSIONS, L.R\n 4. MULTIPLE BULLA NOTED T/O BILATERAL LUNGS\n 5. CARDIOMEGALY W/ CAD.S/P CABG W/ MULIT BROKEN STERNOTOMY SUTURES. NO\n PERICARDIAL EFFUSION\n 6. MEDIASTINAL AND HILAR LAD, WITH PREVASCULAR NODE MEASURING 1.7 CM -\n POSSIBLY REACTIVE, BUT CANT EXLCUDE MALIGNANCY PARTICULARLY IN SETTING OF\n LOBAR CONSOLIDATION\n 7. ETT 4CM ABOVE CARINA. NGT TIP IN STOMACH\n 8. TRACE PERIHEAPTIC FLUID. TRACE INTRAABDOMINAL FLUID TRACKING ALONG\n BILATERAL GEROTA'S FASCIA INTO BILATERAL PARACOLIC GUTTERS.\n 9. AREA OF MINIMALLY CIRCUMFERENTIALLY THICKENED BOWEL WALL IN DESCENIDING\n COLON WITHOUT SIGNIF SURROUNDING MESENTERIC INFLAMM (601B:29, 2:109) BE\n DUE TO COLLAPSE, THOUGH CANT R/O EARLY COLITIS.\n 10. APPENDIX NORMAL.\n PBISHOP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with pneumonia, intubated with new abdominal pain\n and rising WBC. Evaluate for fluid collections or colitis.\n\n COMPARISON: CT chest, abdomen and pelvis from .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic outlet to the\n pubic symphysis without the administration of contrast material. Coronal and\n sagittal reformats were completed.\n\n FINDINGS:\n\n CT CHEST: The thyroid gland is unremarkable. There is no supraclavicular or\n axillary lymphadenopathy. There is a lipoma in the left subscapularis muscle.\n There is extensive mediastinal lymphadenopathy involving the paraaortic,\n subcarinal, and pretracheal regions. For example, large lymph node measuring\n 2.3 x 1.8 cm, image 2:20, in the right paraaortic region as well as one\n measuring 1.9 x 1.3 cm in the left paratracheal region, 2:21. There is also\n (Over)\n\n 12:20 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please peform nonIV contrast study with po contrast: eval ri\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hilar and mediastinal adenopathy. This is likely reactive. The heart is\n enlarged with features consistent with anemia as the muscle wall is more dense\n than the . There has been a prior sternotomy and there are coronary\n stents. There is no pericardial effusion. The ET tube is above the carina.\n\n There is dense consolidation involving almost the entire left lung with\n aeration only in the apicoanterior segment of the left upper lobe. There is\n patchy consolidation of the right middle and right lower lobe with sparing of\n the right upper lobe. There is a pleural bleb in the right upper lobe. There\n are small bilateral pleural effusions. There is no evidence of mucus plugging\n and the bronchi are open without obstruction.\n\n CT ABDOMEN WITHOUT CONTRAST: The study is limited without the administration\n of intravenous contrast material. Given this limitation, the liver appears\n normal without any focal lesions. There is an area of hyperdensity within the\n gallbladder wall, 2:64, which may represent small gallstones. There is no\n gallbladder wall thickening. The pancreas and spleen are unremarkable. The\n adrenal glands are unremarkable. There is bilateral nephrolithiasis without\n any hydronephrosis or evidence of obstruction. There are no focal masses in\n the kidneys. There is an NG tube terminating in the stomach. The visualized\n small and large bowel appear unremarkable. There is no evidence of colitis\n including bowel wall thickening. There is no intra-abdominal or mesenteric\n lymphadenopathy. There is a small amount of perihepatic ascites. There are\n extensive aortic calcifications.\n\n CT PELVIS WITHOUT CONTRAST: There is a catheter within the bladder as well as\n emphysema in the bladder likely from catheter. There is calcification of the\n seminal vesicles. The rectum and sigmoid colon are unremarkable. There is\n soft tissue density in the bilateral inguinal canals which may represent\n loculated fluid. There is no pelvic or inguinal lymphadenopathy.\n\n OSSEOUS AND SOFT TISSUE STRUCTURES: There are no suspicious lytic or blastic\n lesions. There is extensive subcutaneous edema consistent with anasarca.\n\n IMPRESSION:\n 1. Pneumonia, worse in the left lung with aeration of only the apicoanterior\n segment of left upper lobe. Likely reactive mediastinal lymphadenopathy.\n\n 2. Intra-abdominal ascites without any colonic wall thickening.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-23 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1206679, "text": " 10:24 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval cholecystitis\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with pneumonia, chest pain, hemolysis with new\n hyperbilirubinemia, and RUQ tenderness\n REASON FOR THIS EXAMINATION:\n eval cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 63-year-old male with pneumonia, chest pain, hemolysis\n and now hyperbilirubinemia with right upper quadrant tenderness, question\n cholecystitis.\n\n COMPARISON: .\n\n FINDINGS: The liver is normal in echogenicity without focal lesions. The\n gallbladder demonstrates minimal wall thickening (4 mm), with a small amount\n of pericholecystic fluid. Layering debris is seen within its dependent\n portion. Small amount of fluid is seen along the liver capsule. Common bile\n duct is normal in caliber measuring 5 mm. Hepatopetal flow is seen within the\n main portal vein. The spleen is normal in dimensions measuring 12.3 cm in the\n craniocaudal dimension. The pancreas is not visualized due to overlying\n structures.\n\n IMPRESSION: Minimal gallbladder wall thickening, with layering debris and a\n small amount of pericholecystic fluid are equivocal for acute cholecystitis.\n If there is clinical concern for this entity, further evaluation with HIDA\n scan is recommended.\n\n These findings were discussed with Dr. at 5:50 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206736, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with chest pain (which he alternately describes as stabbing and\n crushing with a slight pleuritic component), fatigue, weakness, and \n episodes of vomiting blood.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old man with chest pain, fatigue, weakness and\n episodes of vomiting blood.\n\n COMPARISONS: Multiple priors including most recently a CT chest from\n and chest x-ray from .\n\n FINDINGS: Broken sternotomy wires are unchanged since .\n Multifocal pneumonia, in the right lower lobe, left upper lobe and collapse of\n the left lower lobe are unchanged. A right IJ line ends in the low SVC.\n\n IMPRESSION: Unchanged multifocal pneumonia and left lower lobe collapse.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206887, "text": " 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with multiple medical problems, aspiration pna, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple medical problems, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is increasing opacity\n at the right lung base. This could reflect atelectasis or developing\n pneumonia. Short-term followup is required. The extensive opacities on the\n left are unchanged. Unchanged retrocardiac atelectasis, unchanged\n cardiomegaly. The monitoring and support devices are also unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206542, "text": " 2:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with DM HTN, CAD, Fourniers, CKD, intubated for multifocal\n pnuemonia\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Diabetes mellitus, intubation, multifocal pneumonia. Evaluation\n for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is minimal\n improvement with a reduction in extent of the pre-existing opacities on the\n right. On the left, the pre-existing opacities and consolidations are\n unchanged. Also unchanged is the size of the cardiac silhouette. Unchanged\n monitoring and support devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-24 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1206849, "text": " 3:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man intubated with new hyppotension\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n WET READ: OXZa MON 5:03 PM\n Findings consistent with multifocal pneumonia, not significantly changed from\n the prior examination.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male, intubated with multifocal pneumonia, now with\n new hypotension.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent radiograph of the same\n date obtained approximately 12 hours prior and comparison with CT of the chest\n also dated .\n\n FINDINGS: Again seen are multifocal consolidations, greatest in the left\n upper lobe and at the left base. Consolidation in the right base is also\n present though to a lesser degree. Overall, the appearance is not\n significantly changed from the prior examination. Mild pulmonary edema is\n unchanged. No pneumothorax is seen. No significant effusion is seen on the\n right. A small left pleural effusion is likely present.\n\n An esophageal catheter courses inferior to the diaphragm with tip out of view\n of the radiograph. A right-sided internal jugular catheter reaches the low\n SVC. Endotracheal tube is in standard position. Multiple fractured median\n sternotomy wires appear similar in position. Mediastinal clips from prior\n CABG are noted.\n\n IMPRESSION: Findings consistent with multifocal pneumonia, not significantly\n changed from the prior examination.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-23 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1206724, "text": " 7:11 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? PTX ? line placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new R IJ.\n REASON FOR THIS EXAMINATION:\n ? PTX ? line placement\n ______________________________________________________________________________\n WET READ: KKgc SUN 9:07 PM\n New R IJ CVL ends in the mid-low SVC. No pneumothorax. Multifocal\n consolidation in the RLL, LUL and LLL, are unchaged. NG tube and ETT are in\n optimal position.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old man with new right-sided line placement,\n question pneumothorax.\n\n COMPARISON: Multiple prior examinations including most recently from\n , earlier today.\n\n FINDINGS: A new right IJ line ends in the mid-to-lower SVC. There is no\n pneumothorax, appreciable pleural effusion or mediastinal widening.\n Multifocal consolidation in the right lower lobe, left upper lobe and left\n lower lobe, is unchanged. An NG tube is in optimal position, its tip 4.5 cm\n from the carina.\n\n IMPRESSION:\n 1. New right IJ line ends in low SVC. No complications.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1206634, "text": " 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for worsening pulmonary issues\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aspiration, eval worsening pulmonary issues\n REASON FOR THIS EXAMINATION:\n eval for worsening pulmonary issues\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Aspiration, evaluation for worsening pulmonary pathology.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there could be minimally\n improved ventilation at the right lung base. However, the extensive\n consolidations on the left and right basal parenchymal opacities are overall\n unchanged in extent. Unchanged moderate cardiomegaly with retrocardiac\n atelectasis. Unchanged appearance of the monitoring and support devices.\n Unchanged alignment of the sternal wires, some of which are fractured.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-24 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1206766, "text": "GALLBLADDER SCAN Clip # \n Reason: , PNA, PERSISTENT FEVER AND RISING WBC AND NEW RUQ PAIN, INTUBATED\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 3.7 mCi Tc-m DISIDA ();\n 2.0 mCi Tc-99m DISIDA ();\n HISTORY: 63-year-old man admitted for pneumonia, now with persistent fever,\n increased WBC count and new RUQ pain. Please rule out acute cholecystitis.\n\n INTERPRETATION: Serial images over the abdomen show uptake of tracer into the\n hepatic parenchyma. There was a persistent cardiac blood pool and decreased\n liver uptake of radiotracer compatible with significant hepatic dysfunction. The\n gallbladder was not clearly demonstrated after this sequence, although some\n activity was noted in the small bowel.\n\n Since the gallbladder was not be visualized, 2 mg of morphine were administered\n i.v. and another imaging sequence was taken. There was visualization of the\n gallbladder 2 minutes after morphine administration, ruling out cholecystitis. A\n right lateral decubitus scan was performed to verify that area of increased\n activity corresponded to the gallbladder.\n\n IMPRESSION: 1. Hepatic dysfunction. 2. No evidence of acute cholecystitis.\n\n\n -\n , M.D. Approved: TUE 3:55 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": "2136-09-25 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1206940, "text": " 10:01 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: please perform RUQ with DOPPLER to r/o PVT\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with rising LFTs, WBC and persistent fever with renal failure\n REASON FOR THIS EXAMINATION:\n please perform RUQ with DOPPLER to r/o PVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 63-year-old man with rising LFTs, fever, renal failure.\n\n COMPARISON: Liver ultrasound .\n\n FINDINGS: No biliary dilatation is seen. The common hepatic duct measures\n 0.3 cm. Sludge is again seen within the lumen of the gallbladder. No focal\n abnormality is seen within the liver. The spleen is mildly enlarged measuring\n 13.5 cm. A scant trace of ascites is seen in the right upper quadrant. No\n ascites is seen in the lower quadrants. There is a bilateral pleural effusion\n noted.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main, right and left portal veins are patent with hepatopetal\n flow. Note is made that the extrahepatic portal vein is difficult to\n visualize.\n\n IMPRESSION:\n 1. No portal vein thrombus identified. Note is made that the extrahepatic\n portal vein is not well visualized.\n 2. Right and left pleural effusion with a scant trace of ascites seen in the\n right upper quadrant.\n 3. Mild splenomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1206582, "text": " 11:11 AM\n PORTABLE ABDOMEN Clip # \n Reason: ? obstruction\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with pna?, ? obstruction\n REASON FOR THIS EXAMINATION:\n ? obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, obstruction, evaluation.\n\n COMPARISON: \n FINDINGS: Limited image quality. The tip of nasogastric tube projects over\n the proximal parts of the stomach. No evidence of pathologic calcifications.\n No distension of small bowel or colonic loops. No evident wall thickening.\n No pathologic air-fluid levels.\n\n" }, { "category": "Echo", "chartdate": "2136-09-25 00:00:00.000", "description": "Report", "row_id": 89934, "text": "PATIENT/TEST INFORMATION:\nIndication: Shock Assess heart function\nHeight: (in) 69\nWeight (lb): 185\nBSA (m2): 2.00 m2\nBP (mm Hg): 121/43\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 09:28\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: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nModerate global LV hypokinesis.\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Mild PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. Left\nventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. There is probably moderate global left ventricular\nhypokinesis (LVEF = 35-40 %; however views are suboptimal). The right\nventricle is borderline dilated with borderline preserved free wall\ncontractility. The aortic root is mildly dilated at the sinus level. There is\nno aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\nfunction is now depressed and mitral regurgitation is now more prominent.\nTricuspid regurgitation is now more prominent.\n\n\n" }, { "category": "ECG", "chartdate": "2136-09-20 00:00:00.000", "description": "Report", "row_id": 236149, "text": "Supraventricular tachycardia, probably sinus in origin. Occasional premature\natrial contractions. Probable left ventricular hypertrophy. Compared to the\nprevious tracing no significant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2136-09-19 00:00:00.000", "description": "Report", "row_id": 236150, "text": "Sinus tachycardia with premature atrial contractions and one run of apparent\natrial tachycardia. Compared to the previous tracing earlier today there is an\nincrease in atrial ectopy.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2136-09-19 00:00:00.000", "description": "Report", "row_id": 236151, "text": "Sinus rhythm with occasional premature atrial contractions and one ventricular\npremature beat. Probable left ventricular hypertrophy. Non-specific\nST segment abnormality. Compared to the previous tracing earlier this date\nno significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2136-09-20 00:00:00.000", "description": "Report", "row_id": 236152, "text": "Sinus rhythm. Non-specific ST segment abnormality. Probable left ventricular\nhypertrophy. Compared to the previous tracing of one day earlier, there is a\nslight slowing of the sinus rate. Otherwise, no significant change.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2136-09-19 00:00:00.000", "description": "Report", "row_id": 236153, "text": "Sinus tachycardia. Non-specific ST-T wave changes. Left ventricular\nhypertrophy. Compared to the previous tracing of the rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2136-09-21 00:00:00.000", "description": "Report", "row_id": 236147, "text": "Probable multifocal atrial tachycardia. Left ventricular hypertrophy with\nsecondary repolarization abnormalities. Compared to the previous tracing\nthe findings are similar other than the rhythm.\n\n" }, { "category": "ECG", "chartdate": "2136-09-19 00:00:00.000", "description": "Report", "row_id": 236148, "text": "Sinus tachycardia. Prominent voltage. Diffuse non-specific ST segment\nabnormality. Compared to the previous tracing of no significant change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2167-05-13 00:00:00.000", "description": "Report", "row_id": 1564808, "text": "MICU nursing progresss note 7A-7P\nNeuro - A&O x 3. MAE, weak lower extremities. Flat affect, pt is on Paxil. Cooperative with care. C/o left hip discomfort. HO aware. Pt refuses Tylenol.\n\nCV - BP 111-142/46-51, mostly in 120's. HR 58-72 SB/NSR. No ectopy. EKG this AM at pt baseline. Repeat K 5.4 @ 800 & 1500. Pt R/O MI by enzymes x 3. Started on Florinef in exchange for Kayexelate. R fem dialysis catheter d/c'd by HO @ 1200. Pressure dsg on, no ooze/hematoma. Pt flat in bed x 3 hrs until 1500. + distal pulses. Afebrile.\n\nResp - Lungs clear, dim at bases. Sats high 90's RA.\n\nGI - Abd soft, NT, +BS. Colostomy functioning for ~500cc watery brown stool. OB neg. Given Lantis insulin at 1100. Appetite good. FSBS covered by HISS, see Careview.\n\nGU - U/O labile 15->50cc/hr via foley.\n\nID - +MRSA sputum, contact precautions.\n\nSocial - No phone calls or visitors today.\n\nPlan - FSBS q 6 hrs. Renal diabetic diet. Check right groin. Pt is called out to floor.\n\nPlan\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-05-14 00:00:00.000", "description": "Report", "row_id": 1564809, "text": "Nsg Note (1900hrs-0700)\n\nNeuro: A&Ox3; appropriate however requesting minimal care/interruption . Slept most of . MAE\n\nCV: Afebrile, hemodynamically stable. Hct 34.5, WBC 8.1; lytes WNL> (2)peripheral iv's patent, hl'd. SQ heparin. Lopressor held last evening for sinus brady.Right groin site w/o bleeding/hematoma.\n\nResp: LS clear, diminished. No cough. 02 sat >95% RA. MRSA sputum\n\nGI: No glargine at hs per orders; no need for humalog coverage, BS <150. Colostomy w/mod stool, mod consistency. Taking gd po's\n\nGU: U/O baseline at 15-20cc/hr at times; req no IVF\n\nAssess: Stable for call out when bed available\nPlan: Cont present level of care.\n" }, { "category": "Nursing/other", "chartdate": "2167-05-14 00:00:00.000", "description": "Report", "row_id": 1564810, "text": "Nursing Note (addendum)\n\nPt not covered w/humalog insulin. He is covered w/ reg insulin. Received 2 units 6am for bs 200.\n" }, { "category": "Nursing/other", "chartdate": "2167-05-12 00:00:00.000", "description": "Report", "row_id": 1564805, "text": "MICU nursing adm note 17:30\nPt is 75 yo male adm from EW for hemodialysis for K 10.1 on adm to EW. Pt fell at home, had increasing fatigue x 3 days. Caregiver found pt, called 911-> EW. Pt bradycardic 30's, peaked Twaves, wide QRS. Given Cagluc, D50, 10 reg insulin, NaHCO3 2 amps in 1liter. Right HD catheter placed and pt was dialysed on adm to MICU.\n\nNeuro - A&O x 3, pleasant and cooperative. Pt became agitated after dialysis, c/o back pain, wanting to go home. MD and several RNs in to reposition pt. Pt finally agreed to take Tylenol and fell off to sleep. MAE.\n\nCV - BP 91-132/48-55, HR NSR 60's-70's. No ectopy. BP was labile during dialysis. Extremities W&D, no edema. Lytes drawn after dialysis pending. CKs being cycled, AM CK 45. Trop and afternoon CKs pending.\n\nResp - Lungs sl dim at bases, clear throughout. Sats 96-100% RA.\n\nGI - Abd soft, NT, +BS. Colostomy functioning for liquid brown stool ~100cc. Pt able to eat low K, diabetic diet. Please follow asp precautions as pt had problem in recent past. Pt ref dinner right now d/t back pain, will check later. FSBS qid, cover with RISS. Takes Lantis at HS.\n\nGU - U/O via foley is adequate. U/A CS sent. BUN 44, cr 1.7. Baseline cr ~1.4.\n\nSocial - Daughter called, expressed multiple concerns about how pt is living at home. Pt has been hospitalized since with brief periods at home. She does not think he takes all his meds as he should, doesn't follow his diet, can't manage his colostomy, etc. pt fired night caregiver first night home last Saturday. HO talked to daughter and aware of situation.\n\nPlan - Cycle CKs, Check labs, next CK due 2200. ? if will need dialysis tomorrow. EKG in AM. FSBS qid. Asp precautions. Discharge planning.\n" }, { "category": "Nursing/other", "chartdate": "2167-05-12 00:00:00.000", "description": "Report", "row_id": 1564806, "text": "addendum\nChemistry back, drawn immediately after dialysis so itis not accurate. Will redraw chem 10. Pt is MRSA+ in sputum, contact precautions.\n" }, { "category": "Nursing/other", "chartdate": "2167-05-13 00:00:00.000", "description": "Report", "row_id": 1564807, "text": "Nursing Progress Note\n->0730\n\nS/O\nNEURO: Lethargic. Aware of date, time, location and self. Denies pain. Moves all extremities with 4+ strength; no pronator drift, smile symmetrical.\n\nCV: HR dropped to 50's, SB, dropped once to 49; Lopressor held. SBP dropped to 90's, responded to IVB.\n\nRESP: LS distant. NO distress on room air.\n\nGI: BS positive. Colostomy putting out small anounts flatus and stool. apple juice. No N/V/D.\n\nFEN: BS low -> held Lantis . Tretaed low BS with juice. NS IVB 250mL x4 with response.\n\nGU: U/O decreased -> treated with IVB to which u/o responded.\n\nA/P\nContinue curent care.\n" }, { "category": "ECG", "chartdate": "2167-05-13 00:00:00.000", "description": "Report", "row_id": 290838, "text": "Sinus bradycardia\nMarked left axis deviation\nOld inferior infarct/ posterior myocardial infarct\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2167-05-12 00:00:00.000", "description": "Report", "row_id": 290839, "text": "Sinus rhythm\nAbnormal extreme QRS axis deviation\nOld inferior/ posterior myocardial infarct\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2167-05-12 00:00:00.000", "description": "Report", "row_id": 290840, "text": "Normal sinus rhythm\nAbnormal extreme QRS axis deviation\nConduction defect of RBBB type\nOld inferior infarct\nHyperkalemia\nSince last ECG, hyperkalemia has improved\n\n" }, { "category": "ECG", "chartdate": "2167-05-12 00:00:00.000", "description": "Report", "row_id": 290841, "text": "sinus bradycardia\nFirst degree AV block\nRight bundle branch block\nleft anterior fascicular block\nHyperkalemia\n\n" } ]

[ { "category": "Echo", "chartdate": "2141-07-21 00:00:00.000", "description": "Report", "row_id": 79930, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve prolapse. Preoperative assessment.\nHeight: (in) 60\nWeight (lb): 120\nBSA (m2): 1.50 m2\nBP (mm Hg): 91/50\nStatus: Inpatient\nDate/Time: at 14:40\nTest: Portable TTE (Congenital, complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Aneurysmal interatrial\nseptum. Left-to-right shunt across the interatrial septum at rest. Small\nsecundum ASD.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. [Intrinsic LV systolic\nfunction depressed given the severity of valvular regurgitation.]\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet\nflail. Mild thickening of mitral valve chordae. Moderate to severe (3+) MR.\nEccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is moderately dilated.\nThe interatrial septum is aneurysmal with left-to-right flow across the\ninteratrial septum c/w secundum type ASD. Left ventricular wall thickness,\ncavity size, and systolic function are normal (LVEF>55%). Regional left\nventricular wall motion is normal. [Intrinsic left ventricular systolic\nfunction may be more depressed given the severity of mitral regurgitation.]\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 with partial posterior mitral leaflet flail. An eccentric jet of at\nleast moderate-to-severe (+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is mild-moderate pulmonary artery\nsystolic hypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Partial posterior leaflet flail with at least moderate to severe\nmitral regurgitation. Mild-moderate pulmonary artery systolic hypertension.\nSecundum type atrial septal defect. Preserved global and regional\nbiventricular systolic function.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-21 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 872942, "text": " 2:52 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: MITRAL VALVE DISEASE\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with as above\n REASON FOR THIS EXAMINATION:\n pre op for MVR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for MVR.\n\n X-RAYS: Chest AP and lateral view.\n\n No comparison.\n\n Patchy opacities are seen in the right lower zone consistent with atelectasis.\n There is cardiomegaly. Aortic contour is prominent. There is bilateral hilar\n prominence. Small bilateral effusions are seen, more on the left than right.\n\n No osseous abnormality is seen.\n\n IMPRESSION:\n 1. Mild CHF.\n 2. Right lower zone atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-21 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 872950, "text": " 3:38 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre op for MVR w/h/o CVA-r/o carotid stenosis\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with\n REASON FOR THIS EXAMINATION:\n pre op for MVR w/h/o CVA-r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient is preoperative for mitral valve replacement.\n\n FINDINGS: -scale ultrasound, duplex evaluation and spectral analysis of\n the bilateral extracranial carotid artery systems do not give an indication\n for any hemodynamically significant impairment. Minimal calcified plaque is\n identified at the bulb at the take off of the external carotid artery. The\n vertebral artery is antegrade.\n\n IMPRESSION: No indication for hemodynamically significant stenosis in the\n bilateral extracranial carotid artery systems.\n\n" }, { "category": "Radiology", "chartdate": "2141-07-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 873207, "text": " 11:50 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p MVrepair/ASD closure/Maze/lig. left atrial appendage\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVR and ASD closure, postop.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating approximately\n 1.7 cm from the carina. Nasogastric tube terminates in the gastric body. A\n pulmonary artery catheter is in place via a right internal jugular venous\n access sheath approach, with tip in the main pulmonary artery. Right-sided\n chest tube. Mediastinal drain. There is stable cardiomegaly. Slight\n prominence of the mediastinum is probably consistent with postoperative state.\n There is apparent overinflation of the endotracheal tube cuff. There is\n diffuse haziness of the interstitial markings consistent with pulmonary edema\n versus volume overload. Small right pleural effusion. New sternal suture\n wires and mediastinal clips.\n\n IMPRESSION:\n 1. Lines and tubes in satisfactory position. However, there is probable\n overinflation of the endotracheal tube cuff.\n\n 2. Cardiomegaly and congestive heart failure.\n\n 3. Right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873314, "text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?ptx\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p MVrepair/ASD closure/Maze/lig. left atrial appendage.\n Now s/p chest tube d/c\n REASON FOR THIS EXAMINATION:\n ?ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MV repair and ASD closure.\n\n AP bedside chest. Since similar exam one day previous, the ET, NG, and right\n chest tubes have been removed with no PTX. The heart is probably enlarged\n with borderline vascular congestion and interstitial edema. Since previous\n exam, the diaphragms are somewhat higher and subsegmental atelectasis has\n developed in the left lower lobe. No change in position of the SG catheter\n with tip in proximal right pulmonary artery.\n\n IMPRESSION: Interval removal of tubes and catheters are without PTX.\n Interval development of left lower lobe atelectasis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-07-24 00:00:00.000", "description": "Report", "row_id": 1397405, "text": "csru adm/update\nNEURO: REMAINS SLEEPY. AWAKENS TO VOICE. NODS AND MAE IN BED. FOLLOWS COMMANDS.\n\nCV: VS/HEMOS AS PER FLOWSHEET. SVO2 INITIALLY HIGH (PT W/ TEMP 35) NOW WNL ~70. THERMO CO ~3.5, FICK CI 3.5. ON AMIODARONE DRIP DECREASED TO .5MG/MIN. A-PACED AT 7O, UNDERLYING SINUS BRADY 50'S. ON NTG DRIP BRIEFLY.\n\nRESP: PT ON CPAP IPS. LUNGS CLEAR BILAT. ABG'S GOOD, AWAITING CPAP ABG. CT PRESENT. MIN SANG DNG WITH NO AIR LEAK NOTED.\n\nGI/GU: UOP QS. ABD SOFT. OGT MIN CLEAR DNG. CARAFATE BEGAN.\n\nASSESS: STABLE POST-OP\n\nPLAN: MONITOR HEMOS/VS CLOSELY. WEAN TO EXTUBATION AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2141-07-25 00:00:00.000", "description": "Report", "row_id": 1397406, "text": "Neuro: pt alert oriented following commands.\nResp: pt weaned from Face tent to 4l np sats would dip when pt slept at time on her back 2nd to mouth breather. Coughing and raising blood tinged thick sputum. Chest tube draining serous sanguinous drainage no air leak detected.\nC/V: pt on neo most of night 0.75-0.25 mcg/kg/min Good hemodynmics. Heart rate in the 70's 1st degree av block. Svo2 62-65% with CI>2.2.\nGI: tolerating clear liquids.\nEndo: blood sugars well controlled.\nGU: Urine outputs dipped pt received 20mg iv lasix with good effect.\nSkin: Incisions clean and dry.\nPain: pt complains of ache in chest medicated with morphine 2mg sc with good effect.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-07-25 00:00:00.000", "description": "Report", "row_id": 1397407, "text": "CV: SR with 1st degree AVB 70's-80's; SBP 90's-130's, isolated dip to 80's when asleep; CT dc'd this am; 2a wires 2v wires->a wires sense but don't capture, v wires sense and capture, pacer set at 60 but mA turned off; palpable bil pedal pulses; amio/neo gtts dc'd and pt started on amio po; K+ repleated; will receive coumadin 3mg today\n\nResp: Sats high 90's on 4L NC; LS clear in uppers but crackles in bil bases; loose, occasionally productive cough\n\nNeuro: Alert, oriented x3; MAE; PERLA\n\nGI/GU: Abd soft with normoactive bowel sounds, taking po fair; adequate clear yellow HUO per foley catheter to gravity, good diuresis from lasix 20mg iv\n\nEndo: BS covered by SS (see flowsheet)\n\nID: TMax 99.9, cont course of ABX; pt found to have resistant proteus in urine and placed on contact precautions\n\nActivity: OOB to chair x hours and tol well\n\nPlan: Cont to diurese, monitor lytes and replace prn, dose coumadin to PT/INR, pulmonary hygiene, increase diet and activity as tol, ? 2 tomorrow\n\n" }, { "category": "Nursing/other", "chartdate": "2141-07-26 00:00:00.000", "description": "Report", "row_id": 1397408, "text": "Ekg nsr, no ectopy, rate 90-100. sbp stable in 110s except for drift to 90s when asleep, after pain med. afebrile. adequate uo, good response to lasix but only lasted a couple of hours. k and ca repleted, glucose stable with minimal insulin requirement. breath sounds clear with crackles at bases, improved after lasix. maintains spo2 > 95 on nc, dropped to 86 when off o2 briefly during am care. chest and mediastinal dressings dry, changed. abd soft, active bowel sounds, tolerating fluids. skin warm and dry, feet warm, palp pulses bilat. aline d/cd, non functional. alert and oriented, med for pain x 2 with 2 mg iv mso4, slept when undisturbed.\n" }, { "category": "Nursing/other", "chartdate": "2141-07-26 00:00:00.000", "description": "Report", "row_id": 1397409, "text": "3P-7P\nPT HR 70-80 AF, COUMADIN 3MG TONIGHT. PT LUNGS CRACKLES B/L BASES, UOP <30 X2 HRS, EXTRA LASIX 20MG IV WITH GOOD RESPONSE. SATS>96% 3L NC. SBP LOW 90'S. LG BM. AWAITING BED ON 2. URINE CX PENDING FROM AM. CONT CURRENT PLAN, TX WHEN BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2141-07-26 00:00:00.000", "description": "Report", "row_id": 1397410, "text": "7p-11p\n\nAssessment unchanged - pt turns and moves w/ assistance - no c/o pain. 8pm dose of lasix held until 2230 because of additional dose given at 1800. Lopressor given at 2100 w/ no effect on BP. Diruesing well - lungs clear bilat after lasix.\n" }, { "category": "Nursing/other", "chartdate": "2141-07-27 00:00:00.000", "description": "Report", "row_id": 1397411, "text": "11pm-7am nsg update\npt alert and orientated x3. MAE and able to follow commands. pt remains in afib, HR 80's. continues on coumadin. SBP 90-100's. pp palpable. LS clear with dim bases bil. pt weaned to 2 L nc, o2 sats 94-98%. + bs. LBM . foley draining yellow urine. on contact for proteus in urine. foley draining clear yellow urine. UO adequate.\n\nplan: transfer to 2, pulm toleit, advance diet and activity as tolerated, contiune coumadin, ??? dc epicardial wires\n" }, { "category": "ECG", "chartdate": "2141-07-24 00:00:00.000", "description": "Report", "row_id": 212658, "text": "Sinus bradycardia\nFirst degree A-V block\nProlonged Q-Tc interval\nRight axis deviation\nProbable modest nonspecific right ventricular conduction delay\nLeft atrial abnormality\nDiffuse nonspecific low amplitude T waves\nClinical correlation is suggested for in part metabolic/drug effect and\npossible in part RV overload\nSince previous tracing of , atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2141-07-21 00:00:00.000", "description": "Report", "row_id": 212659, "text": "Atrial fibrillation with a controlled ventricular response. Diffuse\nnon-specific ST-T wave flattening. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2132-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226976, "text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Infiltrate?\n Admitting Diagnosis: SEIZURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with worsening seizure frequency\n REASON FOR THIS EXAMINATION:\n Infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Worsening seizure, questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: Compared to the previous radiograph, there is no relevant change.\n The right central venous access line has been removed. Tubes of an oxygen\n mask are visible at the superior part of the image. Atelectasis at the left\n lung base but no evidence of pneumonia. Normal size of the cardiac\n silhouette. No pulmonary edema.\n\n\n" }, { "category": "ECG", "chartdate": "2132-03-11 00:00:00.000", "description": "Report", "row_id": 221789, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2132-03-10 00:00:00.000", "description": "Report", "row_id": 221790, "text": "Sinus rhythm. Compared to the previous tracing of RSR' pattern no\nlonger seen in leads V1 and V2 and T waves are more prominent in these leads.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2137-11-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 987358, "text": " 1:45 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: MITRAL REGURGITATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with CABG/MVR/PFO\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \n with issues . Pt in OR 1 and will be in CSRU in 90 mins.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG.\n\n FINDINGS: In comparison with the study of , the patient has undergone a\n CABG. Endotracheal tube tip lies about 2.5 cm above the carina. Right IJ\n Swan-Ganz catheter extends to the pulmonary outflow tract. A prosthetic\n mitral valve is noted. Left chest tube is in place with no pneumothorax.\n Atelectatic changes are seen in the left perihilar and basilar areas as well\n as possibly the right mid zone laterally. Of incidental note is calcification\n in at least the left lower neck, most likely within the carotid bifurcation.\n\n IMPRESSION: Standard appearance following cardiac surgery with some\n additional atelectatic or possibly infiltrative changes in the right mid zone.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986797, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusions, pulmonary congestion, consolidations\n Admitting Diagnosis: MITRAL REGURGITATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with CHF, mod to sev MR for CHF exacerbation.\n REASON FOR THIS EXAMINATION:\n r/o effusions, pulmonary congestion, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive failure, exacerbation.\n\n FINDINGS: In comparison with the study of , the cardiac silhouette\n remains enlarged in this patient with a single lead pacemaker device in place.\n However, the interstitial markings are essentially within normal limits with\n no definite evidence of vascular congestion. No acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987516, "text": " 2:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube pull, look for effusion, PTX\n Admitting Diagnosis: MITRAL REGURGITATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p chest tube pull, look for effusion, PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left chest tube removal, to search for pneumothorax.\n\n FINDINGS: In comparison with the study of , the endotracheal tube,\n nasogastric tube, and left chest tube have been removed. No evidence of\n pneumothorax. Generalized underpenetration of the image makes it difficult to\n evaluate the area, though no definite pneumonia is appreciated.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-11-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 988080, "text": " 8:43 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusions\n Admitting Diagnosis: MITRAL REGURGITATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman s/p MV repair/CABGx1\n REASON FOR THIS EXAMINATION:\n eval for effusions\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest .\n\n HISTORY: Evaluate for pleural effusion.\n\n FINDINGS: Comparison is made to previous study from .\n\n The single lead pacemaker and median sternotomy wires are unchanged. There is\n unchanged cardiomegaly. There is improvement of the left-sided pleural\n effusion since the previous study. There remains some atelectasis at both\n lung bases.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2137-11-03 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 987239, "text": " 1:43 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: MITRAL REGURGITATION;CORONARY ARTERY DISEASE\n Admitting Diagnosis: MITRAL REGURGITATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with CAD/MR awaiting surgery\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n INDICATION: 69-year-old man with CAD, pre-operative film.\n\n COMPARISON: .\n\n FINDINGS: Cardiac silhouette remains enlarged with a single-lead pacemaker\n device in place, unchanged. There is no focal consolidation, pleural effusion\n or pneumothorax. Again noted is a mild anterior wedging of inferior thoracic\n vertebral bodies, probably unchanged from .\n\n IMPRESSION: Stable cardiac enlargement. No acute cardiopulmonary process.\n\n" }, { "category": "Echo", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 84233, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 11:43\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the LAA. Good\n(>20 cm/s) LAA ejection velocity. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. PFO is present.\nLeft-to-right shunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -\nhypo; inferior apex - hypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPRE BYPASS\nThe left atrium is markedly dilated. No mass/thrombus is seen in the left\natrium or left atrial appendage. The right atrium is moderately dilated. A\npatent foramen ovale is present. A left-to-right shunt across the interatrial\nseptum is seen at rest. The left ventricular cavity size is normal. There is\nmild regional left ventricular systolic dysfunction with mild inferior waqll\nhypokinesis. The remaining left ventricular segments contract normally. The\nright ventricular cavity is mildly dilated. Right ventricular systolic\nfunction is normal. There are simple atheroma in the descending thoracic\naorta. The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen with a systolic BP of 100mm Hg.\nSBP was raised to 160mmHg with phenylephrine and Trendelenberg position. This\nresulted in moderate to severe (3+) MR with a posteriorly directed MR jet..\nThe tricuspid valve leaflets are mildly thickened.\n\nPOST BYPASS\nBiventricular function remains unchanged from prebypass. There is a ring\nprosthesis in the mitral position. NoMR is visualized. Peak and mean gradient\nacross MV is 7 and 3 mm Hg respectively. Flow by Color Doppler is still\nvisualized across the patent foramen ovale.\n\n\n" }, { "category": "Echo", "chartdate": "2137-10-31 00:00:00.000", "description": "Report", "row_id": 84234, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function. Mitral valve disease. Shortness of breath.\nHeight: (in) 61\nWeight (lb): 182\nBSA (m2): 1.82 m2\nBP (mm Hg): 112/50\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Calcified tips of papillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Moderate mitral regurgitation.\nModerate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , pulmonary\nhypertension has developed. Mild symmetric LVH is better appreciated on the\ncurrent study. The other findings, including severity of mitral regurgitation\nand ventricular function, are similar.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 1667997, "text": "Resp. Care Addenda;\nAddenda:\nPt extubated to a 50% cool neb...\n" }, { "category": "Nursing/other", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 1667998, "text": "NEURO: APPEARS INTACT, MAE, FOLLOWING COMMANDS, ORIENTED X 2.\n\nCARDIAC: HEART RATE VPACED, PERMANENT PACER. CO/CI BY FICK ACCEPTABLE. CT'S PATENT FOR MINIMAL SERO-SANG DRAINAGE. DOPPLERABLE PULSE, ABSENT LT PT.\n\nRESP: CS DIMINISHED IN BASES. EXTUBATED AT , PHH AT 50%. O2 SAT 93-94%, NP'S 4 LITERS ADDED WITH NO CHANGE. WITH DEEP BREATH O2 SAT INCREASED TO 98%. NON PRODUCTIVE COUGH.\n\nGI: OG PULLED WITH EXTUBATION. TOLERATING ICE CHIPS. NO BOWEL SOUNDS.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\n\nENDO: FOLLOWING INSULIN PROTOCOL.\n\nPAIN: MEDICATED FOR INCISIONAL AND BACK PAIN WITH SOME RELIEF.\n\nFAMILY: FAMILY HERE POST EXTUBATION, PLEASED WITH PROGRESS. WILL VISIT .\n\nPLAN: ENCOURAGE PATIENT TO COUGH/DEEP BREATH. MONITOR HEMODYNAMICS, CO/CI BY FICK. REPLEATE LAB VALUES AS NEEDED. MEDICATE FOR PAIN AS NEEDED. REASUURE PATIENT AND EXPLAIN ALL PROCEDURES.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-05 00:00:00.000", "description": "Report", "row_id": 1667999, "text": "Neuro) Pt. awakens when spoken to but drifts to sleep when left alone.\nAnswers questions appropriately.\n\nCV) CI by Fick >2 but svo2 50's only. Despite fluid bolus, Milrinone and av pacing, SVO2 with no improvements.\n\nPulm) hypoxic with po2 64. O2 increased to 100% and 5l. Needs constant reminders to deep breath. Rales at right base.\n\nGI) taking po's well. no n/v.\n\nGU) huo borderline at times.. Improved with fluid bolus.\n\nEndo) insulin drip continues to be titrated per protocol.\n\nPLAN) get pt. OOB. encourage pulm hygeine and c&db. ? diuresis today.\nmonitor Fick/SVO2. Glucose management.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-10-30 00:00:00.000", "description": "Report", "row_id": 1667992, "text": "CCU NPN: please see flowsheet & FHPA for objective\n\n69 yo w/ PMH HTN,pacer,ablation,CHF,anemia,severe MVP\n\nsurgery for MVP postponed,last few weeks SOB worsening,today no activity tolerance called ambulance,received aspirin on route. In EW at OH received lasix 40mg,NGT drip,pacer rate increased, transferred to for CHF exacerbation.\n\nCardiac: HR 70 Vpaced,BP 110-148/50-60's on NTG gtt at 0.33mcg/kg/min\n\nResp: on 4l NP crackles at bases,sats mid 90's,breathing heavy\n\nID: afebrile\n\nGU: good response to lasix\n\nGI: good appetite,+BS\n\nNeuro: alert and oriented x3\n\nSocial: daughter-in-law is spokesperson and her son is health care proxy.\n\nA/P: 69 yo with CHF admitted for medical management until MVP surgery.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-10-31 00:00:00.000", "description": "Report", "row_id": 1667993, "text": "CCU Nursing Progress Note 7pm-7am\nS: Denies sob or chest pain\n\nO: CV - HR 70- 100% v paced. BP 111-130/50's. Rec'd lopressor 50mg last eve. Pt on Toprol xl 50mg qd. Explained need to change to dosing during hospitalization. To recieve home dose of Lisinopril 5mg po daily. Cont on NTG 0.33mcg/kg/min. Home dose of coumadin held d/t INR 4.7 on . Awaiting CT eval.\n\nResp - cont w/ fine bbr. O2 on 4ln/p maintaining sats 95-99%. RR occasionally tachypnic up to 30's during sleep.\n\nGU - Foley draining clear yellow urine. 180cc/hr down to 45cc/hr. Last rec'd lasix 12noon . Creat 1.4 on admit.\n\nGI - Abd soft w/ +bs. No stool.\n\nID - t max 99 po\n\nNeuro - Alert and oriented x3. Pleasant and cooperative. Per daughter in law, pt became agitated, combative and disoriented during last admit. Currently, pt is stable on home doseage of Namenda and Seroquel.\n\nSocial - Daughter in law called and inquired about pt. Updated by this nurse.\n\nA: Stable CV, but cont w/ bbr. Awaiting CT eval for MVR.\n\nP: Cont monitor i/o and assess need for lasix, cont med teaching, monitor neuro status for change, increase activity as tolerated, keep pt and family informed of poc per multidisiciplinary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-05 00:00:00.000", "description": "Report", "row_id": 1668000, "text": "NEURO: Lethargic, alert/oriented x3, follows commands, c/o incisional pain, given percocets as need, pain improved, transferred with 2 person assist, tolerated good\n\nRESP: Weaned O2 to 6L NC, lung sounds clear with crackles on bases, Pt encouraged to c/db, use IS (pulls 300mL at best), CT discontinued by MD this afternoon (dressing dry/intact)\n\nCV: Pt vpaced at 70 (own pacer), epicardial wires captures/ approp (pacerbox off), rare PVCs, weaned Milrinone to 0.13mcg/kg/min, Nitro off, SBP 90-120s, PAD 17-20, CVP 7-11, SVO2 57, CI >2.0 (by thermodilution), afebrile\n\nGI/GU: Pt's diet advanced to regular, dentures in place, abd obese/soft/nontender, +BS, no BM; Foley to gravity draining yellow/clear urine, small diuresis after IV lasix, no lytes repleted\n\nENDO: Weaned insulin drip off per protocol, on SSRI\n\nSOCIAL: Children visited this afternoon and updated on Pt's plan of care/status, Pt's belongings brought in by family\n\nPLAN: Continue to ?wean milrinone, monitor resp, urine outputs, LABS, ?de-line tomorrow, increase activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2137-11-06 00:00:00.000", "description": "Report", "row_id": 1668001, "text": "cvicu update\nneuro: sleeps in naps. awakens easily.\n\npain: increasing pain by this am. despite percoct 2 tabs-> morphine iv w/ effect. napping at present.\n\ncv: vs/hemos as per flowsheet. thermo CI ~2. receiving 1 unit prbc for hct 23.7. milrinone to off at 0600. remains V paced by perm pacer. epicardial wires remain.\n\nresp: o2 6L n/c w/ 02 sats 93%. did drift to 90% -> ofm .40 added while sleeping w/ effect. lungs essentially clear. dim bases. congested non-product cough. tol gentle CPT.\n\ngi/gu: uop qs as noted. creat 1.2.abd soft. bsp. tol h2o/meds tonoc. denies nausea.\n\nassess: stable pm though hct to 23.7\n\nplan: milrinone to off. d/c swan later in day if hemo stable. pulm hygiene. analgsia.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 1667994, "text": "Respiratory Care:\npt is S/P MVR and is weaning. See Carevue for Hx:\n" }, { "category": "Nursing/other", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 1667995, "text": "~1329 female patient admitted from or, a/p cabg x1, lima to lad, mvr. Patient intubated and sedated with iv Propofol. Iv neo infusing. pserl. Patient being Av paced, rate 88 with permanent pacer under, rate 70. Og in place, patent for bilious, placement checked. Ct's patent for minimal drainage. Foley in place, patent for clear yellow urine. Dopplerable pulses.\nFamily in, explained plan.\n\nPatient reversed, woke, mae, following commands.\nPlan: wean to extubate\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 1667996, "text": "Resp. Care Addenda;\nWean held up a little so she could have more fluids. Appears to be I.V. dry...\n" }, { "category": "ECG", "chartdate": "2137-11-04 00:00:00.000", "description": "Report", "row_id": 227193, "text": "Regular ventricular pacing with underlying sinus bradycardia. Compared to\nprior tracing atrial fibrillation is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2137-10-31 00:00:00.000", "description": "Report", "row_id": 227194, "text": "Ventricular paced rhythm. Compared to previous tracing no diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2137-10-30 00:00:00.000", "description": "Report", "row_id": 227195, "text": "Ventricular paced rhythm with underlying atrial fibrillation. Compared to\nprevious tracing of pacemaker artifact is less evident. Otherwise,\nno major change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2102-06-16 00:00:00.000", "description": "Report", "row_id": 1504297, "text": "focus hemodynmics\ndata: neuro: alert and oriented.l moves all extremites on the bed. perla and reaacts briskly.\n\nresp: on open face tent at 50%.o2sats 100%. 2 liters np appliied and o2sats 97%. resp rate 20's. chest pt done. turned q2hrs. coughing but not raising any sputum.\n\ncardiac: remains in nsr. inr 1.3, k 4.0, hct 34.3\n\ngu: foley patent and draining red urine with sediment present. creat 1.1. urine repleted 1/2cc /cc with 1/2ns.\n\ngI abd soft. jp's to self suction and draining cherry colored drainage. ast 1079, alt 1029. total bili 1.5. no stools tonite.\n\naction: labs as ordered. o2 at 2liters via np. and tol well. abd dsg changed and incision clean and intact. jp's patent and to self suction. output emptied q2hrs.mso4 2mg iv x3. for pain control and effective. pad #'s low and dr called. 500cc ns repleted. spirits good. girlfriend in to visit tonite. cco swan in place and will be changed to triple lumen today. ngt d/c'd by the transplant team . clear liquids prn. today.\n\nrespne: monitror closely.\n" }, { "category": "Nursing/other", "chartdate": "2102-06-15 00:00:00.000", "description": "Report", "row_id": 1504293, "text": "Admit note/Condition Update\nPlease see carevue for sepecifics and FHP for PMH:\n\npt admitted at 2145 s/p OL transplant and kidney transplant secondary to ETOH cirrhosis and HEP C causing hepatorenal syndrome with stable VS after receiving multiple blood products with an otherwise stable intraoperative course. Pt has right IJ CCO SWAN in place, which was recalibrated upon admission, but pt had high SV02 intra-op and continues post-op to have SV02's 89-91, CO 6.6-8.8, CI 3.6-4.2, SVR 655-1115. Pt's temp was intitially dropping to as low as 96.4 and pt placed on bair hugger to maintain normothermic state; hr 80-100's (100's during admission and one administered fluids, HR decreased to 80's) nad sbp 120-160's. Pt sedated on propofol from OR and was continued overnoc and was weaned overnight for extubation in am- propofol gtt stopped completely x2 to perform a full neuro exam, but his sbp increased to 190's after minuts and pt would open eyes to sternal rub but was not awake enouigh to follow any toerh , pateitn was re-strted on gtt; dr. was aware of situation and will wean pt slowly and perform full neur exam after propofol gtt sucessfully weaned off. Pt with PERRL 3-5mm/3-5mm briskly reactive; pt not following commands and very slight twiched to nailbed pressure; pt only opening eyes to sternal rub. LS clear into bases; pt had decreassed sounds on left side after admission and CXR showed right main stem intubation- ETT was pulled back 4cm per dr. and BS in all four fields were present. 02 sats 99-100% on AC 50% 600x12 with 5 PEEP and pt not breathing over with adequate ABG's. Abd with hypoactive bs x4 and soft belly; DSD present covering most of upper abdomen and stained with serosang drainage (transpplant team would like to change dressing in am- keep original dressing on overnoc) and pt has lateral amd medial JP's which were draining moderate amountsof sanguinous leading ot serosang drainage overnoc and a JP from the kidney site with scant amounts of sanguinous/serosang drainage overnoc. Foley draining large amounts of blood tinged to bloody urine- after first admitted foley with small amountsof output- foley found ot be dislodged from the catheter due to a pinhole in the balloon,after a new catheter was placed, foley draing large amountso of urine and a q 1 hour cc:cc 1/2NS replacement was initiated to keep adequate kidney flow. Pt has chrnonic renal insufficieny due to hepatorenal syndrome and lives with a baseline creat of 2.0 which has been trending down post-op and is now 1.6 with a creat of 28. Pt +1L at mn and currently +200cc's. Pt labs drawn on admission and at 0200 as prdered and HCT went from 32.8 to 30.8 and is not to be treated at this time, along with a platelet count of 92. Pt has WBC of 3.6; lactates are being followed and have been treanding down (2.2 to 1.4). Continue surveillance of labs, vs, i/o's, and adminsiter psychosocial support to patietn and family upon extubation. No family called or was waiting when p\n" }, { "category": "Nursing/other", "chartdate": "2102-06-15 00:00:00.000", "description": "Report", "row_id": 1504294, "text": "Admit note/Condition Update\n(Continued)\natietn caame from OR- he lives alone but his sister (kim_) is his HCP and a great source of support, per social work. Pt will need medication education provided ot pt and sister.\n" }, { "category": "Nursing/other", "chartdate": "2102-06-15 00:00:00.000", "description": "Report", "row_id": 1504295, "text": "Respiratory Care Note:\n patient received from OR this shift s/p liver and kidney transplant. patient intubated with a #8.5 ett, 21 at the lip. ETT withdrawn from 24cm marking to 21cm after cxr revealed right main stem intubation. Repeat CXR pending. BS are clear throughout. Fio2 weaned to 50%. for other specifics please refer to carevue. SX for scant to no secretions via ett. RSBI this am is 12.3 on 0 peep and 5 psv. SPO2 remained 99-100%. Latest ABG within normal limits. Plan is to wean to extubate this am.\n" }, { "category": "Nursing/other", "chartdate": "2102-06-15 00:00:00.000", "description": "Report", "row_id": 1504296, "text": "Please See Carevue for Specifics.\n\nA+OX3, MAE, PERL, denies pain, extubated this afternoon, lungs are clear, O2 sat 98-99% on .50% face tent. SvO2 80's, CCI , PA 22. Duplex of liver and kidney this morning, WNL. Abd -BSx4, NGT to LWCS with scant amounts of bilious fluid. Abd dressing changed due to duplex and DSD reapplied. Lateral, Medial, and renal JP's with sero/sang drainage. Foley with rosey clear urine and replaced cc/cc every hour. Insulin gtt dc'd and dextrose 10% off as well. RISS as ordered. BG WNL.\n\nPOC: Monitor hemodynamics, respir status, urine output and Jp drainage. Monitor pain and Morphine prn. Continue transplant medication teaching and offer emotional and spiritual support to pt and pt. family.\n" }, { "category": "ECG", "chartdate": "2102-06-17 00:00:00.000", "description": "Report", "row_id": 186401, "text": "Sinus tachycardia. Low limb lead voltage. Occasional ventricular premature\nbeats. Non-specific ST-T wave abnormalities. Compared to the previous tracing\nof no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2102-06-15 00:00:00.000", "description": "Report", "row_id": 186402, "text": "Normal sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof no diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2102-06-13 00:00:00.000", "description": "Report", "row_id": 186403, "text": "Normal sinus rhythm. Q-T interval prolongation. Compared to the previous\ntracing of no diagnostic interval change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2102-06-17 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 917390, "text": " 10:23 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: L arm swelling r/o dvt\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with\n REASON FOR THIS EXAMINATION:\n L arm swelling r/o dvt\n ______________________________________________________________________________\n WET READ: JWK SAT 11:47 PM\n No evidence of thrombus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man with left upper extremity arm swelling.\n\n No prior studies for comparison.\n\n FINDINGS: Unilateral left upper extremity ultrasound, grayscale, color, and\n Doppler son of the left internal jugular, subclavian, axillary, and\n brachial veins demonstrate normal compressibility, waveforms, and color flow.\n The basilic and cephalic veins compress normally.\n\n IMPRESSION:\n\n 1. No evidence of thrombus.\n\n" }, { "category": "Radiology", "chartdate": "2102-06-15 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 916994, "text": " 7:25 AM\n RENAL TRANSPLANT U.S. PORT Clip # \n Reason: Post transplant U/S Liver/ and Kidney please assess flows, P\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o hep C/ETOH cirrhosis on transplant list with q2wk abd\n taps, here for ugib\n REASON FOR THIS EXAMINATION:\n Post transplant U/S Liver/ and Kidney please assess flows, Please do first\n thing in AM\n ______________________________________________________________________________\n FINAL REPORT\n RENAL TRANSPLANT ULTRASOUND\n\n HISTORY: 55-year-old male first day post kidney transplant.\n\n FINDINGS: The transplanted kidney located in the right lower quadrant has\n normal size and echogenicity. There is no hydronephrosis. There is a small\n 20 x 8 mm fluid collection adjacent to the upper pole of the transplanted\n kidney.\n\n Doppler assessment shows normal upstroke and normal spectral flow in the main\n and intrarenal arterial vessels. RIs range from 0.56 to 0.8. The renal vein\n is patent.\n\n IMPRESSION:\n 1. Unremarkable Doppler assessment of the transplanted kidney.\n\n 2. Small peritransplant fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2102-06-13 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 916799, "text": " 10:26 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HEPATO RENAL SYNDROME\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis with hepatorenal syndrome pre-op for\n liver-kidney transplant\n REASON FOR THIS EXAMINATION:\n ?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatorenal syndrome, pre-operative study.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPHS.\n\n Cardiac, mediastinal and hilar contours appear unremarkable. Lungs are clear.\n Pulmonary vascularity is within normal limits. No evidence of pleural\n effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 917200, "text": " 11:51 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? IJ tip ? ptx\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o hep c cirrhosis new R IJ placed\n REASON FOR THIS EXAMINATION:\n ? IJ tip ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n For jugular CV line placement.\n\n Right jugular CV line is in distal SVC. No pneumothorax. Bibasilar\n atelectases.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-14 00:00:00.000", "description": "O PORTABLE ABDOMEN IN O.R.", "row_id": 916965, "text": " 9:05 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: ?FB\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: ? FB.\n\n There is no prior abdominal radiograph for comparison.\n\n FINDINGS: The patient is status post liver transplant. Note is made of NG\n tube terminating in the left upper quadrant. There is drainage tube overlying\n the right upper quadrant. Bowel gas pattern is unremarkable. The evaluation\n is somewhat limited overlying material, and note is made of 4 mm tiny\n radiopaque density overlying the right upper quadrant, of unknown etiology.\n Surgical staples and clips are noted. There is drainage tube overlying the\n lower pelvis as well.\n\n IMPRESSION: Status post liver transplant. Tubes as described above. 4 mm\n tiny radiodense opacity overlying the right upper quadrant, of unknown\n etiology. Please correlate clinically. The findings are discussed with the\n referring surgeon, Dr. by telephone immediately after the\n interpretation of the study.\n\n" }, { "category": "Radiology", "chartdate": "2102-06-15 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 917009, "text": " 8:36 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: Post transplant U/S Liver/ and Kidney please assess flows, p\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o hep C/ETOH cirrhosis on transplant list with q2wk abd\n taps, here for ugib\n REASON FOR THIS EXAMINATION:\n Post transplant U/S Liver/ and Kidney please assess flows, please do first\n thing in AM\n ______________________________________________________________________________\n FINAL REPORT\n LIVER OR GALLBLADDER ULTRASOUND\n\n HISTORY: 55-year-old male, one day post liver and kidney transplant.\n\n FINDINGS: There is a small right pleural effusion.\n\n There are no peritransplant collections.\n\n The left, middle, and right hepatic veins are patent, as is the IVC. The\n main, right, and left portal veins are patent with normal hepatopetal flow.\n\n The main, right, and left hepatic arteries are patent with normal spectral\n flow and RIs within normal limits, 0.64.\n\n IMPRESSION: Patent hepatic and portal vessels.\n\n Patent main, right, and left hepatic arteries with normal spectral flow.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916988, "text": " 6:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for change\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o hep c cirrhosis, known varices, here with sob and\n crackles on lung exam\n REASON FOR THIS EXAMINATION:\n assess for change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath and crackles.\n\n Portable AP chest radiograph compared to made at 22:12 p.m.\n\n The ET tube tip is again very low at the level of the carina pointing towards\n the right bronchus. After communication with Dr. , the information\n was received that the ET tip was repositioned.\n\n There is marked improvement in the left lung atelectasis with almost complete\n resolving of the left lower lobe atelectasis with some partial discoid\n atelectasis and retrocardiac opacity and complete resolution of the left upper\n lobe atelectasis.\n\n The Swan-Ganz tip is at the right main pulmonary artery. The NG tube tip is\n in the stomach. There are no abnormalities in the right lung and the upper\n portion of the left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 916971, "text": " 9:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: S/P liver Kidney tranplant\n Admitting Diagnosis: HEPATO RENAL SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o hep c cirrhosis, known varices, here with sob and\n crackles on lung exam\n REASON FOR THIS EXAMINATION:\n S/P liver Kidney tranplant\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breast and crackles on lung examination\n in a patient with hepatitis and cirrhosis.\n\n Portable AP chest radiograph compared to preoperative film.\n\n The ET tube tip is in the right main bronchus. The left lung is almost\n completely collapsed with some residual variation of the left upper lobe. The\n left lung is over expanded.\n\n The tip of the Swan-Ganz catheter is in the main pulmonary trunk. The tip of\n the NG tube is in the stomach. Two abdominal drains are in inserted.\n\n The subsequent film demonstrated an improvement of the lung atelectasis after\n repositioning of the chest tube.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-01-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1056559, "text": " 4:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man MVC\n REASON FOR THIS EXAMINATION:\n eval for trauma\n CONTRAINDICATIONS for IV CONTRAST:\n unknown head bleed\n ______________________________________________________________________________\n WET READ: DSsd 5:23 PM\n no acute intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: None.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass effect,\n edema, or infarction. Ventricles and sulci are normal in size and\n configuration. There is no fracture. Visualized paranasal sinuses are\n normally aerated.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2101-01-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1056560, "text": " 4:22 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man MVC\n REASON FOR THIS EXAMINATION:\n eval for trauma\n CONTRAINDICATIONS for IV CONTRAST:\n unknown cr\n ______________________________________________________________________________\n WET READ: DSsd 5:23 PM\n no fx or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast cervical spine CT with multiplanar reformations.\n\n FINDINGS: There is no fracture or cervical spine malalignment. There is a\n 2.0-cm metallic round foreign body in the mid esophagus, only partially imaged\n on this examination. Prevertebral and paraspinal soft tissues are otherwise\n unremarkable. Endotracheal tube and nasogastric tube are in place. Visualized\n outline of the thecal sac appears normal, but please note that CT is unable to\n provide intrathecal detail comparable to MRI.\n\n IMPRESSION:\n\n 1. No cervical spine fracture or malalignment.\n\n 2. 2.0-cm metallic round foreign object in the mid esophagus, possibly a coin\n or battery.\n\n" }, { "category": "Radiology", "chartdate": "2101-01-14 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 1057111, "text": " 8:21 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: track progress\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with a quarter in his colon\n REASON FOR THIS EXAMINATION:\n track progress\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:43 PM\n Coin again seen in the ascending colon.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old man with coin in his colon. Track progress.\n\n TECHNIQUE: Portable abdominal radiograph.\n\n COMPARISON: Compared to portable abdominal radiograph from .\n\n FINDINGS: There is a single radiopaque density seen in the right mid-to-lower\n abdomen, likely in the ascending colon, consistent with the coin. The coin\n has not significantly changed position compared to the prior radiograph.\n\n There is no definite evidence of free air.\n\n IMPRESSION: Coin again seen in the ascending colon.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-01-14 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 1057112, "text": ", B. MED FA7A 8:21 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: track progress\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with a quarter in his colon\n REASON FOR THIS EXAMINATION:\n track progress\n ______________________________________________________________________________\n PFI REPORT\n Coin again seen in the ascending colon.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-01-14 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 1057256, "text": " 5:21 PM\n ABDOMEN (SUPINE ONLY); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval if quarters are still in colon\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man w/ingestion of quarters, has had multiple BMs\n REASON FOR THIS EXAMINATION:\n eval if quarters are still in colon\n ______________________________________________________________________________\n WET READ: RSRc 9:08 PM\n Coin still in ascending colon. - 8pm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ingestion of multiple coins (quarters), status post multiple bowel\n movements, evaluate for persistent foreign bodies.\n\n FINDINGS: A single view of the abdomen again demonstrates a foreign body\n consistent with the coin projecting over the ascending colon, not\n significantly changed from prior plain film from earlier . No other\n radiopaque foreign bodies are identified. The bowel gas pattern is within\n normal limits. The osseous structures are intact. The remaining soft tissues\n are within normal limits.\n\n IMPRESSION: Foreign body (quarter) again projects over the ascending colon,\n not significantly changed from earlier .\n\n" }, { "category": "Radiology", "chartdate": "2101-01-11 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1056558, "text": " 4:17 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n CHEST, ONE VIEW: Allowing for portable supine technique, and very low lung\n volumes, cardiomediastinal contours are within normal limits. No focal\n airspace consolidation is seen. There is no definite pleural effusion. There\n is no pneumothorax. No displaced rib fractures are seen. There is a 2.0 cm\n metallic round foreign object in the expected location of the mid-esophagus.\n\n IMPRESSION:\n 1. Low lung volumes.\n 2. 2.0 cm metallic foreign object in the expected location of the mid-\n esophagus, confirmed on concurrently performed torso CT.\n\n" }, { "category": "Radiology", "chartdate": "2101-01-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1056562, "text": " 4:23 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man MVC\n REASON FOR THIS EXAMINATION:\n eval for trauma\n CONTRAINDICATIONS for IV CONTRAST:\n unknown cr\n ______________________________________________________________________________\n WET READ: DSsd 5:23 PM\n no acute traumatic injury.\n\n 2 ingested foreign objects (? coins or batteries), 1 in mid-esophagus, 2nd in\n cecum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC.\n\n COMPARISON: None.\n\n TECHNIQUE: Volumetric CT acquisition of the chest, abdomen, and pelvis was\n performed following administration of intravenous contrast only.\n\n CT CHEST: Endotracheal tube is in place, tip 3.8 cm above the carina.\n Nasogastric tube is in place, tip curled in the body of the stomach. There is\n a 2.0-cm thin round coin-like metallic foreign body in the mid esophagus.\n\n Heart, pericardium, and great vessels are unremarkable. There is no pleural\n or pericardial effusion. There is no pathologic lymphadenopathy within the\n chest. There is mild bibasilar atelectasis, but the lungs are otherwise\n clear.\n\n CT ABDOMEN: There is a tiny exophytic low attenuation lesion off the right\n kidney too small to otherwise characterize. Statistically, it is\n likely a cyst. Otherwise, the liver, gallbladder, pancreas, spleen, adrenal\n glands, and kidneys are normal. Stomach and intra- abdominal loops of bowel\n are normal. There is no free air, free fluid, or abnormal intra- abdominal\n lymphadenopathy. A few scattered non- enlarged lymph nodes are seen in the\n porta hepatis, and aortocaval region.\n\n CT PELVIS: A second round metallic foreign object is seen within the cecum.\n Pelvic loops of large and small bowel are otherwise unremarkable. There is no\n free pelvic fluid or abnormal pelvic or inguinal lymphadenopathy.\n\n Visualized osseous structures are unremarkable. There is no spinal, pelvic,\n rib or other fracture noted. Thoracolumbar spinal alignment is anatomic.\n\n IMPRESSION:\n\n 1. No acute traumatic injury in the chest, abdomen, or pelvis.\n (Over)\n\n 4:23 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Two ingested round metallic foreign objects, one in the mid esophagus, and\n the second in the cecum. These likely represent ingested coins, or possibly\n batteries.\n\n Findings discussed with Dr. at the time of study interpretation at\n approximately 6 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2101-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056692, "text": " 10:23 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Scout film, ? interval change\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with coin ingestion, assess pre-endoscopy\n REASON FOR THIS EXAMINATION:\n Scout film, ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:27 A.M. ON \n\n HISTORY: Coin ingestion prior to endoscopy.\n\n IMPRESSION: AP chest compared to and through , 4:04 a.m.\n\n Coin sits the left of the midline at the thoracic inlet, presumably in the\n esophagus, unchanged in position since at least , 4:18 p.m.:\n\n Lungs clear. Heart size normal. No pleural abnormality or evidence of\n central adenopathy. Nasogastric tube ends in the mid stomach. A second coin\n projects to the left of the nasogastric tube in the left upper abdominal\n quadrant. Whether this is in the stomach or more distally in the intestinal\n tract is radiographically indeterminate.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-01-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1056603, "text": " 9:31 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval ET tube position\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with intubation s/p MVC\n REASON FOR THIS EXAMINATION:\n eval ET tube position\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:38 P.M. \n\n HISTORY: Intubated after motor vehicle collision.\n\n IMPRESSION: AP chest compared to 4:18 p.m., presented for review on . ET tube and nasogastric tube were in standard placements. Coin projects\n to the left of the midline at the thoracic inlet, roughly 28 mm wide, only 2\n cm more distal than 5 hours previously. ET tube in standard placement. Lungs\n clear. Heart size normal. No pneumothorax.\n\n Second coin in the left upper abdominal quadrant localized by a torso CT scan\n earlier in the day of the right colon has now progressed the left.\n\n" }, { "category": "Nursing", "chartdate": "2101-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551799, "text": "Chief Complaint: s/p MVC, foreign body in esophagus\n HPI:\n 40M unknown PMH presents after MVC as unrestrained driver.\n .\n Problem\n ingestion of foreign objects\n Assessment:\n Patient received from ED vented and sedated on propofol, HR 40\ns B/P\n 80\ns over 50\ns. Pupils PEARLA, abd soft ,positive bowel sounds, OG tube\n to low wall suction, foley patent draining amber colored urine. Chest\n x-ray showed foreign object in esophagus and abd CT showed a foreign\n object in cecum.\n Action:\n Titrating propofol for increased heart rate and systolic B/P, repeat\n chest x-ray for object in esophagus, glucagon 1 mg IV. EKG done for\n bradycardia\n Response:\n Patient able to open eyes to voice HR increased to 60\ns B/P increased\n to 110-120\ns over 50\ns-60\ns, moves limbs on bed.\n Plan:\n Continue to monitor and support patient and report any changes to MIcu\n team, consult Social worker for family dynamics.\n" }, { "category": "Physician ", "chartdate": "2101-01-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 551785, "text": "Chief Complaint: s/p MVC, foreign body in esophagus\n HPI:\n 40M unknown PMH presents after MVC as unrestrained driver.\n .\n Per social work note from ED ---\n \"Per EMS report +LOC, there were no visible skid marks on the road &\n pt's car went head on into tree. There was concern that crash might\n have been intentional. However, pt was confused & not arousable in the\n ED to clarify details. Pt became agitated, threatening & hitting staff,\n so he was intubated. Police at the scene reported to EMS that\n they thought they recognized pt from court earlier in the day. There is\n a question as to whether pt was the same man from court who had a\n restraining order taken out against him by brother. This information\n has not been confirmed. Identification for pt has not been confirmed\n either. Police took the license in patient's possession. The license\n listed DOB , , , MA. Police &\n EMS could not confirm that it was pt's license. Car was also registered\n to .\"\n .\n In the ED, vitals 60, 110/64, 100% on A/C 550x14/5/100%. On exam, no\n trauma injuries. GCS 7 or 8 initially. Labs normal, only notable for\n tox screen positive for benzos. Thought he was clearly intoxicated from\n something though. Given tetanus shot, haldol, ativan. Intubated for\n agitation on propofol. CT chest revealed foreign body in esophagus\n (?coin or battery). GI consulted and thought that most likely a coin\n based on appearance, plan to get Xray in AM to see if it has cleared\n and if not then scope at that time. Admit MICU.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n unkown\n Past medical history:\n Family history:\n Social History:\n unkown\n unkown\n unkown\n Review of systems: unable to assess as intubated, sedated\n Flowsheet Data as of 09:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 46 (46 - 52) bpm\n BP: 94/53(63) {85/53(60) - 94/53(63)} mmHg\n RR: 14 (11 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 2,581 mL\n PO:\n TF:\n IVF:\n 81 mL\n Blood products:\n Total out:\n 0 mL\n 135 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,446 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 580 (550 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.35/42/82.//-2\n Ve: 7.6 L/min\n PaO2 / FiO2: 166\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 220\n 90 mg/dL\n 1.2\n 14\n 101\n 4.4\n 143\n 42.7\n 10.4\n [image002.jpg]\n \n 2:33 A1/13/ 08:58 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 24\n Glucose\n 90\n Other labs: PT / PTT / INR:13.5/27.2/1.2, Lactic Acid:1.1\n Fluid analysis / Other labs: pH 7.35 pCO2 42 pO2 83\n Urine tox + for benzos\n Serum tox negative\n Imaging: CXR: *prelim* Foreign body in esophagus, no acute pulmonary\n process.\n .\n CT torso: *prelim* No acute traumatic injury. There are 2 ingested\n foreign objects (? coins or batteries), 1 in mid-esophagus, 2nd in\n cecum.\n .\n CT C-Spine W/O Contrast: *prelim* No fx or malalignment.\n .\n CT Head W/O Contrast: *prelim* No acute intracranial process.\n Microbiology: none\n ECG: sinus, 74bpm, normal axis and intervals, no acute ST-T changes\n Assessment and Plan\n 40M unknown PMH presents after MVC as unrestrained driver, found to\n have foreign body in esophagus and cecum, intubated for agitation.\n .\n # Foreign body: Located within esophagus and cecum. GI thinks likely\n coin and may pass spontaneously, although somewhat unusual egg-shaped\n appearance on pa/lat CXR. Unclear circumstances surrounding ingestion,\n could be due to collision although similar cecal foreign body suggests\n prior intentional ingestion.\n - GI consulted, would like serial CXR, may need endoscopic intervention\n if not passing, low concern for precipitating ulceration or perforation\n and do not believe it is a battery, will see in AM\n - Remain intubated on propofol until f/u CXR performed and contact GI\n - Clarify history with patient once extubated\n .\n # MVC: No clear traumatic injuries from head on crash with tree and\n unrestrained driver. Some indication that may have been suicide\n attempt.\n - f/u final CT scan reads\n - Psych consult once extubated\n - Appreciate SW help in obtaining family information\n .\n # Tox screen: Positive for benzos and agitated in ED concerning for\n intoxication or withdrawal, although no current signs after receiving\n ativan and propofol. EtOH negative on arrival.\n - Follow for signs withdrawal\n - Continue propofol\n - Ativan prn for agitation or CIWA>10\n - Thiamine IV, folate\n .\n # Sinus bradycardia: Likely due to sedation from benzos and propofol.\n Will lighten and monitor on tele. Check 12-lead ECG to confirm tele\n monitoring.\n .\n # FEN: NPO, hydration with NS, replete 'lytes prn\n # PPX: heparin sc tid, PPI\n # Code: FULL\n # Dispo: ICU\n # Communication: unknown\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2101-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551787, "text": " Problem\n ingestion of foreign objects\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2101-01-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 551796, "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 Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: Did not tolerate RSBI, no spontaneous respirations\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2101-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551884, "text": "Foreign Body Ingestion\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory\n Unable to maintain own airway\n Assessment:\n Action:\n Response:\n Plan:\n Psych - ? intentional harm to self\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551893, "text": "Foreign Body Ingestion\n Assessment:\n - Pt found to have swallowed a quarter that was lodged within his\n esophagus.\n - Abdomen soft, bowel sounds present\n Action:\n - upper GI done, removed quarter and sent for pathology\n Response:\n - tolerated procedure well\n Plan:\n - patient still has FB in cecum, monitor for patient to pass object on\n own\n Respiratory\n Unable to maintain own airway\n Assessment:\n Pt CPAP well, LS clear, weaned sedation, + cuff leak, appropriate\n criteria for extubation\n Action:\n Pt extubated at 1800 and placed on 35% face tent per order\n Response:\n Pt tolerating extubation well, RR 12-20, strong cough noted, remains\n drowsy\n Plan:\n Continue to monitor patient closely, wean O2 as appropriate\n Psych - ? intentional harm to self/Safety\n Assessment:\n Pt drowsy, following commands\n Action:\n Psych consult, 1:1 ordered, continuous monitoring/suicide precautions\n in place\n Response:\n Pt within a safe environment this shift\n Plan:\n Continue to eval patient, social worker involved, psych\n involved\n" }, { "category": "Nursing", "chartdate": "2101-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551790, "text": "Chief Complaint: s/p MVC, foreign body in esophagus\n HPI:\n 40M unknown PMH presents after MVC as unrestrained driver.\n .\n Problem\n ingestion of foreign objects\n Assessment:\n Patient received from ED vented and sedated on propofol, HR 40\ns B/P\n 80\ns over 50\ns. Pupils PEARLA, abd soft ,positive bowel sounds, OG tube\n to low wall suction, foley patent draining amber colored urine. Chest\n x-ray showed foreign object in esophagus and abd CT showed a foreign\n object in cecum.\n Action:\n Titrating propofol for increased heart rate and systolic B/P, repeat\n chest x-ray for object in esophagus, glucagon 1 mg IV. EKG done for\n bradycardia\n Response:\n Patient able to open eyes to voice HR increased to 60\ns B/P increased\n to 110-120\ns over 50\ns-60\ns, moves limbs on bed.\n Plan:\n Continue to monitor and support patient and report any changes to MIcu\n team, consult Social worker for family dynamics.\n" }, { "category": "Respiratory ", "chartdate": "2101-01-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 551881, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\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 Comments: pt will be extubated once wakes up b/c foreign body has been\n removed from airway today.\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2101-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551889, "text": "Foreign Body Ingestion\n Assessment:\n - Pt found to have swallowed a quarter that was lodged within his\n esophagus.\n - Abdomen soft, bowel sounds present\n Action:\n -\n Response:\n Plan:\n Respiratory\n Unable to maintain own airway\n Assessment:\n Action:\n Response:\n Plan:\n Psych - ? intentional harm to self\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551949, "text": "At beginning of shift pt was very lethargic, after being recently\n extubated. Was in 2 soft upper limb restraints. Disoriented stating it\n was and unsure of where he was. At approximately , pt became\n extremely dangerously agitated, combative, swinging at staff, cursing,\n spitting and kicking. A code purple was called. staff were in room\n attempting to calm patient and prevent patient from harming self &\n others. Security in to assess. 4 point leather restraints were placed\n on the patient and pt received IV Haldol and IV ativan as ordered.\n Remains disoriented to place and repeatedly refuses to answer questions\n re: name and date/month/year. Another code purple was called when pt\n was kicking edge of bed, jumping off of bed while restrained and\n verbally threatening nursing staff. A third code purple was called at\n approximately 2300 when patient was hitting his head against the side\n rails. Medicated as ordered. Seizure pads placed on bed to prevent\n further attempts. Pt able to move all extremities though is\n uncooperative with care and RN cannot complete a full neuro exam d/t\n combativeness and potential of harm to pt and staff.\n Episodically throughout the night, pt would become severely agitated,\n aggressive and combative even while restrained. MICU intern/resident\n notified and in to evaluate frequently. RN and/or PCT remained in the\n pt\ns room and at the door for the entire shift- pt was never left\n alone. After discussion with oncall psych, plan is to medicate pt\n according to CIWA scale d/t pt\ns admission of daily klonopin and xanax\n use to MICU H.O. Tmax 100.4. Intermittently tachycardiac and at times\n diaphoretic. MICU team aware. CIWA scale ranging from . Psych\n will continue to follow.\n At approximately midnight, decision was made to release left lower leg\n restraint. Since, pt has remained safe to self and staff with only 3\n limbs restrained. Small skin irritations under/around restraints. Aloe\n Vesta applied and gauze around restraints to minimize friction. Room\n remains quiet, with bed low, locked and bed alarm on.\n Abd soft, nondistended. + BS x4. No BM this shift. Awaiting passage of\n 2^nd coin that is currently in cecum per Xrays. Pt had fluid at KVO\n however during multiple code purples, patient initiated discontinuation\n of fluids. Discussed with Dr. ? need to resume fluids. u/o\n adequate, approx 30-100 per hour. Address fluid status if needed.\n Pt\ns valuables, 4 gold coins and 4 quarters and one nickel, were placed\n in SICU A safe with pt\ns name and according to policy.\n RN spoke to pt\ns brother at beginning of shift and updated brother\n accordingly. Brother asked if pt is transferred to any other\n unit or floor, to please notify him prior to transfer.\n PLAN: Medicate with Valium as indicated for CIWA >10. Provide quiet,\n calm environment with minimal stimulation. D/w psych medication\n management and ? medically cleared. Also, d/w team potential transfer\n to psych unit/facility if pt continues to pose a threat to himself and\n others. Provide comfort and support.\n ------ Protected Section ------\n Pt repeatedly requesting to speak to MD. Pt refusing to communicate\n to RN what he needs. Dr. paged at . MD and\n stated that she is unable to come and evaluate pt at the current time\n and that she has been over to speak/see the pt repeatedly throughout\n the night and cannot come to see the pt. Pt remains hemodynamically\n stable and after RN explained situation pt continues to refuse to\n communicate to RN what he needs.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:36 ------\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551940, "text": "At beginning of shift pt was very lethargic, after being recently\n extubated. Was in 2 soft upper limb restraints. Disoriented stating it\n was and unsure of where he was. At approximately , pt became\n extremely dangerously agitated, combative, swinging at staff, cursing,\n spitting and kicking. A code purple was called. staff were in room\n attempting to calm patient and prevent patient from harming self &\n others. Security in to assess. 4 point leather restraints were placed\n on the patient and pt received IV Haldol and IV ativan as ordered.\n Remains disoriented to place and repeatedly refuses to answer questions\n re: name and date/month/year. Another code purple was called when pt\n was kicking edge of bed, jumping off of bed while restrained and\n verbally threatening nursing staff. A third code purple was called at\n approximately 2300 when patient was hitting his head against the side\n rails. Medicated as ordered. Seizure pads placed on bed to prevent\n further attempts. Pt able to move all extremities though is\n uncooperative with care and RN cannot complete a full neuro exam d/t\n combativeness and potential of harm to pt and staff.\n Episodically throughout the night, pt would become severely agitated,\n aggressive and combative even while restrained. MICU intern/resident\n notified and in to evaluate frequently. RN and/or PCT remained in the\n pt\ns room and at the door for the entire shift- pt was never left\n alone. After discussion with oncall psych, plan is to medicate pt\n according to CIWA scale d/t pt\ns admission of daily klonopin and xanax\n use to MICU H.O. Tmax 100.4. Intermittently tachycardiac and at times\n diaphoretic. MICU team aware. CIWA scale ranging from . Psych\n will continue to follow.\n At approximately midnight, decision was made to release left lower leg\n restraint. Since, pt has remained safe to self and staff with only 3\n limbs restrained. Small skin irritations under/around restraints. Aloe\n Vesta applied and gauze around restraints to minimize friction. Room\n remains quiet, with bed low, locked and bed alarm on.\n Abd soft, nondistended. + BS x4. No BM this shift. Awaiting passage of\n 2^nd coin that is currently in cecum per Xrays. Pt had fluid at KVO\n however during multiple code purples, patient initiated discontinuation\n of fluids. Discussed with Dr. ? need to resume fluids. u/o\n adequate, approx 30-100 per hour. Address fluid status if needed.\n Pt\ns valuables, 4 gold coins and 4 quarters and one nickel, were placed\n in SICU A safe with pt\ns name and according to policy.\n RN spoke to pt\ns brother at beginning of shift and updated brother\n accordingly. Brother asked if pt is transferred to any other\n unit or floor, to please notify him prior to transfer.\n PLAN: Medicate with Valium as indicated for CIWA >10. Provide quiet,\n calm environment with minimal stimulation. D/w psych medication\n management and ? medically cleared. Also, d/w team potential transfer\n to psych unit/facility if pt continues to pose a threat to himself and\n others. Provide comfort and support.\n" }, { "category": "Social Work", "chartdate": "2101-01-13 00:00:00.000", "description": "Social Work Admission Note", "row_id": 552018, "text": "Family Information\n Next of : Mother\n Health Proxy appointed: \n Guardian appointed:\n \n Family Spokesperson designated: \n Communication or visitation restriction: brother and sister in law have\n a restraining order against pt\n Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions: NA\n Past psychiatric history: per family pt has a hx of depression and\n anxiety, no professional assessment. Pt had one prior suicide attempt\n Past addictions history: unknown\n Employment status: Unemployed\n Legal involvement: current restraining orders in place\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n Assess need for family meeting\n Continuing issues to be addressed: psychiatry following and has plan\n for inpatient treatment upon medical clearance. Will be in contact\n with pt's mother who recently asked pt to move out of the home. Will\n try to provide her with some community recourses\n" }, { "category": "Physician ", "chartdate": "2101-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 551856, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:01 PM\n Events:\n - CXR showed no change in location of foreign body\n Contact the patient\ns mother at (. She\n is willing to consent for procedures, however is very distressed by\n this situation. She is not feeling well herself and recent was\n admitted to a psychiatric facility for suicidal ideation herself. She\n reports that Mr. attempted a suicide attempt one year ago with\n placing a garden hose into his exhaust pipe. She also reports that he\n recently has not been acting like himself. She reports he is\nout of\n control\n and determined to\ndestroy\n his brother\ns career.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\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 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 53 (44 - 63) bpm\n BP: 119/64(77) {85/53(60) - 120/100(104)} mmHg\n RR: 14 (11 - 15) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 2,873 mL\n 802 mL\n PO:\n TF:\n IVF:\n 373 mL\n 802 mL\n Blood products:\n Total out:\n 205 mL\n 300 mL\n Urine:\n 205 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,668 mL\n 502 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 580 (550 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.35/42/82./27/-2\n Ve: 8.3 L/min\n PaO2 / FiO2: 166\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 237 K/uL\n 13.4 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 106 mEq/L\n 144 mEq/L\n 38.3 %\n 9.6 K/uL\n [image002.jpg]\n 08:58 PM\n 02:17 AM\n WBC\n 9.6\n Hct\n 38.3\n Plt\n 237\n Cr\n 1.0\n TCO2\n 24\n Glucose\n 90\n 83\n Other labs: PT / PTT / INR:14.3/29.9/1.2, Differential-Neuts:70.5 %,\n Lymph:20.9 %, Mono:6.0 %, Eos:1.7 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n 40M unknown PMH presents after MVC as unrestrained driver, found to\n have foreign body in esophagus and cecum, intubated for agitation.\n .\n # Foreign body: Located within esophagus and cecum. GI on board. Will\n likely extract the coin today. Unclear circumstances surrounding\n ingestion, could be due to collision although similar cecal foreign\n body suggests prior intentional ingestion.\n - GI consulted, endoscopic intervention today\n - Remain intubated on propofol GI intervention\n - Clarify history with patient once extubated\n .\n # MVC: No clear traumatic injuries from head on crash with tree and\n unrestrained driver. Some indication that may have been suicide\n attempt.\n - f/u final CT scan reads\n - Psych consult once extubated to determine circumstances around\n accident\n - Appreciate SW help in obtaining family information\n .\n # Tox screen: Positive for benzos and agitated in ED concerning for\n intoxication or withdrawal, although no current signs after receiving\n ativan and propofol. EtOH negative on arrival.\n - Follow for signs withdrawal\n - Continue propofol\n - Ativan prn for agitation or CIWA>10\n - Thiamine IV, folate\n .\n # Sinus bradycardia: Likely due to sedation from benzos and propofol.\n Will lighten and monitor on tele. Check 12-lead ECG to confirm tele\n monitoring.\n .\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer: PPI\n Communication: Comments: Mother, (\n Code status: Full Code\n Disposition: Remain in the ICU until FB removal\n" }, { "category": "Physician ", "chartdate": "2101-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 552015, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:00 PM\n upper endoscopy, pt tolerated well. FB located within esophagus,\n removed and sent to pathology lab. Pt tolerated well.\n INVASIVE VENTILATION - STOP 06:00 PM\n Events:\n -Successfully extubated, remained aggitated despite security presence.\n Spit in face of security, placed in 4 pt restraints received haldol and\n ativan. Became aggitated again at night, given additional 5 of haldol\n and 5 ativan. Suspect benzo withdrawal-patient states he takes 10 mg\n Klonopin and 10 Xanax QD. Was tachy,hypertensive and had temp of 100.4.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Haloperidol (Haldol) - 10:30 PM\n Lorazepam (Ativan) - 10:40 PM\n Diazepam (Valium) - 06:28 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 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 102 (51 - 118) bpm\n BP: 119/80(90) {91/47(58) - 164/80(94)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,337 mL\n PO:\n TF:\n IVF:\n 2,337 mL\n Blood products:\n Total out:\n 1,325 mL\n 260 mL\n Urine:\n 1,325 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,012 mL\n -260 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 580 (580 - 580) mL\n Vt (Spontaneous): 827 (827 - 827) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 237 K/uL\n 13.4 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 106 mEq/L\n 144 mEq/L\n 38.3 %\n 9.6 K/uL\n [image002.jpg]\n 08:58 PM\n 02:17 AM\n WBC\n 9.6\n Hct\n 38.3\n Plt\n 237\n Cr\n 1.0\n TCO2\n 24\n Glucose\n 90\n 83\n Other labs: PT / PTT / INR:14.3/29.9/1.2, Differential-Neuts:70.5 %,\n Lymph:20.9 %, Mono:6.0 %, Eos:1.7 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n 40M unknown PMH presents after MVC as unrestrained driver, found to\n have foreign body in esophagus and cecum, intubated for agitation.\n .\n # Foreign body: S/p removal of coin from esophagus per GI. Will get\n KUB today to see location of the second coin.\n - GI consulted\n - Extubated yesterday\n - advance diet as tolerated\n .\n # MVC: No clear traumatic injuries from head on crash with tree and\n unrestrained driver. Some indication that may have been suicide\n attempt.\n - f/u final CT scan reads\n - Psych consult recommends haldol and ativan standing, will check labs\n per psych\n - Appreciate SW help in obtaining family information\n - will transfer the patient to inpatient psychiatric facility when\n stable medically\n - maintain restraints while combative\n .\n # Tox screen: Positive for benzos and agitated in ED concerning for\n intoxication or withdrawal, although no current signs of withdrawal.\n - Follow for signs withdrawal\n - d/c CIWA per psych\n - Thiamine IV, folate\n .\n # Sinus bradycardia: Resolved, Likely due to sedation from benzos and\n propofol. Will lighten and monitor on tele. Check 12-lead ECG to\n confirm tele monitoring.\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin SC TID\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: will transfer to inpatient psych facility when stable\n" }, { "category": "Radiology", "chartdate": "2101-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056642, "text": ", F. MED SICU-B 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with foreign body\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Two foreign bodies, one in unchanged position in the proximal esophagus.\n Second moved from ____ to the splenic flexure.\n\n" }, { "category": "Radiology", "chartdate": "2101-01-13 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1057013, "text": " 4:11 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? coin movement\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p swallowing of coins, pls eval for movement of coin\n REASON FOR THIS EXAMINATION:\n ? coin movement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 5:31 PM\n PFI: Coin is seen in the ascending colon.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN.\n\n INDICATION: 44-year-old man who swallowed a coin. Evaluate for movement.\n\n COMPARISON: .\n\n FINDINGS: Single radiopaque density is seen in the right mid to lower\n abdomen, in the ascending colon, consistent with a coin. It has not\n significantly changed since the previous CT. No evidence of free air. The\n bones are normal.\n\n IMPRESSION: Coin again seen in the ascending colon.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-01-13 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1057014, "text": ", MED SICU-B 4:11 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? coin movement\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p swallowing of coins, pls eval for movement of coin\n REASON FOR THIS EXAMINATION:\n ? coin movement\n ______________________________________________________________________________\n PFI REPORT\n PFI: Coin is seen in the ascending colon.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056641, "text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with foreign body\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 9:36 AM\n Two foreign bodies, one in unchanged position in the proximal esophagus.\n Second moved from ____ to the splenic flexure.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of known esophageal foreign body.\n\n Portable AP chest radiograph was compared to CT torso and chest radiographs\n from .\n\n The known esophageal foreign body is unchanged in location projecting over the\n tip of the ET tube terminating approximately 4.5 cm above the carina being\n still in the proximal esophagus. The NG tube tip is in the stomach in\n unchanged position. Additional foreign body seen on the prior scout view\n of the CT has moved from the cecum and is currently projecting over the\n splenic flexure.\n\n" }, { "category": "Radiology", "chartdate": "2101-01-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1057343, "text": ", B. MED FA7A 8:37 AM\n PORTABLE ABDOMEN Clip # \n Reason: please check for coin in colon\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with coin ingestion s/p multiple bm's\n REASON FOR THIS EXAMINATION:\n please check for coin in colon\n ______________________________________________________________________________\n PFI REPORT\n The coin is in the cecum, grossly the position is unchanged dating back to\n .\n\n\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551927, "text": "At beginning of shift pt was lethargic, after being recently extubated.\n Was in 2 soft upper limb restraints. Disoriented stating it was \n and unsure of where he was. At approximately , pt became extremely\n dangerously agitated, combative, swinging at staff, cursing, spitting\n and kicking. A code purple was called. Security in to assess. 4 point\n leather restraints were placed on the patient and pt received IV Haldol\n and IV ativan as ordered.\n" }, { "category": "General", "chartdate": "2101-01-13 00:00:00.000", "description": "Generic Note", "row_id": 552009, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan. He is somewhat less agitated\n this am after recurrent Code Purple episodes last night. Has not moved\n bowels. No abd pain tenderness. Continuing PPI.\n Per Psychiatry\n Haldol/ Ativan for agitation. Will need inpatient\n Psychiatry adm. 1:1 sitter until placed. ECG today. Does not need\n CIWA.\n Time spent 30 min\n" }, { "category": "Physician ", "chartdate": "2101-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 551822, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:01 PM\n Events:\n - CXR showed no change in location of foreign body\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\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 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 53 (44 - 63) bpm\n BP: 119/64(77) {85/53(60) - 120/100(104)} mmHg\n RR: 14 (11 - 15) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 2,873 mL\n 802 mL\n PO:\n TF:\n IVF:\n 373 mL\n 802 mL\n Blood products:\n Total out:\n 205 mL\n 300 mL\n Urine:\n 205 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,668 mL\n 502 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 580 (550 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.35/42/82./27/-2\n Ve: 8.3 L/min\n PaO2 / FiO2: 166\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 237 K/uL\n 13.4 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 106 mEq/L\n 144 mEq/L\n 38.3 %\n 9.6 K/uL\n [image002.jpg]\n 08:58 PM\n 02:17 AM\n WBC\n 9.6\n Hct\n 38.3\n Plt\n 237\n Cr\n 1.0\n TCO2\n 24\n Glucose\n 90\n 83\n Other labs: PT / PTT / INR:14.3/29.9/1.2, Differential-Neuts:70.5 %,\n Lymph:20.9 %, Mono:6.0 %, Eos:1.7 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2101-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 551823, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:01 PM\n Events:\n - CXR showed no change in location of foreign body\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\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 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 53 (44 - 63) bpm\n BP: 119/64(77) {85/53(60) - 120/100(104)} mmHg\n RR: 14 (11 - 15) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 2,873 mL\n 802 mL\n PO:\n TF:\n IVF:\n 373 mL\n 802 mL\n Blood products:\n Total out:\n 205 mL\n 300 mL\n Urine:\n 205 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,668 mL\n 502 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 580 (550 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.35/42/82./27/-2\n Ve: 8.3 L/min\n PaO2 / FiO2: 166\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 237 K/uL\n 13.4 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 106 mEq/L\n 144 mEq/L\n 38.3 %\n 9.6 K/uL\n [image002.jpg]\n 08:58 PM\n 02:17 AM\n WBC\n 9.6\n Hct\n 38.3\n Plt\n 237\n Cr\n 1.0\n TCO2\n 24\n Glucose\n 90\n 83\n Other labs: PT / PTT / INR:14.3/29.9/1.2, Differential-Neuts:70.5 %,\n Lymph:20.9 %, Mono:6.0 %, Eos:1.7 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n 40M unknown PMH presents after MVC as unrestrained driver, found to\n have foreign body in esophagus and cecum, intubated for agitation.\n .\n # Foreign body: Located within esophagus and cecum. GI thinks likely\n coin and may pass spontaneously, although somewhat unusual egg-shaped\n appearance on pa/lat CXR. Unclear circumstances surrounding ingestion,\n could be due to collision although similar cecal foreign body suggests\n prior intentional ingestion.\n - GI consulted, would like serial CXR, may need endoscopic intervention\n if not passing, low concern for precipitating ulceration or perforation\n and do not believe it is a battery, will see in AM\n - Remain intubated on propofol until f/u CXR performed and contact GI\n - Clarify history with patient once extubated\n .\n # MVC: No clear traumatic injuries from head on crash with tree and\n unrestrained driver. Some indication that may have been suicide\n attempt.\n - f/u final CT scan reads\n - Psych consult once extubated\n - Appreciate SW help in obtaining family information\n .\n # Tox screen: Positive for benzos and agitated in ED concerning for\n intoxication or withdrawal, although no current signs after receiving\n ativan and propofol. EtOH negative on arrival.\n - Follow for signs withdrawal\n - Continue propofol\n - Ativan prn for agitation or CIWA>10\n - Thiamine IV, folate\n .\n # Sinus bradycardia: Likely due to sedation from benzos and propofol.\n Will lighten and monitor on tele. Check 12-lead ECG to confirm tele\n monitoring.\n .\n # FEN: NPO, hydration with NS, replete 'lytes prn\n # PPX: heparin sc tid, PPI\n # Code: FULL\n # Dispo: ICU\n # Communication: unknown\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2101-01-12 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 551830, "text": "Chief Complaint: s/p MVC, foreign body in esophagus\n HPI:\n 40M unknown PMH presents after MVC as unrestrained driver.\n .\n Per social work note from ED ---\n \"Per EMS report +LOC, there were no visible skid marks on the road &\n pt's car went head on into tree. There was concern that crash might\n have been intentional. However, pt was confused & not arousable in the\n ED to clarify details. Pt became agitated, threatening & hitting staff,\n so he was intubated. Police at the scene reported to EMS that\n they thought they recognized pt from court earlier in the day. There is\n a question as to whether pt was the same man from court who had a\n restraining order taken out against him by brother. This information\n has not been confirmed. Identification for pt has not been confirmed\n either. Police took the license in patient's possession. The license\n listed DOB , , , MA. Police &\n EMS could not confirm that it was pt's license. Car was also registered\n to .\"\n .\n In the ED, vitals 60, 110/64, 100% on A/C 550x14/5/100%. On exam, no\n trauma injuries. GCS 7 or 8 initially. Labs normal, only notable for\n tox screen positive for benzos. Thought he was clearly intoxicated from\n something though. Given tetanus shot, haldol, ativan. Intubated for\n agitation on propofol. CT chest revealed foreign body in esophagus\n (?coin or battery). GI consulted and thought that most likely a coin\n based on appearance, plan to get Xray in AM to see if it has cleared\n and if not then scope at that time. Admit MICU.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 20 mcg/Kg/\n Other ICU medications:\n Other medications:\n unkown\n Past medical history:\n Family history:\n Social History:\n unkown\n unkown\n unkown\n Review of systems: unable to assess as intubated, sedated\n Flowsheet Data as of 09:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 46 (46 - 52) bpm\n BP: 94/53(63) {85/53(60) - 94/53(63)} mmHg\n RR: 14 (11 - 14) insp/\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 2,581 mL\n PO:\n TF:\n IVF:\n 81 mL\n Blood products:\n Total out:\n 0 mL\n 135 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,446 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 580 (550 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.35/42/82.//-2\n Ve: 7.6 L/\n PaO2 / FiO2: 166\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: \n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 220\n 90 mg/dL\n 1.2\n 14\n 101\n 4.4\n 143\n 42.7\n 10.4\n [image002.jpg]\n \n 2:33 A1/13/ 08:58 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 24\n Glucose\n 90\n Other labs: PT / PTT / INR:13.5/27.2/1.2, Lactic Acid:1.1\n Fluid analysis / Other labs: pH 7.35 pCO2 42 pO2 83\n Urine tox + for benzos\n Serum tox negative\n Imaging: CXR: *prelim* Foreign body in esophagus, no acute pulmonary\n process.\n .\n CT torso: *prelim* No acute traumatic injury. There are 2 ingested\n foreign objects (? coins or batteries), 1 in mid-esophagus, 2nd in\n cecum.\n .\n CT C-Spine W/O Contrast: *prelim* No fx or malalignment.\n .\n CT Head W/O Contrast: *prelim* No acute intracranial process.\n Microbiology: none\n ECG: sinus, 74bpm, normal axis and intervals, no acute ST-T changes\n Assessment and Plan\n 40M unknown PMH presents after MVC as unrestrained driver, found to\n have foreign body in esophagus and cecum, intubated for agitation.\n .\n # Foreign body: Located within esophagus and cecum. GI thinks likely\n coin and may pass spontaneously, although somewhat unusual egg-shaped\n appearance on pa/lat CXR. Unclear circumstances surrounding ingestion,\n could be due to collision although similar cecal foreign body suggests\n prior intentional ingestion.\n - GI consulted, would like serial CXR, may need endoscopic intervention\n if not passing, low concern for precipitating ulceration or perforation\n and do not believe it is a battery, will see in AM\n - Remain intubated on propofol until f/u CXR performed and contact GI\n - Clarify history with patient once extubated\n .\n # MVC: No clear traumatic injuries from head on crash with tree and\n unrestrained driver. Some indication that may have been suicide\n attempt.\n - f/u final CT scan reads\n - Psych consult once extubated\n - Appreciate SW help in obtaining family information\n .\n # Tox screen: Positive for benzos and agitated in ED concerning for\n intoxication or withdrawal, although no current signs after receiving\n ativan and propofol. EtOH negative on arrival.\n - Follow for signs withdrawal\n - Continue propofol\n - Ativan prn for agitation or CIWA>10\n - Thiamine IV, folate\n .\n # Sinus bradycardia: Likely due to sedation from benzos and propofol.\n Will lighten and monitor on tele. Check 12-lead ECG to confirm tele\n monitoring.\n .\n # FEN: NPO, hydration with NS, replete 'lytes prn\n # PPX: heparin sc tid, PPI\n # Code: FULL\n # Dispo: ICU\n # Communication: unknown\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ 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 admitted with likely benzo ingestion c/b\n MVA. Noted on CXR and CT to have FB in esophagus and cecum. Intubated\n for combative behavior and admitted to MICU.\n Exam notable for Tm 97.9 BP 100/60 HR 50 RR 18 with sat 100 on VAC.\n , responsive on propofol. Clear chest, RRR s1s2. Soft\n distended abdomen. No edema. Labs notable for WBC 9K, HCT 35, K+ 3.5,\n Cr 1.0. CXR with FB in mid esophagus on multiple views, does not appear\n to be moving.\n Agree with plan to continue MV and propofol for sedation while awaiting\n f/u CXR and likely endoscopic removal of esophageal FB. Will need\n valium PRN for component of possible benzo dependence to avoid\n withdrawal. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 \n ------ Protected Section Addendum Entered By: , MD\n on: 07:35 ------\n" }, { "category": "General", "chartdate": "2101-01-12 00:00:00.000", "description": "Generic Note", "row_id": 551841, "text": "TITLE: Critical Care\n Present for key portions of resident\ns history and exam. Agree\n substantially with assessment and plan as above. Unrestrained MVA with\n FB in esophagus. CXR this am shows no movement of apparent coin in\n esophagus. Plan for EGD this am. We believe his mother is next of \n and will contact her for consent. Have to assume this was a suicide\n attempt\n plan for sitters when no longer heavily sedated and will need\n Psychiatry clearance.\n Time spent 40 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 552049, "text": "44M unknown PMH presents after MVA as unrestrained driver against a\n tree and no skid marks to suggest it may have been a suicide attempt,\n found to have foreign body in esophagus and cecum, intubated for\n agitation. S/p removal of coin from esophagus per GI. Continues with\n one coin in cecum per x-ray. Abd x-ray done today to identify coin\n location as pt has not moved his bowels-results pending. Tox screen:\n Positive for benzos and agitated in ED concerning for intoxication or\n withdrawal, although no current signs of withdrawal. Initially on CIWA\n scale which has been discontinued. Extubated pm.\n Suicidality / Suicide Attempt\n Assessment:\n Patient requiring four-point leather restraints this am (see previous\n nursing note for details of overnight shift/violent behavior), becoming\n more cooperative and calm in late morning/noon time. Security asked to\n be present for skin assessment while removing restraints this am.\n Initially left arm restraint discontinued with compliance and\n eventually all leather restraints discontinued. He is now alert and\n oriented x3, some recall of events that brought him to hospital and\n being cooperative with care as well as taking po medications, which he\n had refused earlier. He is overall somewhat lethargic and sleeping\n frequently. No attempts to get out of bed, no inappropriate language or\n behavior since noon. Continues to require 1:1 sitter for suicide\n attempt (MVA). Psychiatry in to assess this am but pt. too lethargic at\n that time. Patient continues to make accusations regarding brother. \n is also distraught about his situation and states he has no place to\n live, no job and chronic back and heel pain.\n Action:\n Medication changed per Psychiatry recommendations to Haldol and Ativan\n po ATC. Diet liberalized to clears and now regular diet with good\n tolerance. police in to serve pt. restraining order from his\n brother and family/copies in chart. Mother and brother updated on pt.\n condition. Emotional support and encouragement provided to patient and\n family and reinforced often.\n Response:\n Pt. compliant with nursing care.\n Plan:\n Transfer to floor when bed available. Continue with 1:1 sitter for\n suicide attempt. Psychiatric f/u in am. Possible admission to Psych\n unit pending. Pls make family aware of patient transfers within\n hospital and particularly in the event he is discharged home, per their\n request, as his brother states he fears for his family\ns safety. Plan\n discussed with .\n Demographics\n Attending MD:\n \n Admit diagnosis:\n FB IN ESOPHAGUS\n Code status:\n Full code\n Height:\n Admission weight:\n 91 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:54\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 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 96% %\n O2 flow:\n FiO2 set:\n 35% %\n 24h total in:\n 1,170 mL\n 24h total out:\n 750 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 09:37 AM\n Potassium:\n 3.8 mEq/L\n 09:37 AM\n Chloride:\n 110 mEq/L\n 09:37 AM\n CO2:\n 21 mEq/L\n 09:37 AM\n BUN:\n 7 mg/dL\n 09:37 AM\n Creatinine:\n 0.9 mg/dL\n 09:37 AM\n Glucose:\n 83 mg/dL\n 09:41 AM\n Hematocrit:\n 36.7 %\n 09:37 AM\n Finger Stick Glucose:\n 88\n 04:00 PM\n Valuables / Signature\n Patient valuables: money locked in ED safe, and coins locked in SICU A\n safe. All slips in pt\ns chart.\n Other valuables: 2 bags of clothing.\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: 709\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2101-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 551965, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:00 PM\n upper endoscopy, pt tolerated well. FB located within esophagus,\n removed and sent to pathology lab. Pt tolerated well.\n INVASIVE VENTILATION - STOP 06:00 PM\n Events:\n -Successfully extubated, remained aggitated despite security presence.\n Spit in face of security, placed in 4 pt restraints received haldol and\n ativan. Became aggitated again at night, given additional 5 of haldol\n and 5 ativan. Suspect benzo withdrawal-patient states he takes 10 mg\n Klonopin and 10 Xanax QD. Was tachy,hypertensive and had temp of 100.4.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Haloperidol (Haldol) - 10:30 PM\n Lorazepam (Ativan) - 10:40 PM\n Diazepam (Valium) - 06:28 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 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 102 (51 - 118) bpm\n BP: 119/80(90) {91/47(58) - 164/80(94)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,337 mL\n PO:\n TF:\n IVF:\n 2,337 mL\n Blood products:\n Total out:\n 1,325 mL\n 260 mL\n Urine:\n 1,325 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,012 mL\n -260 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 580 (580 - 580) mL\n Vt (Spontaneous): 827 (827 - 827) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 7.2 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 237 K/uL\n 13.4 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 106 mEq/L\n 144 mEq/L\n 38.3 %\n 9.6 K/uL\n [image002.jpg]\n 08:58 PM\n 02:17 AM\n WBC\n 9.6\n Hct\n 38.3\n Plt\n 237\n Cr\n 1.0\n TCO2\n 24\n Glucose\n 90\n 83\n Other labs: PT / PTT / INR:14.3/29.9/1.2, Differential-Neuts:70.5 %,\n Lymph:20.9 %, Mono:6.0 %, Eos:1.7 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2101-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 551966, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:00 PM\n upper endoscopy, pt tolerated well. FB located within esophagus,\n removed and sent to pathology lab. Pt tolerated well.\n INVASIVE VENTILATION - STOP 06:00 PM\n Events:\n -Successfully extubated, remained aggitated despite security presence.\n Spit in face of security, placed in 4 pt restraints received haldol and\n ativan. Became aggitated again at night, given additional 5 of haldol\n and 5 ativan. Suspect benzo withdrawal-patient states he takes 10 mg\n Klonopin and 10 Xanax QD. Was tachy,hypertensive and had temp of 100.4.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Haloperidol (Haldol) - 10:30 PM\n Lorazepam (Ativan) - 10:40 PM\n Diazepam (Valium) - 06:28 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 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 102 (51 - 118) bpm\n BP: 119/80(90) {91/47(58) - 164/80(94)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,337 mL\n PO:\n TF:\n IVF:\n 2,337 mL\n Blood products:\n Total out:\n 1,325 mL\n 260 mL\n Urine:\n 1,325 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,012 mL\n -260 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 580 (580 - 580) mL\n Vt (Spontaneous): 827 (827 - 827) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 237 K/uL\n 13.4 g/dL\n 83 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 106 mEq/L\n 144 mEq/L\n 38.3 %\n 9.6 K/uL\n [image002.jpg]\n 08:58 PM\n 02:17 AM\n WBC\n 9.6\n Hct\n 38.3\n Plt\n 237\n Cr\n 1.0\n TCO2\n 24\n Glucose\n 90\n 83\n Other labs: PT / PTT / INR:14.3/29.9/1.2, Differential-Neuts:70.5 %,\n Lymph:20.9 %, Mono:6.0 %, Eos:1.7 %, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n 40M unknown PMH presents after MVC as unrestrained driver, found to\n have foreign body in esophagus and cecum, intubated for agitation.\n .\n # Foreign body: Located within esophagus and cecum. GI on board. Will\n likely extract the coin today. Unclear circumstances surrounding\n ingestion, could be due to collision although similar cecal foreign\n body suggests prior intentional ingestion.\n - GI consulted, endoscopic intervention today\n - Remain intubated on propofol GI intervention\n - Clarify history with patient once extubated\n .\n # MVC: No clear traumatic injuries from head on crash with tree and\n unrestrained driver. Some indication that may have been suicide\n attempt.\n - f/u final CT scan reads\n - Psych consult once extubated to determine circumstances around\n accident\n - Appreciate SW help in obtaining family information\n .\n # Tox screen: Positive for benzos and agitated in ED concerning for\n intoxication or withdrawal, although no current signs after receiving\n ativan and propofol. EtOH negative on arrival.\n - Follow for signs withdrawal\n - Continue propofol\n - Ativan prn for agitation or CIWA>10\n - Thiamine IV, folate\n .\n # Sinus bradycardia: Likely due to sedation from benzos and propofol.\n Will lighten and monitor on tele. Check 12-lead ECG to confirm tele\n monitoring.\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 08:30 PM\n 18 Gauge - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 552041, "text": "44M unknown PMH presents after MVA as unrestrained driver against a\n tree and no skid marks to suggest it may have been a suicide attempt,\n found to have foreign body in esophagus and cecum, intubated for\n agitation. S/p removal of coin from esophagus per GI. Continues with\n one coin in cecum per x-ray. Abd x-ray done today to identify coin\n location as pt has not moved his bowels-results pending. Tox screen:\n Positive for benzos and agitated in ED concerning for intoxication or\n withdrawal, although no current signs of withdrawal. Initially on CIWA\n scale which has been discontinued. Extubated pm.\n Suicidality / Suicide Attempt\n Assessment:\n Patient requiring four-point leather restraints this am (see previous\n nursing note for details of overnight shift/violent behavior), becoming\n more cooperative and calm in late morning/noon time. Security asked to\n be present for skin assessment while removing restraints this am.\n Initially left arm restraint discontinued with compliance and\n eventually all leather restraints discontinued. He is now alert and\n oriented x3, some recall of events that brought him to hospital and\n being cooperative with care as well as taking po medications, which he\n had refused earlier. He is overall somewhat lethargic and sleeping\n frequently. No attempts to get out of bed, no inappropriate language or\n behavior since noon. Continues to require 1:1 sitter for suicide\n attempt (MVA). Psychiatry in to assess this am but pt. too lethargic at\n that time. Patient continues to make accusations regarding brother. \n is also distraught about his situation and states he has no place to\n live, no job and chronic back and heel pain.\n Action:\n Medication changed per Psychiatry recommendations to Haldol and Ativan\n po ATC. Diet liberalized to clears and now regular diet with good\n tolerance. police in to serve pt. restraining order from his\n brother and family/copies in chart. Mother and brother updated on pt.\n condition. Emotional support and encouragement provided to patient and\n family and reinforced often.\n Response:\n Pt. compliant with nursing care.\n Plan:\n Transfer to floor when bed available. Continue with 1:1 sitter for\n suicide attempt. Psychiatric f/u in am. Possible admission to Psych\n unit pending. Pls make family aware of patient transfers within\n hospital and particularly in the event he is discharged home, per their\n request, as his brother states he fears for his family\ns safety. Plan\n discussed with .\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 551959, "text": "At beginning of shift pt was very lethargic, after being recently\n extubated. Was in 2 soft upper limb restraints. Disoriented stating it\n was and unsure of where he was. At approximately , pt became\n extremely dangerously agitated, combative, swinging at staff, cursing,\n spitting and kicking. A code purple was called. staff were in room\n attempting to calm patient and prevent patient from harming self &\n others. Security in to assess. 4 point leather restraints were placed\n on the patient and pt received IV Haldol and IV ativan as ordered.\n Remains disoriented to place and repeatedly refuses to answer questions\n re: name and date/month/year. Another code purple was called when pt\n was kicking edge of bed, jumping off of bed while restrained and\n verbally threatening nursing staff. A third code purple was called at\n approximately 2300 when patient was hitting his head against the side\n rails. Medicated as ordered. Seizure pads placed on bed to prevent\n further attempts. Pt able to move all extremities though is\n uncooperative with care and RN cannot complete a full neuro exam d/t\n combativeness and potential of harm to pt and staff.\n Episodically throughout the night, pt would become severely agitated,\n aggressive and combative even while restrained. MICU intern/resident\n notified and in to evaluate frequently. RN and/or PCT remained in the\n pt\ns room and at the door for the entire shift- pt was never left\n alone. After discussion with oncall psych, plan is to medicate pt\n according to CIWA scale d/t pt\ns admission of daily klonopin and xanax\n use to MICU H.O. Tmax 100.4. Intermittently tachycardiac and at times\n diaphoretic. MICU team aware. CIWA scale ranging from . Psych\n will continue to follow.\n At approximately midnight, decision was made to release left lower leg\n restraint. Since, pt has remained safe to self and staff with only 3\n limbs restrained. Small skin irritations under/around restraints. Aloe\n Vesta applied and gauze around restraints to minimize friction. Room\n remains quiet, with bed low, locked and bed alarm on.\n Abd soft, nondistended. + BS x4. No BM this shift. Awaiting passage of\n 2^nd coin that is currently in cecum per Xrays. Pt had fluid at KVO\n however during multiple code purples, patient initiated discontinuation\n of fluids. Discussed with Dr. ? need to resume fluids. u/o\n adequate, approx 30-100 per hour. Address fluid status if needed.\n Pt\ns valuables, 4 gold coins and 4 quarters and one nickel, were placed\n in SICU A safe with pt\ns name and according to policy.\n RN spoke to pt\ns brother at beginning of shift and updated brother\n accordingly. Brother asked if pt is transferred to any other\n unit or floor, to please notify him prior to transfer.\n PLAN: Medicate with Valium as indicated for CIWA >10. Provide quiet,\n calm environment with minimal stimulation. D/w psych medication\n management and ? medically cleared. Also, d/w team potential transfer\n to psych unit/facility if pt continues to pose a threat to himself and\n others. Provide comfort and support.\n ------ Protected Section ------\n Pt repeatedly requesting to speak to MD. Pt refusing to communicate\n to RN what he needs. Dr. paged at . MD and\n stated that she is unable to come and evaluate pt at the current time\n and that she has been over to speak/see the pt repeatedly throughout\n the night and cannot come to see the pt. Pt remains hemodynamically\n stable and after RN explained situation pt continues to refuse to\n communicate to RN what he needs.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:36 ------\n Pt refusing a.m. labs. RN discussed need for morning labs and pt stated\n that he had\nlabs drawn a month ago to check things and does not need\n anymore. Check those labs\n. Readdress labs on the day shift.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:18 ------\n" }, { "category": "Nursing", "chartdate": "2101-01-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 552034, "text": "Suicidality / Suicide Attempt\n Assessment:\n Patient requiring four-point leather restraints this am (see previous\n nursing note for details of overnight shift/violent behavior), becoming\n more cooperative and calm in late morning/noon time. Security asked to\n be present for skin assessment while removing restraints this am.\n Initially left arm restraint discontinued with compliance and\n eventually all leather restraints discontinued. He is now alert and\n oriented x3, some recall of events that brought him to hospital and\n being cooperative with care as well as taking po medications, which he\n had refused earlier. He is overall somewhat lethargic and sleeping\n frequently. No attempts to get out of bed, no inappropriate language or\n behavior since noon. Continues to require 1:1 sitter for suicide\n attempt (MVA). Psychiatry in to assess this am but pt. too lethargic at\n that time. Patient continues to make accusations regarding brother.\n Action:\n Medication changed per Psychiatry recommendations to Haldol and Ativan\n po ATC. Diet liberalized to clears and now regular diet with good\n tolerance. police in to serve pt. restraining order from his\n brother and family/copies in chart. Mother and brother updated on pt.\n condition.\n Response:\n Pt. compliant with nursing care.\n Plan:\n Transfer to floor when bed available. Continue with 1:1 sitter for\n suicide attempt. Psychiatric f/u in am. Possible admission to Psych\n unit pending. Pls make family aware of patient transfers within\n hospital and particularly in the event he is discharged home, per their\n request, as his brother states he fears for his family\ns safety.\n" }, { "category": "Radiology", "chartdate": "2101-01-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1057342, "text": " 8:37 AM\n PORTABLE ABDOMEN Clip # \n Reason: please check for coin in colon\n Admitting Diagnosis: FB IN ESOPHAGUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with coin ingestion s/p multiple bm's\n REASON FOR THIS EXAMINATION:\n please check for coin in colon\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 10:54 AM\n The coin is in the cecum, grossly the position is unchanged dating back to\n .\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the position of swallowed coin.\n\n Portable AP chest radiograph was compared to several prior studies dating back\n to .\n\n The coin in the cecum is in unchanged position over multiple radiographs\n dating back to . No evidence of bowel dilatation is present.\n\n\n" }, { "category": "ECG", "chartdate": "2101-01-14 00:00:00.000", "description": "Report", "row_id": 242825, "text": "Sinus bradycardia. Low QRS voltage in the limb leads. Compared to the\nprevious tracing of no definite change.\n\n" }, { "category": "ECG", "chartdate": "2101-01-13 00:00:00.000", "description": "Report", "row_id": 242826, "text": "Sinus rhythm with probable modest wandering atrial pacemaker/question period of\nectopic atrial rhythm. Otherwise, normal tracing. Since the previous tracing\nof marked sinus bradycardia is absent.\n\n" }, { "category": "ECG", "chartdate": "2101-01-11 00:00:00.000", "description": "Report", "row_id": 242827, "text": "Sinus bradycardia\nOtherwise probably normal ECG\nSince previous tracing of the same date, sinus bradycardia now present\n\n" }, { "category": "ECG", "chartdate": "2101-01-11 00:00:00.000", "description": "Report", "row_id": 242828, "text": "Sinus arrhythmia\nNormal ECG\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Physician ", "chartdate": "2192-08-16 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 342566, "text": "Chief Complaint: Hypotension\n 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 patient with increased lethargy at home without specific associated\n symptoms now found to have significant hypotension at dialysis today.\n In ED she had minimal hypotension and in the setting of recurrent\n hypotension patient was given one additional liter of IVF (2 total)\n with reasonable response.\n patient had CXR that suggested pneumonia and patient started on\n Vanco/Levo for abx.\n head CT negative for investigation in ED\n Patient to ICU for further care with hypotension and with significant\n hypercarbia noted on ABX with BIPAP started for respiratory failure\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n ESRD-On HD\n PVD-S/P BKA\n Osteomyelitis--Abx completed 3 months ago\n OSA\n None contributory\n Occupation: Unemp\n Drugs: None\n Tobacco: None now, 30 py history\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Nutritional Support: NPO\n Respiratory: bradypnea\n Gastrointestinal: No(t) Abdominal pain\n Integumentary (skin): No(t) Rash\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 64 (61 - 65) bpm\n BP: 96/24(38) {78/16(36) - 114/45(59)} mmHg\n RR: 10 (8 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 15 mL\n 117 mL\n PO:\n 100 mL\n TF:\n IVF:\n 15 mL\n 17 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n 117 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, BIPAP Mask in place\n Cardiovascular: (S1: Normal), (S2: Distant), (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), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 1+, Left: BKA\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 109\n 33\n 7.6\n 43\n 24\n 105\n 5\n 142\n 7.8\n [image002.jpg]\n Other labs: CK / CKMB / Troponin-T://Trop=0.82\n Fluid analysis / Other labs: 7.31/51/75\n Imaging: CXR-Low lung volumes noted, no focal collapse\n Assessment and Plan\n 54 yo female with history of ESRD on HD and now presenting with\n significant hypotension noted at rehab. Patient does have difficult to\n assess BP but with reproducible readings hypotension has been seen\n which is responsive to IVF. She does have worsening hypercarbia noted\n in the setting of increased narcotic dosing which may be contributing\n to the presence of hypotension as well. Her respiratory pattern is one\n of bradypnea and short cycle central apnea, again concerning for\n narcotic effect. Certainly sepsis is of concern and pulmonary source\n is raised with infiltrate on CXR but patient is without cough, fever or\n phelgm production.\n 1)Hypotension- be related to vasodilatory effects of narcotic dosing\n but active infection is raised as issue as well.\n -IVF bolus to maintain MAP >60\n -Will purse blood cultures, urine if possible and sputum if possible.\n -Will utilize multiple sites for BP checks.\n -Vanco/Levo until cultures negative\n 2)Respiratory Failure-\n -BIPAP support with o2 as needed\n -Decrease narcotic dosing\n -Wean O2\n -Move to RA in am\n -Patient with good tolerance of mask support.\n 3)Chronic Renal Failure-\n -Dialysis tomorrow if BP able to be stabilized\n -Goal to keep fluid balance even at that time\n -Catheter appears in good position and minimal irritation at site.\n 4)Altered Mental Status-\n -Hold sedating medications\n -CT reassuring\n -Will monitor neuro exam\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Dialysis Catheter - 11:00 PM\n 20 Gauge - 11:00 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342710, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management\n Hypotension (not Shock)\n Assessment:\n Known hypotensive during,hd sbp 90-140,dbp 20-55\n Action:\n No fluid blous required in this shift,Bp roatated in rt brachial as\n well left radial\n Response:\n Sbp 90-140,map>60,pt tolerated the HD\n Plan:\n Follow blood pressure\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Known esrd,on hemodialysis\n Action:\n Pt is on HD\n Response:\n Plan:\n Cont HD,follow lytes\n Diarrhea\n Assessment:\n Pt had 3 episodes of loose bm in this shift following keyxalate,with\n abd cramps\n Action:\n Received maloox for cramps\n Response:\n pending\n Plan:\n Follow,\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342739, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management.\n Events;pt had HD today,tolerated well,blood cx x1 sent from the HD\n line.\n Hypotension (not Shock)\n Assessment:\n Known hypotensive during,hd sbp 90-140,dbp 20-55\n Action:\n No fluid bolus required in this shift,BP roatated in rt brachial as\n well left radial\n Response:\n Sbp 90-140,map>60,pt tolerated the HD\n Plan:\n Follow blood pressure\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Known esrd,on hemodialysis\n Action:\n Pt has Hd today\n Response:\n 1L removed\n Plan:\n Cont current HD schedule,\n" }, { "category": "Physician ", "chartdate": "2192-08-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 342639, "text": "Chief Complaint: Chief complaint: hypotension and altered mental\n status\n HPI:\n Ms. is a 54 yo female with ESRD on HD, PVD s/p L BKA, h/o L\n stump osteomyelitis s/p Vanco/ for 6 weeks completed in , DM,\n OSA, admitted with hypotension of 64/42 at dialysis. She was given 1L\n NS at dialysis and her BP improved to 140/doppler.\n .\n In the ED, her initial vitals were 149/72, RR 18, HR 59, 94% on 2LNC.\n She was hypotensive to 90/D in the , she was given another L of\n IVF. CXR showed possible PNA, so she was given vancomycin and\n levaquin. She was also noted to be somnolent and patient was found to\n have two fentanyl patches on her body, one of which was removed. A\n head CT was performed which was unchagned. Given her history of OSA,\n an ABG was performed with showed a pCO2 of 49.\n .\n Upon arrival to the floor, her vitals are ???. She reports fatigue\n over the past three days and increased sleepiness. She is tearful\n intermittently though denies home stressors or depressed mood. She\n denies cough, shortness of breath, chest pain, fevers, chills, dysuria,\n skin rash, or any other symptoms.\n Allergies:\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Albuterol PRN\n Aspirin 81 daily\n Plavix 75 mg daily\n Fentanyl patch 75 meq daily\n Lactulose 15 ml Daily\n Metoprolol Tartrate 25 \n Mirtazapine 15 mg qhs\n Multivitamin\n Pantoprazole 40 mg daily\n Percocet prn\n Simvastatin 10 mg qhs\n Colace \n Senna PRN\n HSQ TID\n Neurontin 300 qhd\n Reglan 5 mg TID\n Tramadol 50 mg \n Ambien 5-10 mg qhs\n Sevelamer HCl 800 mg TID with meals\n Cinacalcet 30 mg po daily\n Lanthanum 500 mg TID with meals\n Seroquel 12.5 prn\n Insulin Novolog 8, 8, and 10 units before meals and sliding scale.\n Paricalcitol 6 mg q HD\n Past medical history:\n Family history:\n Social History:\n -Peripheral vascular disease s/p L SFA-DP bypass in for gangrenous\n heel, s/p R proximal SF-proximal AT bypass in , s/p L BKA in \n for non healing ulcer\n - Left stump osteomyelitis in treated with vanco/ from\n \n - ESRD on HD. MWF schedule.\n - HTN\n - Diabetes Mellitus\n - Renal Cell Carcinoma s/p right nephrectomy\n - Obesity\n - Depression\n - s/p CCY\n - Gastric Ulcer\n - Obstructive Sleep Apnea.\n - Gastroparesis\n - COPD on 3-4L NC baseline\n - h/o ischemic colitis\n - left adrenal adenoma\n Mother died of stomach cancer in her 40s. Father had an unknown\n cancer in his 70s. Stated that diabetes, high cholesterol, and\n high blood pressure run in her family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Admitted from rehab. Has two sisters, one daughter. is a\n former smoker with a 30 pack year history, quit 20 years ago.\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 74 (60 - 74) bpm\n BP: 112/22(46) {68/16(26) - 114/53(59)} mmHg\n RR: 14 (7 - 14) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 15 mL\n 175 mL\n PO:\n 100 mL\n TF:\n IVF:\n 15 mL\n 75 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n 175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n VS: T 97.5, HR 61, BP 114/34, 96% on 3LNC, RR 8\n Gen: alert and oriented x 2 (did not know date), conversant\n HEENT: PERRL, EOMI, o/p clear\n CV: RRR, systolic murmur at LUSB\n Pulm: Clear anteriorly, though poor inspiratory effort, unlabored,\n decreased respiratory rate\n Abd: obese, soft, NT, ND\n Ext: peripheral edema present, left AKA\n Neuro: alert and oriented x 2, moving all extremities, CNs intact\n .\n Labs / Radiology\n 110 K/uL\n 10.0 g/dL\n 110 mg/dL\n 7.9 mg/dL\n 45 mg/dL\n 23 mEq/L\n 106 mEq/L\n 5.7 mEq/L\n 143 mEq/L\n 33.0 %\n 5.8 K/uL\n [image002.jpg]\n \n 2:33 A9/18/ 02:45 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 5.8\n Hct\n 33.0\n Plt\n 110\n Cr\n 7.9\n TropT\n 0.84\n Glucose\n 110\n Other labs: PT / PTT / INR:18.2/37.6/1.7, CK / CKMB /\n Troponin-T:55//0.84, ALT / AST:37/37, Alk Phos / T Bili:160/0.3,\n Amylase / Lipase:22/12, Albumin:4.0 g/dL, LDH:233 IU/L, Ca++:9.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: Labs:\n .\n 142 | 105 | 43 /\n --------------- 114\n 5.5 | 24 | 7.6 \\\n .\n Ca 9.6\n Mg 2.5\n P 5.7\n .\n .. \\ 10.4 /\n 7.8 ------ 109\n .. / 33.7 \\\n .\n ABG 7.31/51/75/27\n .\n Lactate 1.1\n Imaging: Imaging:\n . CT Head. No acute process seen.\n .\n . CXR. Wet read: linear opacity right mid lung concerning for\n evolving pneumonia, ddx includes atelectasis.\n .\n Assessment and Plan\n Ms. is a 54 yo female with ESRD on HD, HTN, DM, OSA, COPD,\n obesity, PVD admitted for hypotension at dialysis and somnolence.\n .\n 1. Hypotension. Patient noted to be hypotensive at dialysis with\n ongoing blood pressure readings with systolics of 90s though patient is\n entirely asymptomatic. As outpatient, patient is noted to have SBPs of\n 130s and 140s. Most likely dehydration versus med effect secondary to\n over-sedation with narcotics. Patient has already received 2L IVF and\n is on HD, so will avoid further fluid boluses unless SBP in 80s or\n symptomatic. Accurate blood pressures are difficult to attain given\n patients obesity. No evidence to suggest sepsis in spite of concern\n for pneumonia in ED; patient denies symptoms of pneumonia, is afebrile\n and does not have a wbc. Also with normal lactate. No evidence of\n blood loss or EKG changes.\n - monitor BP\n - IVF boluses for SBPs in 80s\n - hold antihypertesnives and narcotics\n - no need for narcan at present\n .\n 2. Altered mental status. Patient reportedly somnolent in the ED,\n though per daughter, patient is at her baseline at present, though has\n slept more frequently during the day than normal. be secondary to\n OSA (and lack of consistent BIPAP use), depression (patient tearful on\n exam), or overmedication with opiods. Head CT in ED unchagned. Patient\n noted to have PCO2 of 51 which is increased from the past.\n - obtain records for rehab re: home med list and ?uptitration of\n medications recently\n - remove both fentanyl patches\n - monitor mental status.\n - BIPAP at night\n - hold all psych meds\n .\n 3. Diabetes. Continue standing humalog and HISS.\n - follow fingersticks\n - diabetic/renal diet\n .\n 4. OSA. Patient noted to have elevated CO2 on admission. This may\n have contributed to patient's somnolence in ED. Patient reports she ws\n not using bipap every night.\n - BIPAP at night\n .\n 5. Hyperkalemia. No evidence of EKG changes. Will likely get\n dialysis tomorrow as she missed today's session.\n - kayexelate x 1\n - follow K\n - dialysis\n .\n 6. CAD. Unclear why patient is on plavix; patient does not report\n history of stent placement.\n - continue aspirin, statin, plavix\n .\n 7. ESRD on HD.\n - continue phos binders, nephrocaps\n - dialysis MWF\n .\n PPI, HSQ\n Diabetic/Renal diet\n FULL CODE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:00 PM\n 20 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2192-08-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342645, "text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 11:00 PM\n History obtained from Patient\n Allergies:\n History obtained from PatientLisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 74 (60 - 74) bpm\n BP: 112/22(46) {68/16(26) - 114/53(59)} mmHg\n RR: 14 (7 - 14) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 15 mL\n 180 mL\n PO:\n 100 mL\n TF:\n IVF:\n 15 mL\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 110 K/uL\n 10.0 g/dL\n 110 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 5.7 mEq/L\n 45 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.0 %\n 5.8 K/uL\n [image002.jpg]\n 02:45 AM\n WBC\n 5.8\n Hct\n 33.0\n Plt\n 110\n Cr\n 7.9\n TropT\n 0.84\n Glucose\n 110\n Other labs: PT / PTT / INR:18.2/37.6/1.7, CK / CKMB /\n Troponin-T:55//0.84, ALT / AST:37/37, Alk Phos / T Bili:160/0.3,\n Amylase / Lipase:22/12, Albumin:4.0 g/dL, LDH:233 IU/L, Ca++:9.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:6.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:00 PM\n 20 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2192-08-16 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 342652, "text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 54 y/o F w/ESRD on HD, severe PVD, admitted with hypotension noted at\n dialysis.\n 24 Hour Events:\n DIALYSIS CATHETER - START 11:00 PM\n Admitted to the MICU last night.\n Daughter visited her last night and felt like her mental status was at\n her baseline.\n Allergies:\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:35 AM\n Other medications:\n lanthanum, cinacelcet, renagel, reglan, colace, simvastatin,\n nephrocaps, plavix, aspirin, insulin sliding scale\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.5\nC (97.7\n HR: 63 (60 - 74) bpm\n BP: 114/20(45) {68/16(26) - 114/53(65)} mmHg\n RR: 8 (7 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 15 mL\n 192 mL\n PO:\n 100 mL\n TF:\n IVF:\n 15 mL\n 92 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n 192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n SEM at LLSB\n Peripheral 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, Obese\n Extremities: Right: 2+, Left: Absent, s/p left BKA\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 110 K/uL\n 110 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 5.7 mEq/L\n 45 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.0 %\n 5.8 K/uL\n [image002.jpg]\n 02:45 AM\n WBC\n 5.8\n Hct\n 33.0\n Plt\n 110\n Cr\n 7.9\n TropT\n 0.84\n Glucose\n 110\n Other labs: PT / PTT / INR:18.2/37.6/1.7, CK / CKMB /\n Troponin-T:55//0.84, ALT / AST:37/37, Alk Phos / T Bili:160/0.3,\n Amylase / Lipase:22/12, Albumin:4.0 g/dL, LDH:233 IU/L, Ca++:9.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:6.0 mg/dL\n Imaging: CXR: small bilateral pleural effusions, enlarged R heart.\n Microbiology: Blood cx pending\n Assessment and Plan\n 54 yo female with history of ESRD on HD, presenting with hypotension,\n now resolving.\n 1)Hypotension-Most likely due to vasodilation from narcotics (had 2\n fentanyl patches on). Now improved overnight, mental status at\n baseline.\n -will f/u blood cx, but no signs/symptoms of sepsis so will hold on\n empiric antibiotics\n 2)Respiratory Failure- Now doing well, on nasal cannula (2-4L at\n home). Was on bipap overnight per her home regimen.\n 3)Chronic Renal Failure- HD today as did not receive full session\n yesterday.\n 4)Altered Mental Status- Now resolved, back to baseline. Likely due to\n narcotics.\n - hold narcotics; if continued pain will start low-dose fentanyl patch\n - restart home psych meds\n -tylenol prn pain (which she takes at home)\n -discuss her outpt pain regimen with providers at rehab\n 5) PVD: Cont aspirin, plavix.\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Blood sugar well controlled, Comments: home humalog\n regimen\n Lines:\n Dialysis Catheter - 11:00 PM\n 20 Gauge - 11:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2192-08-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 342657, "text": "Chief Complaint:\n 24 Hour Events:\n Patient\ns blood pressure readings were difficult to obtain but ranging\n from 70s to 110s overnight. She did not receive any fluid boluses as\n she was entirely asymptomatic.\n Mental status is at baseline per daughter.\n She was on cpap overnight.\n History obtained from Patient\n Allergies:\n History obtained from PatientLisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 74 (60 - 74) bpm\n BP: 112/22(46) {68/16(26) - 114/53(59)} mmHg\n RR: 14 (7 - 14) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 15 mL\n 180 mL\n PO:\n 100 mL\n TF:\n IVF:\n 15 mL\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Gen: well appearing, obese African American female, NAD\n HEENT: PERRL, o/p clear\n CV: RRR, soft systolic murmur at LUSB\n Pulm: clear anteriorly, dimished breath sounds, poor inspiratory effort\n Abd: soft, NT, ND, bowel sounds present\n Ext: pitting edema of right LE, left AKA\n Labs / Radiology\n 110 K/uL\n 10.0 g/dL\n 110 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 5.7 mEq/L\n 45 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.0 %\n 5.8 K/uL\n [image002.jpg]\n 02:45 AM\n WBC\n 5.8\n Hct\n 33.0\n Plt\n 110\n Cr\n 7.9\n TropT\n 0.84\n Glucose\n 110\n Other labs: PT / PTT / INR:18.2/37.6/1.7, CK / CKMB /\n Troponin-T:55//0.84, ALT / AST:37/37, Alk Phos / T Bili:160/0.3,\n Amylase / Lipase:22/12, Albumin:4.0 g/dL, LDH:233 IU/L, Ca++:9.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:6.0 mg/dL\n Assessment and Plan\n A/P: Ms. is a 54 yo female with ESRD on HD, HTN, DM, OSA,\n COPD, obesity, PVD admitted for hypotension at dialysis and somnolence\n secondary to dehydration versus over-medication with fentanyl.\n .\n 1. Hypotension. Patient noted to be hypotensive at dialysis with\n ongoing blood pressure readings with systolics of 90s though patient is\n entirely asymptomatic. This represents departure from patients\n outpatient blood pressures of SBPs of 130s and 140s. Most likely\n dehydration versus med effect secondary to over-sedation with narcotics\n (found to have two fentanyl patches on body). Patient has already\n received 2L IVF and is on HD, so will avoid further fluid boluses\n unless SBP in 80s or symptomatic. Accurate blood pressures are\n difficult to attain given patients obesity. No evidence to suggest\n sepsis in spite of concern for pneumonia in ED; patient denies symptoms\n of pneumonia, is afebrile and does not have a wbc. Also with normal\n lactate. No evidence of blood loss or EKG changes.\n - monitor BP\n - IVF boluses for SBPs in 80s or symptoms\n - hold antihypertensives and narcotics, but consider resuming home\n lopressor 12.5 if her blood pressure tolerates it)\n .\n 2. Altered mental status. Patient reportedly somnolent in the ED,\n though per daughter, patient is at her baseline at present, though has\n slept more frequently during the day than normal. be secondary to\n OSA (and lack of consistent BIPAP use), depression (patient tearful on\n exam), or overmedication with opiods. Head CT in ED unchagned. Patient\n noted to have PCO2 of 51 which is increased from the past. Patient was\n on fentanyol patch 75 q 72 hour, ultram 50 mg , prn percocet, prn\n neurontin.\n - off all opiods; start standing Tylenol\n - monitor mental status.\n - BIPAP at night\n - hold all psych meds (was on seroquel 12.5 prn, neurontin prn)\n .\n 3. Diabetes. Continue standing humalog and HISS.\n - follow fingersticks\n - diabetic/renal diet\n .\n 4. OSA. Patient noted to have elevated CO2 on admission. This may\n have contributed to patient's somnolence in ED. Patient reports she ws\n not using bipap every night.\n - CPAP of 12 at night\n .\n 5. Hyperkalemia. No evidence of EKG changes. Will likely get\n dialysis tomorrow as she missed today's session.\n - kayexelate x 1\n - follow K\n - dialysis\n .\n 6. CAD.\n - continue aspirin, statin\n .\n 7. ESRD on HD.\n - continue phos binders, nephrocaps, sensipar, zemplar\n - dialysis MWF\n .\n PPI, HSQ\n Diabetic/Renal diet\n FULL CODE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:00 PM\n 20 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: not needed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor if needed\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342570, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM &\n OSAon home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis. 1.5 L fluid given at rehab before transferring to .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2192-08-16 00:00:00.000", "description": "Respiratory Care Note", "row_id": 342718, "text": "TITLE: Resp. Care note:\n Patient has been on Nasal O2 at 2Liters all shift, appears comfortable\n Maintaining good oxygen saturations, and comfortable breathing pattern.\n Plan to wear Cpap at night.\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 342777, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management. Pt had Hd today() and about 1L removed pt\n tolerated the Hd well,no hypotension noted.afebrile currently,cx result\n pending,rpt blood cx sent from the HD line.\n ROS:neuro;AO x2,pleasant,able to make needs known>resp:Ls diminished at\n base,on 2l satting 98-100%,uses BIPAP at night,no cough/sobCVS:normal\n sinus, sbp 100-140,dbp runs lower side.GI:abd obese ,BS+,inc of\n stool,loose bm after keyxalate,Gu;anuric on HD,Skin:warm dry,satge 2\n buttock,left above knee amputation with open area on the stump.\n Iv access:rt arm piv(20g).\n Precautions:contact(mrsa/vre).\n Allergies:lisinopril\n Code satus: full code.\n Hypotension (not Shock)\n Assessment:\n Known hypotensive during,hd sbp 90-140,dbp 20-55\n Action:\n No fluid bolus required in this shift,BP rotated in rt brachial as well\n left radial\n Response:\n Sbp 100-140,map>60,pt tolerated the HD,at times dbp noted <40,mental\n status clear.\n Plan:\n Follow blood pressure\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Known esrd,on hemodialysis,K levl 5.7\n Action:\n Pt has HD today,received 30gm keyxalate today\n Response:\n 1L removed.\n Plan:\n Cont current HD schedule,follow labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaints pain in rt arm rt leg and abdomen\n Action:\n On standing Tylenol,pt received maalox for abd pain,repositioned Q2H\n Response:\n Abd cramps better after Maalox ,over all better pain control\n Plan:\n Follow pain level,narcotics are deferred due to mental status changes\n Impaired Skin Integrity\n Assessment:\n Stage 2 ulcer on the buttock,open area on the left above knee\n stump,with out any drainage\n Action:\n Alleveyn applied to the buttock stage 2,respositioned q2h.left above\n OTA.\n Response:\n Dsg clean dry and intact,no s/s of infection\n Plan:\n Will cont to monitor,change dsg prn.\n ------ Protected Section ------\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 117 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Cough;\n Precautions:\n PMH: COPD, Diabetes - Insulin, HEMO or PD, Renal Failure\n CV-PMH: Hypertension, PVD\n Additional history: PVD s/p L SFA- DP bypass for L gangrenous heel in\n , s/p r proximal AT bypass in , s/p multiple debridements of\n b/l LE for infected/ non-healing wounds, S/p L BKA , L AKA for\n non-healing BKA ulcer ( prior MRSA, VRE, MDR klebsiella) ,L AKA\n stump osteomyelitis requiring admission in , on IV antibiotics,\n VAC dressing in place. ESRD on HD ( MWF schedule), renal cell carcinoma\n s/p rt nephrectomy, obesity, depression, S/p CCY, Gastric ulcer, OSA (\n uses BIPAP at night), gastroparesis, COPD on L NC baseline, H/O\n ischemic colitis, Left adrenal adenoma.\n Surgery / Procedure and date: PVDs/p L SFA -DP bypass for L gangrenous\n heel in , s/p R proximal AT bypassin , s/p multiple\n debridements of b/l LE for infected non-healing wounds, s/p L BKA ,\n L AKA for non-healing BKA ulcer , s/p CCY.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:24\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,371 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:45 AM\n Potassium:\n 5.7 mEq/L\n 02:45 AM\n Chloride:\n 106 mEq/L\n 02:45 AM\n CO2:\n 23 mEq/L\n 02:45 AM\n BUN:\n 45 mg/dL\n 02:45 AM\n Creatinine:\n 7.9 mg/dL\n 02:45 AM\n Glucose:\n 110 mg/dL\n 02:45 AM\n Hematocrit:\n 33.0 %\n 02:45 AM\n Finger Stick Glucose:\n 155\n 06:00 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: micu7\n Transferred to: cc717\n Date & time of Transfer: \n ------ Protected Section Addendum Entered By: , RN\n on: 22:09 ------\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342598, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Patient uses BIPAP at night. Denies any short of breath. On nasal\n cannula 2 L upon arrival to ICU. CXR shows Rt middle lung PNA.\n Action:\n BIPAP since 2300 hrs. Am CXR done.\n Response:\n Satting at high 90\ns on BIPAP/ 2 L nasal cannula.\n Plan:\n Decrease narcotic dosing. Move to RA in AM.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient on hemodialysis. Hypotensive episode during dialysis at\n OSH. HD cath in place.\n Action:\n Possible HD today.\n Response:\n Awaiting Lab results.\n Plan:\n HD today if BP stabilized., Goal to keep fluid balance at that time.\n F/U with renal.\n Impaired Skin Integrity\n Assessment:\n H/O obesity. Several skinbreakdown noted at coccyx, back, left leg AKA\n site, gluteal skin folds & axillary skin folds. Incontinent of stool.\n Patient Anuric.\n Action:\n Allevyn dressing in place @ back. Diaper in place.\n Response:\n No improvement noted.\n Plan:\n Need antifungal powder for excoriated skin . Q 2 hourly repositioning.\n Hypotension (not Shock)\n Assessment:\n SBP ranges from 80-100\ns. SBP Drops while sleeping. DBP low 13-34 mm\n of hg. Resident notified. Edema noted.\n Action:\n 1 L fluid bolus given @ ED. No fluid bolus required.. Utilizing\n multiple sites ( rt brachial, left radial) for BP checks.\n Response:\n Stimulation would increase her SBP from 70\ns to 90\n Plan:\n F/U with blood culture. Urine culture to be send if possible. (\n patient Anuric).\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342599, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Patient uses BIPAP at night. Denies any short of breath. On nasal\n cannula 2 L upon arrival to ICU. CXR shows Rt middle lung PNA.\n Action:\n BIPAP since 2300 hrs. Am CXR done.\n Response:\n Satting at high 90\ns on BIPAP/ 2 L nasal cannula.\n Plan:\n Decrease narcotic dosing. Move to RA in AM.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient on hemodialysis. Hypotensive episode during dialysis at\n OSH. HD cath in place.\n Action:\n Possible HD today.\n Response:\n Awaiting Lab results.\n Plan:\n HD today if BP stabilized., Goal to keep fluid balance at that time.\n F/U with renal.\n Impaired Skin Integrity\n Assessment:\n H/O obesity. Several skinbreakdown noted at coccyx, back, left leg AKA\n site, gluteal skin folds & axillary skin folds. Incontinent of stool.\n Patient Anuric.\n Action:\n Allevyn dressing in place @ back. Diaper in place.\n Response:\n No improvement noted.\n Plan:\n Need antifungal powder for excoriated skin . Q 2 hourly repositioning.\n Hypotension (not Shock)\n Assessment:\n SBP ranges from 80-100\ns. SBP Drops while sleeping. DBP low 13-34 mm\n of hg. Resident notified. Edema noted.\n Action:\n 1 L fluid bolus given @ ED. No fluid bolus required.. Utilizing\n multiple sites ( rt brachial, left radial) for BP checks.\n Response:\n Stimulation would increase her SBP from 70\ns to 90\n Plan:\n F/U with blood culture. Urine culture to be send if possible. (\n patient Anuric).\n" }, { "category": "Physician ", "chartdate": "2192-08-16 00:00:00.000", "description": "ICU Fellow Progress Note - MICU attending addendum", "row_id": 342686, "text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 54 y/o F w/ESRD on HD, severe PVD, admitted with hypotension noted at\n dialysis.\n 24 Hour Events:\n DIALYSIS CATHETER - START 11:00 PM\n Admitted to the MICU last night.\n Daughter visited her last night and felt like her mental status was at\n her baseline.\n Allergies:\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:35 AM\n Other medications:\n lanthanum, cinacelcet, renagel, reglan, colace, simvastatin,\n nephrocaps, plavix, aspirin, insulin sliding scale\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.5\nC (97.7\n HR: 63 (60 - 74) bpm\n BP: 114/20(45) {68/16(26) - 114/53(65)} mmHg\n RR: 8 (7 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 15 mL\n 192 mL\n PO:\n 100 mL\n TF:\n IVF:\n 15 mL\n 92 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n 192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n SEM at LLSB\n Peripheral 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, Obese\n Extremities: Right: 2+, Left: Absent, s/p left BKA\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 110 K/uL\n 110 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 5.7 mEq/L\n 45 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.0 %\n 5.8 K/uL\n [image002.jpg]\n 02:45 AM\n WBC\n 5.8\n Hct\n 33.0\n Plt\n 110\n Cr\n 7.9\n TropT\n 0.84\n Glucose\n 110\n Other labs: PT / PTT / INR:18.2/37.6/1.7, CK / CKMB /\n Troponin-T:55//0.84, ALT / AST:37/37, Alk Phos / T Bili:160/0.3,\n Amylase / Lipase:22/12, Albumin:4.0 g/dL, LDH:233 IU/L, Ca++:9.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:6.0 mg/dL\n Imaging: CXR: small bilateral pleural effusions, enlarged R heart.\n Microbiology: Blood cx pending\n Assessment and Plan\n 54 yo female with history of ESRD on HD, presenting with hypotension,\n now resolving.\n 1)Hypotension-Most likely due to vasodilation from narcotics (had 2\n fentanyl patches on). Now improved overnight, mental status at\n baseline.\n -will f/u blood cx, but no signs/symptoms of sepsis so will hold on\n empiric antibiotics\n 2)Respiratory Failure- Now doing well, on nasal cannula (2-4L at\n home). Was on bipap overnight per her home regimen.\n 3)Chronic Renal Failure- HD today as did not receive full session\n yesterday.\n 4)Altered Mental Status- Now resolved, back to baseline. Likely due to\n narcotics.\n - hold narcotics; if continued pain will start low-dose fentanyl patch\n - restart home psych meds\n -tylenol prn pain (which she takes at home)\n -discuss her outpt pain regimen with providers at rehab\n 5) PVD: Cont aspirin, plavix.\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Blood sugar well controlled, Comments: home humalog\n regimen\n Lines:\n Dialysis Catheter - 11:00 PM\n 20 Gauge - 11:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n ------ Protected Section ------\n MICU attending addendum\n I saw and examined the patient and was physically present with the\n ICU fellow and residents for key portions of the service provided. I\n agree with the above note including the assessment and plan.\n Alert and appropriate. Hypotension resolved.\n EXAM notable for AF BP 144/36 HR 65 RR 2-14 O2 sat 98-100% 2 L NC\n (BiPAP at night) (+ 175 cc)\n Obese F alert in NAD, decreased BS b/b, clear ant, RR with sys m, obese\n abd NT soft, R le warm, trace edema\n Labs with wbc 5.8 bun 45 serum co2 23\n bl cx's pending\n CXR underpenetrated, R tunnel line, small lung volumes but improved c/t\n yesterday, chronic eff, lcardiomegaly\n 54 yo obese F with esrd on hd, known OSA with intermittent BiPAP\n compliance, and chronic pain and increased narcotics dosing at rehab\n presents with hypotension and increased somnolence, and hypercarbia.\n Hypotension appears multifactorial possibly from dehydration and\n increased narcotics dosing and has now resolved. AMS also likely from\n med effect and hypercarbia. No evidence of infectious source--AF,\n asymptomatic, nl WBC and no obvious infiltrate on CXR. BP is difficult\n to assess though improved with IVF. Will continue to follow parameters\n such as mental status which appears at baseline.\n Agree with plan to hold on antibx and f/u cx's. BiPAP at night, HD\n today pre renal. Should have reassessment of pain regimen--perhaps\n standing tylenol and single fent patch. Comfortable at present without\n pain complaints.\n Remainder as per resident and fellow note.\n Continue in ICU pending HD. As long as BP remains stable post HD\n appears stable for floor transfer\n Time spent 45\n ------ Protected Section Addendum Entered By: , MD\n on: 01:57 PM ------\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 342744, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management.\n Events;pt had HD today,tolerated well,blood cx x1 sent from the HD\n line.plan to call out today\n Hypotension (not Shock)\n Assessment:\n Known hypotensive during,hd sbp 90-140,dbp 20-55\n Action:\n No fluid bolus required in this shift,BP roatated in rt brachial as\n well left radial\n Response:\n Sbp 100-140,map>60,pt tolerated the HD,at times dbp noted <40,mental\n status clear.\n Plan:\n Follow blood pressure\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Known esrd,on hemodialysis,K levl 5.7\n Action:\n Pt has HDtoday,received 30gm keyxalate today\n Response:\n 1L removed.\n Plan:\n Cont current HD schedule,follow labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaints pain in rt arm rt leg and abdomen\n Action:\n On standing Tylenol,pt received maaox for abd pain,repositioned Q2H\n Response:\n Abd cramps better after Maalox ,over all better pain control\n Plan:\n Follow pain level,narcotics are deferred due to mental status changes\n Impaired Skin Integrity\n Assessment:\n Stage 2 ulcer on the buttock,open area on the left above knee\n stump,with out any drainage\n Action:\n Alleveyn applied to the buttock stage 2,respositioned q2h.left above\n OTA.\n Response:\n Dsg clean dry and intact,no s/s of infection\n Plan:\n Will cont to monitor,change dsg prn.\n" }, { "category": "Nursing", "chartdate": "2192-08-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 342748, "text": "This 54 Y/O F with history of multiple medical problems including PVD,\n s/p bypass procedures bilaterally & left AKA with likely left stump\n osteomyelitis, end stage renal disease on hemodialysis( MWF), DM & OSA\n on home oxygen & BIPAP during night transferred from rehab ( Hospital) with hypotension & altered mental status prior to\n dialysis on . 1.5 L fluid given at rehab before transferring to\n .\n In ED patient was alert, O x3 but sleepy. found to have 2 fentanyl\n patches on upon arrival. CXR done : Rt mid lung PNA. 12 lead EKG shows\n RBBB. head Ct w/o contrast done, nothing remarkable. 1 L IVF given in\n ED for hypotension. SBP up from 70 's to 140's after fluid bolus.\n Blood culture sent. Levo , vanco IV given in ED.Tranx to MICU-07 for\n furthur management. Pt had Hd today() and about 1L removed pt\n tolerated the Hd well,no hypotension noted.afebrile currently,cx result\n pending,rpt blood cx sent from the HD line.\n ROS:neuro;AO x2,pleasant,able to make needs known>resp:Ls diminished at\n base,on 2l satting 98-100%,uses BIPAP at night,no cough/sobCVS:normal\n sinus, sbp 100-140,dbp runs lower side.GI:abd obese ,BS+,inc of\n stool,loose bm after keyxalate,Gu;anuric on HD,Skin:warm dry,satge 2\n buttock,left above knee amputation with open area on the stump.\n Iv access:rt arm piv(20g).\n Precautions:contact(mrsa/vre).\n Allergies:lisinopril\n Code satus: full code.\n Hypotension (not Shock)\n Assessment:\n Known hypotensive during,hd sbp 90-140,dbp 20-55\n Action:\n No fluid bolus required in this shift,BP rotated in rt brachial as well\n left radial\n Response:\n Sbp 100-140,map>60,pt tolerated the HD,at times dbp noted <40,mental\n status clear.\n Plan:\n Follow blood pressure\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Known esrd,on hemodialysis,K levl 5.7\n Action:\n Pt has HD today,received 30gm keyxalate today\n Response:\n 1L removed.\n Plan:\n Cont current HD schedule,follow labs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaints pain in rt arm rt leg and abdomen\n Action:\n On standing Tylenol,pt received maalox for abd pain,repositioned Q2H\n Response:\n Abd cramps better after Maalox ,over all better pain control\n Plan:\n Follow pain level,narcotics are deferred due to mental status changes\n Impaired Skin Integrity\n Assessment:\n Stage 2 ulcer on the buttock,open area on the left above knee\n stump,with out any drainage\n Action:\n Alleveyn applied to the buttock stage 2,respositioned q2h.left above\n OTA.\n Response:\n Dsg clean dry and intact,no s/s of infection\n Plan:\n Will cont to monitor,change dsg prn.\n" }, { "category": "ECG", "chartdate": "2192-08-16 00:00:00.000", "description": "Report", "row_id": 281038, "text": "Sinus rhythm. Right bundle-branch block. Since the previous tracing\nof no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-08-15 00:00:00.000", "description": "Report", "row_id": 281039, "text": "Sinus rhythm. Right bundle-branch block. Since the previous tracing\nof no change.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-06-12 00:00:00.000", "description": "UGI SGL CONTRAST W/ KUB", "row_id": 873354, "text": " 3:42 PM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: s/p lap gastric bypass r/o leak\n Admitting Diagnosis: MORBID OBESITY/GALLSTONES/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post laparoscopic gastric bypass, evaluate for anastomotic\n leak.\n\n COMPARISON: None.\n\n UPPER GI STUDY: Water-soluble contrast and thin barium were administered\n under direct fluoroscopic imaging. Contrast passes freely through the distal\n esophagus into the stomach remnant. Contrast passed freely through the\n remnant and through the gastrojejunostomy without any holdup. No contrast\n extravasation identified at the anastomotic site.\n\n IMPRESSION: No anastomotic leak identified.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-06-12 00:00:00.000", "description": "Report", "row_id": 1392125, "text": "SICU NPN\nS-\"They(MDs) told me I wouldn't have any pain afterwards.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-A/O/X/3. Pleasant and cooperative with care. Received c/o of severe pain. Previously bolused with Methadone at 1730 upon arrival. Given additional Methadone bolus, in addtion to PRN Dilaudid and Ativan overnight with some improvement in pain. Needing constant re-inforcement of use of PCA and pain management. Hemodynamically stable. Instructed to CDB. Cough pillow given. Maintenance continues at 200cc/hr(LR). HUO adequate. Abd soft with absent bowels sounds. NGT to LCS. JP with s/s drainage in moderate amounts. Afebrile. No issues.\n\nA/P:POD#1 s/p gastic bypass\nContinue to instruct on PCA uses on pain management\nOOB to chair\nTransfer out to floor today\n" }, { "category": "Nursing/other", "chartdate": "2164-06-12 00:00:00.000", "description": "Report", "row_id": 1392126, "text": "Nursing NOte 7a-7p:\nNursing Assessment:\n\nPt is alert and orientated x 3. Complained of pain this morning and medicated with dilaudid and given ativan for anxiety with good effect. PT remains on methadone pca. To Fluoro twice d/t first time fluoro afraid to get pt oob d/t increased sedation. Pt returned to floor and presented lethargic but easily awakened and good strength. PT rescheduled for fluoro and all pain meds held, off pca. Back down with surgery intern and was able to get oob to wheelchair with assist and stood for study. To begin on bariatric stage one after a one time 30cc drink with dye. Will monitor jp output. Pt is cooperative with care but needs alot of emotional support in pain control. NC 3 Liters per minute continues and pt has weak productive cough. Sitting up in bed and dozing intermittently. Still awaiting a floor bed.\nPlease refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2164-06-14 00:00:00.000", "description": "Report", "row_id": 1392127, "text": "Nursing Note--B Shift\nPlease see Carevue for complete assessment and specifics.\n\nGI: Abd large soft +BS. Tol 30cc of H2o/hour. JP intact draining moderate amts of serosang drainage. Abd dressings intact with no drainage.\n\nPAIN MGMT: Dilaudid PCA d/c'd at 2115. ROXICET 10ml q4hrs with good relief.\n\nGU: Voiding qs clear yellow urine on bedpan.\n\nNEURO: Intact.\n\nRESP: LS clear and diminished. Sat 93-98% 2L. Productive cough, thin whitish secretions.\n\nCARDIAC: Afebrile. HR 50-60's. SR SBP 120-150. +PP Pboots on.\n\nINTEG: Abd dressing CDI. JP site CDI.\n\nPLAN: D/C to floor pending bed availability.\n" }, { "category": "Nursing/other", "chartdate": "2164-06-11 00:00:00.000", "description": "Report", "row_id": 1392124, "text": "Admit note\nPatient arrived from @1815 a little lethargic but reporting improvement with pain control. Vital signs all stable, A/Ox3. Pt using methadone pca frequently and dozing intermittently. No issues at this time. See carevue flowsheet for specifics.\nPLAN:\n Closely monitor resp status d/t lge amt of narcotics given in PACU\n Encourage IS\n Keep pt NPO\n Notify H.O. with any changes\n" } ]

[ { "category": "Radiology", "chartdate": "2132-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230988, "text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: RIJ CVL and ETT placement\n Admitting Diagnosis: AMPULLARY MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p Whipple\n REASON FOR THIS EXAMINATION:\n RIJ CVL and ETT placement\n ______________________________________________________________________________\n WET READ: PBec WED 11:20 PM\n R IJ central venous catheter in mid SVC. No pneumothorax idntified. NGT ith\n tip instomach. no ETT identified. Minmal pulmonary edema. unchanged\n mediastinal and cardiac contours. no plerual effusion surgical clips in upper\n abdomen. pbishop\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax or large\n pleural effusions. NG tube tip is seen in the stomach. There is mild\n cardiomegaly. There is mild pulmonary edema. Patient has known emphysema.\n\n\n" }, { "category": "ECG", "chartdate": "2132-03-31 00:00:00.000", "description": "Report", "row_id": 223264, "text": "Sinus bradycardia. Prolonged Q-T interval. Compared to the previous tracing\nof the heart rate has decreased.\n\n" } ]

[ { "category": "ECG", "chartdate": "2121-07-12 00:00:00.000", "description": "Report", "row_id": 258944, "text": "Sinus rhythm. Downsloping ST segment depression and T wave inversion in\nleads I and aVL with diffuse ST-T wave flattening. Compared to the previous\ntracing of the ST-T wave abnormalities are more prominent in\nleads I and aVL, while the rate has decreased, suggesting evolution of a\nlateral ischemic process. Followup and clinical correlation are suggested.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2164-10-26 00:00:00.000", "description": "Intensivist Note", "row_id": 703593, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n BRBPR\n PMHx:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Internal\n Jugular Order date: @ 1703\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1703\n 2. IV access: Temporary central access (ICU) Location: Right Subclavian\n Order date: @ 1703\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain\n hold for sedation Order date: @ 1221\n 3. IV access: Temporary central access (ICU) Location: Left Femoral\n Order date: @ 1703\n 13. Fluconazole 200 mg IV Q24H Order date: @ 1703\n 4. 1000 mL LR\n Continuous at 0 ml/hr for 0 ml\n please give 1/2 cc / cc JP output repletion Order date: @ 0945\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 5. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1320\n 15. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 1703\n 6. 500 mL NS Bolus 500 ml Over 20 mins Order date: @ 1851\n 16. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 1703\n 7. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 0416\n 17. 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: @ 1703\n 8. Albumin 25% (12.5g / 50mL) 25 g IV ONCE Duration: 1 Doses Order\n date: @ 1851\n 18. Sodium Bicarbonate 50 mEq IV PRN ascitic loss\n for each 3 liters of ascitic ouput, please replace with 1 amp bicarb\n Order date: @ 0802\n 9. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758\n 19. Vancomycin 1000 mg IV Q 24H Order date: @ 1448\n 10. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 24 Hour Events:\n Continued on minimal vent settings. Continued high JP output.\n Intermittent fluid boluses throughout day with LR as needed for BP /\n UOP; JP repletion changed from NS to LR. Tube feeds increased to\n 40mL/hr. Octreotide d/c'd.\n Post operative day:\n POD#9 - ex lap duod ulcer repair\n POD#6 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Fluconazole - 10:01 PM\n Piperacillin/Tazobactam (Zosyn) - 03:59 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 12:30 AM\n Sodium Bicarbonate 8.4% (Amp) - 01:06 AM\n Other medications:\n Flowsheet Data as of 06:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.4\nC (97.5\n HR: 108 (98 - 125) bpm\n BP: 99/57(69) {89/46(58) - 148/77(98)} mmHg\n RR: 18 (12 - 22) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.9 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 10 (8 - 21) mmHg\n Total In:\n 10,015 mL\n 3,726 mL\n PO:\n Tube feeding:\n 760 mL\n 260 mL\n IV Fluid:\n 7,186 mL\n 2,771 mL\n Blood products:\n 450 mL\n 200 mL\n Total out:\n 11,673 mL\n 4,838 mL\n Urine:\n 638 mL\n 238 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n 700 mL\n Drains:\n 9,635 mL\n 4,500 mL\n Balance:\n -1,658 mL\n -1,112 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 580 (562 - 869) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: 7.44/32/110/22/0\n Ve: 16.8 L/min\n PaO2 / FiO2: 220\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 65 K/uL\n 11.7 g/dL\n 158 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 72 mg/dL\n 115 mEq/L\n 143 mEq/L\n 35.2 %\n 16.6 K/uL\n [image002.jpg]\n 02:13 PM\n 08:11 PM\n 02:05 AM\n 02:24 AM\n 10:27 AM\n 04:26 PM\n 02:32 AM\n 02:37 AM\n 02:17 AM\n 02:28 AM\n WBC\n 13.4\n 12.9\n 14.7\n 16.6\n Hct\n 33.8\n 34.6\n 35.0\n 35.2\n Plt\n 74\n 69\n 59\n 65\n Creatinine\n 1.8\n 1.7\n 1.7\n TCO2\n 19\n 18\n 16\n 17\n 19\n 22\n Glucose\n 154\n 122\n 126\n 143\n 158\n Other labs: PT / PTT / INR:21.8/72.1/2.0, ALT / AST:, Alk-Phos / T\n bili:60/7.2, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:143 IU/L, Ca:7.9 mg/dL, Mg:1.9\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan:\n Neurologic: Intubated s/p PPF gtt. Beginning to be more awake, moving\n extremeties to command.\n Cardiovascular: stable; follow\n Pulmonary: Intubated, CPAP 5/5. Daily ABG.\n Gastrointestinal / Abdomen: NPO, protonix drip, TPN, TF nepro \n strength advancing slowly, now at 40mL/hr.\n Nutrition: TF at 40mL/hr\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with LR. Albumin 12.5g per 1L ascites, also giving HCO3 for\n every 3L ascites. Hx of hepatorenal syndrome.\n Hematology: Hct stable type and crossed for 4 units\n Endocrine: RISS\n Infectious Disease: vanc / zosyn / fluc; f/u cx\n Lines / Tubes / Drains: ETT, foley, s/p L IJ triple lumen, R SC trauma\n line ( PIV x1, JP x2, NGT, J-tube\n Wounds: abdominal wound closed, clean / dry / intact\n Imaging: none\n Fluids: Replacing ascites drain output 0.5 to 1 with LR. Albumin 12.5g\n per 1L ascites, also giving HCO3 for every 3L ascites.\n Consults: transplant surgery\n Billing Diagnosis: UGIB s/p ex lap, gastrotomy, duodenotomy w/suturing\n of bleeding vessel, draining jejunostomy\n ICU Care\n Nutrition:\n NovaSource Renal () - 10:18 PM 40 mL/hour\n TPN without Lipids - 11:21 PM 66. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 701847, "text": "Chief Complaint: Bright red blood per rectum\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 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr.\n He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was recently hospitalized at from to for UGIB due\n to duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\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 Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Past medical history:\n Family history:\n Social History:\n - EtOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n - duodenal ulcer\n - internal hemorrhoids\n - s/p bilateral knee replacements\n Father had cirrhosis EtOH.\n Occupation: Disabled\n Drugs: Denies any h/o IVDU.\n Tobacco: Non-smoker.\n Alcohol: Drank -1 pint of vodka a day for years until he quit on\n .\n Other:\n Review of systems:\n Constitutional: 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)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Flowsheet Data as of 06:20 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: 95 (95 - 98) bpm\n BP: 107/63(73) {107/63(73) - 107/65(76)} mmHg\n RR: 23 (17 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n Total out:\n 0 mL\n 140 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -132 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 134\n 25.5\n 8.5\n 111\n 1.0\n 33\n 10\n 120\n 5.2\n 138\n 15.0\n [image002.jpg]\n Other labs:\n PT / PTT / INR:22 / 54 / 2.0,\n ALT / AST:18 / 34, Alk Phos / T Bili:102 / 4.6,\n Amylase / Lipase:/ 71, Albumin:1.4\n Fluid analysis / Other labs: Last paracentesis from was not\n consistent with SBP (WBC 155.)\n Imaging: No imaging this hospitalization.\n Microbiology: No cultures results since late .\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n GI performed endoscopy on arrival to the MICU and there was no clear\n source of brisk bleeding. There was an area of possible prior bleeding\n at the ampula, a possible non-bleeding ucler. A small bowel or lower\n intestinal source of his bleeding on presentation is certainly possible\n and further evaluation (push-enteroscopy +/- c-scope) will be\n considered going forward. For the time being, if indeed this was an\n upper GI bleed that has spontaneously resolved, we will continue\n Protonix IV and Octreotide as per UGIB protocol. He should receive\n Ceftriaxone for a 7 day course. Will follow his Hcts serially and, more\n importantly, his HR and BP in the acute setting for any clinical e/o\n brisk bleeding. He has two 20g IVs and an 18g IV. We will place a\n central line for frequent blood draws and resuscitation should he\n require it.\n END STAGE LIVER DISEASE\n Hold Spironolactone and Lasix in the acute setting. Hold Lactulose\n while monitoring him for further episodes of GI bleeding. Follow Liver\n recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 52M with cirrhosis, here with GIB. Upper endoscopy did not offer and\n explanation. He continues to bleed and is receiving a series of PRBCs.\n He is currently awaiting a bleeding scan with the possibility of\n embolization if the results are positive.\n Exam notable for Tmax: 35.9\nC (96.6\nF) Tcurrent: 35.9\nC (96.6\n HR: 95 (95 - 98) bpm BP: 107/63(73) {107/63(73) - 107/65(76)} mmHg\n RR: 23 (17 - 23) insp/min SpO2: 100%\n O2 Delivery Device: Nasal cannula\n General Appearance: No acute distress, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No Murmur\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, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place\n Labs reviewed and recorded above\n Imaging:\n abd U/S 1. Partially occluded portal vein thrombosis which is new when\n compared to\n prior exam. 2. Cirrhotic-appearing liver with ascites. 3. Patent\n umbilical vein. 4. Splenomegaly. 5. Gallbladder sludge and wall\n thickening likely due to chronic liver disease. No evidence of acute\n cholecystitis. 6. No intrahepatic or extrahepatic biliary dilatation.\n CXR LIJ, clear\n Problems: GIB, blood loss anemia, cirrhosis, portal vein thrombosis,\n EtOH abuse\n Agree with plan to maintain adequate access, continue to transfuse PRBC\n and FFP as needed, cont octreotide for now, tagged RBC scan with\n possible embolization, surgery and liver aware and involved.\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 36 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:56 ------\n" }, { "category": "Physician ", "chartdate": "2164-11-01 00:00:00.000", "description": "Intensivist Note", "row_id": 704531, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n fungal sepsis\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n Calcium Gluconate 9. Fentanyl Citrate 10. Fentanyl Citrate 11. Insulin\n 12. Micafungin 13. Pantoprazole 14. Phenylephrine 15. Sodium Chloride\n 0.9% Flush 16. Sodium Chloride 0.9% Flush\n 17. Tetracaine HCl 18. Vancomycin\n 24 Hour Events:\n Hypotension requiring progressive increases in phenylephrine drip.\n Albumin bolus x1. ID consulted. Aline replaced\n ARTERIAL LINE - STOP 01:01 PM\n ARTERIAL LINE - START 01:20 PM\n Post operative day:\n POD#15 - ex lap duod ulcer repair\n POD#12 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:05 AM\n Other medications:\n Flowsheet Data as of 06:00 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: 36.6\nC (97.9\n HR: 100 (98 - 117) bpm\n BP: 118/60(78) {81/44(56) - 119/67(83)} mmHg\n RR: 17 (15 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 8 (-1 - 9) mmHg\n Total In:\n 11,108 mL\n 2,713 mL\n PO:\n Tube feeding:\n 3,000 mL\n 731 mL\n IV Fluid:\n 7,741 mL\n 1,849 mL\n Blood products:\n 367 mL\n 133 mL\n Total out:\n 8,638 mL\n 2,961 mL\n Urine:\n 493 mL\n 121 mL\n NG:\n 200 mL\n 300 mL\n Stool:\n Drains:\n 7,725 mL\n 2,540 mL\n Balance:\n 2,470 mL\n -248 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///20/\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: CTA bilateral : )\n Abdominal: Soft, Distended, Tender:\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 222 K/uL\n 9.7 g/dL\n 125 mg/dL\n 2.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 103 mEq/L\n 131 mEq/L\n 28.8 %\n 19.6 K/uL\n [image002.jpg]\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n 01:59 AM\n WBC\n 26.0\n 21.9\n 26.1\n 25.5\n 19.6\n Hct\n 33.7\n 32.1\n 32.5\n 32.6\n 28.8\n Plt\n 130\n 140\n 192\n 244\n 222\n Creatinine\n 1.7\n 2.0\n 1.9\n 2.0\n 2.2\n 2.4\n TCO2\n 20\n 18\n 15\n Glucose\n 135\n 130\n 102\n 128\n 155\n 162\n 125\n Other labs: PT / PTT / INR:23.9/58.6/2.3, ALT / AST:17/43, Alk-Phos / T\n bili:97/8.8, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:3.2 g/dL, LDH:182 IU/L, Ca:7.7 mg/dL, Mg:1.4\n mg/dL, PO4:4.5 mg/dL\n Imaging: EGD - EGD showed 1 cord of non-bleeding grade II\n varices at 36 cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal\n duodenal bulb, clotted blood in the antrum, and slight ulceration of\n the ampulla of Vater with a small amount of blood on it.\n EGD - 2 cords of grade I varices were seen in the lower third\n of the esophagus.\n C-scope Medium non-bleeding grade 2 internal hemorrhoids were\n noted. Two 4 mm non bleeding ulcers noted on hemorrhoid likely at site\n of previous banding.\n EKG: SR 93 bpm NA/NI no ST-T wave abnormalities\n CXR - left basal consolidation, persistent and may represent\n atelectasis versus infectious process\n TTE - EF > 75%, globally hyperdynamic; no vegitation or valve\n abnormality\n .\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Fentanyl prn, awake and following commands\n CVS: Vasolitory shock, fluid repletion 3/4:1 on neo gtt for\n hypotension; If increased need for pressors, start Zosyn per ID recs\n PULM: extubated on NC now\n RENAL: Foley, follow UOP, replacing ascites drain output to 1 with\n LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. UA(-)\n FEN/GI: protonix 40 , TF impact 3/4 strength at 125ml/hr\n ID: micafungin started non-albicans yeast blood/ascites-ok'd by\n ID; vanc for GPC tip cx; ophthalmology consulted , exam negative.\n Daily surveillance coverage. All lines changed out. Follow vanco level\n prior to 4th dose. Survaliance cx daily. Ascites gs(-)\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:57 PM 125 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701889, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received pt post CVL placement. A&Ox3. Denies SOB/CP or\n lightheadedness. Pt has had multiple LARGE amts of melena (~ 500cc\n Q1-2hrs). Flexiseal expelled by pt. SBP low 65 w/ MAPS in the 40\ns. Pt\n cont to mentate despite drop in BP. Hct ranging 22-25. INR 2.0. UOP\n marginal. Temp 95.6.\n Action:\n Bair hugger placed for hypothermia. Pt received a total of 8 units\n PRBC\ns, 2 units of FFP & 2L NS since . Pt was started on\n Neosynephrine for low SBP and active bleed. CVP transduced (~ )\n Bedside ultrasound. Red tag scan.\n Response:\n Pt titrated of Neo gtt. Mentating well. Cont to have significant amts\n of melena w/ large clots noted. Tolerating blood products. AM Hct 34.0.\n INR 1.6. Red tag scan grossly positive in duodenal area. Temp this AM\n 98.1\n Plan:\n Cont to assess Hct Q4-6 & PRN. Transfuse blood products as warranted.\n Will most likely head to IR this AM. Rapid infuser in room.\n Code status: Full Code\n 18g PIV x 3 (including R EJ) L IJ TLC\n" }, { "category": "Physician ", "chartdate": "2164-10-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 701839, "text": "Chief Complaint: hematochezia, hypotension\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Describes multiple episodes of \"a lot\" of bright red blood\n starting on the morning of admission, both in the toilet as well as in\n his bed. Endorses dizziness but no syncope. No fever, chills, chest\n pain, nausea, vomiting, hematemesis, abd pain, diarrhea, NSAID or ETOH\n use. Presented to Hospital where BP 85/43 HR 102 (BP nadir 68/36)\n Hct 17.6% INR 1.9. EKG unremarkable, CXR clear. Given 2U PRBC, NS x 1L,\n protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr.\n .\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the ICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n .\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation. EGD\n showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum. C-scope showed medium non-bleeding grade 2 internal\n hemorrhoids and two 4 mm non bleeding ulcers noted on the hemorrhoid at\n a site of previous banding.\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 Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Other medications:\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n Past medical history:\n Family history:\n Social History:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Dad died of ETOH cirrhosis.\n Occupation:\n Drugs: None.\n Tobacco: None.\n Alcohol: Drank 1/2-1 pint of vodka daily for many years until quitting\n in .\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: lightheadedness\n Gastrointestinal: hematochezia\n Flowsheet Data as of 10:25 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 99 (95 - 107) bpm\n BP: 70/40(47) {70/40(47) - 107/66(76)} mmHg\n RR: 21 (17 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,246 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n Blood products:\n 1,078 mL\n Total out:\n 0 mL\n 1,330 mL\n Urine:\n 330 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n 0 mL\n 3,916 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: icteric sclera\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 lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 134\n 1.0\n 33\n 10\n 120\n 52\n 138\n 25.0 %\n 15.0\n [image002.jpg]\n \n 2:33 A10/13/ 08:46 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 25.0\n Other labs: PT / PTT / INR:21.2//2.0, Lactic Acid:1.5 mmol/L\n Imaging: EGD - EGD showed 1 cord of non-bleeding grade II\n varices at 36 cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal\n duodenal bulb, clotted blood in the antrum, and slight ulceration of\n the ampulla of Vater with a small amount of blood on it.\n EGD - 2 cords of grade I varices were seen in the lower third\n of the esophagus.\n C-scope Medium non-bleeding grade 2 internal hemorrhoids were\n noted. Two 4 mm non bleeding ulcers noted on hemorrhoid likely at site\n of previous banding.\n ECG: SR 93 bpm NA/NI no ST-T wave abnormalities\n Assessment and Plan\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension.\n #BRBPR - initially concerning for bleeding from esophageal varices or\n duodenal ulcer but these sites were not actively bleeding by EGD\n -appreciate liver recs\n -L IJ placed\n -neo gtt if MAP <65\n -active T&S, x-fuse to Hct 30%\n -octreotide gtt\n -protonix gtt\n -ceftriaxone for SBP ppx\n -hold BB, diuretics\n -RUQ U/S to eval for ductal dilatation\n -MRCP or ERCP if ductal pathology seen on U/S\n .\n #Non-gap metabolic acidosis - unclear etiology, most likely represents\n GI losses in the setting of massive GIB; could represent RTA but new\n phenomenon and no underlying renal insufficiency; lactate WNL, no\n ketonuria, or serum salicylates (although no gap, as above)\n -cont monitor after fluid resuscitation\n .\n #FEN: NPO\n .\n #PPX: PPI IV gtt, pneumoboots\n .\n #ACCESS: 18 g R EJ, 18 g R AC, 20 g L AC\n .\n #CODE: Full code\n .\n #CONTACT: , wife, \n .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704528, "text": "Shock, septic\n Assessment:\n Pt lethargic in bed. Oriented x3 although needing help at\n times to specific month. Assisting with turns in bed, weak in\n movements. Pt with c/o generalized pain primarily in abdomen rating\n on pain scale.\n NGT to medium continuous wall suction. Small amounts bilious\n drainage.\n Abdomen soft/ascetic. Lateral JP to self suction with\n moderate amounts ascetic/ser-sang drainage. Medial JP to wall suction\n with large amounts of drainage.\n Upper J-tube to gravity with bilious output. Lower J-tube\n with TF infusing at goal.\n Foley patent pt making amber clear urine about 15-25cc\n hourly.\n Lungs clear at apeces diminished in bases. Sat\ns 94-97% RA.\n Strong productive cough. Using IS pulling 1000-1300cc. Clearing own\n secretions well.\n Afebrile. WBC 25.5. NSR/ST HR 95-115. No ectopy. Continues\n on Neo drip.\n Action:\n Giving Fentanyl as needed for pain.\n Repleting JPx2 outputs with LR\n cc:cc. Administering 25%\n Albumin for every 1L of JP drainage.\n Encouraging c/db.\n Titrating Neo drip for goal MAP >65.\n Response:\n Mild pain relief with Fentanyl. Pt with sharp breakthrough\n of pain during night. Dr and Transplant team notified and\n arrived at bedside to further assess pt >> given additional dose of\n albumin and extra fentanyl for pain.\n Pt 2.4L positive at midnight. Teams notified and continuing\n with fluid repletions.\n WBC this AM 19.6\n Plan:\n Monitor pain/comfort treating as needed.\n Continue to monitor all drain outputs and continue LR\n cc:cc JP drain repletions.\n Encourage c/db. IS use.\n F/u cultures. Continue antibiotics and WBC trend.\n Titrate Neo to goal MAP.\n Provide emotional support.\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704617, "text": "Shock, septic\n Assessment:\n -Patient is lethargic but oriented x 3, labile at times, c/o pain in\n abdomen out of 10 pain, angry about being in the hospital.\n - continues to be on Neo gtt with Map 65-75, occasional drops to MAP in\n 50\ns. HR 90\ns-120\n -Output from JP drains 150-450.\n -Urine output 15-35 cc/hr.\n INR 2.3\n Lactate 1.7\n Action:\n - continues with\n cc:cc repletion, IVF changed from LR to NS\n because of low sodium of 131,\n - given a 500 cc NS fluid bolus after episode of hypotension\n this am\n - continued with 25% concentrated albumin per each 1 L of jp\n output,\n - SICU team and transplant team called in to assess patient\n for increased pain, increased pain in patients abdomen.\n - Pain meds changed from fentanyl to Dilaudid for longer\n lasting pain control.\n - KUB done to detect any acute changes.\n - PT in to work with patient, slid over to chair,\n - Continued to titrate Neo for MAP > 65,\n - Given 2 units FFP and 10 mg vit K\n Response:\n - MAP > 65 currently on 1.5 of Neo,\n - Approx 1 L pos. for the day so far,\n - MAP > 65 after fluid bolus,\n - INR now 2.1\n - patient states pain is more tolerable after Dilaudid given, able to\n nap.\n Plan:\n - attempt to make patient closer to an even fluid balance, continue\n with\n cc: cc repletion and concentrated albumin with every 1 L jp\n output, Dilaudid prn for pain.\n Impaired Physical Mobility\n Assessment:\n Patient weak and has hard time helping with turns in the bed. Able to\n lift and hold upper extremities well, has a hard time lifting legs and\n bending at knee.\n Action:\n PT in to work with patient, Patient able to sit on side of bed with 2\n person assist and stand with max assist.\n Slid over to chair.\n Response:\n Patient unable to pivot to chair, c/o pain with activity despite being\n medicated for pain management prior.\n Unable to stay in chair long due to pain in abdomen.\n Plan:\n Continue to work with PT, patient would like to try to pivot to chair\n tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient sating 94-99% on room air, lungs sound rhonchorous at times and\n diminished at bases. Able to pull in volumes of on IS. Able\n to cough up and clear own secretions.\n Action:\n - ABG drawn.\n - sat on side of bed, stood up, sat in chair,\n - encouraged to cough and deep breathe,\n - encouraged to use IS, Chest PT done.\n Response:\n ABG- 7.45/ 23/ 82 / -5/ 16\n Lungs sound clearer, continues to be diminished at bases.\n Plan:\n Continue to work with PT to get OOB, continue with IS and coughing and\n deep breathing.\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704618, "text": "Shock, septic\n Assessment:\n -Patient is lethargic but oriented x 3, labile at times, c/o pain in\n abdomen out of 10 pain, angry about being in the hospital.\n - continues to be on Neo gtt with Map 65-75, occasional drops to MAP in\n 50\ns. HR 90\ns-120\n -Output from JP drains 150-450.\n -Urine output 15-35 cc/hr.\n INR 2.3\n Lactate 1.7\n Action:\n - continues with\n cc:cc repletion, IVF changed from LR to NS\n because of low sodium of 131,\n - given a 500 cc NS fluid bolus after episode of hypotension\n this am\n - continued with 25% concentrated albumin per each 1 L of jp\n output,\n - SICU team and transplant team called in to assess patient\n for increased pain, increased pain in patients abdomen.\n - Pain meds changed from fentanyl to Dilaudid for longer\n lasting pain control.\n - KUB done to detect any acute changes.\n - PT in to work with patient, slid over to chair,\n - Continued to titrate Neo for MAP > 65,\n - Given 2 units FFP and 10 mg vit K\n Response:\n - MAP > 65 currently on 1.5 of Neo,\n - Approx 1 L pos. for the day so far,\n - MAP > 65 after fluid bolus,\n - INR now 2.1\n - patient states pain is more tolerable after Dilaudid given, able to\n nap.\n Plan:\n - attempt to make patient closer to an even fluid balance, continue\n with\n cc: cc repletion and concentrated albumin with every 1 L jp\n output, Dilaudid prn for pain.\n Impaired Physical Mobility\n Assessment:\n Patient weak and has hard time helping with turns in the bed. Able to\n lift and hold upper extremities well, has a hard time lifting legs and\n bending at knee.\n Action:\n PT in to work with patient, Patient able to sit on side of bed with 2\n person assist and stand with max assist.\n Slid over to chair.\n Response:\n Patient unable to pivot to chair, c/o pain with activity despite being\n medicated for pain management prior.\n Unable to stay in chair long due to pain in abdomen.\n Plan:\n Continue to work with PT, patient would like to try to pivot to chair\n tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient sating 94-99% on room air, lungs sound rhonchorous at times and\n diminished at bases. Able to pull in volumes of on IS. Able\n to cough up and clear own secretions.\n Action:\n - ABG drawn.\n - sat on side of bed, stood up, sat in chair,\n - encouraged to cough and deep breathe,\n - encouraged to use IS, Chest PT done.\n Response:\n ABG- 7.45/ 23/ 82 / -5/ 16\n Lungs sound clearer, continues to be diminished at bases.\n Plan:\n Continue to work with PT to get OOB, continue with IS and coughing and\n deep breathing.\n" }, { "category": "Nursing", "chartdate": "2164-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703402, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains on vent CPAP/PS 5/5, no changes overnight.. LS clear\n with occasional rochi,\n Action:\n ABG sent, O 2sat 97-99%, suctioned yellow thin secretion, Good cough,\n and impaired gag. Cont with rotating bed. 1amp sodium bicarb given. ET\n tube rotated to lt side by RT, pt bites the tube.\n Response:\n LS clear, LS clear, o2 sat 98-100%, good cough.\n Plan:\n Cont to monitor, pulm hygiene, ? Change to regular ICU bed.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abdomen softly distended, medial JP with copious amt of leak around,\n NGT to LCS with clear drainage. Edge of the staples slightly swollen,\n WBC 14.7, s.lactate is 1.7, BUN 67 and creat 1.7, livber enzymes WNL.\n Action:\n JP taped with tegaderm by primary team early shift, replacing JP out\n with LR 1/2cc /cc, albumin 12.5gm for every 1L of JP out put given,\n sodium bicarb 1amp for every 3L JP out put. So sodium bicarb 1amp x1.\n Fentanyl for pain prn given.\n Response:\n Still leaking around JP , medial looks okay, but leaking around\n lateral now Tachy cardic HR 110-130/min, team aware. Stable HCT,\n rising BUN and chloride.\n Plan:\n Replace JP out put with LR, albumin 12.5gm for every Liter of JP out\n put, sodium bicarb 1amp for 3 L JP out put, ? suture the jp\n" }, { "category": "Nursing", "chartdate": "2164-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703686, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains intubated on CPAP 5/5, 40% FiO2\n Suctioned prn for scant amount of secretions\n ABG wnl\n Pt arousable to voice, following commands, MAE, Pupils equal\n and reactive. Pt nodding appropriately to yes/no questions, pos cough,\n impaired gag. At approx 220 pt became agitated and restless, attempting\n to mouth words, reaching for ETT and NGT, pt nodding yes to pain,\n restraints reapllied and fentanyl given with pos effect.\n Abd incision OTA, staples intact, JPx2, Suction dsg applied\n by Nsg in order to quantify acites drainage; copious amounts of\n serosang drainage from drains. Jtube x2, one to drainage, one to\n feeding. NGT to LCS, clear drainage.\n HR 95-120\ns, improving with albumin and fluids. BP 95-130\n with MAP >65 throughout majority of shift, dipped BP to 80\ns with MAP\n 60 x1, improved with fluid bolus and albumin\n CVP 10-13, PPV \n U/O 5-45cc/hr, improving throughout shift, dark amber urine\n via foley cath. Cr 1.7, BUN 72\n Afebrile, tmax 97.5. WBC 16.6 up from 14.7\n Hct stable, Plt 65, Chloride 115 from 119\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Abx as ordered\n Fentanyl prn pain\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin and bicarb as ordered\n Possible extubation this AM\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704000, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions related to realitry\nwhen does the courthouse open?\n Pt able\n to sleep for a couple of hours through the night. Following commands,\n MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. J tube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains on 70% cool-neb, O2 sat 98-100%. LS clear to\n ronchii, diminished at bases. Coughing and raising small amounts of\n thick white sputum into mouth\n HR 100-115, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift.\n Pt fluid balance approximately even as of MN\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 2 BUN\n 87\n Afebrile, tmax 98.5 WBC 26 up from 21\n Hct stable, Plt 130\n Pt denies pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 3/4cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 3/4cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701886, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received pt post CVL placement. A&Ox3. Denies SOB/CP or\n lightheadedness. Pt has had multiple LARGE amts of melena (~ 500cc\n Q1-2hrs). Flexiseal expelled by pt. SBP low 65 w/ MAPS in the 40\ns. Pt\n cont to mentate despite drop in BP. Hct ranging 22-25. INR 2.0. UOP\n marginal. Temp 95.6.\n Action:\n Bair hugger placed for hypothermia. Pt received a total of 8 units\n PRBC\ns, 2 units of FFP & 2L NS since . Pt was started on\n Neosynephrine for low SBP and active bleed. CVP transduced (~ )\n Bedside ultrasound. Red tag scan.\n Response:\n Pt titrated of Neo gtt. Mentating well. Cont to have significant amts\n of melena w/ large clots noted. Tolerating blood products. AM Hct 34.0.\n Red tag scan positive in duodenal area.\n Plan:\n Cont to assess Hct Q4-6 & PRN. Transfuse blood products as warranted.\n Will most likely head to IR this AM. Rapid infuser in room.\n Code status: Full Code\n 18g PIV x 3 (including R EJ) L IJ TLC\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 702024, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr\n IV gtt. He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was hospitalized at from to for UGIB due to\n duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n 24 Hour Events:\n ENDOSCOPY - At 05:19 PM\n last night, an area of prior\n bleeding was noted at the ampulla but no brisk obvious bleeding. He\n also had one cord of grade II non-bleeding varices and two linear\n ulcers in the stomach.\n ULTRASOUND - At 09:00 PM\n done last night without ductal\n dilitation but partial portal vein thrombus\n URINE CULTURE - At 09:00 PM\n MULTI LUMEN - START 09:19 PM\n left IJ CVL placed in MICU.\n NUCLEAR MEDICINE - At 01:00 AM: Red Tag Cell Scan\n focal\n area of bleeding in the proximal duodenum.\n EKG - At 06:30 AM\nHis MAPs dropped to the 30s in the setting of voluminous melena; he\n received 11 units of pRBCs, 6 units of FFP. Transplant surgery was\n consulted.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Changes to medical and family history: No change from admission.\n Review of systems is unchanged from admission except as noted below\n Review of systems: No change from admission.\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 104/59 {64/27 - 132/75} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 4 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 2,117 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 421 mL\n Blood products:\n 2,546 mL\n 1,696 mL\n Total out:\n 1,830 mL\n 428 mL\n Urine:\n 330 mL\n 128 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 84 K/uL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n Differential-Neuts:81.6 %, Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %,\n RUQ U/S: Cirrhotic liver, splenomegaly, gallbladder sludge, no ductal\n dilation. Partial portal vein thrombosis.\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs:\n PT / PTT / INR:18.1/45.8/1.6,\n Lactic Acid:2.3 mmol/L,\n Ca++:6.2 mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Now s/p endoscopy x 2 (one last night that revealed an area of possible\n bleeding at the ampulla) as well as a second EGD this morning \n continued bleeding and the positive tagged RBC scan. He is to go to IR\n this morning for angiography. If they are unable to achieve hemostasis\n in the IR suite, then he may need to go to the OR for surgical\n intervention. With regard to resuscitation, he should receive blood\n products primarily. There is no indication for normal saline at this\n time given that his underlying process is hemorrhagic shock. Continue\n Protonix and Octreotide. Continue Ceftriaxone for a seven day course.\n Ultimately, need to clarify his ultimate disposition with regard to his\n transplant candidacy particularly if hemostasis cannot be achieved in\n angiography or, if warranted, the operating room. He is quite ill and\n without achieving hemostasis he is at extremely high risk for adverse\n outcomes including death.\n END STAGE LIVER DISEASE\n Continue to hold Spironolactone, Lasix, and Lactulose while treating\n him for further episodes of GI bleeding. Follow Liver recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent: 60\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704625, "text": "Shock, septic\n Assessment:\n -Patient is lethargic but oriented x 3, labile at times, c/o pain in\n abdomen out of 10 pain, angry about being in the hospital.\n - continues to be on Neo gtt with Map 65-75, occasional drops to MAP in\n 50\ns. HR 90\ns-120\n -Output from JP drains 150-450.\n -Urine output 15-35 cc/hr.\n INR 2.3\n Lactate 1.7\n Action:\n - continues with\n cc:cc repletion, IVF changed from LR to NS\n because of low sodium of 131,\n - given a 500 cc NS fluid bolus after episode of hypotension\n this am\n - continued with 25% concentrated albumin per each 1 L of jp\n output,\n - SICU team and transplant team called in to assess patient\n for increased pain, increased pain in patients abdomen.\n - Pain meds changed from fentanyl to Dilaudid for longer\n lasting pain control.\n - KUB done to detect any acute changes.\n - PT in to work with patient, slid over to chair,\n - Continued to titrate Neo for MAP > 65,\n - Given 2 units FFP and 10 mg vit K\n Response:\n - MAP > 65 currently on 1.5 of Neo,\n - Approx 1 L pos. for the day so far,\n - MAP > 65 after fluid bolus,\n - INR now 2.1\n - patient states pain is more tolerable after Dilaudid given, able to\n nap.\n Plan:\n - attempt to make patient closer to an even fluid balance, continue\n with\n cc: cc repletion and concentrated albumin with every 1 L jp\n output, Dilaudid prn for pain.\n Impaired Physical Mobility\n Assessment:\n Patient weak and has hard time helping with turns in the bed. Able to\n lift and hold upper extremities well, has a hard time lifting legs and\n bending at knee.\n Action:\n PT in to work with patient, Patient able to sit on side of bed with 2\n person assist and stand with max assist.\n Slid over to chair.\n Response:\n Patient unable to pivot to chair, c/o pain with activity despite being\n medicated for pain management prior.\n Unable to stay in chair long due to pain in abdomen.\n Plan:\n Continue to work with PT, patient would like to try to pivot to chair\n tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient sating 94-99% on room air, lungs sound rhonchorous at times and\n diminished at bases. Able to pull in volumes of on IS. Able\n to cough up and clear own secretions.\n Action:\n - ABG drawn.\n - sat on side of bed, stood up, sat in chair,\n - encouraged to cough and deep breathe,\n - encouraged to use IS, Chest PT done.\n Response:\n ABG- 7.45/ 23/ 82 / -5/ 16\n Lungs sound clearer, continues to be diminished at bases.\n Plan:\n Continue to work with PT to get OOB, continue with IS and coughing and\n deep breathing.\n" }, { "category": "Nursing", "chartdate": "2164-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703851, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asks about\nwhen the\n court house is open\n or asks if\nthe dog has been fed\n. Following\n commands, MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. Jtube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains extubated, O2 sat 95-100% on 50% cool-neb. LS\n clear to ronchii, diminished at bases. Coughing and raising small\n amounts of thick white sputum into mouth\n HR 109-120\ns, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift. At approx 0200, pt\n dropped SBP to 78, Map 54, Fluid given (only 300cc) with pos effect,\n SBP sustained 85-95 with MAP 53-60, MD notified, 5% Albumin given\n with pos effect\n Pt approx 2400cc neg as of MN, currently even due to fluid\n boluses\n CVP 8-11\n U/O 20-45cc/hr, dark amber urine via foley cath. Cr 1.6 BUN\n 81. At approx 0200, no u/o, MD notified, foley flushed easily, 5%\n albumin given, labs sent, next hour 25cc of urine\n Afebrile, tmax 97.1 WBC 21 up from 18.2\n Hct stable, Plt 92\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 1/2cc:cc repletion for JP outputs with LR\n 5% Albumin x1\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 701991, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr\n IV gtt. He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was hospitalized at from to for UGIB due to\n duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n 24 Hour Events:\n ENDOSCOPY - At 05:19 PM\n last night, an area of prior\n bleeding was noted at the ampulla but no brisk obvious bleeding. He\n also had one cord of grade II non-bleeding varices and two linear\n ulcers in the stomach.\n ULTRASOUND - At 09:00 PM\n done last night without ductal\n dilitation but partial portal vein thrombus\n URINE CULTURE - At 09:00 PM\n MULTI LUMEN - START 09:19 PM\n left IJ CVL placed in MICU.\n NUCLEAR MEDICINE - At 01:00 AM: Red Tag Cell Scan\n focal\n area of bleeding in the proximal duodenum.\n EKG - At 06:30 AM\nHis MAPs dropped to the 30s in the setting of voluminous melena; he\n received 11 units of pRBCs, 6 units of FFP. Transplant surgery was\n consulted.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Changes to medical and family history: No change from admission.\n Review of systems is unchanged from admission except as noted below\n Review of systems: No change from admission.\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 104/59 {64/27 - 132/75} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 4 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 2,117 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 421 mL\n Blood products:\n 2,546 mL\n 1,696 mL\n Total out:\n 1,830 mL\n 428 mL\n Urine:\n 330 mL\n 128 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 84 K/uL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n Differential-Neuts:81.6 %, Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %,\n RUQ U/S: Cirrhotic liver, splenomegaly, gallbladder sludge, no ductal\n dilation. Partial portal vein thrombosis.\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs:\n PT / PTT / INR:18.1/45.8/1.6,\n Lactic Acid:2.3 mmol/L,\n Ca++:6.2 mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Now s/p endoscopy x 2 (one last night that revealed an area of possible\n bleeding at the ampulla) as well as a second EGD this morning \n continued bleeding and the positive tagged RBC scan. He is to go to IR\n this morning for angiography. If they are unable to achieve hemostasis\n in the IR suite, then he may need to go to the OR for surgical\n intervention. With regard to resuscitation, he should receive blood\n products primarily. There is no indication for normal saline at this\n time given that his underlying process is hemorrhagic shock. Continue\n Protonix and Octreotide. Continue Ceftriaxone for a seven day course.\n Ultimately, need to clarify his ultimate disposition with regard to his\n transplant candidacy particularly if hemostasis cannot be achieved in\n angiography or, if warranted, the operating room. He is quite ill and\n without achieving hemostasis he is at extremely high risk for adverse\n outcomes including death.\n END STAGE LIVER DISEASE\n Continue to hold Spironolactone, Lasix, and Lactulose while treating\n him for further episodes of GI bleeding. Follow Liver recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704614, "text": "Shock, septic\n Assessment:\n -Patient is lethargic but oriented x 3, labile at times, c/o pain in\n abdomen out of 10 pain, angry about being in the hospital.\n - continues to be on Neo gtt with Map 65-75, occasional drops to MAP in\n 50\ns. HR 90\ns-120\n -Output from JP drains 150-450.\n -Urine output 15-35 cc/hr.\n INR 2.2\n Action:\n - continues with\n cc:cc repletion, IVF changed from LR to NS\n because of low sodium of 131,\n - given a 500 cc NS fluid bolus after episode of hypotension\n this am\n - continued with 25% concentrated albumin per each 1 L of jp\n output,\n - SICU team and transplant team called in to assess patient\n for increased pain, increased pain in patients abdomen.\n - Pain meds changed from fentanyl to Dilaudid for longer\n lasting pain control.\n - PT in to work with patient, slid over to chair,\n - Continued to titrate Neo for MAP > 65,\n - Given 2 units FFP and 10 mg vit K\n Response:\n - MAP > 65 currently on 1.5 of Neo,\n - Approx 1 L pos. for the day so far,\n - MAP > 65 after fluid bolus,\n - Patient unable to pivot to chair but did stand and sit on end of bed,\n slid to chair.\n Plan:\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703572, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains intubated on CPAP 5/5, 40% FiO2\n Suctioned prn for small amounts of thick tan secretions\n ABG wnl\n Pt arousable to voice, following commands, MAE, Pupils equal\n and reactive. Pt nodding appropriately to yes/no questions, pos cough,\n impaired gag\n Abd incision OTA, staples intact, JPx2, Suction dsg applied\n by Nsg in order to quantify acites drainage; copious amounts of\n serosang drainage from drains. Jtube x2, one to drainage, one to\n feeding. NGT to LCS, clear drainage.\n HR 95-120\ns, improving with albumin and fluids. BP 95-130\n with MAP >65 throughout majority of shift, dipped BP to 80\ns with MAP\n 60 x1, improved with fluid bolus and albumin\n CVP 10-13, PPV \n U/O 5-45cc/hr, improving throughout shift, dark amber urine\n via foley cath. Cr 1.7, BUN 72\n Afebrile, tmax 97.5. WBC 16.6 up from 14.7\n Hct stable, Plt 65, Chloride 115 from 119\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n 1 amp bicarb given for every 3000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Abx as ordered\n Fentanyl prn pain\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin and bicarb as ordered\n Possible extubation this AM\n Provide pt and family with emotional support\n" }, { "category": "Respiratory ", "chartdate": "2164-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703392, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\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: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: AM RSBI 37\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\n" }, { "category": "Nursing", "chartdate": "2164-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703571, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains intubated on CPAP 5/5, 40% FiO2\n Suctioned prn for small amounts of thick tan secretions\n ABG wnl\n Pt arousable to voice, following commands, MAE, Pupils equal\n and reactive. Pt nodding appropriately to yes/no questions, pos cough,\n impaired gag\n Abd incision OTA, staples intact, JPx2, Suction dsg applied\n by Nsg in order to quantify acites drainage; copious amounts of\n serosang drainage from drains. Jtube x2, one to drainage, one to\n feeding. NGT to LCS, clear drainage.\n HR 95-120\ns, improving with albumin and fluids. BP 95-130\n with MAP >65 throughout majority of shift, dipped BP to 80\ns with MAP\n 60 x1, improved with fluid bolus and albumin\n CVP 10-13, PPV \n U/O 5-45cc/hr, improving throughout shift, dark amber urine\n via foley cath. Cr 1.7, BUN 72\n Afebrile, tmax 97.5. WBC 16.6 up from 14.7\n Hct stable, Plt 65, Chloride 115 from 119\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n 1 amp bicarb given for every 3000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Abx as ordered\n Fentanyl prn pain\n Response:\n VS improving with fluid boluses and albumin\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703844, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asks about\nwhen the\n court house is open\n or asks if\nthe dog has been fed\n. Following\n commands, MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. Jtube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains extubated, O2 sat 95-98% on 50% cool-neb. LS\n clear to ronchii, diminished at bases. Coughing and raising small\n amounts of thick white sputum into mouth\n HR 109-120\ns, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift\n Pt approx 24oocc neg as of MN, currently even due to fluid\n boluses\n CVP 8-11\n U/O 20-45cc/hr, dark amber urine via foley cath. Cr 1.5, BUN\n 76\n Afebrile, tmax 97.1 WBC 21 up from 18.2\n Hct stable, Plt 92\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Physician ", "chartdate": "2164-10-16 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 701814, "text": "Chief Complaint: Bright red blood per rectum\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 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr.\n He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was recently hospitalized at from to for UGIB due\n to duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\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 Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Past medical history:\n Family history:\n Social History:\n - EtOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n - duodenal ulcer\n - internal hemorrhoids\n - s/p bilateral knee replacements\n Father had cirrhosis EtOH.\n Occupation: Disabled\n Drugs: Denies any h/o IVDU.\n Tobacco: Non-smoker.\n Alcohol: Drank -1 pint of vodka a day for years until he quit on\n .\n Other:\n Review of systems:\n Constitutional: 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)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Flowsheet Data as of 06:20 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: 95 (95 - 98) bpm\n BP: 107/63(73) {107/63(73) - 107/65(76)} mmHg\n RR: 23 (17 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n Total out:\n 0 mL\n 140 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -132 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 134\n 25.5\n 8.5\n 111\n 1.0\n 33\n 10\n 120\n 5.2\n 138\n 15.0\n [image002.jpg]\n Other labs:\n PT / PTT / INR:22 / 54 / 2.0,\n ALT / AST:18 / 34, Alk Phos / T Bili:102 / 4.6,\n Amylase / Lipase:/ 71, Albumin:1.4\n Fluid analysis / Other labs: Last paracentesis from was not\n consistent with SBP (WBC 155.)\n Imaging: No imaging this hospitalization.\n Microbiology: No cultures results since late .\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n GI performed endoscopy on arrival to the MICU and there was no clear\n source of brisk bleeding. There was an area of possible prior bleeding\n at the ampula, a possible non-bleeding ucler. A small bowel or lower\n intestinal source of his bleeding on presentation is certainly possible\n and further evaluation (push-enteroscopy +/- c-scope) will be\n considered going forward. For the time being, if indeed this was an\n upper GI bleed that has spontaneously resolved, we will continue\n Protonix IV and Octreotide as per UGIB protocol. He should receive\n Ceftriaxone for a 7 day course. Will follow his Hcts serially and, more\n importantly, his HR and BP in the acute setting for any clinical e/o\n brisk bleeding. He has two 20g IVs and an 18g IV. We will place a\n central line for frequent blood draws and resuscitation should he\n require it.\n END STAGE LIVER DISEASE\n Hold Spironolactone and Lasix in the acute setting. Hold Lactulose\n while monitoring him for further episodes of GI bleeding. Follow Liver\n recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2164-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703505, "text": "Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\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: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\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: Triggering synchronously\n :\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2164-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703562, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-10-27 00:00:00.000", "description": "Intensivist Note", "row_id": 703774, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1000 mL LR\n Albumin 25% (12.5g / 50mL)\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Fentanyl Citrate\n Fluconazole\n Insulin\n Pantoprazole\n Piperacillin-Tazobactam\n Sodium Bicarbonate\n Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n continue 1/2 cc per cc replacement of ascited with LR\n continue 12.5 g albumin for every 1L ascites output\n LR boluses prn to keep no more than 1L negative for the day\n Post operative day:\n POD#10 - ex lap duod ulcer repair\n POD#7 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:31 PM\n Fluconazole - 10:07 PM\n Piperacillin/Tazobactam (Zosyn) - 04:33 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 01:32 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.4\n HR: 114 (97 - 129) bpm\n BP: 113/58(74) {88/47(59) - 131/81(97)} mmHg\n RR: 23 (15 - 28) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 9 (7 - 169) mmHg\n Total In:\n 14,096 mL\n 3,734 mL\n PO:\n Tube feeding:\n 964 mL\n 236 mL\n IV Fluid:\n 10,870 mL\n 2,967 mL\n Blood products:\n 550 mL\n 100 mL\n Total out:\n 15,007 mL\n 4,964 mL\n Urine:\n 642 mL\n 264 mL\n NG:\n 750 mL\n 700 mL\n Stool:\n Drains:\n 13,215 mL\n 4,000 mL\n Balance:\n -911 mL\n -1,230 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 577 (577 - 687) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: 7.43/32/86./21/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, JP drains in place, J tube x 2 in plaec\n Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm), (Pulse\n - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 77 K/uL\n 11.1 g/dL\n 141 mg/dL\n 1.5 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 76 mg/dL\n 111 mEq/L\n 138 mEq/L\n 33.0 %\n 18.2 K/uL\n [image002.jpg]\n 10:27 AM\n 04:26 PM\n 02:32 AM\n 02:37 AM\n 02:17 AM\n 02:28 AM\n 08:37 AM\n 03:03 PM\n 02:00 AM\n 02:05 AM\n WBC\n 14.7\n 16.6\n 18.2\n Hct\n 35.0\n 35.2\n 33.0\n Plt\n 59\n 65\n 77\n Creatinine\n 1.7\n 1.7\n 1.5\n TCO2\n 16\n 17\n 19\n 22\n 20\n 22\n Glucose\n 122\n 126\n 143\n 158\n 152\n 141\n Other labs: PT / PTT / INR:22.4/76.1/2.1, ALT / AST:, Alk-Phos / T\n bili:53/5.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:120 IU/L, Ca:7.8 mg/dL, Mg:1.6\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated. Fentanyl prn, following commands\n CVS: stable; follow\n PULM: Intubated, CPAP 5/5. extubate am\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with LR. Albumin 12.5g per 1L ascites, also giving HCO3 for\n every 3L ascites. Hx of hepatorenal syndrome.\n FEN/GI: NPO, protonix drip, TPN, TF nepro 3/4 strength at 40\n ID: vanc / zosyn / fluc; f/u cx\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, s/p L IJ triple lumen, R SC trauma line ( PIV x1,\n JP x2, NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:00 PM 72. mL/hour\n NovaSource Renal () - 10:10 PM 40. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703842, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asks about\nwhen the\n court house is open\n or asks if\nthe dog has been fed\n. Following\n commands, MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. Jtube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains extubated, O2 sat 95-98% on 50% cool-neb. LS\n clear to ronchii, diminished at bases. Coughing and raising small\n amounts of thick white sputum into mouth\n HR 109-120\ns, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift\n Pt approx 24oocc neg as of MN, currently even due to fluid\n boluses\n CVP 8-11\n U/O 20-45cc/hr, dark amber urine via foley cath. Cr 1.5, BUN\n 76\n Afebrile, tmax 97.1 WBC 18.2 up from 16.6\n Hct stable, Plt 77, Chloride 111 from 115\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703566, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2164-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703567, "text": "Demographics\n Day of mechanical ventilation: 10\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 22 cm at lip\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\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 Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=51 AM ABG 7.32/32/110/22. Possible extubation this am?\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704094, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient continues to be NPO- NG to suction draining moderate amt. of\n bilious drainage. JP\ns putting out 300-600 cc/hr serosang drainage.\n MAP 60-70\ns, MAP down to 57-60 x 3. HR 100\ns-115. Urine output \n cc/hr dark amber color.\n Afebrile,\n WBC up to 26\n Action:\n given moist swabs for comfort,\n changed from\n cc: cc replacement to cc:cc replacement q hour,\n given 500 cc LR x 3 for low MAP and decreased u/o.\n echo done.\n foley changed,\n Left subclavian d/c\nd tip sent for cx.\n Right IJ initiated,\n blood cx. Sent.\n Response:\n MAP > 65 after fluid bolus given, u/o increased to 25 cc/hr after\n bolus. Patient is now approx. 2 L pos. for the day.\n Plan:\n follow up on cultures, Keep MAP > 65, follow up on echo results. NPO\n continue to monitor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on 60% face tent sating 99-100%. Able to cough up secretions\n but unable to clear them on own.\n Action:\n Patient encouraged to cough and deep breath, use of IS, chest pt.\n ABG drawn this am. 7.46/144/24,\n O2 weaned to 50% then 40%.\n Response:\n Patient sating 94% on 40% so put back on 50% face tent. Now sating\n 95-100%.\n Plan:\n Continue to monitor, aggressive pulm. Toilet.\n" }, { "category": "Nursing", "chartdate": "2164-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704259, "text": "Impaired Skin Integrity\n Assessment:\n Skin tears noted Right abd and upper anterior chest where face mask was\n digging in.\n Action:\n Areas wwere cleansed with NSand the abd skin tear was left open to air.\n The upper ant chest skin tear was covered with meriplex dsg.\n Another skin tear RRQ is covered by the drain dsg.\n Response:\n impaired skin\n Plan:\n Continue meriplex dsg to upper chest skin tear.\n left abd skin tears OTA\n Do not use tegaderm on skin tears please.\n Fungal Infection, Other\n Assessment:\n Blood culture and ascitic fluid from positive for yeast\n all cultures negative for bacteria\n WBC 26\n Action:\n Pipercillin, vanco and fluconazole discontinued\n Continues on micafungin\n Response:\n septic\n Plan:\n Continue micafungin as ordered\n blood culture in am as ordered f/u culture\n Hypomagnesemia (Low magneseium)\n Assessment:\n Serum magnesium 1.3\n Action:\n Magnesium sulfate 1 GM given as ordered\n Response:\n n/a\n Plan:\n recheck Magnesium with am labs\n Shock, septic\n Assessment:\n Low grade temps\n hypotensive low of systolic 78, MAP 50s\n Positive fungemia\n Action:\n LR 1000ml for hypotensive episode\n neo titrated for MAP >65\n micafungin as ordered given.\n cc/cc replacement of JP lateral , medial tube and wound drain output\n hourly.\n Response:\n MAP>65\n Plan:\n Maintain MAP>65\n Titrate neo for MAP>65\n warm blankets as needed for comfort\n" }, { "category": "Physician ", "chartdate": "2164-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 704330, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Artificial Tear Ointment\n Calcium Gluconate\n Fentanyl Citrate\n Insulin\n Magnesium Sulfate\n Micafungin\n Ondansetron\n Pantoprazole\n Phenylephrine\n Tetracaine HCl\n Vancomycin\n 24 Hour Events:\n URINE CULTURE - At 01:10 PM\n cont pressors\n cath tip cx +GPC - resumed vancomycin\n Post operative day:\n POD#14 - ex lap duod ulcer repair\n POD#11 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 06:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 AM\n Fentanyl - 02:44 AM\n Other medications:\n Flowsheet Data as of 05:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.3\nC (99.2\n HR: 107 (98 - 112) bpm\n BP: 91/53(65) {78/44(56) - 129/63(83)} mmHg\n RR: 19 (16 - 24) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 1 (-5 - 11) mmHg\n Total In:\n 12,291 mL\n 1,636 mL\n PO:\n Tube feeding:\n 2,045 mL\n 621 mL\n IV Fluid:\n 9,795 mL\n 965 mL\n Blood products:\n 450 mL\n 50 mL\n Total out:\n 11,061 mL\n 1,588 mL\n Urine:\n 466 mL\n 83 mL\n NG:\n 425 mL\n 50 mL\n Stool:\n Drains:\n 10,170 mL\n 1,455 mL\n Balance:\n 1,230 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (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 244 K/uL\n 10.8 g/dL\n 162 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 77 mg/dL\n 104 mEq/L\n 132 mEq/L\n 32.6 %\n 25.5 K/uL\n [image002.jpg]\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n WBC\n 21.0\n 26.0\n 21.9\n 26.1\n 25.5\n Hct\n 34.1\n 33.7\n 32.1\n 32.5\n 32.6\n Plt\n 95\n 130\n 140\n 192\n 244\n Creatinine\n 1.6\n 1.7\n 2.0\n 1.9\n 2.0\n 2.2\n TCO2\n 20\n 18\n 15\n Glucose\n 148\n 135\n 130\n 102\n 128\n 155\n 162\n Other labs: PT / PTT / INR:20.4/58.3/1.9, ALT / AST:17/44, Alk-Phos / T\n bili:107/7.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:182 IU/L, Ca:7.5 mg/dL, Mg:1.6\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Fentanyl prn, awake and following commands\n CVS: fluid boluses, neo gtt for hypotension; wean as tolerated\n PULM: extubated on NC now\n RENAL: Foley, follow UOP, replacing ascites drain output 1 to 1 with\n LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. F/u urine\n lytes. Goal even balance.\n FEN/GI: protonix 40 , TF impact 3/4 strength at 125ml/hr\n ID: micafungin started yeast blood/ascites; vanc for GPC tip cx;\n ophthalmology consult 10/27 per ID recommendation for ?ophthalmic\n involvement of fungal infection\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n Impact with Fiber () - 12:00 AM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:20 PM\n Multi Lumen - 12:06 PM\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": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704088, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient continues to be NPO- NG to suction draining moderate amt. of\n bilious drainage. JP\ns putting out 300-600 cc/hr serosang drainage.\n MAP 60-70\ns, MAP down to 57-60 x 3. HR 100\ns-115. Urine output \n cc/hr dark amber color.\n Afebrile,\n WBC up to 26\n Action:\n given moist swabs for comfort,\n changed from\n cc: cc replacement to cc:cc replacement q hour,\n given 500 cc LR x 3 for low MAP and decreased u/o.\n echo done.\n foley changed,\n Left subclavian d/c\nd tip sent for cx.\n R IJ initiated,\n blood cx. Sent.\n Response:\n MAP > 65 after fluid bolus given, u/o increased to 25 cc/hr after\n bolus. Patient is now approx. 2 L pos. for the day.\n Plan:\n follow up on cultures, Keep MAP > 65, follow up on echo results. NPO\n continue to monitor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704441, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, lethargic today, oriented x 3 although occasionally\n believes he is at , able to lift and hold\n all extremties although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of ascitic fluid,\n medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr.\n Patient sating 94-99% on room air. Good cough and able to clear\n secretions with yankur.\n -urine output 15-35 cc/hr.\n Action:\n - SICU and transplant team in to assess.\n - Continued with cc:cc fluid repleation from jp drain output,\n continued with 25% albumin administration q 1 L output from jp\n - Ascitic fluid from lateral drain sent off for culture, urine\n culture sent, blood cultures sent this am.\n - Neo titrated to keep MAP > 65.\n - 500 cc LR bolus given in am for low urine output down to 15\n cc/hr.\n - Encouraged to cough and deep breath, use of IS, chest PT,\n turned and repositioned for comfort.\n - Vac dsg changed with UBE due to leakage.\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703980, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asks about\nwhen the\n court house is open\n or asks if\nthe dog has been fed\n. Following\n commands, MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. Jtube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains extubated, O2 sat 95-100% on 50% cool-neb. LS\n clear to ronchii, diminished at bases. Coughing and raising small\n amounts of thick white sputum into mouth\n HR 109-120\ns, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift. At approx 0200, pt\n dropped SBP to 78, Map 54, Fluid given (only 300cc) with pos effect,\n SBP sustained 85-95 with MAP 53-60, MD notified, 5% Albumin given\n with pos effect\n Pt approx 2400cc neg as of MN, currently even due to fluid\n boluses\n CVP 8-11\n U/O 20-45cc/hr, dark amber urine via foley cath. Cr 1.6 BUN\n 81. At approx 0200, no u/o, MD notified, foley flushed easily, 5%\n albumin given, labs sent, next hour 25cc of urine\n Afebrile, tmax 97.1 WBC 21 up from 18.2\n Hct stable, Plt 92\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 1/2cc:cc repletion for JP outputs with LR\n 5% Albumin x1\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703986, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions related to realitry\nwhen does the courthouse open?\n Following commands, MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. Jtube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains on 70% cool-neb, O2 sat 98-100%. LS clear to\n ronchii, diminished at bases. Coughing and raising small amounts of\n thick white sputum into mouth\n HR 100-115, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift.\n Pt fluid balance approximately even as of MN\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 1.6\n BUN 81.\n Afebrile, tmax 98.5 WBC 21 up from 18.2\n Hct stable, Plt 92\n Pt denies pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 3/4cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 3/4cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704325, "text": "Shock, septic\n Assessment:\n Afebrile. HR SR/ST 95-110. No ectopy. Continues on Neo\n titrating for goal MAP >65.\n JP drain x2. Lateral to large bulb suction. Medial to LCWS\n with moderate amounts of serosang drainage.\n J-tube x2. TF at goal tolerating well with no residuals.\n Upper J-tube to gravity draining small amounts of bile.\n Abdomen soft. + BS. FIB intact with small amounts of loose\n golden stool. Guaiac Negative. NGT intact to wall suction. Scant\n amounts of bilious output. Not to manipulate.\n Ophthalmology into assess pt and no noted fungus in eyes.\n Lungs coarse. Oxygen saturations >96% on 4L NC. Weak\n productive/congested cough. Using yankeur and clearing own secretions\n well.\n Pt c/o generalized pain primarily in abdominal region.\n Action:\n Giving pt LR for cc/cc repletion\ns from drain outputs\n hourly. Held x7 hours overnight per Dr as pt had become\n positive 2L and has goal of running even daily (+1.2L at midnight) >>\n cc/cc re-started at 0200.\n Albumin 25% given for every 1L out from JP drains.\n Receiving IV antibiotics for gram pos cocci from CVL tip\n culture.\n Titrating Neo as needed.\n Encouraging c/db. CPT with turns/repositions.\n Treating pain with Fentanyl IVP as needed.\n Response:\n Maintaining MAP >65.\n WBC slightly improved down from 26 to 25.5\n Pain moderately relieved. Pt able to sleep in small\n intervals.\n Pt currently on RA sats >96% lungs clear. Diminished in\n bases.\n Plan:\n Continue to titrate Neo for MAP >65.\n Monitor JP drain outputs and continue with Albumin\n administration and LR cc/cc repletion\n Monitor TF residuals every 4 hours.\n Encourage c/db and IS.\n Continue to monitor pain/comfort treating as needed.\n Provide emotional support to pt as pt starting to verbalize\n feelings of being\ntired and wanting to go home\n Impaired Skin Integrity\n Assessment:\n Skin tears noted on right abdomen. Mepliex applied to upper\n anterior chest from face tent skin irritation.\n Action:\n Abdominal areas cleansed with NS. Skin tear open to air.\n Additional skin tear in RQ covered by the drain dressing.\n Response:\n Skin remains impaired. No further breakdown or irritation\n noted.\n Plan:\n Dressings remain intact with abdominal skin tear open to\n air.\n Not to use Tegaderm dressings on skin tears.\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704434, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, oriented x 3 although occasionally believes he is\n at , able to lift and hold all extremties\n although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of serosang\n drainage, medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr impact\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704436, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, lethargic today, oriented x 3 although occasionally\n believes he is at , able to lift and hold\n all extremties although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of ascitic fluid,\n medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr.\n Patient sating 94-99% on room air. Good cough and able to clear\n secretions with yankur.\n -urine output 15-35 cc/hr.\n Action:\n - SICU and transplant team in to assess.\n - Continued with cc:cc fluid repleation from jp drain output,\n continued with 25% albumin administration q 1 L output from jp\n - Ascitic fluid from lateral drain sent off for culture.\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704438, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, lethargic today, oriented x 3 although occasionally\n believes he is at , able to lift and hold\n all extremties although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of ascitic fluid,\n medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr.\n Patient sating 94-99% on room air. Good cough and able to clear\n secretions with yankur.\n -urine output 15-35 cc/hr.\n Action:\n - SICU and transplant team in to assess.\n - Continued with cc:cc fluid repleation from jp drain output,\n continued with 25% albumin administration q 1 L output from jp\n - Ascitic fluid from lateral drain sent off for culture, urine\n culture sent, blood cultures sent this am.\n - Neo titrated down\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-11-01 00:00:00.000", "description": "Intensivist Note", "row_id": 704551, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n fungal sepsis\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n Calcium Gluconate 9. Fentanyl Citrate 10. Fentanyl Citrate 11. Insulin\n 12. Micafungin 13. Pantoprazole 14. Phenylephrine 15. Sodium Chloride\n 0.9% Flush 16. Sodium Chloride 0.9% Flush 17. Tetracaine HCl 18.\n Vancomycin\n 24 Hour Events:\n Hypotension requiring progressive increases in phenylephrine drip.\n Albumin bolus x1. ID consulted. Aline replaced\n ARTERIAL LINE - STOP 01:01 PM\n ARTERIAL LINE - START 01:20 PM\n Post operative day:\n POD#15 - ex lap duod ulcer repair\n POD#12 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:05 AM\n Other medications:\n Flowsheet Data as of 06:00 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: 36.6\nC (97.9\n HR: 100 (98 - 117) bpm\n BP: 118/60(78) {81/44(56) - 119/67(83)} mmHg\n RR: 17 (15 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 8 (-1 - 9) mmHg\n Total In:\n 11,108 mL\n 2,713 mL\n PO:\n Tube feeding:\n 3,000 mL\n 731 mL\n IV Fluid:\n 7,741 mL\n 1,849 mL\n Blood products:\n 367 mL\n 133 mL\n Total out:\n 8,638 mL\n 2,961 mL\n Urine:\n 493 mL\n 121 mL\n NG:\n 200 mL\n 300 mL\n Stool:\n Drains:\n 7,725 mL\n 2,540 mL\n Balance:\n 2,470 mL\n -248 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///20/\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: CTA bilateral : )\n Abdominal: Soft, Distended, Tender on LEFT side\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 222 K/uL\n 9.7 g/dL\n 125 mg/dL\n 2.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 103 mEq/L\n 131 mEq/L\n 28.8 %\n 19.6 K/uL\n [image002.jpg]\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n 01:59 AM\n WBC\n 26.0\n 21.9\n 26.1\n 25.5\n 19.6\n Hct\n 33.7\n 32.1\n 32.5\n 32.6\n 28.8\n Plt\n 130\n 140\n 192\n 244\n 222\n Creatinine\n 1.7\n 2.0\n 1.9\n 2.0\n 2.2\n 2.4\n TCO2\n 20\n 18\n 15\n Glucose\n 135\n 130\n 102\n 128\n 155\n 162\n 125\n Other labs: PT / PTT / INR:23.9/58.6/2.3, ALT / AST:17/43, Alk-Phos / T\n bili:97/8.8, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:3.2 g/dL, LDH:182 IU/L, Ca:7.7 mg/dL, Mg:1.4\n mg/dL, PO4:4.5 mg/dL\n Imaging: EGD - EGD showed 1 cord of non-bleeding grade II\n varices at 36 cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal\n duodenal bulb, clotted blood in the antrum, and slight ulceration of\n the ampulla of Vater with a small amount of blood on it.\n EGD - 2 cords of grade I varices were seen in the lower third\n of the esophagus.\n C-scope Medium non-bleeding grade 2 internal hemorrhoids were\n noted. Two 4 mm non bleeding ulcers noted on hemorrhoid likely at site\n of previous banding.\n EKG: SR 93 bpm NA/NI no ST-T wave abnormalities\n CXR - left basal consolidation, persistent and may represent\n atelectasis versus infectious process\n TTE - EF > 75%, globally hyperdynamic; no vegitation or valve\n abnormality\n .\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Fentanyl prn, awake and following commands\n CVS: Vasodilatory shock thought to be fungemia, compounded by\n ongoing volume losses from abd/ascites, current fluid repletion 3/4:1\n cc\n change to 1:1 repletion with NS, on neo gtt for hypotension; If\n increased need for pressors, start Zosyn per ID recs\n PULM: extubated on NC now\n RENAL: Foley, follow UOP, replacing ascites drain output. Albumin 12.5g\n per 1L ascites. Hx of hepatorenal syndrome. UA(-)\n FEN/GI: protonix 40 , TF impact 3/4 strength at 125ml/hr; more\n tender to palpation in , check KUB/CXR to evaluate for\n perforation\n ID: micafungin started non-albicans yeast blood/ascites-ok'd by\n ID\n speciated, will discuss with ID best for\n tx, continue Micafungin; vanc for GPC tip cx; ophthalmology consulted\n , exam negative. Daily surveillance coverage. All lines changed\n out. Follow vanco level prior to 4th dose. Surveillance cx daily.\n Ascites gs(-).\n HEME: Hct stable type and crossed for 4 units; INR 2.3\n FFP per\n transplant, Vit K also;\n ENDO: RISS, adequate control\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ TLC, JP x2, NGT, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:57 PM 125 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31min\n" }, { "category": "Nursing", "chartdate": "2164-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704149, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions related to realitry\nwhen does the courthouse open?\n Pt able\n to sleep for a couple of hours through the night. Following commands,\n MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. J tube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains on 70% cool-neb, O2 sat 98-100%. LS clear to\n ronchii, diminished at bases. Coughing and raising small amounts of\n thick white sputum into mouth\n HR 100-115, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift. At approx 0400 pt\n dropped BP to 70\ns, min u/o, HR 120\ns. MD notified and in to\n assess pt. Albumin and fluid boluses given with mod effect.\n Pt fluid balance approximately even as of MN\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 2 BUN\n 87\n Afebrile, tmax 98.5 WBC 26 up from 21\n Hct stable, Plt 130\n Pt denies pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 3/4cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Cdiff specimen sent\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 3/4cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704152, "text": "52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum. IR\n unable to embolize, surgiseal in place.\n S/P transfusion of 30+ units pRBC, FFP in MICU\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions:\nWhen can I talk to the Judge?\n Pt able to sleep in naps.\n , with generalized weakness, following commands\n Abd incision OTA, staples intact, JPx2 with nursing\n engineered\nVac dressing\n (NGT sumping excess drainage from JP sites),\n copious amounts of serosanguinous drainage from drains. J tube x2, one\n to drainage draining moderate amts bilious fluid, other one feeding,\n NGT to LCS, clear drainage.\n Pt remains on 50% face tent, O2 sat 98-100%. LS clear to\n rhonchorous, diminished at bases. Weak cough, raising small amounts of\n thick white sputum into mouth with encouragement\n HR 99-115, small improvement with fluid boluses and Albumin.\n Albumin given ~q 2 hours for drain output 1 liter\n Neo gtt at 0.6-BP 95-120\ns with MAP >60.\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 2 BUN\n 87\n Afebrile, tmax 98.1 WBC 26 up from 21\n Hct stable 32\n Reports pain at incision sites with movement/turning\n Action:\n Aggressive pulm hygiene\n JP drainage monitored q 1\n cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring labs\n DSD over JP sites changed\n Fentanyl prn pain\n 3^rd Cdiff specimen sent\n Emotional support/reorientation provided\n A-line re-wired by Dr. \n UA and urine lytes sent\n Response:\n Hemodynamics improving with fluid/Albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Cont aggressive pulm hygiene\n Monitor Labs\n Continue with cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Cont provide emotional support to pt and family\n" }, { "category": "Nursing", "chartdate": "2164-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704150, "text": "52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions:\nWhen can I talk to the Judge?\n Pt able to sleep in naps.\n , with generalized weakness, following commands\n Abd incision OTA, staples intact, JPx2 with nursing\n engineered\nVac dressing\n (NGT sumping excess drainage from JP sites),\n copious amounts of serosanguinous drainage from drains. J tube x2, one\n to drainage draining moderate amts bilious fluid, other one feeding,\n NGT to LCS, clear drainage.\n Pt remains on 50% face tent, O2 sat 98-100%. LS clear to\n rhonchorous, diminished at bases. Weak cough, raising small amounts of\n thick white sputum into mouth with encouragement\n HR 99-115, small improvement with fluid boluses and Albumin.\n Albumin given ~q 2 hours for drain output 1 liter\n Neo gtt at 0.6-BP 95-120\ns with MAP >60.\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 2 BUN\n 87\n Afebrile, tmax 98.1 WBC 26 up from 21\n Hct stable 32\n Reports pain at incision sites with movement/turning\n Action:\n Aggressive pulm hygiene\n JP drainage monitored q 1\n cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring labs\n DSD over JP sites changed\n Fentanyl prn pain\n Cdiff specimen sent\n Emotional support/reorientation provided\n A-line re-wired by Dr. \n UA and urine lytes sent\n Response:\n Hemodynamics improving with fluid/Albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 3/4cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704484, "text": "Shock, septic\n Assessment:\n Pt lethargic in bed. Oriented x3 although needing help at\n times to specific month. Assisting with turns in bed, weak in\n movements. Pt with c/o generalized pain primarily in abdomen rating\n on pain scale.\n NGT to medium continuous wall suction. Small amounts bilious\n drainage.\n Abdomen soft/ascetic. Lateral JP to self suction with\n moderate amounts ascetic/ser-sang drainage. Medial JP to wall suction\n with large amounts of drainage.\n Upper J-tube to gravity with bilious output. Lower J-tube\n with TF infusing at goal.\n Foley patent pt making amber clear urine about 15-25cc\n hourly.\n Lungs clear at apeces diminished in bases. Sat\ns 94-97% RA.\n Strong productive cough. Using IS pulling 1000-1300cc. Clearing own\n secretions well.\n Afebrile. WBC 25.5. NSR/ST HR 95-115. No ectopy. Continues\n on Neo drip.\n Action:\n Giving Fentanyl as needed for pain.\n Repleting JPx2 outputs with LR\n cc:cc. Administering 25%\n Albumin for every 1L of JP drainage.\n Encouraging c/db.\n Titrating Neo drip for goal MAP >65.\n Response:\n Mild pain relief with Fentanyl. Pt with sharp breakthrough\n of pain during night. Dr and Transplant team notified and\n arrived at bedside to further assess pt.\n Pt 2.4L positive at midnight. Teams notified. Thus far\n continuing fluid repletions.\n Plan:\n Monitor pain/comfort treating as needed.\n Continue to monitor all drain outputs and continue LR\n cc:cc JP drain repletions.\n Encourage c/db. IS use.\n F/u cultures. Continue antibiotics and WBC.\n Titrate Neo to goal.\n" }, { "category": "Physician ", "chartdate": "2164-10-25 00:00:00.000", "description": "Intensivist Note", "row_id": 703423, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n .\n MEDICATIONS (per d/c summary )\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n Albumin 25% (12.5g / 50mL) 6. Artificial Tear Ointment 7. Calcium\n Gluconate\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Fentanyl Citrate 10.\n Fluconazole 11. Insulin 12. Octreotide Acetate\n 13. Pantoprazole 14. Piperacillin-Tazobactam 15. Potassium Chloride 16.\n Sodium Chloride 0.9% Flush\n 17. Sodium Bicarbonate 18. Vancomycin\n 24 Hour Events:\n Weaned vent to minimal settings. Continued to have high output around\n JP drains. Ascities replacement schedule adjusted. Surgical team\n evaluated and re-dressed.\n .\n Post operative day:\n POD#8 - ex lap duod ulcer repair\n POD#5 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:19 AM\n Fluconazole - 10:01 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:02 PM\n Fentanyl - 12:15 AM\n Other medications:\n Flowsheet Data as of 06:29 AM\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: 128 (107 - 132) bpm\n BP: 117/67(82) {91/48(62) - 133/71(90)} mmHg\n RR: 31 (15 - 31) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.9 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 13 (10 - 327) mmHg\n Total In:\n 7,563 mL\n 2,010 mL\n PO:\n Tube feeding:\n 616 mL\n 193 mL\n IV Fluid:\n 5,318 mL\n 1,277 mL\n Blood products:\n 350 mL\n 100 mL\n Total out:\n 10,109 mL\n 3,638 mL\n Urine:\n 879 mL\n 193 mL\n NG:\n 650 mL\n 300 mL\n Stool:\n 300 mL\n 700 mL\n Drains:\n 8,280 mL\n 2,445 mL\n Balance:\n -2,546 mL\n -1,628 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 595 (576 - 720) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 59.1 cmH2O/mL\n SPO2: 99%\n ABG: 7.37/32/108/18/-5\n Ve: 11.6 L/min\n PaO2 / FiO2: 216\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli, Unresponsive), Moves all extremities\n Labs / Radiology\n 59 K/uL\n 11.9 g/dL\n 143 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 67 mg/dL\n 119 mEq/L\n 144 mEq/L\n 35.0 %\n 14.7 K/uL\n [image002.jpg]\n 10:03 AM\n 02:06 PM\n 02:13 PM\n 08:11 PM\n 02:05 AM\n 02:24 AM\n 10:27 AM\n 04:26 PM\n 02:32 AM\n 02:37 AM\n WBC\n 14.1\n 13.4\n 12.9\n 14.7\n Hct\n 35.3\n 33.8\n 34.6\n 35.0\n Plt\n 80\n 74\n 69\n 59\n Creatinine\n 1.9\n 1.8\n 1.7\n TCO2\n 19\n 19\n 18\n 16\n 17\n 19\n Glucose\n 133\n 145\n 154\n 122\n 126\n 143\n Other labs: PT / PTT / INR:20.1/62.9/1.8, ALT / AST:12/32, Alk-Phos / T\n bili:66/8.6, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:158 IU/L, Ca:8.0 mg/dL, Mg:2.0\n mg/dL, PO4:3.4 mg/dL\n Imaging: CXR - overall improvement in lung herniation except for left\n basal consolidation, which is persistent and may represent atelectasis\n versus infectious process\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated s/p PPF gtt. Beginning to be more awake, moving\n extremeties to command.\n CVS: s/p neo gtt;\n PULM: Intubated, s/p bronch for mucus plug . Daily ABG.\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Albumin 12.5g per 1L ascites, also giving HCO3 for\n every 3L ascites. Hx of hepatorenal syndrome, renal following. No HD at\n this time. 24 hr urine creatinine ordered\n FEN/GI: NPO, protonix drip, octreotide gtt, TPN, TF nepro 1/2 strength\n at 20 cc/hr (not advancing). Consider wean of octreotide.\n ID: vanc / zosyn / fluc; f/u cx\n HEME: Hct stable type and crossed for 4 units. Given\n ENDO: RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, s/p L IJ triple lumen, R SC trauma line ( PIV x1,\n JP x2, NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 03:23 PM 30 mL/hour\n TPN without Lipids - 06:11 PM 66. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701772, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704304, "text": "Shock, septic\n Assessment:\n Afebrile. HR SR/ST 95-110. No ectopy. Continues on Neo\n titrating for goal MAP >65.\n JP drain x2. Lateral to large bulb suction. Medial to LCWS\n with moderate amounts of serosang drainage.\n J-tube x2. TF at goal tolerating well with no residuals.\n Upper J-tube to gravity draining small amounts of bile.\n Abdomen soft. + BS. FIB intact with small amounts of loose\n golden stool. Guaiac Negative. NGT intact to wall suction. Scant\n amounts of bilious output. Not to manipulate.\n Ophthalmology into assess pt and no noted fungus in eyes.\n Lungs coarse. Oxygen saturations >96% on 4L NC. Weak\n productive/congested cough. Using yankeur and clearing own secretions\n well.\n Pt c/o generalized pain primarily in abdominal region.\n Action:\n Giving pt LR for cc/cc repletion\ns from drain outputs\n hourly. Held for a few hours overnight as pt had become positive and\n has goal of running even daily>> cc/cc re-started at 0200.\n Albumin 25% given for every 1L out from JP drains.\n Receiving IV antibiotics for funducemia and gram pos cocci\n from CVL tip culture.\n Titrating Neo as needed.\n Encouraging c/db. CPT with turns/repositions.\n Treating pain with Fentanyl IVP as needed.\n Response:\n Maintaining MAP >65.\n WBC\n Pain moderately relieved. Pt able to sleep in small\n intervals.\n Plan:\n Continue to titrate Neo for MAP >65.\n Monitor JP drain outputs and continue with Albumin\n administration and LR cc/cc repletion\n Monitor TF residuals every 4 hours.\n Encourage c/db and IS.\n Continue to monitor pain/comfort treating as needed.\n Provide emotional support to pt as pt starting to verbalize\n feelings of being\ntired and wanting to go home\n Impaired Skin Integrity\n Assessment:\n Skin tears noted on right abdomen. Mepliex applied to upper\n anterior chest from face tent skin irritation.\n Action:\n Abdominal areas cleansed with NS. Skin tear open to air.\n Additional skin tear in RQ covered by the drain dressing.\n Response:\n Skin remains impaired. No further breakdown or irritation\n noted.\n Plan:\n Dressings remain intact with abdominal skin tear open to\n air.\n Not to use Tegaderm dressings on skin tears.\n" }, { "category": "Rehab Services", "chartdate": "2164-11-02 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 704764, "text": "Subjective:\n Patient agreeable to PT and OT.\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n with railing\n\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n requires min A x 1 and mod A x 1\n\n\n\n x1\n x 1\n\n Transfer:\n n/a 2\n tachycardia\n\n\n\n\n\n\n Sit to Stand:\n n/a\n\n\n\n\n\n\n Ambulation:\n n/a\n\n\n\n\n\n\n Stairs:\n n/a\n\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 123\n 106/52\n 22\n 95% RA\n Activity\n Sit\n 148\n /\n 94% RA\n Recovery\n Supine\n 130\n 110/56\n 27\n 93% RA\n Supine\n 122\n 125/59\n 27\n 98% RA\n Total distance walked: n/a\n Minutes:\n Clarification:\n Rolling: requires verbal cues to bend knee and reach across for bed\n rail, then requires max A x 1.\n Sidelying to sit: requires assist to bring B LE off EOB. Then requires\n min A x 1 and mod A x 1 to push up to sitting.\n Balance: Seated: sat EOB x 5-10 minutes with CG to min A x 1, limited\n by tachycardia\n Education / Communication: Educated patient as to role of PT and OT.\n Communicated with RN.\n Other: n/a\n Assessment: Patient showed improved function, requiring less assistance\n for mobility, but did become tachycardic with activity. Patient\n sustained a HR of > 140 for several minutes; thus further treatment was\n deferred. Patient will benefit from rehab of 3 hours/day on discharge.\n Anticipated Discharge: Rehab\n Plan: Transfer training, balance training at EOB, sit to stand, stand\n pivot transfers, patient education\n Face Time: 11:10 - 11:40\n RN Recommendations: OOB to stretcher chair via slideboard\n" }, { "category": "Nursing", "chartdate": "2164-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704983, "text": "Electrolyte & fluid disorder, other\n Assessment:\n As of 12 noon pt has been negative 1 liter today.\n Replacing ascites with\n CC per CC with NS\n u/o decreased to 15ml x 1\n neo at 1.5mcg/kg/min\n Na 132, Magnesium 1.3\n tachy 120-130 (intravasc dehydration vs pain) Pain subjective\n Action:\n Extra dose albumin to replete intravasc volume.\n neo decreased to 1mcg/kg/min\n NS used to replace ascitic fliud as ordered.\n neo decreased to 1mcg/kg/min\n replacement changed back to cc/cc per D.O.\n Response:\n u/o increased to 60mlx 1 hr then back down to minimal\n Plan:\n Continue to monitor F&E\n replace/replete as ordered\n Shock, septic\n Assessment:\n MAP >65\n Neo at 1.5mcg/kg/min\n Line tip from positive for GM pos cocci\n fungal c/s pos ascitic fluid and blood\n vanco level 23\n Action:\n Micofungin and vanco\n Response:\n T99, MAP>65 with neo on 1mcg\n Plan:\n Titrate down on neo for MAP>65\n Impaired Skin Integrity\n Assessment:\n meriplex removed from upper ant chest below neck\n area pinl healing so meriplex removed.\n Another area closer to RIJ TL skin tear noted\n Action:\n Meriplex applied to new skin tear\n continue to asswess skin qshift\n Response:\n Old skin tear healed.\n Plan:\n Prevent new skin tears\n Avoid use of tegaderm\n" }, { "category": "Physician ", "chartdate": "2164-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 704383, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Artificial Tear Ointment\n Calcium Gluconate\n Fentanyl Citrate\n Insulin\n Magnesium Sulfate\n Micafungin\n Ondansetron\n Pantoprazole\n Phenylephrine\n Tetracaine HCl\n Vancomycin\n 24 Hour Events:\n URINE CULTURE - At 01:10 PM\n cont pressors\n cath tip cx +GPC - resumed vancomycin\n Post operative day:\n POD#14 - ex lap duod ulcer repair\n POD#11 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 06:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 AM\n Fentanyl - 02:44 AM\n Other medications:\n Flowsheet Data as of 05:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.3\nC (99.2\n HR: 107 (98 - 112) bpm\n BP: 91/53(65) {78/44(56) - 129/63(83)} mmHg\n RR: 19 (16 - 24) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 1 (-5 - 11) mmHg\n Total In:\n 12,291 mL\n 1,636 mL\n PO:\n Tube feeding:\n 2,045 mL\n 621 mL\n IV Fluid:\n 9,795 mL\n 965 mL\n Blood products:\n 450 mL\n 50 mL\n Total out:\n 11,061 mL\n 1,588 mL\n Urine:\n 466 mL\n 83 mL\n NG:\n 425 mL\n 50 mL\n Stool:\n Drains:\n 10,170 mL\n 1,455 mL\n Balance:\n 1,230 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (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 244 K/uL\n 10.8 g/dL\n 162 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 77 mg/dL\n 104 mEq/L\n 132 mEq/L\n 32.6 %\n 25.5 K/uL\n [image002.jpg]\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n WBC\n 21.0\n 26.0\n 21.9\n 26.1\n 25.5\n Hct\n 34.1\n 33.7\n 32.1\n 32.5\n 32.6\n Plt\n 95\n 130\n 140\n 192\n 244\n Creatinine\n 1.6\n 1.7\n 2.0\n 1.9\n 2.0\n 2.2\n TCO2\n 20\n 18\n 15\n Glucose\n 148\n 135\n 130\n 102\n 128\n 155\n 162\n Other labs: PT / PTT / INR:20.4/58.3/1.9, ALT / AST:17/44, Alk-Phos / T\n bili:107/7.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:182 IU/L, Ca:7.5 mg/dL, Mg:1.6\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Fentanyl prn, awake and following commands; Ophtho exam w/o e/o\n retinal involvement\n CVS: intermittent fluid boluses, neo gtt for hypotension, wean as\n tolerated;\n PULM: extubated on NC now, IS\n RENAL: Foley, follow UOP, creatinine rising; send urine sediment, eval\n for ATN; replacing ascites drain output 1 to 1 with LR. Albumin 12.5g\n per 1L ascites. Hx of hepatorenal syndrome. F/u urine lytes. Goal even\n balance.\n FEN/GI: protonix 40 , TF impact 3/4 strength at 125ml/hr\n ID: micafungin started yeast blood/ascites, discuss with ID\n whether change in needed given persistent WBC and prelim NOT\n albicans; vanc for GPC tip cx; ophthalmology consult w/o e/o retinal\n involvement; will broaden and add GN coverage if clinically\n deteriorating\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS, adequate control\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube, A-line\n (place new A-line, send tip for cx)\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n Impact with Fiber () - 12:00 AM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:20 PM\n Multi Lumen - 12:06 PM\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": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704468, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, lethargic today, oriented x 3 although occasionally\n believes he is at , able to lift and hold\n all extremities although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of ascitic fluid,\n medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr.\n Patient sating 94-99% on room air. Good cough and able to clear\n secretions.\n -urine output 15-35 cc/hr.\n -c/o out of 10 abdominal pain especially with activity/ turning.\n *MAP down to 55 in afternoon\n Action:\n - SICU and transplant team in to assess.\n - Continued with cc:cc fluid repleation from jp drain output,\n continued with 25% albumin administration q 1 L output from jp\n - Ascitic fluid from lateral drain sent off for culture, urine\n culture sent, blood cultures sent this am.\n - Neo titrated to keep MAP > 65.\n - 500 cc LR bolus given in am for low urine output down to 15\n cc/hr.\n - Encouraged to cough and deep breath, use of IS, chest PT,\n turned and repositioned for comfort.\n - Vac dsg changed with UBE due to leakage.\n - Given 50 mcg fent prn pain.\n * SICU team and transplant team aware of hypotensive episode in\n afternoon. Transplant is ok with going up on Neo, gave 1 extra dose of\n concentrated 25% albumin in 50 cc.\n Response:\n Patient is currently 2 L pos. for the day so far,\n 500 cc LR bolus increased u/o from 15 cc-35 cc/hr,\n Awaiting results from cultures,\n Map > 65 on Neo.\n Ascetic output continues to be 200-500 cc/hr\n Patient able to nap during day, appears comfortable after fent given\n for pain.\n Plan:\n Continue with cc:cc repleation for now with 25% albumin to give q 1 L\n output of ascitic fluid,\n Avoid extra bolus\n per transplant, ok to go up on Neo, contact\n transplant if patient needs fluid bolus.\n ------ Protected Section ------\n Transplant team in to assess, changed to\n cc per cc ascetic output.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:11 ------\n" }, { "category": "Physician ", "chartdate": "2164-11-03 00:00:00.000", "description": "Intensivist Note", "row_id": 704889, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n BRBPR\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular Order date: @ 1311\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 2. 1000 mL NS\n Continuous at 0 ml/hr\n please give 3/4 cc for every 1 cc JP output repletion Order date: \n @ 0805\n 12. Micafungin 100 mg IV DAILY Order date: @ 0917\n 3. 1000 mL LR\n Continuous at 1000 ml/hr Order date: @ 2237\n 13. Ondansetron 4 mg IV Q8H:PRN N/V Order date: @ 0447\n 4. Albumin 25% (12.5g / 50mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 1329\n 14. Pantoprazole 40 mg IV Q12H Order date: @ 0946\n 5. Albumin 25% (12.5g / 50mL) 12.5 g IV Q2H Duration: 48 Hours\n Please give 12.5g per 1L ascites output from abdominal drains. Order\n date: @ 0109\n 15. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>60 Order\n date: @ 1407\n 6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758\n 16. Rifaximin 400 mg PO TID\n can crush and administer via J-tube per pharmacy Order date: @\n 0919\n 7. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 17. 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: @ 1311\n 8. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain\n please hold for oversedation or rr<8 Order date: @ 1338\n 18. 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: @ 1703\n 9. HYDROmorphone (Dilaudid) 0.5 mg IV ONCE Duration: 1 Doses Order\n date: @ 1811\n 19. Tetracaine HCl *NF* 0.5 % OU as directed\n Tetracain 0.5% oph gtt one drop to each eye prior to giving\n phenylephrine and tropicamide drops. Thanks. Order date: @ 1435\n 10. HYDROmorphone (Dilaudid) 0.5 mg IV ONCE Duration: 1 Doses Order\n date: @ 0256\n 20. Vancomycin 1000 mg IV Q 24H *Awaiting ID Approval*\n ID Approval is required for this order.\n check vanc trough after third dose; HOLD PM DOSE 10/30 Order date:\n @ \n 24 Hour Events:\n Dry heaving, no emesis or blood. Started zofran. Complaining of\n intermittent LLQ pain, given small doses of dilauded with some\n improvement. 1U PRBCs, weaning neo gtt.\n Post operative day:\n POD#17 - ex lap duod ulcer repair\n POD#14 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 AM\n Hydromorphone (Dilaudid) - 03:15 AM\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.2\nC (99\n HR: 118 (109 - 127) bpm\n BP: 110/57(75) {92/48(67) - 128/68(88)} mmHg\n RR: 21 (16 - 23) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 10 (2 - 12) mmHg\n Total In:\n 10,045 mL\n 2,778 mL\n PO:\n Tube feeding:\n 3,041 mL\n 748 mL\n IV Fluid:\n 6,299 mL\n 1,880 mL\n Blood products:\n 704 mL\n 150 mL\n Total out:\n 9,669 mL\n 3,088 mL\n Urine:\n 499 mL\n 128 mL\n NG:\n Stool:\n 60 mL\n Drains:\n 9,110 mL\n 2,960 mL\n Balance:\n 376 mL\n -310 mL\n Respiratory support\n SPO2: 94%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Tender: LLQ\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: Jaundice, (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 194 K/uL\n 9.2 g/dL\n 140 mg/dL\n 3.1 mg/dL\n 14 mEq/L\n 4.1 mEq/L\n 90 mg/dL\n 108 mEq/L\n 132 mEq/L\n 27.5 %\n 17.1 K/uL\n [image002.jpg]\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n 01:59 AM\n 08:25 AM\n 02:03 AM\n 02:11 AM\n 04:11 PM\n 02:35 AM\n WBC\n 21.9\n 26.1\n 25.5\n 19.6\n 18.1\n 18.1\n 17.1\n Hct\n 32.1\n 32.5\n 32.6\n 28.8\n 28.1\n 28.1\n 27.5\n Plt\n 140\n 192\n 244\n 222\n 210\n 210\n 194\n Creatinine\n 1.9\n 2.0\n 2.2\n 2.4\n 2.8\n 3.1\n TCO2\n 15\n 16\n 15\n Glucose\n 128\n 155\n 162\n 125\n 136\n 140\n Other labs: PT / PTT / INR:24.0/55.8/2.3, ALT / AST:17/42, Alk-Phos / T\n bili:89/14.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:3.4 g/dL, LDH:164 IU/L, Ca:7.4 mg/dL, Mg:1.3\n mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Vasolitory shock, fluid repletion 3/4:1, on neo gtt for\n hypotension\n PULM: on NC now\n RENAL: Foley, follow UOP, replacing ascites output to 1 with LR.\n Albumin 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not\n believe this is related to micafungin. FeNa = 0.2, giving boluses with\n albumin PRN for BP / UOP.\n FEN/GI: protonix 40\", TF impact 3/ strength at 125ml/hr. Rifaximin for\n hepatic encephalopathy.\n ID: micafungin started blood/ascites; vanc for\n coag neg staph tip cx; ophthalmology exam negative. Daily surv cx. All\n lines changed out. Follow vanco level prior to 4th dose. Ascites gs(-)\n HEME: Hct stable\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Total Time Spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704013, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions related to realitry\nwhen does the courthouse open?\n Pt able\n to sleep for a couple of hours through the night. Following commands,\n MAE, Pupils equal and reactive.\n Abd incision OTA, staples intact, JPx2 with nsg engineered\n VAC dsg, copious amounts of serosang drainage from drains. J tube x2,\n one to drainage, one to feeding, bilious drainage from the other. NGT\n to LCS, clear drainage.\n Pt remains on 70% cool-neb, O2 sat 98-100%. LS clear to\n ronchii, diminished at bases. Coughing and raising small amounts of\n thick white sputum into mouth\n HR 100-115, small improvement with fluid boluses. BP\n 95-120\ns with MAP >65 throughout majority of shift. At approx 0400 pt\n dropped BP to 70\ns, min u/o, HR 120\ns. MD notified and in to\n assess pt. Albumin and fluid boluses given with mod effect.\n Pt fluid balance approximately even as of MN\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 2 BUN\n 87\n Afebrile, tmax 98.5 WBC 26 up from 21\n Hct stable, Plt 130\n Pt denies pain\n Action:\n Pulmonary hygiene per VAP protocol, aggressive pulm\n toileting\n 3/4cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Fentanyl prn pain\n Cdiff specimen sent\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 3/4cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704289, "text": "Shock, septic\n Assessment:\n Afebrile. HR SR/ST 95-110. No ectopy. Continues on Neo\n titrating for goal MAP >65.\n JP drain x2. Lateral to large bulb suction. Medial to LCWS\n with moderate amounts of serosang drainage.\n J-tube x2. TF at goal tolerating well with no residuals.\n Upper J-tube to gravity draining small amounts of bile.\n Abdomen soft. + BS. FIB intact with small amounts of loose\n golden stool. Guaiac Negative. NGT intact to wall suction. Scant\n amounts of bilious output. Not to manipulate.\n Ophthalmology into assess pt and no noted fungus in eyes.\n Lungs coarse. Oxygen saturations >96% on 4L NC. Weak\n productive/congested cough. Using yankeur and clearing own secretions\n well.\n Action:\n Giving pt LR for cc/cc repletion\ns from drain outputs\n hourly. Held for a few hours overnight as pt had become positive and\n has goal of running even daily.\n Albumin 25% given for every 1L out from JP drains.\n Receiving IV antibiotics for funducemia and gram pos cocci\n from CVL tip culture.\n Titrating Neo as needed.\n Encouraging c/db. CPT with turns/repositions.\n Response:\n Maintaining MAP >65.\n WBC\n Plan:\n Continue to titrate Neo for MAP >65.\n Monitor JP drain outputs and continue with Albumin\n administration and LR cc/cc repletion\n Monitor TF residuals every 4 hours.\n Encourage c/db and IS.\n Impaired Skin Integrity\n Assessment:\n Skin tears noted on right abdomen. Mepliex applied to upper\n anterior chest from face tent skin irritation.\n Action:\n Abdominal areas cleansed with NS. Skin tear open to air.\n Additional skin tear in RQ covered by the drain dressing.\n Response:\n Skin remains impaired. No further breakdown or irritation\n noted.\n Plan:\n Dressings remain intact with abdominal skin tear open to\n air.\n Not to use Tegaderm dressings on skin tears.\n" }, { "category": "Physician ", "chartdate": "2164-11-01 00:00:00.000", "description": "Intensivist Note", "row_id": 704602, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Artificial Tear Ointment\n Calcium Gluconate\n Fentanyl Citrate\n Insulin\n Magnesium Sulfate\n Micafungin\n Ondansetron\n Pantoprazole\n Phenylephrine\n Tetracaine HCl\n Vancomycin\n 24 Hour Events:\n URINE CULTURE - At 01:10 PM\n cont pressors\n cath tip cx +GPC - resumed vancomycin\n Post operative day:\n POD#14 - ex lap duod ulcer repair\n POD#11 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 06:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 AM\n Fentanyl - 02:44 AM\n Other medications:\n Flowsheet Data as of 05:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.3\nC (99.2\n HR: 107 (98 - 112) bpm\n BP: 91/53(65) {78/44(56) - 129/63(83)} mmHg\n RR: 19 (16 - 24) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 1 (-5 - 11) mmHg\n Total In:\n 12,291 mL\n 1,636 mL\n PO:\n Tube feeding:\n 2,045 mL\n 621 mL\n IV Fluid:\n 9,795 mL\n 965 mL\n Blood products:\n 450 mL\n 50 mL\n Total out:\n 11,061 mL\n 1,588 mL\n Urine:\n 466 mL\n 83 mL\n NG:\n 425 mL\n 50 mL\n Stool:\n Drains:\n 10,170 mL\n 1,455 mL\n Balance:\n 1,230 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (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 244 K/uL\n 10.8 g/dL\n 162 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 77 mg/dL\n 104 mEq/L\n 132 mEq/L\n 32.6 %\n 25.5 K/uL\n [image002.jpg]\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n WBC\n 21.0\n 26.0\n 21.9\n 26.1\n 25.5\n Hct\n 34.1\n 33.7\n 32.1\n 32.5\n 32.6\n Plt\n 95\n 130\n 140\n 192\n 244\n Creatinine\n 1.6\n 1.7\n 2.0\n 1.9\n 2.0\n 2.2\n TCO2\n 20\n 18\n 15\n Glucose\n 148\n 135\n 130\n 102\n 128\n 155\n 162\n Other labs: PT / PTT / INR:20.4/58.3/1.9, ALT / AST:17/44, Alk-Phos / T\n bili:107/7.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:182 IU/L, Ca:7.5 mg/dL, Mg:1.6\n mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Fentanyl prn, awake and following commands; Ophtho exam w/o e/o\n retinal involvement\n CVS: intermittent fluid boluses, neo gtt for hypotension, wean as\n tolerated;\n PULM: extubated on NC now, IS\n RENAL: Foley, follow UOP, creatinine rising; send urine sediment, eval\n for ATN; replacing ascites drain output 1 to 1 with LR. Albumin 12.5g\n per 1L ascites. Hx of hepatorenal syndrome. F/u urine lytes. Goal even\n balance.\n FEN/GI: protonix 40 , TF impact 3/4 strength at 125ml/hr\n ID: micafungin started yeast blood/ascites, discuss with ID\n whether change in needed given persistent WBC and prelim NOT\n albicans; vanc for GPC tip cx; ophthalmology consult w/o e/o retinal\n involvement; will broaden and add GN coverage if clinically\n deteriorating\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS, adequate control\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube, A-line\n (place new A-line, send tip for cx)\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n Impact with Fiber () - 12:00 AM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:20 PM\n Multi Lumen - 12:06 PM\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": "2164-11-04 00:00:00.000", "description": "Intensivist Note", "row_id": 705122, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1000 mL NS\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W\n Albumin 25% (12.5g / 50mL)\n Calcium Gluconate\n Cosyntropin\n HYDROmorphone (Dilaudid)\n Insulin\n Magnesium Sulfate\n Micafungin\n Midodrine\n Miconazole Powder 2%\n Octreotide Acetate\n Ondansetron\n Pantoprazole\n Phenylephrine\n Rifaximin\n Sodium Bicarbonate\n Tetracaine HCl\n Vancomycin\n 24 Hour Events:\n NaBicarb given\n weaned neo\n Post operative day:\n POD#18 - ex lap duod ulcer repair\n POD#15 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Micafungin - 02:21 PM\n Infusions:\n Phenylephrine - 0.6 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Hydromorphone (Dilaudid) - 03:45 AM\n Other medications:\n Flowsheet Data as of 05:32 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\nC (98.6\n HR: 120 (110 - 136) bpm\n BP: 100/51(68) {87/43(61) - 136/74(97)} mmHg\n RR: 19 (16 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.4 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 5 (4 - 10) mmHg\n Total In:\n 11,036 mL\n 4,157 mL\n PO:\n Tube feeding:\n 3,017 mL\n 683 mL\n IV Fluid:\n 7,369 mL\n 3,374 mL\n Blood products:\n 600 mL\n 100 mL\n Total out:\n 9,881 mL\n 4,080 mL\n Urine:\n 528 mL\n 130 mL\n NG:\n 2,525 mL\n 750 mL\n Stool:\n 600 mL\n Drains:\n 6,828 mL\n 2,600 mL\n Balance:\n 1,155 mL\n 77 mL\n Respiratory support\n SPO2: 96%\n ABG: 7.41/22/81./14/-7\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: , JP drains\n in place\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: Jaundice, (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 156 K/uL\n 9.2 g/dL\n 165 mg/dL\n 3.0 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.6 %\n 12.2 K/uL\n [image002.jpg]\n 01:59 AM\n 08:25 AM\n 02:03 AM\n 02:11 AM\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n WBC\n 19.6\n 18.1\n 18.1\n 17.1\n 15.8\n 12.2\n Hct\n 28.8\n 28.1\n 28.1\n 27.5\n 28.5\n 27.6\n Plt\n 222\n 210\n 210\n 194\n 179\n 156\n Creatinine\n 2.4\n 2.8\n 3.1\n 3.3\n 3.0\n TCO2\n 16\n 15\n 12\n 14\n Glucose\n 125\n 136\n 140\n 122\n 165\n Other labs: PT / PTT / INR:25.1/59.2/2.4, ALT / AST:19/48, Alk-Phos / T\n bili:61/12.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:164 IU/L, Ca:8.5 mg/dL, Mg:1.7\n mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW\n MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Vasodilatory shock, fluid repletion 3/4:1, on neo gtt for\n hypotension\n PULM: on NC now\n RENAL: Foley, follow UOP, replacing ascites output 1:1 with NS. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Giving boluses with albumin PRN for BP /\n UOP.,acidosis likely diarrhea induced,stool culture,?cdiff.\n FEN/GI: protonix 40\", TF impact 3/4 strength at 125ml/hr. Rifaximin for\n hepatic encephalopathy.\n ID: micafungin started blood/ascites; vanc for\n coag neg staph tip cx; ophthalmology exam negative. Daily surv cx. All\n lines changed out. Follow vanco level prior to 4th dose. Ascites gs(-)\n HEME: Hct stable\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis: Duodenal bleed s/p ex lap, repair\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:17 PM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\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": "2164-11-05 00:00:00.000", "description": "Intensivist Note", "row_id": 705261, "text": "SICU\n HPI:\n POD 19 / 16 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: vanc, micafungin \n PPx: boots, PPI \n TLD: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n Current medications:\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n 24 Hour Events:\n : On phenylephrine, given albumin. 3units FFP given prior to\n removal of femoral sheath by IR. Renal c/s FeNa<0.1. Rec replacing\n drain loss cc per cc. No need for HD at this time.\n : OR for closure of abdominal wound. Req inc MAP to maintain\n oxygenation. Albumin x1. Right femoral art line pulled s/p blood\n products.\n : Droppped BP to 50s in AM, noted bloody stool; given 2U PRBCs and\n increased neo gtt to 4, SBP increased to 110s. At same time, desat to\n 70%s on CPAP; FiO2 inc to 100% and CXR revealed diffuse opacity of L\n lung consistent with mucus plug. Bedside bronch to remove thick mucus\n plug, O2 sats recovered to high 90%s, vent weaned back to 50% FiO2.\n : Rigors. Afebrile. Recultured. EEG performed, results pending.\n : TF changed to Nepro 1/2 strength, ordered for urine 24hr Cr\n clearance. Removed L femoral without complication. Vit K x 1 dose.\n : Weaned vent to min settings. High output around JP drains.\n Ascities replacement schedule adjusted.\n : Continued on minimal vent settings. Continued high JP output.\n Intermittent fluid boluses throughout day with LR as needed for BP /\n UOP; JP repletion changed from NS to LR. Tube feeds increased to\n 40mL/hr. Octreotide d/c'd.\n : Extubated. Continuing goal of fluid status being 2 liters neg\n : Slowed urine output, given 25g albumin in 500 ml x 1 per\n transplant\n : Stable. No acute issues. Trauma line pulled. Started\n caspiofungin. Bolused by transplant team colloid/LR, multiple times.\n : Ascites cx and blood cx from growing yeast; changed to\n micafungin and restarted vanc/zosyn/flagyl pending further culture\n data. Re-sited CVL and changed A-line over wire. Tube feeds changed\n back to 3/4 strength. Increased ascites repletion to 1cc:1cc. Transient\n decreases in UOP and SBP responded to fluid boluses initially; started\n on neosynephrine gtt overnight for hypotension.\n : Hypotension requiring progressive increases in phenylephrine\n drip. Albumin bolus x1. ID consulted. Aline replaced.\n : Switched to dilaudid for pain. Fractionated bilirubin Tbili=8.8,\n Dbili=4.8. Not obstructed. Following cx were negative: UA, peritoneal\n fluid, and aline tip.\n : Dry heaving, no emesis or blood. Started zofran. Complaining of\n intermittent LLQ pain, given small doses of dilauded with some\n improvement. 1U PRBCs, weaning neo gtt.\n : stool cx sent, getting weaned off of Neo gtt, prn albumin for\n hypotension\n Post operative day:\n POD#19 - ex lap duod ulcer repair\n POD#16 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:21 PM\n Infusions:\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:25 AM\n Other medications:\n Flowsheet Data as of 12:43 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: 35.8\nC (96.5\n HR: 103 (103 - 127) bpm\n BP: 130/58(79) {87/40(60) - 131/67(88)} mmHg\n RR: 16 (14 - 23) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.4 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 7 (0 - 238) mmHg\n Total In:\n 14,939 mL\n 127 mL\n PO:\n Tube feeding:\n 3,002 mL\n 67 mL\n IV Fluid:\n 11,426 mL\n 60 mL\n Blood products:\n 450 mL\n Total out:\n 11,311 mL\n 115 mL\n Urine:\n 436 mL\n 15 mL\n NG:\n 1,575 mL\n Stool:\n 1,075 mL\n Drains:\n 8,225 mL\n 100 mL\n Balance:\n 3,628 mL\n 12 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.41/22/81./20/-7\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Abdominal: Soft, Bowel sounds present, Distended, JPX2, J tube X \n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 156 K/uL\n 9.2 g/dL\n 183 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 90 mg/dL\n 110 mEq/L\n 143 mEq/L\n 27.6 %\n 12.2 K/uL\n [image002.jpg]\n 08:25 AM\n 02:03 AM\n 02:11 AM\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n WBC\n 18.1\n 18.1\n 17.1\n 15.8\n 12.2\n Hct\n 28.1\n 28.1\n 27.5\n 28.5\n 27.6\n Plt\n 79\n 156\n Creatinine\n 2.8\n 3.1\n 3.3\n 3.0\n 3.0\n TCO2\n 16\n 15\n 12\n 14\n Glucose\n 136\n 140\n 122\n 165\n 183\n Other labs: PT / PTT / INR:25.1/59.2/2.4, ALT / AST:19/48, Alk-Phos / T\n bili:61/12.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:164 IU/L, Ca:7.8 mg/dL, Mg:1.7\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW\n MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Vasodilatory shock, fluid repletion 3/4:1, on neo gtt for\n hypotension\n PULM: sats mid 90's on RA\n RENAL: Foley, follow UOP, replacing ascites output 1:1 with NS. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Giving boluses with albumin PRN for BP /\n UOP. D5W with 150 Sod Bicarb @ 150/hr\n FEN/GI: protonix 40\", TF impact 3/4 strength at 125ml/hr. Rifaximin for\n hepatic encephalopathy.\n ID: micafungin started blood/ascites; vanc for\n coag neg staph tip cx; ophthalmology exam negative. All lines changed\n out. Follow vanco level.\n HEME: Hct stable\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: NGT, J-Tube, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: Transplant\n Billing Diagnosis: (Shock: Septic), Liver failure\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:15 PM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2164-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704108, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient continues to be NPO- NG to suction draining moderate amt. of\n bilious drainage. JP\ns putting out 300-600 cc/hr serosang drainage.\n MAP 60-70\ns, MAP down to 57-60 at times. HR 100\ns-115. Urine output\n 10-25 cc/hr dark amber color.\n Afebrile,\n WBC up to 26, lower j tube to gravity draining billeous output, upper j\n tube hooked to tubfeeds at 70 cc/hr.\n Action:\n given moist swabs for comfort,\n changed from\n cc: cc replacement to cc:cc replacement q hour,\n given 500 cc LR x 4 for low MAP and decreased u/o.\n echo done.\n foley changed,\n Left subclavian d/c\nd tip sent for cx.\n Right IJ initiated, all tubing changed.\n blood cx. Sent.\n Tubefeed changed to 45 cc/hr of full strength novasource, then again\n back to\n strength novasource renal.\n Response:\n MAP > 65 after fluid bolus given, u/o increased to 25 cc/hr after\n bolus. Patient is now approx. 3 L pos. for the day.\n Plan:\n follow up on cultures, Keep MAP > 65, follow up on echo results.\n continue to monitor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on 60% face tent sating 99-100%. Able to cough up secretions\n but unable to clear them on own.\n Action:\n Patient encouraged to cough and deep breath, use of IS, chest pt.\n ABG drawn this am. 7.46/144/24,\n O2 weaned to 50% then 40%.\n Response:\n Patient sating 94% on 40% so put back on 50% face tent. Now sating\n 95-100%.\n Plan:\n Continue to monitor, aggressive pulm. Toilet.\n" }, { "category": "Nursing", "chartdate": "2164-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704182, "text": "52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum. IR\n unable to embolize, surgiseal in place.\n S/P transfusion of 30+ units pRBC, FFP in MICU\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2-3, although occasionally asking inappropriate\n questions:\nWhen can I talk to the Judge?\n Pt able to sleep in naps.\n , with generalized weakness, following commands\n Abd incision OTA, staples intact, JPx2 with nursing\n engineered\nVac dressing\n (NGT sumping excess drainage from JP sites),\n copious amounts of serosanguinous drainage from drains. J tube x2, one\n to drainage draining moderate amts bilious fluid, other one feeding,\n NGT to LCS, clear drainage.\n Pt remains on 50% face tent, O2 sat 98-100%. LS clear to\n rhonchorous, diminished at bases. Weak cough, raising small amounts of\n thick white sputum into mouth with encouragement\n HR 99-115, small improvement with fluid boluses and Albumin.\n Albumin given ~q 2 hours for drain output 1 liter\n Neo gtt at 0.6-BP 95-120\ns with MAP >60.\n CVP 4-8\n Remains oliguric, dark amber urine via foley cath. Cr 2 BUN\n 87\n Afebrile, tmax 98.1 WBC 26 up from 21\n Hct stable 32\n Reports pain at incision sites with movement/turning\n Action:\n Aggressive pulm hygiene\n JP drainage monitored q 1\n cc:cc repletion for JP outputs with LR\n 25% Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring labs\n DSD over JP sites changed x2\n Fentanyl prn pain\n 3^rd Cdiff specimen sent\n Emotional support/reorientation provided\n A-line re-wired by Dr. \n UA and urine lytes sent\n Response:\n Hemodynamics improving with fluid/Albumin\n No change in amount of drainage from drains\n Pt continues to cough and raise small amounts of thick white\n sputum\n Plan:\n Continue to monitor VS\n Cont aggressive pulm hygiene\n Monitor Labs\n Continue with cc:cc repletion\n Pain management\n Continue with albumin as ordered\n Cont provide emotional support to pt and family\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704609, "text": "Shock, septic\n Assessment:\n -Patient is lethargic but oriented x 3, labile at times, c/o pain in\n abdomen out of 10 pain, angry about being in the hospital.\n - continues to be on Neo gtt with Map 65-75, occasional drops to MAP in\n 50\ns. HR 90\ns-120\n -Output from JP drains 150-450.\n -Urine output 15-35 cc/hr.\n Action:\n - continues with\n cc:cc repletion, IVF changed from LR to NS\n because of low sodium of 131,\n - given a 500 cc NS fluid bolus after episode of hypotension\n this am\n - continued with 25% concentrated albumin per each 1 L of jp\n output,\n - SICU team and transplant team called in to assess patient\n for increased pain, increased pain requirements in patients abdomen.\n - Pain meds changed from fentanyl to Dilaudid for longer\n lasting pain control.\n - PT in to work with patient, slid over to chair,\n - Continued to titrate Neo for MAP > 65,\n Response:\n MAP > 65 currently on 1.5 of Neo,\n Approx 1 L pos. for the day so far,\n Plan:\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-11-05 00:00:00.000", "description": "Intensivist Note", "row_id": 705326, "text": "SICU\n HPI:\n POD 19 / 16 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: vanc, micafungin \n PPx: boots, PPI \n TLD: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n Current medications:\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n 24 Hour Events:\n : On phenylephrine, given albumin. 3units FFP given prior to\n removal of femoral sheath by IR. Renal c/s FeNa<0.1. Rec replacing\n drain loss cc per cc. No need for HD at this time.\n : OR for closure of abdominal wound. Req inc MAP to maintain\n oxygenation. Albumin x1. Right femoral art line pulled s/p blood\n products.\n : Droppped BP to 50s in AM, noted bloody stool; given 2U PRBCs and\n increased neo gtt to 4, SBP increased to 110s. At same time, desat to\n 70%s on CPAP; FiO2 inc to 100% and CXR revealed diffuse opacity of L\n lung consistent with mucus plug. Bedside bronch to remove thick mucus\n plug, O2 sats recovered to high 90%s, vent weaned back to 50% FiO2.\n : Rigors. Afebrile. Recultured. EEG performed, results pending.\n : TF changed to Nepro 1/2 strength, ordered for urine 24hr Cr\n clearance. Removed L femoral without complication. Vit K x 1 dose.\n : Weaned vent to min settings. High output around JP drains.\n Ascities replacement schedule adjusted.\n : Continued on minimal vent settings. Continued high JP output.\n Intermittent fluid boluses throughout day with LR as needed for BP /\n UOP; JP repletion changed from NS to LR. Tube feeds increased to\n 40mL/hr. Octreotide d/c'd.\n : Extubated. Continuing goal of fluid status being 2 liters neg\n : Slowed urine output, given 25g albumin in 500 ml x 1 per\n transplant\n : Stable. No acute issues. Trauma line pulled. Started\n caspiofungin. Bolused by transplant team colloid/LR, multiple times.\n : Ascites cx and blood cx from growing yeast; changed to\n micafungin and restarted vanc/zosyn/flagyl pending further culture\n data. Re-sited CVL and changed A-line over wire. Tube feeds changed\n back to 3/4 strength. Increased ascites repletion to 1cc:1cc. Transient\n decreases in UOP and SBP responded to fluid boluses initially; started\n on neosynephrine gtt overnight for hypotension.\n : Hypotension requiring progressive increases in phenylephrine\n drip. Albumin bolus x1. ID consulted. Aline replaced.\n : Switched to dilaudid for pain. Fractionated bilirubin Tbili=8.8,\n Dbili=4.8. Not obstructed. Following cx were negative: UA, peritoneal\n fluid, and aline tip.\n : Dry heaving, no emesis or blood. Started zofran. Complaining of\n intermittent LLQ pain, given small doses of dilauded with some\n improvement. 1U PRBCs, weaning neo gtt.\n : stool cx sent, getting weaned off of Neo gtt, prn albumin for\n hypotension\n Post operative day:\n POD#19 - ex lap duod ulcer repair\n POD#16 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:21 PM\n Vancomycin per level\n Infusions:\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:25 AM\n Other medications:\n Flowsheet Data as of 12:43 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: 35.8\nC (96.5\n HR: 103 (103 - 127) bpm\n BP: 130/58(79) {87/40(60) - 131/67(88)} mmHg\n RR: 16 (14 - 23) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.4 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 7 (0 - 238) mmHg\n Total In:\n 14,939 mL\n 127 mL\n PO:\n Tube feeding:\n 3,002 mL\n 67 mL\n IV Fluid:\n 11,426 mL\n 60 mL\n Blood products:\n 450 mL\n Total out:\n 11,311 mL\n 115 mL\n Urine:\n 436 mL\n 15 mL\n NG:\n 1,575 mL\n Stool:\n 1,075 mL\n Drains:\n 8,225 mL\n 100 mL\n Balance:\n 3,628 mL\n 12 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.41/22/81./20/-7\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Abdominal: Soft, Bowel sounds present, Distended, JPX2, J tube X \n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 156 K/uL\n 9.2 g/dL\n 183 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 90 mg/dL\n 110 mEq/L\n 143 mEq/L\n 27.6 %\n 12.2 K/uL\n [image002.jpg]\n 08:25 AM\n 02:03 AM\n 02:11 AM\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n WBC\n 18.1\n 18.1\n 17.1\n 15.8\n 12.2\n Hct\n 28.1\n 28.1\n 27.5\n 28.5\n 27.6\n Plt\n 79\n 156\n Creatinine\n 2.8\n 3.1\n 3.3\n 3.0\n 3.0\n TCO2\n 16\n 15\n 12\n 14\n Glucose\n 136\n 140\n 122\n 165\n 183\n Other labs: PT / PTT / INR:25.1/59.2/2.4, ALT / AST:19/48, Alk-Phos / T\n bili:61/12.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:164 IU/L, Ca:7.8 mg/dL, Mg:1.7\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW\n MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Vasodilatory shock, fluid repletion 3/4:1,currently off neo gtt\n PULM: sats mid 90's on RA\n RENAL: Foley, follow UOP, replacing ascites output 1:1 with NS. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Giving boluses with albumin PRN for BP /\n UOP. D5W with 150 Sod Bicarb @ 150/hr\n FEN/GI: protonix 40\", TF impact 3/4 strength at 125ml/hr. Consider TF\n to full strength. Rifaximin for hepatic encephalopathy.\n ID: micafungin started blood/ascites; vanc for\n coag neg staph tip cx; ophthalmology exam negative. All lines changed\n out. Follow vanco level. Empirically start PO vanc per J tube\n HEME: Hct stable\n ENDO: RISS\n Psyvh: consult\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: NGT, J-Tube, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: Transplant\n Billing Diagnosis: (Shock: Septic), Liver failure\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:15 PM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2164-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704881, "text": "52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt awake all night\n Having abdominal/incisional pain\n Large amount of ascites drainage from JP tube\n Low urine out put all night\n Having several soft BM\n BUN and Creat increased\n Total bili up to 14 today\n Action:\n Med Q3hr with Dilaudid .5mg for pain\n Cont with\n cc:cc replacement\n Received albumen approx Q2-3 hrs for ascites drainage >1000cc\n Response:\n minimal pain relief from dilaudid\n Plan:\n Cont with current plan\n Emotional support for family and patient\n" }, { "category": "Physician ", "chartdate": "2164-11-06 00:00:00.000", "description": "Intensivist Note", "row_id": 705449, "text": "SICU\n HPI:\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with sepsis\n secondary to fungemia\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Artificial Tear Ointment 5. Bicitra 6. Calcium Gluconate HYDROmorphone\n (Dilaudid) Isulin Micafungin Midodrine\n Vancomycin\n 24 Hour Events:\n - drains averaging less than 400cc every 2 hours which is less than\n previous\n -occaisional diarrhea\n -psych consult pending\n Post operative day:\n POD#20 - ex lap duod ulcer repair\n POD#17 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:21 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 10:06 PM\n Pantoprazole (Protonix) - 12:09 AM\n Other medications:\n Flowsheet Data as of 03:07 AM\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: 114 (104 - 128) bpm\n BP: 117/65(83) {98/51(69) - 139/82(100)} mmHg\n RR: 24 (14 - 27) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 108.7 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 5 (2 - 16) mmHg\n Total In:\n 8,995 mL\n 718 mL\n PO:\n 1,040 mL\n Tube feeding:\n 3,019 mL\n 327 mL\n IV Fluid:\n 4,626 mL\n 281 mL\n Blood products:\n 250 mL\n 50 mL\n Total out:\n 7,431 mL\n 1,850 mL\n Urine:\n 466 mL\n 95 mL\n NG:\n 1,700 mL\n 1,150 mL\n Stool:\n Drains:\n 5,265 mL\n 605 mL\n Balance:\n 1,564 mL\n -1,132 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, sclericterus\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Non-tender, Distended\n Left Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: No(t) Diminished)\n Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 147 K/uL\n 8.8 g/dL\n 127 mg/dL\n 3.3 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 97 mg/dL\n 111 mEq/L\n 142 mEq/L\n 25.8 %\n 13.5 K/uL\n [image002.jpg]\n 02:11 AM\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n WBC\n 18.1\n 17.1\n 15.8\n 12.2\n 12.9\n 13.5\n Hct\n 28.1\n 27.5\n 28.5\n 27.6\n 26.4\n 25.8\n Plt\n 56\n 142\n 147\n Creatinine\n 3.1\n 3.3\n 3.0\n 3.0\n 3.0\n 3.3\n TCO2\n 15\n 12\n 14\n Glucose\n 140\n 122\n 165\n 183\n 156\n 127\n Other labs: PT / PTT / INR:23.6/54.2/2.2, ALT / AST:23/47, Alk-Phos / T\n bili:64/14.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.7 g/dL, LDH:164 IU/L, Ca:8.6 mg/dL, Mg:1.7\n mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW\n MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Neuro: Dilaudid prn, awake and following commands\n CVS: Vasodilatory shock improved, fluid repletion 3/4:1PULM: sats mid\n 90's on RA\n RENAL: Foley, follow UOP, replacing ascites output 1:1 with NS. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Giving boluses with albumin PRN for BP /\n UOP. D5W with 150 Sod Bicarb @ 150/hr\n FEN/GI: protonix 40\", TF impact 3/4 strength at 125ml/hr. Consider\n chenge TF to full strength. Rifaximin for hepatic encephalopathy.\n ID: micafungin started blood/ascites; vanc for\n coag neg staph tip cx; ophthalmology exam negative. All lines changed\n out. Follow vanco level.\n HEME: Hct stable. Recieved Vit k for INR last week.\n ENDO: RISS\n Psych: consult pending\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU:\n" }, { "category": "Physician ", "chartdate": "2164-11-07 00:00:00.000", "description": "Intensivist Note", "row_id": 705681, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with sepsis\n secondary to fungemia\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. 2. 1000 mL NS 3. Albumin 25% (12.5g / 50mL) 4. Albumin 25% (12.5g /\n 50mL) 5. Artificial Tear Ointment\n 6. Bicitra 7. Calcium Gluconate 8. HYDROmorphone (Dilaudid) 9. Insulin\n 10. Lidocaine 2% 11. Micafungin\n 12. Midodrine 13. Miconazole Powder 2% 14. Octreotide Acetate 15.\n Ondansetron 16. Pantoprazole 17. Rifaximin\n 18. Sodium Chloride 0.9% Flush 19. Tetracaine HCl 20. Vancomycin\n 24 Hour Events:\n : Blood cx sent, Lateral jp d/ced, neg fluid balance 1l/24h\n Post operative day:\n POD#21 - ex lap duod ulcer repair\n POD#18 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 AM\n Micafungin - 02:00 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.6\nC (97.8\n HR: 109 (95 - 151) bpm\n BP: 139/69(92) {105/49(67) - 156/81(108)} mmHg\n RR: 24 (16 - 34) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.5 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 8 (1 - 11) mmHg\n Total In:\n 8,221 mL\n 2,122 mL\n PO:\n 1,470 mL\n 480 mL\n Tube feeding:\n 3,008 mL\n 729 mL\n IV Fluid:\n 3,283 mL\n 743 mL\n Blood products:\n 100 mL\n 50 mL\n Total out:\n 9,084 mL\n 2,845 mL\n Urine:\n 689 mL\n 205 mL\n NG:\n 4,400 mL\n 1,700 mL\n Stool:\n Drains:\n 3,995 mL\n 940 mL\n Balance:\n -863 mL\n -723 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///16/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: No(t) CTA bilateral : , Crackles :\n at the base, No(t) Diminished: )\n Abdominal: Soft, Distended, appropriately tender\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 121 K/uL\n 8.5 g/dL\n 115 mg/dL\n 3.8 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 99 mg/dL\n 109 mEq/L\n 139 mEq/L\n 25.4 %\n 14.3 K/uL\n [image002.jpg]\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n WBC\n 18.1\n 17.1\n 15.8\n 12.2\n 12.9\n 13.5\n 14.3\n Hct\n 28.1\n 27.5\n 28.5\n 27.6\n 26.4\n 25.8\n 25.4\n Plt\n 56\n 142\n 147\n 121\n Creatinine\n 3.1\n 3.3\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n TCO2\n 12\n 14\n Glucose\n 140\n 122\n 165\n 183\n 156\n 127\n 115\n Other labs: PT / PTT / INR:24.8/55.4/2.4, ALT / AST:24/49, Alk-Phos / T\n bili:64/13.7, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.2 g/dL, LDH:173 IU/L, Ca:8.3 mg/dL, Mg:1.6\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE, FUNGAL INFECTION, OTHER,\n HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n Neurologic: Neuro checks Q: 4 hr, Dilaudid prn, awake and following\n commands\n Cardiovascular: Vasodilatory shock, fluid repletion 3/4:1, on neo gtt\n for hypotension\n Pulmonary: sats mid 90's on RA\n Gastrointestinal / Abdomen: protonix 40\", TF impact 3/4 strength at\n 125ml/hr. Rifaximin for hepatic encephalopathy.\n Nutrition:\n Renal: Foley, follow UOP, replacing ascites output 1:1 with NS. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Giving boluses with albumin PRN for BP /\n UOP. D5W with 150 Sod Bicarb @ 150/hr\n Hematology: Post op anemia\n Endocrine: RISS, Goal BS<150\n Infectious Disease: Check cultures, micafungin started continue\n for 2 weeks after 1st negative cx blood/ascites; vanc\n for coag neg staph tip cx; ophthalmology exam negative. All lines\n changed out. Follow vanco level\n Lines / Tubes / Drains: foley, R IJ triple lumen (), PIV x1, JP\n x1, J-tube x2, A-line\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: transplant surgery , hepatology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber () - 10:44 PM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704454, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, lethargic today, oriented x 3 although occasionally\n believes he is at , able to lift and hold\n all extremities although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of ascitic fluid,\n medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr.\n Patient sating 94-99% on room air. Good cough and able to clear\n secretions.\n -urine output 15-35 cc/hr.\n -c/o out of 10 abdominal pain especially with activity/ turning.\n *MAP down to 55 in afternoon\n Action:\n - SICU and transplant team in to assess.\n - Continued with cc:cc fluid repleation from jp drain output,\n continued with 25% albumin administration q 1 L output from jp\n - Ascitic fluid from lateral drain sent off for culture, urine\n culture sent, blood cultures sent this am.\n - Neo titrated to keep MAP > 65.\n - 500 cc LR bolus given in am for low urine output down to 15\n cc/hr.\n - Encouraged to cough and deep breath, use of IS, chest PT,\n turned and repositioned for comfort.\n - Vac dsg changed with UBE due to leakage.\n - Given 50 mcg fent prn pain.\n * SICU team and transplant team aware of hypotensive episode in\n afternoon. Transplant is ok with going up on Neo, gave 1 extra dose of\n concentrated 25% albumin in 50 cc.\n Response:\n Patient is currently 2 L pos. for the day so far,\n 500 cc LR bolus increased u/o from 15 cc-35 cc/hr,\n Awaiting results from cultures,\n Map > 65 on Neo.\n Ascetic output continues to be 200-500 cc/hr\n Patient able to nap during day, appears comfortable after fent given\n for pain.\n Plan:\n Continue with cc:cc repleation for now with 25% albumin to give q 1 L\n output of ascitic fluid,\n Avoid extra bolus\n per transplant, ok to go up on Neo, contact\n transplant if patient needs fluid bolus.\n" }, { "category": "Nursing", "chartdate": "2164-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703385, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains on vent CPAP/PS 5/5, no changes overnight.. LS clear\n with occasional rochi,\n Action:\n ABG sent, O 2sat 97-99%, suctioned yellow thin secretion, Good cough,\n and impaired gag. Cont with rotating bed. 1amp sodium bicarb given. ET\n tube rotated to lt side by RT, pt bites the tube.\n Response:\n LS clear, ABG\n Plan:\n Cont to monitor, pulm hygiene, ? change to regular ICU bed.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abdomen softly distended, medial JP with copious amt of leak around,\n NGT to LCS with clear drainage. Edge of the staples slightly swollen,\n WBC 14.7, s.lactate is 1.7, BUN 67 and creat 1.7, livber enzymes WNL.\n Action:\n JP taped with tegaderm by primary team early shift, replacing JP out\n with LR 1/2cc /cc, albumin 12.5gm for every 1L of JP out put, sodium\n bicarb 1amp for every 3L JP out put. Fentanyl for pain prn,\n Response:\n Still leaking around JP, Tachy cardic HR 110-130/min, team\n aware.Stable HCT, rising BUN and chloride.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-11-03 00:00:00.000", "description": "Intensivist Note", "row_id": 704936, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n BRBPR\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular Order date: @ 1311\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 2. 1000 mL NS\n Continuous at 0 ml/hr\n please give 3/4 cc for every 1 cc JP output repletion Order date: \n @ 0805\n 12. Micafungin 100 mg IV DAILY Order date: @ 0917\n 3. 1000 mL LR\n Continuous at 1000 ml/hr Order date: @ 2237\n 13. Ondansetron 4 mg IV Q8H:PRN N/V Order date: @ 0447\n 4. Albumin 25% (12.5g / 50mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 1329\n 14. Pantoprazole 40 mg IV Q12H Order date: @ 0946\n 5. Albumin 25% (12.5g / 50mL) 12.5 g IV Q2H Duration: 48 Hours\n Please give 12.5g per 1L ascites output from abdominal drains. Order\n date: @ 0109\n 15. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>60 Order\n date: @ 1407\n 6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758\n 16. Rifaximin 400 mg PO TID\n can crush and administer via J-tube per pharmacy Order date: @\n 0919\n 7. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 17. 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: @ 1311\n 8. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain\n please hold for oversedation or rr<8 Order date: @ 1338\n 18. 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: @ 1703\n 9. HYDROmorphone (Dilaudid) 0.5 mg IV ONCE Duration: 1 Doses Order\n date: @ 1811\n 19. Tetracaine HCl *NF* 0.5 % OU as directed\n Tetracain 0.5% oph gtt one drop to each eye prior to giving\n phenylephrine and tropicamide drops. Thanks. Order date: @ 1435\n 10. HYDROmorphone (Dilaudid) 0.5 mg IV ONCE Duration: 1 Doses Order\n date: @ 0256\n 20. Vancomycin 1000 mg IV Q 24H *Awaiting ID Approval*\n ID Approval is required for this order.\n check vanc trough after third dose; HOLD PM DOSE 10/30 Order date:\n @ \n 24 Hour Events:\n Dry heaving, no emesis or blood. Started zofran. Complaining of\n intermittent LLQ pain, given small doses of dilauded with some\n improvement. 1U PRBCs, weaning neo gtt.\n Post operative day:\n POD#17 - ex lap duod ulcer repair\n POD#14 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 AM\n Hydromorphone (Dilaudid) - 03:15 AM\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.2\nC (99\n HR: 118 (109 - 127) bpm\n BP: 110/57(75) {92/48(67) - 128/68(88)} mmHg\n RR: 21 (16 - 23) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 10 (2 - 12) mmHg\n Total In:\n 10,045 mL\n 2,778 mL\n PO:\n Tube feeding:\n 3,041 mL\n 748 mL\n IV Fluid:\n 6,299 mL\n 1,880 mL\n Blood products:\n 704 mL\n 150 mL\n Total out:\n 9,669 mL\n 3,088 mL\n Urine:\n 499 mL\n 128 mL\n NG:\n Stool:\n 60 mL\n Drains:\n 9,110 mL\n 2,960 mL\n Balance:\n 376 mL\n -310 mL\n Respiratory support\n SPO2: 94%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Tender: LLQ\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: Jaundice, (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 194 K/uL\n 9.2 g/dL\n 140 mg/dL\n 3.1 mg/dL\n 14 mEq/L\n 4.1 mEq/L\n 90 mg/dL\n 108 mEq/L\n 132 mEq/L\n 27.5 %\n 17.1 K/uL\n [image002.jpg]\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n 01:59 AM\n 08:25 AM\n 02:03 AM\n 02:11 AM\n 04:11 PM\n 02:35 AM\n WBC\n 21.9\n 26.1\n 25.5\n 19.6\n 18.1\n 18.1\n 17.1\n Hct\n 32.1\n 32.5\n 32.6\n 28.8\n 28.1\n 28.1\n 27.5\n Plt\n 140\n 192\n 244\n 222\n 210\n 210\n 194\n Creatinine\n 1.9\n 2.0\n 2.2\n 2.4\n 2.8\n 3.1\n TCO2\n 15\n 16\n 15\n Glucose\n 128\n 155\n 162\n 125\n 136\n 140\n Other labs: PT / PTT / INR:24.0/55.8/2.3, ALT / AST:17/42, Alk-Phos / T\n bili:89/14.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:3.4 g/dL, LDH:164 IU/L, Ca:7.4 mg/dL, Mg:1.3\n mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan:\n Neuro: Dilaudid prn, awake and following commands. Localized pain\n CVS: Vasoditory shock, fluid repletion 3/4:1, on neo gtt for\n hypotension. AVP as the second line. BP goal of MAP of 60mmHg. Replete\n intravascular volume with albumin.\n PULM: on NC now. Continue IS.\n RENAL: Foley, follow UOP, replacing ascites output 1:1 with LR. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Possible hepatorenal syndrome. FeNa =\n 0.2, giving boluses with albumin PRN for BP / UOP.\n FEN/GI: protonix 40\", TF impact 3/ strength at 125ml/hr. Rifaximin for\n hepatic encephalopathy. GI worsening abdominal pain\n non contrast CT\n (splenic infarct vs kidney infarct vs mesenteric infarct\n ID: micafungin started blood/ascites;\n considering switching to alternate abx since macrobid can contribute to\n liver toxicity. vanc for coag neg staph tip cx. We will hold a dose for\n traph to stabilize. ophthalmology exam negative. Daily surv cx. All\n lines changed out. Follow vanco level prior to 4th dose. Ascites gs(-).\n Surveillance cultures.\n HEME: Hct stable LDH slightly suggestive of intravascular hemolysis.\n Hct trigger 25%.\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Total Time Spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2164-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705245, "text": "Shock, septic\n Assessment:\n Pt in metabolic acidosis with low TCO2 being repleted with NaHco3\n 150meq/1LD5W at 150ml/hr.\n CC/CC replacement of JPdrains and wound drain\n Neo off several hours back on.Neo .5mcg/kg/min\n Albumin 25% (12.%GM) given for every liter of JP and wound drg out.\n Action:\n Repeat labs drawn at 1400\n Neo restartred for MAP 58\n Albumin as ordered\n Response:\n MAP>60-65\n TCO2 20\n Plan:\n Continue to monitor labs\n Titrate neo for MAP>60-65\n Albumin and replacement fluid as ordered.\n" }, { "category": "Nursing", "chartdate": "2164-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705246, "text": "Impaired Skin Integrity\n Assessment:\n Pt had flexiseal in for liquid stool which was placed on sat 7p-7a\n Flexiseal leaking\n Action:\n Flexiseal leaking and removed.\n Actiflo attempted\n Response:\n Pt had discomfort after actiflo was placed and small am\nt of blood\n noted so it was taken out given pts history.\n Plan:\n Manage liq stools with bedpan and/or FIB\n" }, { "category": "Nursing", "chartdate": "2164-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705589, "text": "Activity Intolerance\n Assessment:\n Physical therapists x 2 at bedside to get pt OOB\n Action:\n Pt sat on side of bed then stood and side stepped to cahir with 2\n assist\n Response:\n HRincreased to 150 ST, no ectopics, O2sat decreased to 94% O2 4l on.\n RRincreased to 32 and BP increased to 160s/70s\n Plan:\n Pt lifted back to bed\n Have PT get pt OOB daily and assess his strength to stand.\n Monitor VS carefully when pt gets OOB.\n Fungal Infection, Other\n Assessment:\n Afeb, Off neo now for 36 hours, VSS, CVP 9, Micafungin given as ordered\n for fungal infec CVL and ascetic fluid.\n Action:\n Blood c/s x 2 perip and right IJ sent\n Ascitic fluid from medial JP sent.\n Response:\n stable off neo\n Plan:\n Monitor closely for relapse\n Electrolyte & fluid disorder, other\n Assessment:\n Pt continues to ask for water freq\nI am thirsty\n CVP 9 today\n u/o 20ml/hr\n lytes wnl today, not repleting magnesium per liver team\n Action:\n cc /cc replacement of JPmed, JP lat and sump drain q 2 hrs with NS\n Response:\n ARF, liver failure, dehydration improving\n Plan:\n Continue plan of care\n replacement fluid as ordered\n vanco level trough in am\n SICU\n HPI:\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with sepsis\n secondary to fungemia\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Artificial Tear Ointment 5. Bicitra 6. Calcium Gluconate HYDROmorphone\n (Dilaudid) Isulin Micafungin Midodrine\n Vancomycin\n 24 Hour Events:\n - drains averaging less than 400cc every 2 hours which is less than\n previous\n -occaisional diarrhea\n" }, { "category": "Nursing", "chartdate": "2164-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705677, "text": "TITLE:\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements. Mild c/o abdominal pain.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n Medial JP to self suction with sump to LCWS. Medial\n drain with moderate amounts ascetic output. Lateral drain removed by\n Transplant team at change of shift with sutures placed. sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65. WBC 13.5\n Action:\n Reorientating pt as needed. Dilaudid given for pain control.\n Repositioning pt to comfort.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Adequate pain relief.\n Pt -900cc at midnight.\n WBC slightly elevated to 14.3\n Plan:\n Reorient pt frequently. Treat pain/comfort as needed.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n f/u with blood and JP output cultures.\n" }, { "category": "Nursing", "chartdate": "2164-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704274, "text": "ADDENDUM:Culture of IV catheter tip RIJ returned positive for GM neg\n rods/vancomycin 1000mg started.\n Opthalmology requested eye gtts be instilled for 4pm appointment then\n ophthalmology did not come. Dr notified and called and talked\n to the on-call optalmologist .\n" }, { "category": "Nursing", "chartdate": "2164-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705799, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt alert and oriented x2-3. Slightly disoriented regarding\n day of week. Upper extremity tremor noted. Appropriate, following\n commands. Lift and holds upper extremities. BLE lifts/falls back. BLE\n painful to bend d/t hx of bilateral knee s/p\n c/o slight pain at abd and bilateral knees\n Abd firm. Positive ascites and generalized edema to BLE\n TF infusing at goal via lower J-tube. Upper J-tube to\n gravity w/ large amts of bilious drainage\n Medial JP to self suction w/ sump to LCWS to collect\n ascites oozing from site. Lateral JP drain removed by Transplant team\n last evening w/ sutures placed. sump w/ moderate amts of output\n depending on pts position. Dressing changed to abd last evening\n Lungs clear but diminished at bases. O2 sats >96% on RA. Pt\n becomes tachypneic to 35-40 w/ strenuous activity and HR to 120\n Baseline HR 100-110\ns. Off pressors x48 hrs maintaining MAP >65\n Afebrile. BCx\ns sent on . WBC 14.3 (13.5)\n Foley to gravity w/ amber u/o 40-55cc/hr. BUN 99 Cr 3.8 AST\n 49\n HCT 25.4. INR 2.4. Repleting every 1 Liter of drain fluid w/\n Albumin 12.5GM\n Action:\n Remained alert and oriented. Ammonia level drawn\n 79.\n Transplant aware\n Pt OOB to chair x 1hr d/t agitated could not work w/ PT\n today. Pt tachypneic/tachy w/ transfer to chair.\n Denied need for PRN IV Dilaudid\n Replacing JP/ sump outputs Q2hrs w/ NS\n cc:cc hrly.\n Goal negative 1-2liters per Dr \n 2u PRBC admin over 2hrs each for HCT <30. Albumin IV x2\n Watery golden BM\ns in small amts. Fecal appliance applied\n Left thigh groin noted to be warm/painful/swollen.\n ?Cellulitis. Transplant/SICU aware. Area marked/outlined\n Vanco trough 21.9. Vanco reduced to 500mg IV Q24.\n Response:\n No change in Neuro status. Slept in naps but easily\n arousable. Spoke w/ wife this afternoon\n Continues to deny need for PRN Dilaudid\n Pt negative prior blood and then turning toward positive and\n noted to be more tachypneic w/ acitivity post blood. Transplant made\n aware. No orders received\n Fecal appliance remains intact\n Meropenem added to Vanco/Micafungin for cellulitis\n Abd dressing remain c/d/I w/o leakage\n Evening CBC/lytes pending post transplant\n Plan:\n Cont to monitor Neuro status/pain mgt\n Admin IVABX per recommendations of ID and Tranplant\n approval. No CT of abd per Transplant at this time.\n Continue w/ strict Intake/output. Goal negative 1-2liters\n Duplex study to r/o DVT. Monitor Cellulitis.\n Skin care w/ frequent BMs\n" }, { "category": "Physician ", "chartdate": "2164-11-08 00:00:00.000", "description": "Intensivist Note", "row_id": 705870, "text": "SICU\n HPI:\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Chief complaint:\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with sepsis\n secondary to fungemia\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 1000 mL NS 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear\n Ointment 5. Bicitra 6. Calcium Gluconate\n 7. HYDROmorphone (Dilaudid) 8. Insulin 9. Meropenem 10. Micafungin 11.\n Midodrine 12. Miconazole Powder 2%\n 13. Octreotide Acetate 14. Ondansetron 15. Pantoprazole 16. Rifaximin\n 17. Sodium Chloride 0.9% Flush\n 18. Tetracaine HCl 19. Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 06:40 PM\n Post operative day:\n POD#22 - ex lap duod ulcer repair\n POD#19 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Micafungin - 02:10 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Hydromorphone (Dilaudid) - 02:12 AM\n Other medications:\n Flowsheet Data as of 05:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 117 (98 - 124) bpm\n BP: 105/51(71) {98/46(67) - 147/69(92)} mmHg\n RR: 17 (17 - 35) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.5 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 11 (1 - 11) mmHg\n Total In:\n 8,837 mL\n 1,438 mL\n PO:\n 960 mL\n Tube feeding:\n 3,000 mL\n 594 mL\n IV Fluid:\n 3,560 mL\n 705 mL\n Blood products:\n 897 mL\n 50 mL\n Total out:\n 8,478 mL\n 1,365 mL\n Urine:\n 1,058 mL\n 265 mL\n NG:\n 3,525 mL\n 475 mL\n Stool:\n Drains:\n 3,895 mL\n 625 mL\n Balance:\n 359 mL\n 73 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n mild)\n Abdominal: Distended, Tender: Left l abd flank thigh\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 101 K/uL\n 10.0 g/dL\n 153 mg/dL\n 3.6 mg/dL\n 14 mEq/L\n 3.8 mEq/L\n 106 mg/dL\n 112 mEq/L\n 141 mEq/L\n 28.5 %\n 19.3 K/uL\n [image002.jpg]\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n WBC\n 15.8\n 12.2\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n Hct\n 28.5\n 27.6\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n Plt\n 179\n 156\n 142\n 147\n 121\n 105\n 101\n Creatinine\n 3.3\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n TCO2\n 12\n 14\n Glucose\n 122\n 165\n 183\n 156\n 127\n 115\n 136\n 153\n Other labs: PT / PTT / INR:26.3/95.8/2.5, ALT / AST:26/55, Alk-Phos / T\n bili:62/18.0, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.4 g/dL, LDH:161 IU/L, Ca:8.4 mg/dL, Mg:1.5\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE, FUNGAL INFECTION, OTHER,\n HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n .\n Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Vasodilatory shock resolved, hypotension fluid repletion 3/4:1,\n PULM: sats mid 90's on RA CXR no evidence of inf /edema\n RENAL: Foley, 45-50/hr UOP, replacing ascites output 1:1 with NS.\n Albumin 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not\n believe this is related to micafungin. Giving boluses with albumin PRN\n for BP / UOP.\n FEN/GI: protonix 40\", TF impact 3/4 strength at 125ml/hr. Rifaximin for\n hepatic encephalopathy. fluid repletion 3/4:1, dx lat DRESSING SUMP\n 150/8hrs and Medial JP 300/2hr NH4 79\n ID:Vanc/mico /meropenum, Vanc trough am\n micafungin started continue for 2 weeks after 1st negative cx\n blood/ascites; vanc for coag neg staph tip cx;\n ophthalmology exam negative. All lines changed out. Follow vanco level.\n Repeat Blood cx , ? c. diff, Peritoneal fluid : GNR and enterococci\n positive sensitivities pending started on Meropenum,\n Cellulitis L thigh noticed at 4 pm . CVC LINE > 10 days, bld cx pend\n HEME: Hct stable. Consider Vit k for INR 2.5,Plts down , HIT \n pending Venous duplex Bilat LE\n ENDO: RISS\n Psych: consult\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen (), PIV x1, JP x2, J-tube x2,\n A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Nutrition:\n Impact with Fiber () - 10:25 PM 125 mL/hour\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704445, "text": "Shock, septic\n Assessment:\n Patient is Afebrile. WBC continues to be elevated at 25.5.\n Arousable to voice, lethargic today, oriented x 3 although occasionally\n believes he is at , able to lift and hold\n all extremties although very weak and helps with turns only minimally.\n HR 100\ns-120\ns, MAP > 65 on Neo gtt,\n Lateral JP to bulb suction putting out scant amount of ascitic fluid,\n medial drain to wall suction putting out 200-500 cc/hr.\n Lower J tube to gravity draining billeous output, upper J tube\n connected to feeding, tubefeeds at goal 125 cc/hr.\n Patient sating 94-99% on room air. Good cough and able to clear\n secretions with yankur.\n -urine output 15-35 cc/hr.\n Action:\n - SICU and transplant team in to assess.\n - Continued with cc:cc fluid repleation from jp drain output,\n continued with 25% albumin administration q 1 L output from jp\n - Ascitic fluid from lateral drain sent off for culture, urine\n culture sent, blood cultures sent this am.\n - Neo titrated to keep MAP > 65.\n - 500 cc LR bolus given in am for low urine output down to 15\n cc/hr.\n - Encouraged to cough and deep breath, use of IS, chest PT,\n turned and repositioned for comfort.\n - Vac dsg changed with UBE due to leakage.\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703660, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continued on CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant to moderate thick, white secretions.\n Cough weak.\n Gag absent.\n Negative 1\n Liter.\n Action:\n Plan was to extubate this am, but patient with lethargy, no gag and\n poor cough.\n After consulting with SICU MD and Transplant MD ,\n extubation aborted.\n Response:\n Minimal to moderate white secretions.\n RR and work of breathing WNL.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours.\n Pt not be more than 1 Liters negative.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT draining clear, thick drainage. Abdomen soft distended.\n BS hypoactive.\n JP\nS draining ascitic fluid.\n Generalized edema resolving.\n HR 100\ns-110\ns. SBP 90\ns-110\n UO diminished, SICU and Transplant Team aware.\n Action:\n JP drainage replaced with LR 1/2 cc / cc output, H.Alb 125.gm for every\n 1Liter of JP drainage given. NA Bicarb held this am as ordered by MD\n .\n\nvac like\n dressing in place over leaking JP drains and collected by\n low continous suction. JP\ns remain with manual bulb suction.\n Transplant Team aware.\n Tachycardia and Low SBP treated with 1000cc bolus of LR.\n Response:\n Patient is lethargic, at times unable to keep eyes open. Following\n simple commands and moving all extremities, but with poor strength.\n PERRLA. X1 25 mcg Fentanyl bolus PRN for pain.\n Maintaining map >60, HR lowered with fluid bolus.\n TF at 40ml/hr.\n JP Drains with less leaking and more improved collection.\n Plan:\n Continue to replete JP output as ordered with LR, albumin.\n Strict I&O\ns to maintain desired fluid status.\n ? Additional LR boluses to maintain desired fluid balance.\n" }, { "category": "Physician ", "chartdate": "2164-10-27 00:00:00.000", "description": "Intensivist Note", "row_id": 703742, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1000 mL LR\n Albumin 25% (12.5g / 50mL)\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Fentanyl Citrate\n Fluconazole\n Insulin\n Pantoprazole\n Piperacillin-Tazobactam\n Sodium Bicarbonate\n Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n continue 1/2 cc per cc replacement of ascited with LR\n continue 12.5 g albumin for every 1L ascites output\n LR boluses prn to keep no more than 1L negative for the day\n Post operative day:\n POD#10 - ex lap duod ulcer repair\n POD#7 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:31 PM\n Fluconazole - 10:07 PM\n Piperacillin/Tazobactam (Zosyn) - 04:33 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 01:32 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.4\n HR: 114 (97 - 129) bpm\n BP: 113/58(74) {88/47(59) - 131/81(97)} mmHg\n RR: 23 (15 - 28) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 9 (7 - 169) mmHg\n Total In:\n 14,096 mL\n 3,734 mL\n PO:\n Tube feeding:\n 964 mL\n 236 mL\n IV Fluid:\n 10,870 mL\n 2,967 mL\n Blood products:\n 550 mL\n 100 mL\n Total out:\n 15,007 mL\n 4,964 mL\n Urine:\n 642 mL\n 264 mL\n NG:\n 750 mL\n 700 mL\n Stool:\n Drains:\n 13,215 mL\n 4,000 mL\n Balance:\n -911 mL\n -1,230 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 577 (577 - 687) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: 7.43/32/86./21/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, JP drains in place, J tube x 2 in plaec\n Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm), (Pulse\n - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 77 K/uL\n 11.1 g/dL\n 141 mg/dL\n 1.5 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 76 mg/dL\n 111 mEq/L\n 138 mEq/L\n 33.0 %\n 18.2 K/uL\n [image002.jpg]\n 10:27 AM\n 04:26 PM\n 02:32 AM\n 02:37 AM\n 02:17 AM\n 02:28 AM\n 08:37 AM\n 03:03 PM\n 02:00 AM\n 02:05 AM\n WBC\n 14.7\n 16.6\n 18.2\n Hct\n 35.0\n 35.2\n 33.0\n Plt\n 59\n 65\n 77\n Creatinine\n 1.7\n 1.7\n 1.5\n TCO2\n 16\n 17\n 19\n 22\n 20\n 22\n Glucose\n 122\n 126\n 143\n 158\n 152\n 141\n Other labs: PT / PTT / INR:22.4/76.1/2.1, ALT / AST:, Alk-Phos / T\n bili:53/5.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:120 IU/L, Ca:7.8 mg/dL, Mg:1.6\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated. Fentanyl prn, following commands\n CVS: stable; follow\n PULM: Intubated, CPAP 5/5. extubate am\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with LR. Albumin 12.5g per 1L ascites, also giving HCO3 for\n every 3L ascites. Hx of hepatorenal syndrome.\n FEN/GI: NPO, protonix drip, TPN, TF nepro 3/4 strength at 40\n ID: vanc / zosyn / fluc; f/u cx\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, s/p L IJ triple lumen, R SC trauma line ( PIV x1,\n JP x2, NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:00 PM 72. mL/hour\n NovaSource Renal () - 10:10 PM 40. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2164-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703662, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 10\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt received on PSV 5/5 as noted with no vent changes this\n shift.\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.\n Reason for continuing current ventilatory support: Cannot protect\n airway; Comments: Pt had a positive cuff leak test, but has no gag\n reflex and a very weak cough.\n" }, { "category": "Nursing", "chartdate": "2164-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705441, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n JP x2 to self suction with sump to LCWS. Medial drain\n with moderate amounts ascetic output. Lateral drain and sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65.\n Action:\n Reorientating pt as needed.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Pt positive 1.5L at midnight.\n Plan:\n Reorient pt frequently.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n" }, { "category": "Nursing", "chartdate": "2164-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705442, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements. Mild c/o abdominal pain.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n JP x2 to self suction with sump to LCWS. Medial drain\n with moderate amounts ascetic output. Lateral drain and sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65.\n Action:\n Reorientating pt as needed. Dilaudid given for pain control.\n Repositioning pt to comfort.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Adequate pain relief.\n Pt positive 1.5L at midnight.\n Remains off Neo maintaining MAP >65\n Plan:\n Reorient pt frequently. Treat pain/comfort as needed.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n" }, { "category": "Nursing", "chartdate": "2164-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705789, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt alert and oriented x2-3. Slightly disoriented regarding\n day of week. Appropriate, following commands. Lift and holds upper\n extremities. BLE lifts/falls back. BLE painful to bend d/t hx of\n bilateral knee s/p\n c/o slightly\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements. Mild c/o abdominal pain.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n Medial JP to self suction with sump to LCWS. Medial\n drain with moderate amounts ascetic output. Lateral drain removed by\n Transplant team at change of shift with sutures placed. sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65. WBC 13.5\n Action:\n Reorientating pt as needed. Dilaudid given for pain control.\n Repositioning pt to comfort.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Adequate pain relief.\n Pt -900cc at midnight.\n WBC slightly elevated to 14.3\n Plan:\n Reorient pt frequently. Treat pain/comfort as needed.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n f/u with blood and JP output cultures.\n" }, { "category": "Nursing", "chartdate": "2164-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705875, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2, but occasionally confused as expressed by some\n comments that are made\n Pt continuing to drain approx 300cc serous fluid from medial\n JP\n Small amount of drainage from sump drain\n Upper J tube (red) to gravity with mod amount of bilious\n drainage\n Lower J tube to tube feeds, currently at goal\n Golden soft stools\n Abd firm, pos bs, c/o pain on L side of ABD\n Pt complains of thirst frequently\n SBP 98-130\ns, MAP\ns >65 throughout shift\n Tmax 100.6, WBC up to 19.3 from 14.1, CVL in x10 days\n Hct 28.5, plt 101, INR 2.5\n BUN 106, Cr 3.6\n Action:\n Monitoring JP, sump drain and J tube outputs\n 3/4cc:cc NS repletion for JP outputs\n 25% Albumin given for every 1L output from drains\n 0.5mg IVP Dilaudid given prn\n Midodrine as ordered\n Response:\n Pt expressing adequate pain relief from Dilaudid\n No change in outputs\n Pt fluid status approx even as of MN\n Plan:\n Continue to monitor drain outputs\n Pain management\n Keep Map >65\n Continue with Albumin as ordered\n Attempt to get pt 1-2L negative\n ? Culture again\n Resite CVL, culture tip\n Ineffective Coping\n Assessment:\n Pt very labile emotionally\n Aggressive towards staff intermittently\n Pt continuously stating he wants to go home\n Pt unable to acknowledge current condition\n Uncooperative with care\n Action:\n Continue to provide pt with emotional support\n Continue to reorient pt to current condition\n Acknowledge and validate pt\ns frustrations\n Response:\n Pt more cooperative after receiving nursing support and\n acknowledgement of pt\ns frustrations\n Pt continues to have moments of aggression and lashing out\n at staff, but more dirctable\n Plan:\n Psych consult, social work consult\n Continue to provide pot with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705305, "text": "Ineffective Coping\n Assessment:\n Pt alert and oriented X3 most of night\n maintain BP > 110\ns with Map >60\n Having LLQ pain intermittently\n Pt very anxious with periods of agitation\n Crying following Octreotide dose\n Numerous large liquid stool\n Action:\n Weaned neo off at 0200\n Med with Dilaudid .5 Q3 hrs\n Pt refusing any stool collection appliance\n Response:\n Minimal pain relief\n Cont with periods of agitation\n Plan:\n ? plan\n Emotional support for pt and family\n Med for pain PRN\n" }, { "category": "Nursing", "chartdate": "2164-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706012, "text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704498, "text": "Shock, septic\n Assessment:\n Pt lethargic in bed. Oriented x3 although needing help at\n times to specific month. Assisting with turns in bed, weak in\n movements. Pt with c/o generalized pain primarily in abdomen rating\n on pain scale.\n NGT to medium continuous wall suction. Small amounts bilious\n drainage.\n Abdomen soft/ascetic. Lateral JP to self suction with\n moderate amounts ascetic/ser-sang drainage. Medial JP to wall suction\n with large amounts of drainage.\n Upper J-tube to gravity with bilious output. Lower J-tube\n with TF infusing at goal.\n Foley patent pt making amber clear urine about 15-25cc\n hourly.\n Lungs clear at apeces diminished in bases. Sat\ns 94-97% RA.\n Strong productive cough. Using IS pulling 1000-1300cc. Clearing own\n secretions well.\n Afebrile. WBC 25.5. NSR/ST HR 95-115. No ectopy. Continues\n on Neo drip.\n Action:\n Giving Fentanyl as needed for pain.\n Repleting JPx2 outputs with LR\n cc:cc. Administering 25%\n Albumin for every 1L of JP drainage.\n Encouraging c/db.\n Titrating Neo drip for goal MAP >65.\n Response:\n Mild pain relief with Fentanyl. Pt with sharp breakthrough\n of pain during night. Dr and Transplant team notified and\n arrived at bedside to further assess pt.\n Pt 2.4L positive at midnight. Teams notified. Thus far\n continuing fluid repletions.\n WBC this AM 19.6\n Plan:\n Monitor pain/comfort treating as needed.\n Continue to monitor all drain outputs and continue LR\n cc:cc JP drain repletions.\n Encourage c/db. IS use.\n F/u cultures. Continue antibiotics and WBC.\n Titrate Neo to goal.\n" }, { "category": "Rehab Services", "chartdate": "2164-11-01 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 704589, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: gastrotomy / 571.1\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 52 yo M with etoh\n cirrhosis with variceal bleed, ascites, and encephalopthy, admitted\n from OSH with hematochezia and hypotension. Underwent angio and\n found to have GDA pseudoaneurysm, went to OR for ex-lap for\n duodenal arterial bleed, gastrotomy, duodenotomy, and draining\n jejunostomy. Extubated .\n Past Medical / Surgical History: etoh cirrhosis, etoh hepatitis, upper\n GIB duodenal ulcer s/p clipping, OA s/p B TKA, chronic GIB \n internal hemorrhoids\n Medications: fentanyl, vancomycin, phenylephrine\n Radiology: CXR pending\n Labs:\n 28.8\n 9.7\n 222\n 19.6\n [image002.jpg]\n Other labs:\n Activity Orders: Activity as tolerated\n Social / Occupational History: lives with wife and 16-year-old\n daughter, does not work- disability\n Living Environment: lives in single-level home with several steps to\n enter\n Prior Functional Status / Activity Level: I pta, no DME\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented x2-3,\n follows all simple commands, verbalizes appropriately\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 108\n 102/51\n 20\n 98% on RA\n Activity\n 128\n 110/44\n 25\n 93%\n Recovery\n 106\n 120/44\n 18\n 99%\n Total distance walked: 0\n Minutes:\n Pulmonary Status: diminished BS bilaterally, non-labored breathing, no\n cough noted.\n Integumentary / Vascular: 2 JP drains, rectal tube, foley, NG tube,\n tele\n Sensory Integrity: intact to light touch B LE's, denies parasthesias\n Pain / Limiting Symptoms: c/o abdominal pain\n Posture: WNL\n Range of Motion\n Muscle Performance\n B LE's WNL, B knee flexion to 90\n B LE's grossly t/o\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to stand, unable to weight shift or advance\n either LE in order to pivot to chair. Total assist slide-transfer to\n stretcher chair. Tolerated OOB <30 min.\n Rolling:\n\n\n\n\n T\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n x2\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Static sitting balance fluctuates CG-min A with LOB backward,\n able to anteriorly weight shift with min A. Static standing balance\n with mod A x2, unable to weight shift. Tolerates standing \n seconds\n Education / Communication: Reviewed PT and discussed d/c planning,\n encouraged OOB. Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n Clinical impression / Prognosis: 52 yo M s/p gastrotomy p/w above\n impairments a/w soft tissue surgery. He is most limited by abdominal\n pain at this time, as well as general weakness and deconditioning a/w\n prolonged bedrest/hospitalization. He is significantly below his\n baseline level and would recommend rehab at this time, anticipate good\n prognosis and rehab potential given his age and prior level of\n function. PT will continue to progress as able while at acute level.\n Goals\n Time frame: 1 week\n 1.\n Min A rolling, mod A supine-to-sit and sit-to-stand, assess transfers\n 2.\n S static sitting, min A static/dynamic standing balance\n 3.\n Tolerate OOB >/= 2 hours/day\n 4.\n Tolerate daily LE strengthening\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n bed mobility, transfers, ambulation, balance, strengthening, endurance,\n education, 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": "2164-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703439, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains on vent CPAP/PS 5/5, no changes overnight.. LS clear\n with occasional rochi,\n Action:\n ABG sent, O 2sat 97-99%, suctioned yellow thin secretion, Good cough,\n and impaired gag. Cont with rotating bed. 1amp sodium bicarb given. ET\n tube rotated to lt side by RT, pt bites the tube.\n Response:\n LS clear, LS clear, o2 sat 98-100%, good cough.\n Plan:\n Cont to monitor, pulm hygiene, ? Change to regular ICU bed.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abdomen softly distended, medial JP with copious amt of leak around,\n NGT to LCS with clear drainage. Edge of the staples slightly swollen,\n WBC 14.7, s.lactate is 1.7, BUN 67 and creat 1.7, livber enzymes WNL.\n Action:\n JP taped with tegaderm by primary team early shift, replacing JP out\n with LR 1/2cc /cc, albumin 12.5gm for every 1L of JP out put given,\n sodium bicarb 1amp for every 3L JP out put. So sodium bicarb 1amp x1.\n Fentanyl for pain prn given.\n Response:\n Still leaking around JP , medial looks okay, but leaking around\n lateral now Tachy cardic HR 110-130/min, responding to pain meds.team\n aware. Stable HCT, rising BUN and chloride.\n Plan:\n Replace JP out put with LR, albumin 12.5gm for every Liter of JP out\n put, sodium bicarb 1amp for 3 L JP out put, ? suture the jp\n" }, { "category": "Physician ", "chartdate": "2164-10-25 00:00:00.000", "description": "Intensivist Note", "row_id": 703441, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n .\n MEDICATIONS (per d/c summary )\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n Albumin 25% (12.5g / 50mL) 6. Artificial Tear Ointment 7. Calcium\n Gluconate\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Fentanyl Citrate 10.\n Fluconazole 11. Insulin 12. Octreotide Acetate\n 13. Pantoprazole 14. Piperacillin-Tazobactam 15. Potassium Chloride 16.\n Sodium Chloride 0.9% Flush\n 17. Sodium Bicarbonate 18. Vancomycin\n 24 Hour Events:\n Weaned vent to minimal settings. Continued to have high output around\n JP drains. Ascities replacement schedule adjusted. Surgical team\n evaluated and re-dressed.\n .\n Post operative day:\n POD#8 - ex lap duod ulcer repair\n POD#5 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:19 AM\n Fluconazole - 10:01 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 25 mcg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:02 PM\n Fentanyl - 12:15 AM\n Other medications:\n Flowsheet Data as of 06:29 AM\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: 128 (107 - 132) bpm\n BP: 117/67(82) {91/48(62) - 133/71(90)} mmHg\n RR: 31 (15 - 31) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.9 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 13 (10 - 327) mmHg\n Total In:\n 7,563 mL\n 2,010 mL\n PO:\n Tube feeding:\n 616 mL\n 193 mL\n IV Fluid:\n 5,318 mL\n 1,277 mL\n Blood products:\n 350 mL\n 100 mL\n Total out:\n 10,109 mL\n 3,638 mL\n Urine:\n 879 mL\n 193 mL\n NG:\n 650 mL\n 300 mL\n Stool:\n 300 mL\n 700 mL\n Drains:\n 8,280 mL\n 2,445 mL\n Balance:\n -2,546 mL\n -1,628 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 595 (576 - 720) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 59.1 cmH2O/mL\n SPO2: 99%\n ABG: 7.37/32/108/18/-5\n Ve: 11.6 L/min\n PaO2 / FiO2: 216\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli, Unresponsive), Moves all extremities\n Labs / Radiology\n 59 K/uL\n 11.9 g/dL\n 143 mg/dL\n 1.7 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 67 mg/dL\n 119 mEq/L\n 144 mEq/L\n 35.0 %\n 14.7 K/uL\n [image002.jpg]\n 10:03 AM\n 02:06 PM\n 02:13 PM\n 08:11 PM\n 02:05 AM\n 02:24 AM\n 10:27 AM\n 04:26 PM\n 02:32 AM\n 02:37 AM\n WBC\n 14.1\n 13.4\n 12.9\n 14.7\n Hct\n 35.3\n 33.8\n 34.6\n 35.0\n Plt\n 80\n 74\n 69\n 59\n Creatinine\n 1.9\n 1.8\n 1.7\n TCO2\n 19\n 19\n 18\n 16\n 17\n 19\n Glucose\n 133\n 145\n 154\n 122\n 126\n 143\n Other labs: PT / PTT / INR:20.1/62.9/1.8, ALT / AST:12/32, Alk-Phos / T\n bili:66/8.6, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:158 IU/L, Ca:8.0 mg/dL, Mg:2.0\n mg/dL, PO4:3.4 mg/dL\n Imaging: CXR - overall improvement in lung herniation except for left\n basal consolidation, which is persistent and may represent atelectasis\n versus infectious process\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated s/p PPF gtt. Beginning to be more awake, moving\n extremeties to command.\n CVS: off pressors\n PULM: Intubated, s/p bronch for mucus plug . On \n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with RL. Albumin 12.5g per 1L ascites, also giving HCO3 for\n every 3L ascites. Hx of hepatorenal syndrome, renal following. No HD at\n this time. 24 hr urine creatinine ordered\n FEN/GI: NPO, protonix drip, octreotide gtt, TPN, TF nepro 1/2 strength\n at 20 cc/hr (not advancing). Consider wean of octreotide.\n ID: vanc / zosyn / fluc; f/u cx. Re-dose vanco by level.\n HEME: Hct stable type and crossed for 4 units. Given\n ENDO: RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, s/p L IJ triple lumen, R SC trauma line ( PIV x1,\n JP x2, NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 03:23 PM 30 mL/hour\n TPN without Lipids - 06:11 PM 66. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 31 min\n" }, { "category": "Respiratory ", "chartdate": "2164-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703734, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at lip Route: Oral\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: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: AM ABG 7.43/32/87/21 RSBI=31. Pt has noted cuff leak and\n gag. Plan to extubate today.\n" }, { "category": "Nursing", "chartdate": "2164-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703819, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n , pt tachycardic majority of time\n sicu resident notified, no new\n orders. Pt afebrile. Alert, oriented x3 with periods of confusion.\n Consistently following commands, lift and holding both arms, moving\n legs on bed. Lungs cta, min suctioning required. Abd softly\n distended, ngt in place to lwcs\n yellow drainage out. Jp\ns putting\n out copious amounts of s/s drainage. Moderate amount of bilious to\n green colored drainage out Jtube. Urine out marginal via foley (see\n flowsheets for specifics). Tolerating tube feeds via jtube.\n Action:\n Pt extubated this a.m. without difficulty. Sats high 90\ns to 100% on\n shovel mask post extubation. No c/o sob. Lungs clear to rhoncorous.\n Pt encouraged to cough and deep breathe. Jp output replaced with 1/2cc\n of LR hourly. Pt also given albumin for every liter of jp drainage out\n md\ns orders. Orders per transplant to keep patient 2L negative.\n Response:\n Pt denies pain or sob. . Remains over 2L negative\n sicu and\n transplant aware.\n Plan:\n Continue strict i/o\ns with fluid replacement. Respiratory toilet.\n Maintain skin integrity. Monitor for s/s of infection.\n" }, { "category": "Physician ", "chartdate": "2164-10-28 00:00:00.000", "description": "Intensivist Note", "row_id": 703889, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n Chief complaint:\n PMHx:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n Albumin\n Fentanyl prn\n Pantoprazole gtt\n ISS\n 24 Hour Events:\n : Continued on albumin (12.5 g) replacement based on ascitic\n fuid output. Slowed urine output and hypotension, given 25g albumin\n in 500 ml x 1 per transplant.\n EXTUBATION - At 10:00 AM\n INVASIVE VENTILATION - STOP 10:00 AM\n Post operative day:\n POD#11 - ex lap duod ulcer repair\n POD#8 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:31 PM\n Fluconazole - 10:07 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 01:00 AM\n Other medications:\n Flowsheet Data as of 06:40 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: 118 (104 - 118) bpm\n BP: 90/41(57) {86/41(57) - 125/59(78)} mmHg\n RR: 22 (17 - 22) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 6 (0 - 156) mmHg\n Total In:\n 12,873 mL\n 3,431 mL\n PO:\n Tube feeding:\n 1,212 mL\n 386 mL\n IV Fluid:\n 9,613 mL\n 2,167 mL\n Blood products:\n 500 mL\n 637 mL\n Total out:\n 15,407 mL\n 4,250 mL\n Urine:\n 782 mL\n 100 mL\n NG:\n 1,350 mL\n Stool:\n Drains:\n 13,275 mL\n 3,850 mL\n Balance:\n -2,534 mL\n -819 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 570 (570 - 570) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: 7.43/29/86/19/-3\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Percussion: No(t) Resonant : ), (Breath Sounds:\n CTA bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 2+), (Temperature: Warm, No(t) Cool)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 95 K/uL\n 11.6 g/dL\n 148 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 81 mg/dL\n 108 mEq/L\n 137 mEq/L\n 34.1 %\n 21.0 K/uL\n [image002.jpg]\n 02:37 AM\n 02:17 AM\n 02:28 AM\n 08:37 AM\n 03:03 PM\n 02:00 AM\n 02:05 AM\n 11:12 AM\n 01:44 AM\n 02:06 AM\n WBC\n 16.6\n 18.2\n 21.0\n Hct\n 35.2\n 33.0\n 34.1\n Plt\n 65\n 77\n 95\n Creatinine\n 1.7\n 1.5\n 1.6\n TCO2\n 19\n 22\n 20\n 22\n 18\n 20\n Glucose\n 158\n 152\n 141\n 148\n Other labs: PT / PTT / INR:22.4/76.1/2.1, ALT / AST:, Alk-Phos / T\n bili:53/5.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:120 IU/L, Ca:8.3 mg/dL, Mg:1.6\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n Neurologic: Fentanyl prn, following commands\n Cardiovascular: stable\n Pulmonary: extubated without complication\n Gastrointestinal / Abdomen: NPO,protonix gtt, bag TPN, TF nepro \n strength at 60\n Nutrition: TPN, Tube feeding\n Renal: Foley, following UOP, replacing ascites drain output 0.5 to 1\n with LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. Goal\n of being 2 L negative f/u urine lytes\n Hematology: Stable. Type and cros for 4 units in the blood bank.\n Endocrine: RISS\n Infectious Disease: Abx d/c'd. Pt afebrile, slight increase in WBC.\n Lines / Tubes / Drains: Foley, NGT, Surgical drains (hemovac, JP)\n Wounds: c/d/i/\n Imaging:\n Fluids: replacing ascites drain output 0.5 to 1 with LR. Albumin 12.5g\n per 1L ascites. Fluid balance goal: 2L negative over 24 hrs\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN w/ Lipids - 10:12 PM 37.5 mL/hour\n NovaSource Renal () - 11:45 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Nexium gtt)\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703825, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n , pt tachycardic majority of time\n sicu resident notified, no new\n orders. Pt afebrile. Alert, oriented x3 with periods of confusion.\n Consistently following commands, lift and holding both arms, moving\n legs on bed. Lungs cta, min suctioning required. Abd softly\n distended, ngt in place to lwcs\n yellow drainage out. Jp\ns putting\n out copious amounts of s/s drainage. Moderate amount of bilious to\n green colored drainage out Jtube. Urine out marginal via foley (see\n flowsheets for specifics). Tolerating tube feeds via jtube.\n Action:\n Pt extubated this a.m. without difficulty. Sats high 90\ns to 100% on\n shovel mask post extubation. No c/o sob. Lungs clear to rhoncorous.\n Pt encouraged to cough and deep breathe. Jp output replaced with 1/2cc\n of LR hourly. Pt also given albumin for every liter of jp drainage out\n md\ns orders. Orders per transplant to keep patient 2L negative.\n Response:\n Pt denies pain or sob. . Remains over 2L negative\n sicu and\n transplant aware.\n Plan:\n Continue strict i/o\ns with fluid replacement. Respiratory toilet.\n Maintain skin integrity. Monitor for s/s of infection.\n" }, { "category": "Nursing", "chartdate": "2164-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705439, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703377, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703378, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains on vent CPAP/PS 5/5, no changes overnight.. LS clear\n with occasional rochi,\n Action:\n ABG sent, O 2sat 97-99%, suctioned yellow thin secretion, Good cough,\n and impaired gag. Cont with rotating bed. 1amp sodium bicarb given. ET\n tube rotated to lt side by RT, pt bites the tube.\n Response:\n LS clear, ABG\n Plan:\n Cont to monitor, pulm hygiene, ? change to regular ICU bed.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abdomen softly distended, medial JP with copious amt of leak around,\n NGT to LCS with clear drainage. Edge of the staples slightly swallen,\n Action:\n JP taped with tegaderm by primary team early shift, replacing JP out\n with LR 1/2cc /cc, albumin 12.5gm\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703725, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains intubated on CPAP 5/5, 40% FiO2\n Suctioned prn for scant amount of secretions\n ABG wnl\n Pt alert, following commands, MAE, Pupils equal and\n reactive. Pt nodding appropriately to yes/no questions, attempting to\n mouth words. Pos cough, pos gag. At approx 2200 pt became agitated and\n restless, attempting to mouth words, reaching for ETT and NGT, pt\n nodding yes to pain, restraints reapplied and fentanyl given with pos\n effect.\n Pt appearing depressed, weepy at times\n Abd incision OTA, staples intact, JPx2, Suction dsg applied\n by Nsg in order to quantify acites drainage; copious amounts of\n serosang drainage from drains. Jtube x2, one to drainage, one to\n feeding. NGT to LCS, clear drainage.\n HR 95-120\ns. BP 95-130\ns with MAP >65 throughout majority of\n shift, dipped BP to 80\ns with MAP 55 x1, improved with fluid bolus and\n albumin\n CVP 10-13, PPV \n U/O 20-60cc/hr, dark amber urine via foley cath. Cr 1.5, BUN\n 76\n Afebrile, tmax 98.5. WBC 18.2 up from 16.6\n Hct stable, Plt 77, Chloride 111 from 115\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Abx as ordered\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin and bicarb as ordered\n Extubate this AM\n Provide pt and family with emotional support\n" }, { "category": "Respiratory ", "chartdate": "2164-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703821, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Pt received intubated and mechanically ventilated on PSV 5/5 as noted.\n Subglottic suctioning done prior to extubation. Pt has a positive cuff\n leak test. Pt extubated to cool aerosol without incident.\n" }, { "category": "Physician ", "chartdate": "2164-10-28 00:00:00.000", "description": "Intensivist Note", "row_id": 703901, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n Chief complaint:\n PMHx:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n Albumin\n Fentanyl prn\n Pantoprazole gtt\n ISS\n 24 Hour Events:\n : Continued on albumin (12.5 g) replacement based on ascitic\n fuid output. Slowed urine output and hypotension, given 25g albumin\n in 500 ml x 1 per transplant.\n EXTUBATION - At 10:00 AM\n INVASIVE VENTILATION - STOP 10:00 AM\n Post operative day:\n POD#11 - ex lap duod ulcer repair\n POD#8 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:31 PM\n Fluconazole - 10:07 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 01:00 AM\n Other medications:\n Flowsheet Data as of 06:40 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: 118 (104 - 118) bpm\n BP: 90/41(57) {86/41(57) - 125/59(78)} mmHg\n RR: 22 (17 - 22) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 6 (0 - 156) mmHg\n Total In:\n 12,873 mL\n 3,431 mL\n PO:\n Tube feeding:\n 1,212 mL\n 386 mL\n IV Fluid:\n 9,613 mL\n 2,167 mL\n Blood products:\n 500 mL\n 637 mL\n Total out:\n 15,407 mL\n 4,250 mL\n Urine:\n 782 mL\n 100 mL\n NG:\n 1,350 mL\n Stool:\n Drains:\n 13,275 mL\n 3,850 mL\n Balance:\n -2,534 mL\n -819 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 570 (570 - 570) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SPO2: 97%\n ABG: 7.43/29/86/19/-3\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Percussion: No(t) Resonant : ), (Breath Sounds:\n CTA bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 2+), (Temperature: Warm, No(t) Cool)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 95 K/uL\n 11.6 g/dL\n 148 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 81 mg/dL\n 108 mEq/L\n 137 mEq/L\n 34.1 %\n 21.0 K/uL\n [image002.jpg]\n 02:37 AM\n 02:17 AM\n 02:28 AM\n 08:37 AM\n 03:03 PM\n 02:00 AM\n 02:05 AM\n 11:12 AM\n 01:44 AM\n 02:06 AM\n WBC\n 16.6\n 18.2\n 21.0\n Hct\n 35.2\n 33.0\n 34.1\n Plt\n 65\n 77\n 95\n Creatinine\n 1.7\n 1.5\n 1.6\n TCO2\n 19\n 22\n 20\n 22\n 18\n 20\n Glucose\n 158\n 152\n 141\n 148\n Other labs: PT / PTT / INR:22.4/76.1/2.1, ALT / AST:, Alk-Phos / T\n bili:53/5.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:120 IU/L, Ca:8.3 mg/dL, Mg:1.6\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n Neurologic: Fentanyl prn, following commands\n Cardiovascular: stable\n Pulmonary: extubated without complication\n Gastrointestinal / Abdomen: NPO,protonix gtt, bag TPN, TF nepro \n strength at 60\n Nutrition: D/C TPN, Tube feeding\n Renal: Foley, following UOP, replacing ascites drain output 0.5 to 1\n with LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. Goal\n of being 2 L negative f/u urine lytes Very low Na\n.probable\n hypovolemia. Watch for hepatorenal.\n Hematology: Stable. Type and cros for 4 units in the blood bank.\n Endocrine: RISS\n Infectious Disease: Abx d/c'd. Pt afebrile, slight increase in WBC.\n Lines / Tubes / Drains: Foley, NGT, Surgical drains (hemovac, JP) D/C\n trauma line\n Wounds: c/d/i/\n Imaging:\n Fluids: replacing ascites drain output 0.75 to 1 with LR. Albumin 12.5g\n per 1L ascites. Fluid balance goal: 2L negative over 24 hrs\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN w/ Lipids - 10:12 PM 37.5 mL/hour\n NovaSource Renal () - 11:45 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Nexium gtt)\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2164-11-06 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 705550, "text": "Subjective:\n I want to go home\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - Slight worsening of patchy opacity at\n the left base which may be due to atelectasis or developing pneumonia.\n Persistent moderate elevation of right hemidiaphragm with adjacent\n linear atelectasis. Small pleural effusions unchanged. Probable ascites\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n X-\n X2\n Sit to Stand:\n\n\n\n X2\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 114\n 117/57\n 20\n 99% on RA\n Activity\n Sit, Stand\n 150\n /\n 28\n 92% on RA\n Recovery\n Sit\n 124\n 134/74\n 22\n 995 on RA\n Total distance walked: 0\n Minutes:\n Gait: able to shift feet minimally to transfer from edge of bed to\n chair. unable to advance LE's in standing.\n Balance: able to maintain static sitting with S/CG once positioned.\n able to maintain static standing with min A x2, dynamic weight shifting\n with mod A x2. No gross LOB.\n Education / Communication: Reviewed PT and d/c planning.\n Communicated with nsg re: status and transfer back to bed.\n Other: Denies pain\n Mod c/o fatigue/SOB with mobility\n HR recovers quickly with seated rest.\n Assessment: 52 yo M s/p gastrotomy making slow steady progress in PT\n with mobility and endurance, continues to be limited by general\n weakness and deconditioning a/w prolonged icu hospitalization. He is\n well below his baseline but has good rehab potential, continue to\n recommned d/c to rehab at this time when medically stable. PT to\n continue to progress as able at acute level.\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Nursing", "chartdate": "2164-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705782, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements. Mild c/o abdominal pain.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n Medial JP to self suction with sump to LCWS. Medial\n drain with moderate amounts ascetic output. Lateral drain removed by\n Transplant team at change of shift with sutures placed. sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65. WBC 13.5\n Action:\n Reorientating pt as needed. Dilaudid given for pain control.\n Repositioning pt to comfort.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Adequate pain relief.\n Pt -900cc at midnight.\n WBC slightly elevated to 14.3\n Plan:\n Reorient pt frequently. Treat pain/comfort as needed.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n f/u with blood and JP output cultures.\n" }, { "category": "Nursing", "chartdate": "2164-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703818, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n VSS, afebrile. Alert, oriented x3 with periods of confusion.\n Consistently following commands, lift and holding both arms, moving\n legs on bed. Lungs cta, min suctioning required. Abd softly\n distended, ngt in place to lwcs\n yellow drainage out. Jp\ns putting\n out copious amounts of s/s drainage. Moderate amount of bilious to\n green colored drainage out Jtube. Urine out marginal via foley (see\n flowsheets for specifics). Tolerating tube feeds via jtube.\n Action:\n Pt extubated this a.m. without difficulty. Sats high 90\ns to 100% on\n shovel mask post extubation. No c/o sob. Lungs clear to rhoncorous.\n Pt encouraged to cough and deep breathe. Jp output replaced with 1/2cc\n of LR hourly. Pt also given albumin for every liter of jp drainage out\n md\ns orders. Orders per transplant to keep patient 2L negative.\n Response:\n Pt denies pain or sob. VSS. Remains over 2L negative\n sicu and\n transplant aware.\n Plan:\n Continue strict i/o\ns with fluid replacement. Respiratory toilet.\n Maintain skin integrity. Monitor for s/s of infection.\n" }, { "category": "Physician ", "chartdate": "2164-11-02 00:00:00.000", "description": "Intensivist Note", "row_id": 704691, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n Chief complaint:\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Albumin 25% (12.5g / 50mL) 6. Artificial Tear Ointment\n 7. Calcium Gluconate 8. Fentanyl Citrate 9. HYDROmorphone (Dilaudid)\n 10. Insulin 11. Micafungin\n 12. Pantoprazole 13. Phenylephrine 14. Phytonadione 15. Sodium Chloride\n 0.9% Flush 16. Sodium Chloride 0.9% Flush\n 17. Tetracaine HCl 18. Vancomycin\n 24 Hour Events:\n : Switched to dilaudid for pain. Fractionated bilirubin Tbili=8.8,\n Dbili=4.8. Not obstructed. Following cx were negative: UA, peritoneal\n fluid, and aline tip.\n : Dry heaving, no emesis or blood. Started zofran.\n Post operative day:\n POD#16 - ex lap duod ulcer repair\n POD#13 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:14 PM\n Pantoprazole (Protonix) - 12:30 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:58 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: 36\nC (96.8\n HR: 112 (100 - 127) bpm\n BP: 106/51(70) {85/44(60) - 128/65(85)} mmHg\n RR: 20 (16 - 28) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 2 (2 - 185) mmHg\n Total In:\n 11,314 mL\n 2,129 mL\n PO:\n Tube feeding:\n 3,000 mL\n 592 mL\n IV Fluid:\n 7,367 mL\n 1,537 mL\n Blood products:\n 947 mL\n Total out:\n 9,707 mL\n 1,939 mL\n Urine:\n 492 mL\n 99 mL\n NG:\n 400 mL\n Stool:\n 50 mL\n Drains:\n 8,685 mL\n 1,840 mL\n Balance:\n 1,607 mL\n 190 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: 7.43/22/96./16/-6\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, Tender: to touch on LLQ\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: No(t) x 3), Follows simple\n commands\n Labs / Radiology\n 210 K/uL\n 9.1 g/dL\n 136 mg/dL\n 2.8 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 86 mg/dL\n 104 mEq/L\n 131 mEq/L\n 28.1 %\n 18.1 K/uL\n [image002.jpg]\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n 01:59 AM\n 08:25 AM\n 02:03 AM\n 02:11 AM\n WBC\n 26.0\n 21.9\n 26.1\n 25.5\n 19.6\n 18.1\n Hct\n 33.7\n 32.1\n 32.5\n 32.6\n 28.8\n 28.1\n Plt\n 130\n 140\n 192\n 244\n 222\n 210\n Creatinine\n 2.0\n 1.9\n 2.0\n 2.2\n 2.4\n 2.8\n TCO2\n 18\n 15\n 16\n 15\n Glucose\n 102\n 128\n 155\n 162\n 125\n 136\n Other labs: PT / PTT / INR:23.8/54.0/2.3, ALT / AST:19/43, Alk-Phos / T\n bili:96/8.7, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.8 g/dL, LDH:209 IU/L, Ca:7.5 mg/dL, Mg:1.3\n mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n Neurologic: Dilaudid prn, awake and following commands\n Cardiovascular: Vasolitory shock, fluid repletion 3/4:1, on neo gtt for\n hypotension\n Pulmonary: on NC, no issues\n Gastrointestinal / Abdomen: protonix 40\", TF impact 3/4 strength at\n 125ml/hr.\n Nutrition: Tube feeding\n Renal: Foley\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: micafungin started \n blood/ascites; vanc for coag neg staph tip cx; ophthalmology exam\n negative. Daily surv cx. All lines changed out. Follow vanco level\n prior to 4th dose. Ascites gs(-)\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP)\n Wounds: c/d/i/\n Imaging:\n Fluids: NS, 3/4:1 of JP output\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:51 PM 125 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703524, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continued on CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant to moderate thick, white secretions.\n Cough improving.\n Gag weak to absent.\n Negative 1 Liter.\n Action:\n Removed from Triadyne bed and placed on Kinair matress.\n Chest X ray this am MD with unchanged R pleural effusion.\n Response:\n Minimal secretions.\n RR and work of breathing WNL.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours.\n Pt not be more than 2 Liters negative.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT draining clear, thick drainage. Abdomen soft distended.\n BS hypoactive.\n JP\nS draining ascitic fluid.\n +++ generalized edema.\n HR 115-120\ns. SBP 90\ns-110\n UO diminished, SICU Team aware.\n Action:\n JP drainage replaced with LR 1/2 cc / cc output, H.Alb 125.gm for every\n 1Liter of JP drainage given and NA Bicarb for every 3 Liters.\n With assistance from CNS , a\nvac like\n dressing in place over\n leaking JP drains and collected by low continous suction. JP\ns remain\n with manual bulb suction. MD from Transplant aware.\n Tachycardia and Low SBP treated with 1000cc bolus of LR.\n Response:\n Patient is opening eyes spontanousley. Following simple commands and\n moving all extremities, PERRLA, Fentanyl bolus PRN for pain.\n Maintaining map >60, HR lowered with fluid bolus.\n TF at 30ml/hr.\n JP Drains with less leaking and more improved collection.\n Plan:\n Continue to replete JP output as ordered with LR, albumin and NA Bicarb\n as indicated.\n Strict I&O\ns to maintain desired fluid status.\n ? D/C NGT.\n" }, { "category": "Nutrition", "chartdate": "2164-10-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 704077, "text": "Objective\n Pertinent medications: Noted\n Labs:\n Value\n Date\n Glucose\n 102 mg/dL\n 02:45 AM\n Glucose Finger Stick\n 142\n 10:00 AM\n BUN\n 87 mg/dL\n 02:45 AM\n Creatinine\n 2.0 mg/dL\n 02:45 AM\n Sodium\n 135 mEq/L\n 02:45 AM\n Potassium\n 3.6 mEq/L\n 02:45 AM\n Chloride\n 106 mEq/L\n 02:45 AM\n TCO2\n 18 mEq/L\n 02:45 AM\n PO2 (arterial)\n 144 mm Hg\n 08:38 AM\n PCO2 (arterial)\n 24 mm Hg\n 08:38 AM\n pH (arterial)\n 7.46 units\n 08:38 AM\n pH (urine)\n 6.5 units\n 03:04 PM\n CO2 (Calc) arterial\n 18 mEq/L\n 08:38 AM\n Albumin\n 2.8 g/dL\n 02:45 AM\n Calcium non-ionized\n 7.8 mg/dL\n 02:45 AM\n Phosphorus\n 4.6 mg/dL\n 02:45 AM\n Ionized Calcium\n 1.09 mmol/L\n 08:38 AM\n Magnesium\n 1.5 mg/dL\n 02:45 AM\n ALT\n 15 IU/L\n 02:45 AM\n Alkaline Phosphate\n 84 IU/L\n 02:45 AM\n AST\n 36 IU/L\n 02:45 AM\n Amylase\n 132 IU/L\n 02:58 AM\n Total Bilirubin\n 5.7 mg/dL\n 02:45 AM\n WBC\n 26.0 K/uL\n 02:45 AM\n Hgb\n 11.3 g/dL\n 02:45 AM\n Hematocrit\n 33.7 %\n 02:45 AM\n Current diet order / nutrition support: 3/4 strength Novasource Renal\n @70ml/hr\n GI: Abd soft/ distended/ (+)BS/ (+)BM\n Assessment of Nutritional Status\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension, now s/p exploratory laparotomy, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy. JP continue to\n drain, UOP minimal. Was on TPN and diluted tube feeds started last\n week.\n Extubated, tube feeds at the above goal providing 2520kcals and 93g\n protein/day- inappropriate formula/rate as overfeeding on calories and\n underfeeding protein requirements.\n .\n Medical Nutrition Therapy Plan - Recommend the Following\n Advance diet to regular when appropriate to do so, consider SLP\n evaluation.\n Discontinue TPN.\n Tube feeding recommendations:\n Change order to Nutren 2.0 w/ 30g beneprotein at goal of 45ml/ hr to\n provide 2270kcals and 112g protein/ day.\n No residual checks w/ J-tube.\n Continue w/ electrolyte management\n Monitor hydration status.\n Following closely, please page w/ questions #\n 14:32\n" }, { "category": "Nutrition", "chartdate": "2164-11-02 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 704780, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 98.2 kg\n 100.3 kg ( )\n 28.5\n Pertinent medications: RISS, Protonix, ABx, RIfaximin, Neosynephrine,\n others noted\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 02:03 AM\n Glucose Finger Stick\n 164\n 10:00 AM\n BUN\n 86 mg/dL\n 02:03 AM\n Creatinine\n 2.8 mg/dL\n 02:03 AM\n Sodium\n 131 mEq/L\n 02:03 AM\n Potassium\n 4.0 mEq/L\n 02:03 AM\n Chloride\n 104 mEq/L\n 02:03 AM\n TCO2\n 16 mEq/L\n 02:03 AM\n PO2 (arterial)\n 96. mm Hg\n 02:11 AM\n PCO2 (arterial)\n 22 mm Hg\n 02:11 AM\n pH (arterial)\n 7.43 units\n 02:11 AM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 15 mEq/L\n 02:11 AM\n Albumin\n 2.8 g/dL\n 02:03 AM\n Calcium non-ionized\n 7.5 mg/dL\n 02:03 AM\n Phosphorus\n 4.6 mg/dL\n 02:03 AM\n Ionized Calcium\n 0.97 mmol/L\n 04:45 AM\n Magnesium\n 1.3 mg/dL\n 02:03 AM\n ALT\n 19 IU/L\n 02:03 AM\n Alkaline Phosphate\n 96 IU/L\n 02:03 AM\n AST\n 43 IU/L\n 02:03 AM\n Amylase\n 132 IU/L\n 02:58 AM\n Total Bilirubin\n 8.7 mg/dL\n 02:03 AM\n WBC\n 18.1 K/uL\n 02:03 AM\n Hgb\n 9.1 g/dL\n 02:03 AM\n Hematocrit\n 28.1 %\n 02:03 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: 3/4 strength Impact with Fiber @ 125mL/hr (2250kcals, 126g\n protein)\n GI: abd soft, distended, + brown liquid stool.\n Assessment of Nutritional Status\n 52 y.o. Male with ETOH cirrhosis complicated by esophageal and rectal\n varices, now s/p exploratory laparotomy, gastrotomy, duodenotomy with\n suturing of bleeding vessel, draining jejunostomy and feeding j-tube.\n JP\ns x2 continue to drain large amounts, and UOP minimal (less than\n 500mL/day). Per team, patient is on diluted tube feedings at goal,\n which provide 23kcals/kg and 1.3g proein/day. Noted that BUN/Cr\n increasing each day, and Mag is low\n not being repleted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with tube feeds.\n Please replete Mag.\n Monitor tube feed tolerance and labs/lytes.\n Following - #\n" }, { "category": "Physician ", "chartdate": "2164-10-26 00:00:00.000", "description": "Intensivist Note", "row_id": 703622, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n BRBPR\n PMHx:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Internal\n Jugular Order date: @ 1703\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1703\n 2. IV access: Temporary central access (ICU) Location: Right Subclavian\n Order date: @ 1703\n 12. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain\n hold for sedation Order date: @ 1221\n 3. IV access: Temporary central access (ICU) Location: Left Femoral\n Order date: @ 1703\n 13. Fluconazole 200 mg IV Q24H Order date: @ 1703\n 4. 1000 mL LR\n Continuous at 0 ml/hr for 0 ml\n please give 1/2 cc / cc JP output repletion Order date: @ 0945\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 5. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1320\n 15. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 1703\n 6. 500 mL NS Bolus 500 ml Over 20 mins Order date: @ 1851\n 16. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 1703\n 7. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 0416\n 17. 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: @ 1703\n 8. Albumin 25% (12.5g / 50mL) 25 g IV ONCE Duration: 1 Doses Order\n date: @ 1851\n 18. Sodium Bicarbonate 50 mEq IV PRN ascitic loss\n for each 3 liters of ascitic ouput, please replace with 1 amp bicarb\n Order date: @ 0802\n 9. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758\n 19. Vancomycin 1000 mg IV Q 24H Order date: @ 1448\n 10. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 24 Hour Events:\n Continued on minimal vent settings. Continued high JP output.\n Intermittent fluid boluses throughout day with LR as needed for BP /\n UOP; JP repletion changed from NS to LR. Tube feeds increased to\n 40mL/hr. Octreotide d/c'd.\n Post operative day:\n POD#9 - ex lap duod ulcer repair\n POD#6 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Fluconazole - 10:01 PM\n Piperacillin/Tazobactam (Zosyn) - 03:59 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 12:30 AM\n Sodium Bicarbonate 8.4% (Amp) - 01:06 AM\n Other medications:\n Flowsheet Data as of 06:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.4\nC (97.5\n HR: 108 (98 - 125) bpm\n BP: 99/57(69) {89/46(58) - 148/77(98)} mmHg\n RR: 18 (12 - 22) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.9 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 10 (8 - 21) mmHg\n Total In:\n 10,015 mL\n 3,726 mL\n PO:\n Tube feeding:\n 760 mL\n 260 mL\n IV Fluid:\n 7,186 mL\n 2,771 mL\n Blood products:\n 450 mL\n 200 mL\n Total out:\n 11,673 mL\n 4,838 mL\n Urine:\n 638 mL\n 238 mL\n NG:\n 700 mL\n 100 mL\n Stool:\n 700 mL\n Drains:\n 9,635 mL\n 4,500 mL\n Balance:\n -1,658 mL\n -1,112 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 580 (562 - 869) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: 7.44/32/110/22/0\n Ve: 16.8 L/min\n PaO2 / FiO2: 220\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 65 K/uL\n 11.7 g/dL\n 158 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 72 mg/dL\n 115 mEq/L\n 143 mEq/L\n 35.2 %\n 16.6 K/uL\n [image002.jpg]\n 02:13 PM\n 08:11 PM\n 02:05 AM\n 02:24 AM\n 10:27 AM\n 04:26 PM\n 02:32 AM\n 02:37 AM\n 02:17 AM\n 02:28 AM\n WBC\n 13.4\n 12.9\n 14.7\n 16.6\n Hct\n 33.8\n 34.6\n 35.0\n 35.2\n Plt\n 74\n 69\n 59\n 65\n Creatinine\n 1.8\n 1.7\n 1.7\n TCO2\n 19\n 18\n 16\n 17\n 19\n 22\n Glucose\n 154\n 122\n 126\n 143\n 158\n Other labs: PT / PTT / INR:21.8/72.1/2.0, ALT / AST:, Alk-Phos / T\n bili:60/7.2, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.5 g/dL, LDH:143 IU/L, Ca:7.9 mg/dL, Mg:1.9\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan:\n Neurologic: Intubated s/p PPF gtt. Beginning to be more awake, moving\n extremeties to command.\n Cardiovascular: stable; follow\n Pulmonary: Intubated, CPAP 5/5. Extubate.\n Gastrointestinal / Abdomen: NPO, protonix drip, TPN, TF nepro \n strength advancing slowly, now at 40mL/hr.\n Nutrition: TF at 40mL/hr will increase concentration. Decrease TPN\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with LR. Albumin 12.5g per 1L ascites,. Hx of hepatorenal\n syndrome.\n Hematology: Hct stable type and crossed for 4 units\n Endocrine: RISS\n Infectious Disease: vanc / zosyn / fluc; f/u cx\n Lines / Tubes / Drains: ETT, foley, s/p L IJ triple lumen, R SC trauma\n line ( PIV x1, JP x2, NGT, J-tube\n Wounds: abdominal wound closed, clean / dry / intact\n Imaging: none\n Fluids: Replacing ascites drain output 0.5 to 1 with LR. Albumin 12.5g\n per 1L ascites, also giving HCO3 for every 3L ascites.\n Consults: transplant surgery\n Billing Diagnosis: UGIB s/p ex lap, gastrotomy, duodenotomy w/suturing\n of bleeding vessel, draining jejunostomy\n ICU Care\n Nutrition:\n NovaSource Renal () - 10:18 PM 40 mL/hour\n TPN without Lipids - 11:21 PM 66. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2164-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703965, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n VSS, sbp improved this shift. Transient episode of hypotension through\n the a.m. as shift progressed sbp sustaining in the 90\ns to low 100\n Pt alert, oriented x3 with periods of making inappropriate statements.\nI need to go to court\n etc. Pt able to deep breath and cough. Cough\n productive for thick, tan to yellow sputum. Lungs clear to rhoncorous\n throughout. Abd remains softly distended, ngt to lwcs for thick yellow\n drainage. Tfeed increased via jtube to 70cc/hr. Other jtube putting\n out sm amt of green drainage. Stool liquid, black, brown in color.\n Urine output poor. Jp drainage decreased from yesterday. Drainage\n from vac dressing greatly decreased. Blood cultures sent for (+)\n culture on jp fluid, cultures including fungal screening.\n Action:\n Strict i/o\ns. Diabetic management per ssri. Jp output replaced with\n cc per cc of output with LR. Albumin given per liter of JP output.\n Attempting to get patient\neven\n. Pt started on md\n orders.\n Response:\n Sbp improved. Sats high 90\ns to 100%. Pt denies sob or pain.\n Plan:\n Cont current treatment plan. Strict i/o\ns. Monitor for s/s of\n infection. Cont patient and family teaching as well as support.\n" }, { "category": "Physician ", "chartdate": "2164-10-29 00:00:00.000", "description": "Intensivist Note", "row_id": 704038, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint: GIB\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n .\n MEDICATIONS (per d/c summary )\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n . Albumin 25% (12.5g / 50mL)\n 10. Artificial Tear Ointment 11. Calcium Gluconate 12. Chlorhexidine\n Gluconate 0.12% Oral Rinse 13. Fentanyl Citrate 14. Insulin 15.\n Micafungin 16. Pantoprazole 17. Potassium Chloride 18. Sodium Chloride\n 0.9% Flush\n 19. Sodium Bicarbonate\n 24 Hour Events:\n Stable. No acute issues. Trauma line pulled. Growing yeast from\n ascites fluid. Started caspiofungin. Bolused by transplant team\n colloid/LR, multiple times over last 24 hours.\n BLOOD CULTURED - At 07:59 AM\n TRAUMA LINE - STOP 12:12 PM\n Post operative day:\n POD#12 - ex lap duod ulcer repair\n POD#9 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:31 PM\n Fluconazole - 10:07 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 AM\n Micafungin - 02:30 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.9\nC (98.4\n HR: 99 (99 - 117) bpm\n BP: 91/45(59) {78/37(53) - 112/61(75)} mmHg\n RR: 19 (18 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.8 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 9 (2 - 178) mmHg\n Total In:\n 11,824 mL\n 4,410 mL\n PO:\n Tube feeding:\n 1,609 mL\n 495 mL\n IV Fluid:\n 8,990 mL\n 3,765 mL\n Blood products:\n 943 mL\n 150 mL\n Total out:\n 11,975 mL\n 4,048 mL\n Urine:\n 325 mL\n 98 mL\n NG:\n 150 mL\n 150 mL\n Stool:\n Drains:\n 11,000 mL\n 3,800 mL\n Balance:\n -151 mL\n 362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///18/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 130 K/uL\n 11.3 g/dL\n 102 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 87 mg/dL\n 106 mEq/L\n 135 mEq/L\n 33.7 %\n 26.0 K/uL\n [image002.jpg]\n 08:37 AM\n 03:03 PM\n 02:00 AM\n 02:05 AM\n 11:12 AM\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n WBC\n 18.2\n 21.0\n 26.0\n Hct\n 33.0\n 34.1\n 33.7\n Plt\n 77\n 95\n 130\n Creatinine\n 1.5\n 1.6\n 1.7\n 2.0\n TCO2\n 20\n 22\n 18\n 20\n Glucose\n 152\n 141\n 148\n 135\n 130\n 102\n Other labs: PT / PTT / INR:22.3/64.7/2.1, ALT / AST:, Alk-Phos / T\n bili:53/5.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.8 g/dL, LDH:120 IU/L, Ca:7.8 mg/dL, Mg:1.5\n mg/dL, PO4:4.6 mg/dL\n Microbiology: Cultures Pending\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Fentanyl prn, following commands\n CVS: stable hemodynamics, fluid boluses prn hypoTN (thought to be \n volume losses via ascitic fluid; TTE today to evaluate volume status ;\n goal MAP>65.\n PULM: extubated , stable on NC\n RENAL: Low UOP 5-20cc/hr, replacing ascites drain output 1 to 1 with\n LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. f/u urine\n lytes.\n FEN/GI: NPO,protonix gtt, TF nepro 3/4 strength at 70ml/hr, ? increase\n protein content in TF\n ID: s/p vanc/zosyn now on caspofungin, growing yeast from ascitic\n fluid, f/u speciation; change CVL today and send tip for cx; place new\n access\n HEME: Hct stable, type and crossed for 4 units\n ENDO: RISS\n PPX: PPI IV gtt, pneumoboots, holding SQ heparin\n ACCESS: foley, a-line, L IJ triple lumen CVL, s/p R SC trauma line now\n removed, PIV x1, JP x2, NGT, J-tube, FlexiSeal\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 05:14 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Code status: Full code\n Total time spent: 32 min\n" }, { "category": "Physician ", "chartdate": "2164-10-30 00:00:00.000", "description": "Intensivist Note", "row_id": 704192, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n BRBPR\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular Order date: @ 1311\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 2. 1000 mL LR\n Continuous at 0 ml/hr for 0 ml\n please give cc / cc JP output repletion Order date: @ 1008\n 12. Lidocaine 1% 2 mL SC ONCE Duration: 1 Doses Order date: @\n \n 3. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1008\n 13. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1018\n 4. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1743\n 14. Micafungin 100 mg IV DAILY Order date: @ 0917\n 5. 1000 mL LR\n Continuous at 1000 ml/hr Order date: @ 2237\n 15. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 1703\n 6. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 1526\n 16. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>60 Order\n date: @ 1407\n 7. Albumin 25% (12.5g / 50mL) 12.5 g IV Q2H Duration: 72 Hours\n replace 12.5 g albumin for every liter ascites output Order date:\n @ 2237\n 17. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 1018\n 8. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758\n 18. 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: @ 1311\n 9. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 19. 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: @ 1703\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain\n hold for sedation Order date: @ 1221\n 20. Vancomycin 1000 mg IV Q 24H Order date: @ 1018\n 24 Hour Events:\n Ascites cx and blood cx from growing yeast; changed to micafungin\n and restarted vanc/zosyn/flagyl pending further culture data. Re-sited\n CVL and changed A-line over wire. Tube feeds changed back to \n strength. Increased ascites repletion to 1cc:1cc. Transient decreases\n in UOP and SBP responded to fluid boluses initially; started on\n neosynephrine gtt overnight for hypotension.\n BLOOD CULTURED - At 12:00 PM\n MULTI LUMEN - START 12:06 PM\n MULTI LUMEN - STOP 02:02 PM\n TRANSTHORACIC ECHO - At 04:45 PM\n Post operative day:\n POD#13 - ex lap duod ulcer repair\n POD#10 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:37 PM\n Micafungin - 03:39 PM\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Infusions:\n Phenylephrine - 0.6 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:56 AM\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: 36.4\nC (97.5\n HR: 109 (101 - 119) bpm\n BP: 109/50(67) {94/42(59) - 126/58(75)} mmHg\n RR: 19 (17 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 97.8 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 5 (1 - 11) mmHg\n Total In:\n 16,116 mL\n 4,285 mL\n PO:\n Tube feeding:\n 1,600 mL\n 484 mL\n IV Fluid:\n 13,966 mL\n 3,651 mL\n Blood products:\n 550 mL\n 150 mL\n Total out:\n 14,021 mL\n 3,760 mL\n Urine:\n 336 mL\n 120 mL\n NG:\n 650 mL\n Stool:\n Drains:\n 12,335 mL\n 3,640 mL\n Balance:\n 2,095 mL\n 525 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 100%\n ABG: 7.46/21/105/18/-5\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Crackles : diffuse b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 192 K/uL\n 11.2 g/dL\n 155 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 76 mg/dL\n 105 mEq/L\n 133 mEq/L\n 32.5 %\n 26.1 K/uL\n [image002.jpg]\n 11:12 AM\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n WBC\n 21.0\n 26.0\n 21.9\n 26.1\n Hct\n 34.1\n 33.7\n 32.1\n 32.5\n Plt\n 95\n 130\n 140\n 192\n Creatinine\n 1.6\n 1.7\n 2.0\n 1.9\n 2.0\n TCO2\n 18\n 20\n 18\n 15\n Glucose\n 148\n 135\n 130\n 102\n 128\n 155\n Other labs: PT / PTT / INR:22.7/64.9/2.1, ALT / AST:12/35, Alk-Phos / T\n bili:84/6.5, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.6 g/dL, LDH:169 IU/L, Ca:7.4 mg/dL, Mg:1.3\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan:\n Neurologic: Fentanyl prn, awake and following commands\n Cardiovascular: fluid boluses, neo gtt for hypotension; wean as\n tolerated\n Pulmonary: extubated on NC now\n Gastrointestinal / Abdomen: NPO, protonix gtt, TF nepro 3/4 strength at\n 70ml/hr\n Nutrition: tube feeds\n Renal: Foley, follow UOP, replacing ascites drain output 1 to 1 with\n LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. F/u urine\n lytes\n Hematology: Hct stable type and crossed for 4 units\n Endocrine: RISS\n Infectious Disease: micafungin started ; vanc/zosyn/flagyl\n restarted ; ophthalmology consult 10/27 per ID recommendation for\n ?ophthalmic involvement of fungal infection\n Lines / Tubes / Drains: foley, L IJ triple lumen, PIV x1, JP x2, NGT,\n J-tube\n Wounds: abdominal incision clean / dry / intact\n Imaging: CXR\n Fluids: replacing ascites drain output 1 to 1 with LR. Albumin 12.5g\n per 1L ascites.\n Consults: transplant surgery (primary team); ID (consult);\n ophthalmology (consult)\n Billing Diagnosis: septic / hypovolemic shock\n ICU Care\n Nutrition:\n NovaSource Renal () - 06:21 PM 70 mL/hour\n Glycemic Control: RISS\n Lines:\n Arterial Line - 08:20 PM\n Multi Lumen - 12:06 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI gtt\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Physician ", "chartdate": "2164-10-30 00:00:00.000", "description": "Intensivist Note", "row_id": 704200, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint: BRBPR\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular Order date: @ 1311\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 2. 1000 mL LR\n Continuous at 0 ml/hr for 0 ml\n please give cc / cc JP output repletion Order date: @ 1008\n 12. Lidocaine 1% 2 mL SC ONCE Duration: 1 Doses Order date: @\n \n 3. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1008\n 13. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1018\n 4. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1743\n 14. Micafungin 100 mg IV DAILY Order date: @ 0917\n 5. 1000 mL LR\n Continuous at 1000 ml/hr Order date: @ 2237\n 15. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 1703\n 6. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 1526\n 16. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>60 Order\n date: @ 1407\n 7. Albumin 25% (12.5g / 50mL) 12.5 g IV Q2H Duration: 72 Hours\n replace 12.5 g albumin for every liter ascites output Order date:\n @ 2237\n 17. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 1018\n 8. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758\n 18. 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: @ 1311\n 9. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 19. 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: @ 1703\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain\n hold for sedation Order date: @ 1221\n 20. Vancomycin 1000 mg IV Q 24H Order date: @ 1018\n 24 Hour Events:\n Ascites cx and blood cx from growing yeast; changed to micafungin\n and restarted vanc/zosyn/flagyl pending further culture data. Re-sited\n CVL and changed A-line over wire. Tube feeds changed back to \n strength. Increased ascites repletion to 1cc:1cc. Transient decreases\n in UOP and SBP responded to fluid boluses initially; started on\n neosynephrine gtt overnight for hypotension. TTE to eval for vegetation\n given fungemia.\n BLOOD CULTURED - At 12:00 PM\n MULTI LUMEN - START 12:06 PM\n MULTI LUMEN - STOP 02:02 PM\n TRANSTHORACIC ECHO - At 04:45 PM\n Post operative day:\n POD#13 - ex lap duod ulcer repair\n POD#10 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:37 PM\n Micafungin - 03:39 PM\n Metronidazole - 04:42 AM\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Infusions:\n Phenylephrine - 0.6 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:56 AM\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: 36.4\nC (97.5\n HR: 109 (101 - 119) bpm\n BP: 109/50(67) {94/42(59) - 126/58(75)} mmHg\n RR: 19 (17 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 97.8 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 5 (1 - 11) mmHg\n Total In:\n 16,116 mL\n 4,285 mL\n PO:\n Tube feeding:\n 1,600 mL\n 484 mL\n IV Fluid:\n 13,966 mL\n 3,651 mL\n Blood products:\n 550 mL\n 150 mL\n Total out:\n 14,021 mL\n 3,760 mL\n Urine:\n 336 mL\n 120 mL\n NG:\n 650 mL\n Stool:\n Drains:\n 12,335 mL\n 3,640 mL\n Balance:\n 2,095 mL\n 525 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 100%\n ABG: 7.46/21/105/18/-5\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Crackles : diffuse b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 192 K/uL\n 11.2 g/dL\n 155 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 76 mg/dL\n 105 mEq/L\n 133 mEq/L\n 32.5 %\n 26.1 K/uL\n [image002.jpg]\n 11:12 AM\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n WBC\n 21.0\n 26.0\n 21.9\n 26.1\n Hct\n 34.1\n 33.7\n 32.1\n 32.5\n Plt\n 95\n 130\n 140\n 192\n Creatinine\n 1.6\n 1.7\n 2.0\n 1.9\n 2.0\n TCO2\n 18\n 20\n 18\n 15\n Glucose\n 148\n 135\n 130\n 102\n 128\n 155\n Other labs: PT / PTT / INR:22.7/64.9/2.1, ALT / AST:12/35, Alk-Phos / T\n bili:84/6.5, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.6 g/dL, LDH:169 IU/L, Ca:7.4 mg/dL, Mg:1.3\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan:\n Neurologic: Fentanyl prn, awake and following commands\n Cardiovascular: fluid boluses to keep even, neo gtt for hypotension;\n wean as tolerated; no veg seen on TTE\n Pulmonary: extubated on NC now\n Gastrointestinal / Abdomen: NPO, protonix gtt, TF nepro 3/4 strength at\n 70ml/hr\n Nutrition: tube feeds at\n strength\n Renal: Foley, follow UOP, replacing ascites drain output 1 to 1 with\n LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. F/u urine\n lytes. Creat stable.\n Hematology: Hct stable, type and crossed for 4 units\n Endocrine: RISS\n Infectious Disease: micafungin started ; vanc/zosyn/flagyl\n restarted ; ophthalmology consult 10/27 per ID recommendation for\n ?ophthalmic involvement of fungal infection\n Lines / Tubes / Drains: foley, L IJ triple lumen, PIV x1, JP x2, NGT,\n J-tube\n Wounds: abdominal incision clean / dry / intact\n Imaging: CXR\n Fluids: replacing ascites drain output 1 to 1 with LR. Albumin 12.5g\n per 1L ascites.\n Consults: transplant surgery (primary team); ID (consult);\n ophthalmology (consult)\n Billing Diagnosis: septic / hypovolemic shock\n ICU Care\n Nutrition:\n NovaSource Renal () - 06:21 PM 70 mL/hour\n Glycemic Control: RISS\n Lines:\n Arterial Line - 08:20 PM\n Multi Lumen - 12:06 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI gtt\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Physician ", "chartdate": "2164-11-09 00:00:00.000", "description": "Intensivist Note", "row_id": 706066, "text": "SICU\n HPI:\n POD 23 / 20 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: micafungin (), Meropenum (), Linezolid ()\n PPx: boots, PPI \n TLD: foley, R IJ triple lumen (), PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n .\n Current medications:\n 2. Albumin 25% (12.5g / 50mL) 3. Artificial Tear Ointment 4. Bicitra 5.\n Calcium Gluconate 6. HYDROmorphone (Dilaudid)\n 7. Insulin 8. Linezolid 9. Magnesium Sulfate 10. Meropenem 11.\n Micafungin 12. Midodrine 13. Miconazole Powder 2%\n 14. Ondansetron 15. Pantoprazole 16. Rifaximin 17. Sodium Chloride 0.9%\n Flush 18. Tetracaine HCl\n 24 Hour Events:\n CT abdomen/pelvis: 14 cm subhepatic mixed air and fluid collection\n in the lesser sac, in the setting of recent perforated duodenal ulcer,\n concerning for infected collection. Wall thickening of ascending colon,\n a nonspecific finding\n : LLE erythema concerning for infection, Octreotide and fluid\n replecements d/ced for goal of negative I/O's\n Post operative day:\n POD#23 - ex lap duod ulcer repair\n POD#20 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Micafungin - 03:37 PM\n Linezolid - 12:35 AM\n Meropenem - 06:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:36 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.4\nC (97.6\n HR: 103 (99 - 121) bpm\n BP: 112/53(71) {80/49(61) - 126/65(86)} mmHg\n RR: 27 (15 - 33) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 102.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 2 (2 - 7) mmHg\n Total In:\n 6,729 mL\n 1,551 mL\n PO:\n Tube feeding:\n 2,494 mL\n 867 mL\n IV Fluid:\n 2,771 mL\n 574 mL\n Blood products:\n 200 mL\n 50 mL\n Total out:\n 6,020 mL\n 1,875 mL\n Urine:\n 1,195 mL\n 400 mL\n NG:\n 975 mL\n Stool:\n 350 mL\n Drains:\n 3,500 mL\n 1,475 mL\n Balance:\n 709 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///14/\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, Distended, Tender: LLQ\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 102 K/uL\n 10.0 g/dL\n 157 mg/dL\n 3.4 mg/dL\n 14 mEq/L\n 3.4 mEq/L\n 107 mg/dL\n 109 mEq/L\n 138 mEq/L\n 30.0 %\n 20.1 K/uL\n [image002.jpg]\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n WBC\n 12.2\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n Hct\n 27.6\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n Plt\n 156\n 142\n 147\n 121\n 105\n 101\n 102\n Creatinine\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n TCO2\n 12\n 14\n Glucose\n 165\n 183\n 156\n 127\n 115\n 136\n 153\n 157\n Other labs: PT / PTT / INR:26.2/55.6/2.5, ALT / AST:29/59, Alk-Phos / T\n bili:95/18.8, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:3.2 g/dL, LDH:169 IU/L, Ca:8.6 mg/dL,\n Mg:2.0 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA,\n BRBPR, GI BLEED, GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n .\n Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Hemodynamically stable for now, will use albumin for intravascular\n fluid replacement\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal syndrome worsening, will continue to\n monitor, replacements currently on hold for his ostomy and Jtube\n outputs\n FEN/GI: Currently not transplant candidate d/t peritoneal infection.\n protonix 40\", TF changed to full strength at 125ml/hr. Rifaximin &\n lactulose for hepatic encephalopathy. Octreotide d/ced for now due to\n LLE erythema.\n ID: Being treated for Candda glabrata fungemia as well as peritonitis\n along with coagulase negative staph with Micafungin, Meropenem and\n Linezolid\n HEME: Hct stable. Trending platelets for downward trend, concern for\n HIT awaiting HIT panel\n ENDO: RISS\n Psych: s/p consult\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen (), PIV x1, JP x2, J-tube x2,\n A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 06:00 PM 150 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2164-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704686, "text": "Shock, septic\n Assessment:\n Pt slept in intervals over course of evening. Easy to arouse\n oriented x3. Asking to call family remaining want to go home. MAE. c/o\n abdominal and generalized pain.\n JPx2 with moderate amounts of ascetic/sersang drainage.\n Upper J-Tube to gravity. Moderate amounts of bilious output.\n Feeding lower J-Tube, at goal rate. Loose golden brown stool via FIB\n bag.\n Lungs clear diminished in bases. Strong productive cough.\n Sat\ns 94-96% RA. Using IS pulling about 1000-1350cc.\n Afebrile. NSR/ST 95-115. Continues on Neo.\n Action:\n Giving Dilaudid IVP for pain. Repositioning to comfort.\n Replacing JPx2 outputs with NS\n cc:cc. Giving 25% Albumin\n for every 1L of JP drainage out.\n Encouraging c/db.\n Titrating Neo for goal MAP >65.\n Response:\n Pt stating pain tolerable and improved. Continues to be able\n to rest well.\n Maintaining MAP >65.\n Pt 1.6L up at midnight.\n WBC\n Plan:\n Continue to monitor pain/comfort treating as needed and\n provide emotional support.\n Continue with NS\n cc:cc repletions with JP drain outputs\n and Albumin administration after 1L out.\n Titrate Neo to goal MAP >65.\n Encourage activity. Pt had stated yesterday ambition to\n pivot to chair today, requires max assist. PT/OT following pt.\n" }, { "category": "Nursing", "chartdate": "2164-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704836, "text": "Shock, septic\n Assessment:\n Alert, oriented x3\n Pt follows commands\n Remains on neo\n Medial Jp switch back to self suction\n Lateral jp remains to self suction\n Medial jp output less than than this morning, dr. \n aware\n Pt c/o pain\n Hr 110-125\ns dr. , dr. aware\n Hct 28.1\n Na 131\n Magnesium 1.3\n Urine output 15-20cc/hr , dr. , dr. aware\n Action:\n Pt received dilaudid for pain\n Continue replacement of\n strength ns with jp output, Giving\n 25% Albumin for every 1L of JP drainage out.\n Pt is receiving one unit of blood\n Neo titrated to keep mean arterial pressure greater than 65\n Response:\n Pt with adequate relief of pain\n Mean arterial pressure greater 65\n Plan:\n Continue to monitor\n Titrate neo to keep mean arterial pressure greater than 65\n Medicate for pain as needed and ordered\n Add: PT had pt sit on side of bed, hr up to 140\ns, pt put back to bed.\n" }, { "category": "Nursing", "chartdate": "2164-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703710, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains intubated on CPAP 5/5, 40% FiO2\n Suctioned prn for scant amount of secretions\n ABG wnl\n Pt alert, following commands, MAE, Pupils equal and\n reactive. Pt nodding appropriately to yes/no questions, attempting to\n mouth words. Pos cough, pos gag. At approx 2200 pt became agitated and\n restless, attempting to mouth words, reaching for ETT and NGT, pt\n nodding yes to pain, restraints reapplied and fentanyl given with pos\n effect.\n Pt appearing depressed, weepy at times\n Abd incision OTA, staples intact, JPx2, Suction dsg applied\n by Nsg in order to quantify acites drainage; copious amounts of\n serosang drainage from drains. Jtube x2, one to drainage, one to\n feeding. NGT to LCS, clear drainage.\n HR 95-120\ns. BP 95-130\ns with MAP >65 throughout majority of\n shift, dipped BP to 80\ns with MAP 55 x1, improved with fluid bolus and\n albumin\n CVP 10-13, PPV \n U/O 20-60cc/hr, dark amber urine via foley cath. Cr 1.7, BUN\n 72\n Afebrile, tmax 98.5. WBC 18.2 up from 16.6\n Hct stable, Plt 77, Chloride 115 from 119\n Minimal c/o pain\n Action:\n Pulmonary hygiene per VAP protocol\n 1/2cc:cc repletion for JP outputs with LR\n Albumin given for every 1000cc output from JP\n Fluid boluses prn\n Monitoring hemodynamics closely\n Monitoring outputs closely\n Monitoring labs\n Skincare\n Abx as ordered\n Fentanyl prn pain\n Emotional support provided\n Response:\n VS improving with fluid boluses and albumin\n Pt expressing adequate pain relief from fentanyl\n U/O improving with fluid and albumin\n Plan:\n Continue to monitor VS\n Monitor Labs\n Continue with 1/2cc:cc repletion\n Pain management\n Continue with albumin and bicarb as ordered\n Extubate this AM\n Provide pt and family with emotional support\n" }, { "category": "Physician ", "chartdate": "2164-10-29 00:00:00.000", "description": "Intensivist Note", "row_id": 704027, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n .\n MEDICATIONS (per d/c summary )\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n . Albumin 25% (12.5g / 50mL)\n 10. Artificial Tear Ointment 11. Calcium Gluconate 12. Chlorhexidine\n Gluconate 0.12% Oral Rinse 13. Fentanyl Citrate\n 14. Insulin 15. Micafungin 16. Pantoprazole 17. Potassium Chloride 18.\n Sodium Chloride 0.9% Flush\n 19. Sodium Bicarbonate\n 24 Hour Events:\n Stable. No acute issues. Trauma line pulled. Started caspiofungin.\n Bolused by transplant team colloid/LR, multiple times.\n BLOOD CULTURED - At 07:59 AM\n TRAUMA LINE - STOP 12:12 PM\n Post operative day:\n POD#12 - ex lap duod ulcer repair\n POD#9 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:31 PM\n Fluconazole - 10:07 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 AM\n Micafungin - 02:30 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.9\nC (98.4\n HR: 99 (99 - 117) bpm\n BP: 91/45(59) {78/37(53) - 112/61(75)} mmHg\n RR: 19 (18 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.8 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 9 (2 - 178) mmHg\n Total In:\n 11,824 mL\n 4,410 mL\n PO:\n Tube feeding:\n 1,609 mL\n 495 mL\n IV Fluid:\n 8,990 mL\n 3,765 mL\n Blood products:\n 943 mL\n 150 mL\n Total out:\n 11,975 mL\n 4,048 mL\n Urine:\n 325 mL\n 98 mL\n NG:\n 150 mL\n 150 mL\n Stool:\n Drains:\n 11,000 mL\n 3,800 mL\n Balance:\n -151 mL\n 362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///18/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 130 K/uL\n 11.3 g/dL\n 102 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 87 mg/dL\n 106 mEq/L\n 135 mEq/L\n 33.7 %\n 26.0 K/uL\n [image002.jpg]\n 08:37 AM\n 03:03 PM\n 02:00 AM\n 02:05 AM\n 11:12 AM\n 01:44 AM\n 02:06 AM\n 08:19 AM\n 10:00 AM\n 02:45 AM\n WBC\n 18.2\n 21.0\n 26.0\n Hct\n 33.0\n 34.1\n 33.7\n Plt\n 77\n 95\n 130\n Creatinine\n 1.5\n 1.6\n 1.7\n 2.0\n TCO2\n 20\n 22\n 18\n 20\n Glucose\n 152\n 141\n 148\n 135\n 130\n 102\n Other labs: PT / PTT / INR:22.3/64.7/2.1, ALT / AST:, Alk-Phos / T\n bili:53/5.4, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.8 g/dL, LDH:120 IU/L, Ca:7.8 mg/dL, Mg:1.5\n mg/dL, PO4:4.6 mg/dL\n Microbiology: Cultures Pending\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Fentanyl prn, following commands\n CVS: stable\n PULM: extubated on NC\n RENAL: Foley, follow UOP, replacing ascites drain output 0.75 to 1 with\n LR. Albumin 12.5g per 1L ascites. Hx of hepatorenal syndrome. f/u urine\n lytes\n FEN/GI: NPO,protonix gtt, TF nepro 3/4 strength at 70ml/hr\n ID: s/p vanc/zosyn now on caspiofungin\n HEME: Hct stable type and crossed for 4 units\n ENDO: RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, L IJ triple lumen, s/p R SC trauma line ( PIV x1,\n JP x2, NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 05:14 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Code status: Full code\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701787, "text": "52 y/o M with PMH of etoh cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management, pt\n has received a total of 5U PRBCS between OSH and ED, total of 4L NS for\n SBP in the 80-90's. Tx to MICU for endoscopy and further management.\n Of note, pt had been recently dc'd from MICU after a 25 stay for GIB\n (received total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701807, "text": "52 y/o M with PMH of etoh cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management, pt\n has received a total of 5U PRBCS between OSH and ED, total of 4L NS for\n SBP in the 80-90's. Tx to MICU for endoscopy and further management.\n Of note, pt had been recently dc'd from MICU after a 25 stay for GIB\n (received total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt had endoscopy done at the bedside. Received total of 75mcg Fentanyl\n and 3mg Versed. Had an episode of approximately 800cc of melena. SBP\n dropped to 70\ns. Pt mentating the whole time.\n Action:\n Received 2L NS bolus and 2U FFP. Flexiseal.\n Response:\n Tolerated scope well. Hemodynamically stable at this time. SBP > or =\n to 100.\n Plan:\n Montor crits. Please draw crit at . Team is to place CVL. If pt\n continues to bleed and HCT continues to drop- pt will need a bleeding\n scan and then to IR.\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701913, "text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n continued to have freq episodes melena\n started neo gtt for MAP 30-40s, weaned off prior to RBC scan\n transplant surgery & IR consulted\n transfused 11U PRBC (+2 prior to arrival at ), 4 U FFP\n tagged RBC scan showed focal site of bleeding in duodenum, IR planning\n for angiography\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 91/57(65) {64/27(33) - 132/75(85)} mmHg\n RR: 23 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n CVP: 7 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 1,916 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 313 mL\n Blood products:\n 2,546 mL\n 1,603 mL\n Total out:\n 1,830 mL\n 400 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///10/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: icteric sclera\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 84 K/uL\n 11.6 g/dL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs: PT / PTT / INR:18.1/45.8/1.6, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Lactic Acid:2.3 mmol/L, Ca++:6.2\n mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 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": "2164-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701917, "text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n continued to have freq episodes melena\n started neo gtt for MAP 30-40s, weaned off prior to RBC scan\n transplant surgery & IR consulted\n transfused 11U PRBC (+2 prior to arrival at ), 4 U FFP\n tagged RBC scan showed focal site of bleeding in duodenum, IR planning\n for angiography\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: Dry mouth\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 91/57(65) {64/27(33) - 132/75(85)} mmHg\n RR: 23 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n CVP: 7 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 1,916 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 313 mL\n Blood products:\n 2,546 mL\n 1,603 mL\n Total out:\n 1,830 mL\n 400 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///10/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: icteric sclera\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 84 K/uL\n 11.6 g/dL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs: PT / PTT / INR:18.1/45.8/1.6, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Lactic Acid:2.3 mmol/L, Ca++:6.2\n mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n RUQ U/S\n 1. Partially occluded portal vein thrombosis which is new when compared\n to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n Assessment and Plan\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR with an\n unrevealing EGD, followed by recurrent melena and hypotension.\n #UGIB\n currently hemodynamically stable s/p aggressive resuscitation\n with blood products; required pressors for only 2 hrs; bleeding source\n localized to 1^st segment duodenum by taggedRBC scan\n -appreciate liver recs\n -central & peripheral access obtained\n -neo gtt if MAP <65, add vasopressin if 2^nd pressor needed\n -active T&S, x-fuse to Hct 30%\n -octreotide gtt\n -protonix gtt\n -ceftriaxone for SBP ppx\n -hold BB, diuretics\n .\n #Partial portal vein thrombosis\n -hold anticoagulation given active bleeding\n .\n #Non-gap metabolic acidosis - unclear etiology, most likely represents\n GI losses in the setting of massive GIB; could represent RTA but new\n phenomenon and no underlying renal insufficiency; lactate WNL, no\n ketonuria, or serum salicylates (although no gap, as above)\n -cont monitor with fluid resuscitation\n .\n #FEN: NPO, replete lytes\n .\n #PPX: PPI IV gtt, pneumoboots\n .\n #ACCESS: L IJ triple-lumen CVL, 18 g R EJ, 18 g R AC, 20 g L AC\n .\n #CODE: Full code\n .\n #CONTACT: , wife, \n .\n # DISPO: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT: PPI gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701919, "text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n continued to have freq episodes melena\n started neo gtt for MAP 30-40s, weaned off prior to RBC scan\n transplant surgery & IR consulted\n transfused 11U PRBC (+2 prior to arrival at ), 4 U FFP\n tagged RBC scan showed focal site of bleeding in duodenum, IR planning\n for angiography\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No dizziness, lightheadedness, chest pain, palpitations, shortness of\n breath, abdominal pain, nausea, vomiting.\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 91/57(65) {64/27(33) - 132/75(85)} mmHg\n RR: 23 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n CVP: 7 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 1,916 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 313 mL\n Blood products:\n 2,546 mL\n 1,603 mL\n Total out:\n 1,830 mL\n 400 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 100%\n VBG:7.29/21/89/10\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: icteric sclera\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 84 K/uL\n 11.6 g/dL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs: PT / PTT / INR:18.1/45.8/1.6, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Lactic Acid:2.3 mmol/L, Ca++:6.2\n mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n RUQ U/S\n 1. Partially occluded portal vein thrombosis which is new when compared\n to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n Assessment and Plan\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR with an\n unrevealing EGD, followed by recurrent melena and hypotension.\n #UGIB\n currently hemodynamically stable s/p aggressive resuscitation\n with blood products; required pressors for only 2 hrs; bleeding source\n localized to 1^st segment duodenum by taggedRBC scan\n -appreciate liver recs\n -central & peripheral access obtained\n -neo gtt if MAP <65, add vasopressin if 2^nd pressor needed\n -active T&S, x-fuse to Hct 30%\n -octreotide gtt\n -protonix gtt\n -ceftriaxone for SBP ppx\n -hold BB, diuretics\n .\n #Partial portal vein thrombosis\n -hold anticoagulation given active bleeding\n .\n #Non-gap metabolic acidosis - unclear etiology, most likely represents\n GI losses in the setting of massive GIB; could represent RTA but new\n phenomenon and no underlying renal insufficiency; lactate WNL, no\n ketonuria, or serum salicylates (although no gap, as above)\n -cont monitor with fluid resuscitation\n .\n #FEN: NPO, replete lytes\n .\n #PPX: PPI IV gtt, pneumoboots\n .\n #ACCESS: L IJ triple-lumen CVL, 18 g R EJ, 18 g R AC, 20 g L AC\n .\n #CODE: Full code\n .\n #CONTACT: , wife, \n .\n # DISPO: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT: PPI gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701860, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received pt post CVL placement. A&Ox3. Denies SOB/CP or\n lightheadedness. Pt has had multiple LARGE amts of melena (~ 500cc\n Q1-2hrs). Flexiseal expelled by pt. SBP low 65 w/ MAPS in the 40\ns. Pt\n cont to mentate despite drop in BP. Hct ranging 22-25. INR 2.0. UOP\n marginal. Temp 95.6.\n Action:\n Bair hugger placed for hypothermia. Pt received a total of 8 units\n PRBC\ns, 2 units of FFP & 2L NS since . Pt was started on\n Neosynephrine for low SBP and active bleed. CVP transduced (~ )\n Bedside ultrasound. Red tag scan.\n Response:\n Pt titrated of Neo gtt. Mentating well. Cont to have significant amts\n of melena w/ large clots noted. Tolerating blood products.\n Plan:\n Cont to assess Hct Q4-6 & PRN. Transfuse blood products as warranted.\n Will most likely head to IR post red tag scan. Rapid infuser in room.\n Code status: Full Code\n 18g PIV x 3 (including R EJ) L IJ TLC\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702058, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt received s/p tagged red scan in neuro med which was grossly positive\n in duodenal area, s/p 8 units PRBCs, 2 units FFP overnoc, with\n additional IVF to maintain hemodynamics. Pt with lg amts maroon loose\n stool from below.\n Action:\n Pt had EGD by GI this am showing ? bleeding from ampula, but no\n evidence of acute bleeding in the upper GI tract. During scope, pt\n dropped BP so transfused 1 unit PRBCs and started on neo gtt. Pt then\n taken to IR where he was found to have a pseudoanuerysm in his GDA,\n thus this was considered area of bleed and area was coiled. During\n coiling, pt noted to drop pressure. HCT dropped 10 points associated\n with drop in clotting factors so pt massively transfused with 11 units\n PRBCs, 6 units FFP, 2 units platelets. Pt was intubated for airway\n protection and an OG tube was dropped and connected to suction putting\n out 425cc BRB. A left radial aline was placed and a left line for\n further access. He was noted to have a pH of 6.94 shortly after\n intubation and s/p massive transfusion, so he was given 3 amps sodium\n bicarb followed by 150 mEq bicarb in 1L D5W. The pt\ns ionized calcium\n was noted to be 0.69 so he was given 1 amp calcium choloride followed\n by 4 gm calcium gluconate. Post coiling, radiology felt the bleeding\n had stopped and pt had been stabilized, so he was transferred back to\n MICU 7 where he was stable for approximately 30mins. The pt was then\n noted to drop his SBP into the 60s while on 0.5mcg/kg/min of neo. He\n was noted to be grossly bleeding from below (maroon blood) via a\n flexiseal and BRB was being suctioned via his OG tube. Neo was maxed @\n 4mcg/kg/min and vasopressin was added. IVFs were bolused to support\n hemodynamics and an additional 4.5 units PRBCs, 4 units FFP, 1 unit\n platelets, 1 unit cryo was given. The pt was given 4 more grams calcium\n gluconate for an ionized calcium of 0.75. A bladder pressure was\n checked and found to be 35. At this point, the surgical transplant team\n who had been following pt throughout day decided to take pt to OR in\n attempt to stop bleeding. Report was given to OR RN and anesthesia.\n Report was also called to SICU who will be receiving the pt post op.\n Response:\n Pending surgical intervention. Pt was stabilized in terms of\n hemodynamics prior to transport to OR.\n Plan:\n Pt to OR.\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702059, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt received s/p tagged red scan in neuro med which was grossly positive\n in duodenal area, s/p 8 units PRBCs, 2 units FFP overnoc, with\n additional IVF to maintain hemodynamics. Pt with lg amts maroon loose\n stool from below.\n Action:\n Pt had EGD by GI this am showing ? bleeding from ampula, but no\n evidence of acute bleeding in the upper GI tract. During scope, pt\n dropped BP so transfused 1 unit PRBCs and started on neo gtt. Pt then\n taken to IR where he was found to have a pseudoanuerysm in his GDA,\n thus this was considered area of bleed and area was coiled. During\n coiling, pt noted to drop pressure. HCT dropped 10 points associated\n with drop in clotting factors so pt massively transfused with 11 units\n PRBCs, 6 units FFP, 2 units platelets. Pt was intubated for airway\n protection and an OG tube was dropped and connected to suction putting\n out 425cc BRB. A left radial aline was placed and a left line for\n further access. He was noted to have a pH of 6.94 shortly after\n intubation and s/p massive transfusion, so he was given 3 amps sodium\n bicarb followed by 150 mEq bicarb in 1L D5W. The pt\ns ionized calcium\n was noted to be 0.69 so he was given 1 amp calcium choloride followed\n by 4 gm calcium gluconate. Post coiling, radiology felt the bleeding\n had stopped and pt had been stabilized, so he was transferred back to\n MICU 7 where he was stable for approximately 30mins. The pt was then\n noted to drop his SBP into the 60s while on 0.5mcg/kg/min of neo. He\n was noted to be grossly bleeding from below (maroon blood) via a\n flexiseal and BRB was being suctioned via his OG tube. Neo was maxed @\n 4mcg/kg/min and vasopressin was added. IVFs were bolused to support\n hemodynamics and an additional 4.5 units PRBCs, 4 units FFP, 1 unit\n platelets, 1 unit cryo was given. The pt was given 4 more grams calcium\n gluconate for an ionized calcium of 0.75. A bladder pressure was\n checked and found to be 35. At this point, the surgical transplant team\n who had been following pt throughout day decided to take pt to OR in\n attempt to stop bleeding. Report was given to OR RN and anesthesia.\n Report was also called to SICU who will be receiving the pt post op.\n Response:\n Pending surgical intervention. Pt was stabilized in terms of\n hemodynamics prior to transport to OR.\n Plan:\n Pt to OR.\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701931, "text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n continued to have freq episodes melena\n started neo gtt for MAP 30-40s, weaned off prior to RBC scan\n transplant surgery & IR consulted\n transfused 11U PRBC (+2 prior to arrival at ), 4 U FFP\n tagged RBC scan showed focal site of bleeding in duodenum, IR planning\n for angiography\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No dizziness, lightheadedness, chest pain, palpitations, shortness of\n breath, abdominal pain, nausea, vomiting.\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 91/57(65) {64/27(33) - 132/75(85)} mmHg\n RR: 23 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n CVP: 7 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 1,916 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 313 mL\n Blood products:\n 2,546 mL\n 1,603 mL\n Total out:\n 1,830 mL\n 400 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 100%\n VBG:7.29/21/89/10\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: icteric sclera\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 84 K/uL\n 11.6 g/dL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs: PT / PTT / INR:18.1/45.8/1.6, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Lactic Acid:2.3 mmol/L, Ca++:6.2\n mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n RUQ U/S\n 1. Partially occluded portal vein thrombosis which is new when compared\n to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n Assessment and Plan\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR with an\n unrevealing EGD, followed by recurrent melena and hypotension.\n #UGIB\n currently hemodynamically stable s/p aggressive resuscitation\n with blood products; required pressors for only 2 hrs; bleeding source\n localized to 1^st segment duodenum by taggedRBC scan\n -appreciate liver recs\n -central & peripheral access obtained\n -repeat EGD to evaluate proximal duodenum; if unable to visualize and\n treat source of bleeding by EGD will pursue angio\n -neo gtt if MAP <65, add vasopressin if 2^nd pressor needed\n -active T&S, x-fuse to Hct 30%\n -octreotide gtt\n -protonix gtt\n -ceftriaxone for SBP ppx\n -hold BB, diuretics\n .\n #Partial portal vein thrombosis\n -hold anticoagulation given active bleeding\n .\n #Non-gap metabolic acidosis - unclear etiology, most likely represents\n GI losses in the setting of massive GIB; could represent RTA but new\n phenomenon and no underlying renal insufficiency; lactate WNL, no\n ketonuria, or serum salicylates (although no gap, as above)\n -cont monitor with fluid resuscitation\n .\n #FEN: NPO, replete lytes\n .\n #PPX: PPI IV gtt, pneumoboots\n .\n #ACCESS: L IJ triple-lumen CVL, 18 g R EJ, 18 g R AC, 20 g L AC\n .\n #CODE: Full code\n .\n #CONTACT: , wife, \n .\n # DISPO: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT: PPI gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 701932, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ENDOSCOPY - At 05:19 PM\n ULTRASOUND - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n MULTI LUMEN - START 09:19 PM\n NUCLEAR MEDICINE - At 01:00 AM\n Red Tag Cell Scan\n EKG - At 06:30 AM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 104/59(68) {64/27(33) - 132/75(85)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 4 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 2,117 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 421 mL\n Blood products:\n 2,546 mL\n 1,696 mL\n Total out:\n 1,830 mL\n 428 mL\n Urine:\n 330 mL\n 128 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.6 g/dL\n 84 K/uL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n Differential-Neuts:81.6 %, Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %,\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs:\n PT / PTT / INR:18.1/45.8/1.6,\n Lactic Acid:2.3 mmol/L,\n Ca++:6.2 mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701934, "text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n continued to have freq episodes melena\n started neo gtt for MAP 30-40s, weaned off prior to RBC scan\n transplant surgery & IR consulted\n transfused 11U PRBC (+2 prior to arrival at ), 4 U FFP\n tagged RBC scan showed focal site of bleeding in proximal duodenum, IR\n consulted for possible angiography\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No dizziness, lightheadedness, chest pain, palpitations, shortness of\n breath, abdominal pain, nausea, vomiting.\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 91/57(65) {64/27(33) - 132/75(85)} mmHg\n RR: 23 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n CVP: 7 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 1,916 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 313 mL\n Blood products:\n 2,546 mL\n 1,603 mL\n Total out:\n 1,830 mL\n 400 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 100%\n VBG:7.29/21/89/10\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: icteric sclera\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 84 K/uL\n 11.6 g/dL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs: PT / PTT / INR:18.1/45.8/1.6, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Lactic Acid:2.3 mmol/L, Ca++:6.2\n mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n RUQ U/S\n 1. Partially occluded portal vein thrombosis which is new when compared\n to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n Assessment and Plan\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR with an\n unrevealing EGD, followed by recurrent melena and hypotension.\n #UGIB\n currently hemodynamically stable s/p aggressive resuscitation\n with blood products; required pressors for only 2 hrs; bleeding source\n localized to proximal duodenum by tagged RBC scan\n -appreciate liver recs\n -central & peripheral access obtained\n -repeat EGD to evaluate proximal duodenum; if unable to visualize and\n treat source of bleeding by EGD will pursue angio\n -neo gtt if MAP <65, add vasopressin if 2^nd pressor needed\n -active T&S, x-fuse to Hct 30%\n -octreotide gtt\n -protonix gtt\n -ceftriaxone for SBP ppx\n -hold BB, diuretics\n .\n #Partial portal vein thrombosis\n -hold anticoagulation given active bleeding\n .\n #Non-gap metabolic acidosis - unclear etiology, most likely represents\n GI losses in the setting of massive GIB; could represent RTA but new\n phenomenon and no underlying renal insufficiency; lactate WNL, no\n ketonuria, or serum salicylates (although no gap, as above)\n -cont monitor with fluid resuscitation\n .\n #FEN: NPO, replete lytes\n .\n #PPX: PPI IV gtt, pneumoboots\n .\n #ACCESS: L IJ triple-lumen CVL, 18 g R EJ, 18 g R AC, 20 g L AC\n .\n #CODE: Full code\n .\n #CONTACT: , wife, \n .\n # DISPO: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT: PPI gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 701935, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr.\n He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was recently hospitalized at from to for UGIB due\n to duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n 24 Hour Events:\n ENDOSCOPY - At 05:19 PM\n ULTRASOUND - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n MULTI LUMEN - START 09:19 PM\n NUCLEAR MEDICINE - At 01:00 AM\n Red Tag Cell Scan\n EKG - At 06:30 AM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 104/59(68) {64/27(33) - 132/75(85)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 4 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 2,117 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 421 mL\n Blood products:\n 2,546 mL\n 1,696 mL\n Total out:\n 1,830 mL\n 428 mL\n Urine:\n 330 mL\n 128 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 84 K/uL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n Differential-Neuts:81.6 %, Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %,\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs:\n PT / PTT / INR:18.1/45.8/1.6,\n Lactic Acid:2.3 mmol/L,\n Ca++:6.2 mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n GI performed endoscopy on arrival to the MICU and there was no clear\n source of brisk bleeding. There was an area of possible prior bleeding\n at the ampula, a possible non-bleeding ucler. On Protonix IV,\n Octreotide and Ceftriaxone as per UGIB protocol. He has adequate IV\n access with a central line and 3 pIVs. Liver service to repeat EGD this\n AM given the positive tagged RBC scan last night.\n END STAGE LIVER DISEASE\n Hold Spironolactone and Lasix in the acute setting. Hold Lactulose\n while monitoring him for further episodes of GI bleeding. Follow Liver\n recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 701943, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr.\n He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was recently hospitalized at from to for UGIB due\n to duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n 24 Hour Events:\n ENDOSCOPY - At 05:19 PM\n ULTRASOUND - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n MULTI LUMEN - START 09:19 PM\n NUCLEAR MEDICINE - At 01:00 AM\n Red Tag Cell Scan\n EKG - At 06:30 AM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 104/59(68) {64/27(33) - 132/75(85)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 4 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 2,117 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 421 mL\n Blood products:\n 2,546 mL\n 1,696 mL\n Total out:\n 1,830 mL\n 428 mL\n Urine:\n 330 mL\n 128 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 84 K/uL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n Differential-Neuts:81.6 %, Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %,\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs:\n PT / PTT / INR:18.1/45.8/1.6,\n Lactic Acid:2.3 mmol/L,\n Ca++:6.2 mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n GI performed endoscopy on arrival to the MICU and there was no clear\n source of brisk bleeding. There was an area of possible prior bleeding\n at the ampula, a possible non-bleeding ucler. On Protonix IV,\n Octreotide and Ceftriaxone as per UGIB protocol. He has adequate IV\n access with a central line and 3 pIVs. Liver service to repeat EGD this\n AM given the positive tagged RBC scan last night.\n END STAGE LIVER DISEASE\n Hold Spironolactone and Lasix in the acute setting. Hold Lactulose\n while monitoring him for further episodes of GI bleeding. Follow Liver\n recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701945, "text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n continued to have freq episodes melena\n started neo gtt for MAP 30-40s, weaned off prior to RBC scan\n transplant surgery & IR consulted\n transfused 11U PRBC (+2 prior to arrival at ), 4 U FFP\n tagged RBC scan showed focal site of bleeding in proximal duodenum, IR\n consulted for possible angiography\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No dizziness, lightheadedness, chest pain, palpitations, shortness of\n breath, abdominal pain, nausea, vomiting.\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 91/57(65) {64/27(33) - 132/75(85)} mmHg\n RR: 23 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n CVP: 7 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 1,916 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 313 mL\n Blood products:\n 2,546 mL\n 1,603 mL\n Total out:\n 1,830 mL\n 400 mL\n Urine:\n 330 mL\n 100 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 100%\n VBG:7.29/21/89/10\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: icteric sclera\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 84 K/uL\n 11.6 g/dL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs: PT / PTT / INR:18.1/45.8/1.6, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Lactic Acid:2.3 mmol/L, Ca++:6.2\n mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n RUQ U/S\n 1. Partially occluded portal vein thrombosis which is new when compared\n to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n Assessment and Plan\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR with an\n unrevealing EGD, followed by recurrent melena and hypotension.\n #UGIB\n currently hemodynamically stable s/p aggressive resuscitation\n with blood products; required pressors for only 2 hrs; bleeding source\n localized to proximal duodenum by tagged RBC scan. Patient was\n rescoped this AM, no interventions found.\n -IR for embolization\n -appreciate liver recs\n -appreciate transplant surgery recs, may require surgery if IR unable\n to contain\n -serial HCT, coags\n -active T&S, x-fuse to Hct 30%, massive transfusion protocol with 1\n prbc:1 ffp, transfuse plt for ct <50\n -octreotide gtt\n -protonix gtt\n -ceftriaxone for SBP ppx\n -hold BB, diuretics\n -neo gtt if MAP <65, add vasopressin if 2^nd pressor needed\n -central & peripheral access obtained\n .\n #Partial portal vein thrombosis\n -hold anticoagulation given active bleeding\n .\n #Non-gap metabolic acidosis - unclear etiology, most likely represents\n aggressive fluid resuscitation. Venous pH is 7.29. ?GI losses in the\n setting of massive GIB; could represent RTA but new phenomenon and no\n underlying renal insufficiency; lactate WNL, no ketonuria, or serum\n salicylates (although no gap, as above)\n -cont monitor with fluid resuscitation\n .\n #FEN: NPO, replete lytes\n .\n #PPX: PPI IV gtt, pneumoboots\n .\n #ACCESS: L IJ triple-lumen CVL, 18 g R EJ, 18 g R AC, 20 g L AC\n .\n #CODE: Full code\n .\n #CONTACT: , wife, \n .\n # DISPO: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Prophylaxis:\n DVT: PPI gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-10-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 701946, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use. He presented to Hospital where his SBP was 85 with a HR\n of 102. His BP nadir there was 68/36. He Hct on admission was 17.6%\n with an INR 1.9. EKG unremarkable, CXR clear. He received 2 units of\n PRBC and NS x 1L, protonix 80 mg IV, octreotide 50 mcg then 25 mcg/hr\n IV gtt. He was transferred here for further care.\n In the ED, he was afebrile with a SBP of 89, HR of 100, and a\n pulse ox of 100% on RA. His Hct was 25.5%, he received 3 more units of\n pRBCs, 2 units FFP were ordered but not yet given.\n He was hospitalized at from to for UGIB due to\n duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n 24 Hour Events:\n ENDOSCOPY - At 05:19 PM\n last night, an area of prior\n bleeding was noted at the ampulla but no brisk obvious bleeding. He\n also had one cord of grade II non-bleeding varices and two linear\n ulcers in the stomach.\n ULTRASOUND - At 09:00 PM\n done last night without ductal\n dilitation but partial portal vein thrombus\n URINE CULTURE - At 09:00 PM\n MULTI LUMEN - START 09:19 PM\n left IJ CVL placed in MICU.\n NUCLEAR MEDICINE - At 01:00 AM: Red Tag Cell Scan\n focal\n area of bleeding in the proximal duodenum.\n EKG - At 06:30 AM\n His MAPs dropped to the 30s in the setting of voluminous melena; he\n received 11 units of pRBCs, 6 units of FFP. Transplant surgery was\n consulted.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Ceftriaxone 1gm IV q24h\n Protonix 8mg/hr IV gtt\n Octreotide 50mcg/hr IV gtt\n Vitamin K 10mg IV x 1\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 121 (87 - 121) bpm\n BP: 104/59 {64/27 - 132/75} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 4 (2 - 11)mmHg\n Total In:\n 6,819 mL\n 2,117 mL\n PO:\n TF:\n IVF:\n 4,273 mL\n 421 mL\n Blood products:\n 2,546 mL\n 1,696 mL\n Total out:\n 1,830 mL\n 428 mL\n Urine:\n 330 mL\n 128 mL\n NG:\n Stool:\n 1,500 mL\n 300 mL\n Drains:\n Balance:\n 4,989 mL\n 1,689 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious\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\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : , No(t) Dullness : ), (Breath Sounds: Clear : , No(t)\n Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, why he is here, Movement: Not\n assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 11.6 g/dL\n 84 K/uL\n 146 mg/dL\n 1.2 mg/dL\n 10 mEq/L\n 4.9 mEq/L\n 37 mg/dL\n 123 mEq/L\n 140 mEq/L\n 31.6 %\n 17.1 K/uL\n [image002.jpg]\n Differential-Neuts:81.6 %, Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %,\n RUQ U/S: Cirrhotic liver, splenomegaly, gallbladder sludge, no ductal\n dilation. Partial portal vein thrombosis.\n 08:46 PM\n 11:31 PM\n 04:17 AM\n 06:12 AM\n WBC\n 17.1\n Hct\n 25.0\n 22.2\n 34.0\n 31.6\n Plt\n 84\n Cr\n 1.2\n Glucose\n 146\n Other labs:\n PT / PTT / INR:18.1/45.8/1.6,\n Lactic Acid:2.3 mmol/L,\n Ca++:6.2 mg/dL, Mg++:1.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension.\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Now s/p endoscopy x 2 (one last night that revealed an area of possible\n bleeding at the ampulla) as well as a second EGD this morning \n continued bleeding and the positive tagged RBC scan. He is to go to IR\n this morning for angiography. If they are unable to achieve hemostasis\n in the IR suite, then he may need to go to the OR for surgical\n intervention. With regard to resuscitation, he should receive blood\n products primarily. There is no indication for normal saline at this\n time given that his underlying process is hemorrhagic shock. Continue\n Protonix and Octreotide. Continue Ceftriaxone for a seven day course.\n Ultimately, need to clarify his ultimate disposition with regard to his\n transplant candidacy particularly if hemostasis cannot be achieved in\n angiography or, if warranted, the operating room.\n END STAGE LIVER DISEASE\n Continue to hold Spironolactone, Lasix, and Lactulose while treating\n him for further episodes of GI bleeding. Follow Liver recs.\n ETOH USE\n None since . Will monitor prospectively. No need for benzos at this\n time. No e/o alcoholic hepatitis.\n RENAL\n He had acute renal failure during his prior hospitalization; his\n creatinine is currently within normal limits. Will follow his\n creatinine and UOP going forward.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines / Intubation: 18 Gauge - 05:09 PM\n Comments:\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI IV.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now.\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702050, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt received s/p tagged red scan in neuro med, s/p 8 units PRBCs, 4\n units FFP overnoc, with obvious\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702044, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702045, "text": "52 y/o M with PMH of ETOH cirrhosis who presented to OSH c/o BRBPR,\n found to have a HCT of 17. Tx to ED for further management. Pt\n received a total of 5 units PRBCS between OSH and ED, 4L NS for SBP in\n the 80-90's. Tx to MICU for endoscopy and further management. Of note,\n pt had been recently dc'd from MICU after a 25 stay for GIB (received\n total of 17u PRBC's during that hospitalization).\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt received s/p tagged red scan in neuro med, s/p 8 units PRBCs, 4\n units FFP overnoc, with obvious\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706465, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. Pleasant in conversation and cooperative in\n care.\n Abdomen firm/distended. + BS. + flatulus. TF continue to be\n off with J-tubes clamped. Tolerating Pos well. Small green loose BM x1.\n Medial JP/sump/pigtail drains with scant to small amounts of\n ascetic drainage. All dressings changed.\n Foley patent. Amber clear urine 20-50cc/hr.\n Pt with c/o mild abdominal and left leg pain.\n Afebrile. VSS. WBC 19.5\n Action:\n JP/sump drainage monitored every 2 hours and replacing with\n LR\n c:cc over 2 hours. Albumin administered for every 1L drain output.\n Giving Dilaudid as needed for pain. Turning/repositioning to\n comfort.\n Receiving IV antibiotics as ordered.\n Response:\n Hemodynamically remains stable.\n Pt +400 at MN and currently +750. Dr aware. Team\n notified and\n cc:cc repletions stopped, continuing with Albumin for\n every 1L drainage.\n Pt with adequate pain relief.\n WBC 20.2\n Plan:\n Continue with\n cc:cc repletions and closely monitor drain\n output. Administer Albumin when 1L drainage out from JP/Sump.\n Monitor labs and treat as needed.\n Maintain skin integrity and cont aggressive skin care.\n Consider wound consult on Monday.\n F/u with Renal as to 24hr urine collection.\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706466, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. Pleasant in conversation and cooperative in\n care.\n Abdomen firm/distended. + BS. + flatulus. TF continue to be\n off with J-tubes clamped. Tolerating Pos well. Small green loose BM x1.\n Medial JP/sump/pigtail drains with scant to small amounts of\n ascetic drainage. All dressings changed.\n Foley patent. Amber clear urine 20-50cc/hr.\n Pt with c/o mild abdominal and left leg pain.\n Afebrile. VSS. WBC 19.5\n Action:\n JP/sump drainage monitored every 2 hours and replacing with\n LR\n c:cc over 2 hours. Albumin administered for every 1L drain output.\n Giving Dilaudid as needed for pain. Turning/repositioning to\n comfort.\n Receiving IV antibiotics as ordered.\n Response:\n Hemodynamically remains stable.\n Pt +400 at MN and currently +750. Dr aware. Team\n notified and\n cc:cc repletions stopped, continuing with Albumin for\n every 1L drainage.\n Pt with adequate pain relief.\n WBC 20.2\n Plan:\n Continue with\n cc:cc repletions and closely monitor drain\n output. Administer Albumin when 1L drainage out from JP/Sump.\n Monitor labs and treat as needed.\n Maintain skin integrity and cont aggressive skin care.\n Consider wound consult on Monday.\n F/u with Renal as to 24hr urine collection.\n ------ Protected Section ------\n Addendum to Plan section of note: Do Not continue with\n cc:cc\n repletions as primary team has discontinued that order. Do however\n continue with the Albumin.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:09 ------\n" }, { "category": "Nursing", "chartdate": "2164-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706622, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative in care. Mild c/o abdominal\n and left leg pain.\n Abdomen firmly distended. +BS. Small amts liquid green/brown\n stool.\n J-tubes clamped. Tolerating clears. have regular/soft\n solids as tolerates.\n Medial JP/sump/pigtail drains draining moderate amts ascetic\n drainage.\n Amber urine 40-60 cc/hr.\n Action:\n JP drainage checked every 2 hours\n Albumin given for every 1 liter drain output\n Renal following-ordered 24 hour urine collection. No\n containers in lab.\n Dilaudid given as needed for pain.\n Receiving IV antibiotics as ordered.\n Response:\n Hemodynamically stable\n Fluid balance -950 at midnight. Currently\n WBC 22.4 (elevated from yesterday)\n Plan:\n Continue holding repletion for drain output.\n Administer Albumin for every 1 liter output form JP/sump\n drains.\n Monitor labs treating as needed.\n Continue aggressive skin care and frequent repositioning.\n Consider wound care consult today.\n Cont OOB as tolerates. PT/OT consults\n Continue antibiotics as ordered per ID team\n Transfer to floor if pt remains stable\n" }, { "category": "Physician ", "chartdate": "2164-11-12 00:00:00.000", "description": "Intensivist Note", "row_id": 706666, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis c/b esophageal and rectal varices with prior\n episodes of bleeding admitted with painless BRBPR and hypotension, s/p\n ex lap, gastrotomy, duodenotomy with suturing of bleeding vessel,\n draining jejunostomy, now with fungemia, S/P IR drainage of fluid\n collection, resolving acute on chronic renal failure\n Chief complaint:\n managment of hemodynamics/infection in setting of massive GI bleed and\n liver failure\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n RISS, Linezolid. Magnesium Sulfate IV Sliding Meropenem, Albumin 25%,\n Midodrine . Miconazole Powder , Calcium Gluconate IV Sliding Scale .\n Dilaudid. Pantoprazole\n 24 Hour Events:\n - stable no issues\n Post operative day:\n POD#26 - ex lap duod ulcer repair\n POD#23 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:00 PM\n Meropenem - 12:12 AM\n Linezolid - 12:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 AM\n Hydromorphone (Dilaudid) - 02:00 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: 36.2\nC (97.1\n T current: 35.9\nC (96.7\n HR: 81 (78 - 96) bpm\n BP: 110/56(72) {96/53(68) - 127/65(86)} mmHg\n RR: 20 (13 - 23) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.8 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 2,848 mL\n 1,051 mL\n PO:\n 1,340 mL\n 480 mL\n Tube feeding:\n IV Fluid:\n 1,168 mL\n 461 mL\n Blood products:\n 100 mL\n 50 mL\n Total out:\n 3,797 mL\n 865 mL\n Urine:\n 1,077 mL\n 260 mL\n NG:\n 400 mL\n Stool:\n Drains:\n 2,320 mL\n 605 mL\n Balance:\n -949 mL\n 186 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases)\n Abdominal: Distended, Tender: mild diffuse tenderness\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), drains in place\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 115 K/uL\n 9.8 g/dL\n 86 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.9 mEq/L\n 112 mg/dL\n 99 mEq/L\n 127 mEq/L\n 28.4 %\n 22.4 K/uL\n [image002.jpg]\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n 03:00 AM\n WBC\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n 22.4\n Hct\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n 28.4\n Plt\n 142\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n 115\n Creatinine\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n 3.2\n TCO2\n 12\n Glucose\n 156\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n 86\n Other labs: PT / PTT / INR:21.5/52.3/2.0, ALT / AST:46/115, Alk-Phos /\n T bili:92/19.8, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:2.9 g/dL, LDH:169 IU/L, Ca:8.6 mg/dL,\n Mg:1.8 mg/dL, PO4:7.5 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia, S/P IR drainage of fluid collection\n .\n Plan: Neuro: Q4H neurochek, Dilaudid prn, A & O X3\n CVS: Hemodynamically stable will use albumin for ascites fluid\n replacement\n PULM: Sats good on RA. OOB and CPT\n RENAL: /CRF/hepatorenal stable cr, will continue to monitor,\n replacements currently on hold for his ostomy and Jtube outputs\n FEN/GI: tolerating po Currently not transplant candidate d/t peritoneal\n infection. protonix 40\", TF changed renal impact with fiber \n strenght . Rifaximin & lactulose for hepatic encephalopathy. s/p IR\n perc drain for abdominal collection \n ID: Being treated for fungemia as well as peritonitis\n along with VRE with Micafungin, Meropenem and Linezolid, leukocytosis\n HEME: Hct stable, plt stable HIT pending JP ascitic replacements held\n up until 1-2 L negative. will restart when -2L WITH 0.5 CC/1CC.\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: to floor?\n Total time spent: 32 min\n" }, { "category": "Nursing", "chartdate": "2164-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706773, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt very pleasant and cooperative, A&Ox3\n Abd firm, pos BS, pos flatus and stool\n Pt on calorie count\n Jtube x2 clamped\n Medial JP and sump drain to wall suction, serous acites\n fluid draining in mod amounts\n Pigtail drain in LLQ with serous drainage in small amounts\n Afebrile\n Skin very excoriated on coccyx and buttocks\n L leg cellulitis improving, pt c/o pain x1\n Pt remains oliguric\n VSS\n Action:\n Dilaudid 0.5mg IV x1\n Abx as ordered\n 24 hr urine collection\n Monitoring drain output\n Pt on fluid restriction\n Albumin 25% 12.5g given for every 1L output of acites\n drainage\n Turn and reposition Q2-3hrs\n \n Response:\n Pt expressing adequate pain relief from pain meds\n No change in u/o\n No change in JP outputs\n Pt fluid balance approx 700cc negative as of MN\n Pt remains afebrile\n VSS\n Plan:\n Continue with abx as ordered\n 24 urine collection until 0800 \n Pain management\n PT/OT consults\n Albumin prn\n \n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706772, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706533, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative\n Abdomen firmly distended. +BS. Small amts liquid brown\n stool. Guaic positive stools x2.\n J-tubes clamped. Tolerating clears.\n Medial JP/sump/pigtail drains draining moderate amts ascitic\n drainage.\n Amber urine 30-50 cc/hr.\n Action:\n JP drainage checked q 2-3 hours\n Albumin given per q 1 liter drain output\n Diet advanced to regular/soft solids\n Renal following-ordered 24 hour urine collection. No\n containers in lab.\n Dilaudid prn pain\n Oob to chair\n Response:\n Hemodynamically stable\n Fluid balance=\n Pt tolerating clears/thick liquids\n Plan:\n Continue holding repletion for drain output\n Albumin per q liter output\n Cont follow labs\n Cont aggressive skin care, frequent repositioning. ?wound\n care consult Monday.\n Cont OOB as tolerated/PT/OT consults\n Cont antibiotics as ordered per ID team\n Transfer to floor if pt remains stable\n" }, { "category": "Nursing", "chartdate": "2164-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706765, "text": "Ineffective Coping\n Assessment:\nI am not getting OOB\n Pt insistent he was not getting OOB because when\n he got OOB Sun he was sore and in pain.\n Action:\n Pt premedicated with pain med prior to getting OOB\n Type of chair changed to regular cardiac chair padded with pillows.\n Response:\n Pt stayed in chair x 1 hour exactly\n Plan:\n Increase time OOB q day\n Activity Intolerance\n Assessment:\n Pt stood and pivoted to chair with too assist\n Pt unsteady on feet and did not pick up feet to take 2 steps toward the\n chair.\n HR increased to 128 when pt stood then returned to baseline\n Action:\n Pt hoyered back to bed\n Response:\n Tolerated getting OOB with significant raise in HR\n Plan:\n Page PT tomorrow to increase pt exercise time and to assist with\n getting pt OOB.\n Plan transfer to floor if ok with Dr \n" }, { "category": "Physician ", "chartdate": "2164-11-13 00:00:00.000", "description": "Intensivist Note", "row_id": 706836, "text": "SICU\n HPI:\n POD 27 / 24 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: micafungin (), Meropenum (), Linezolid ()\n PPx: boots, PPI \n TLD: foley, R IJ triple lumen (), PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis\n Current medications:\n Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5. Bicitra 6.\n Calcium Gluconate 7. HYDROmorphone (Dilaudid) 8. HYDROmorphone\n (Dilaudid) 9. Heparin Flush (10 units/ml) 10. 11. Insulin 12. Linezolid\n 13. Magnesium Sulfate 14. Meropenem 15. Micafungin 16. Miconazole\n Powder 2% 17. Ondansetron\n 18. Pantoprazole 19. Rifaximin 20. Sodium Bicarbonate\n 24 Hour Events:\n NASAL SWAB - At 09:00 AM\n ARTERIAL LINE - STOP 07:00 PM\n Post operative day:\n POD#27 - ex lap duod ulcer repair\n POD#24 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:00 PM\n Meropenem - 10:00 PM\n Linezolid - 12:32 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 09:29 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.5\nC (97.7\n HR: 95 (84 - 107) bpm\n BP: 97/54(64) {97/54(64) - 112/69(88)} mmHg\n RR: 20 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.8 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 3,124 mL\n 465 mL\n PO:\n 1,524 mL\n 120 mL\n Tube feeding:\n 230 mL\n IV Fluid:\n 1,150 mL\n 345 mL\n Blood products:\n 100 mL\n Total out:\n 3,855 mL\n 305 mL\n Urine:\n 920 mL\n 105 mL\n NG:\n Stool:\n Drains:\n 2,935 mL\n 200 mL\n Balance:\n -731 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\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:\n Diminished: bilateral lung base), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 122 K/uL\n 9.5 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.3 mEq/L\n 119 mg/dL\n 99 mEq/L\n 129 mEq/L\n 28.6 %\n 21.6 K/uL\n [image002.jpg]\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n 03:00 AM\n 03:25 AM\n WBC\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n 22.4\n 21.6\n Hct\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n 28.4\n 28.6\n Plt\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n 115\n 122\n Creatinine\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n 3.2\n TCO2\n 12\n Glucose\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n 86\n 122\n Other labs: PT / PTT / INR:20.9/49.6/1.9, ALT / AST:47/116, Alk-Phos /\n T bili:112/21.7, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:2.9 g/dL, LDH:169 IU/L, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:7.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia, S/P IR drainage of abdmoninal fluid collection\n Plan:\n Neurologic: AAOx3, pain well controlled and PRN bases. We will talk\n about discontinuing refaximin.\n Cardiovascular: BP stable off the pressor, HR well controlled.\n Pulmonary: IS, OOB\n Gastrointestinal / Abdomen: not on the list for l;iver transplant\n secondary to the infection. Change protonix to daily dosing.\n Nutrition: po diet, calorie count. ALT/ASP stable. Rising bilirubin\n represent intrahepatic stasis 2 s\n Renal: renal function stable with elevated CREA. We will continue.\n Fluid restriction for hyponatremia. Sodium bicarbonate for metabolic\n acidosis.\n Hematology: H/H stable\n Endocrine: RISS (2units / 24hrs), blood glucose below desired goal\n 1500mg%.\n Infectious Disease: WBC stable at to 21.6 but febrile. Currently, being\n treated for fungemia as well as peritonitis along with\n VRE with Micafungin, Meropenem and Linezolid,. Will consider\n discontinuing micafungin 2 weeks after negative cultures that were sent\n yesterday.\n Lines / Tubes / Drains: PICC placed foley, PIV x1, JP x2, J-tube x2,\n A-line\n Imaging: none\n Fluids: Replace ascites with 25% albumin\n Consults: renal,\n Billing Diagnosis: Acute kidney failure, acute liver failure,\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 07:00 PM\n Prophylaxis:\n DVT: Boots (not indicated)\n Stress ulcer: PPI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2164-11-10 00:00:00.000", "description": "Intensivist Note", "row_id": 706292, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n Liver failure\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5.\n Bicitra 6. Calcium Gluconate\n 7. HYDROmorphone (Dilaudid) 8. Heparin Flush (10 units/ml) 9. 10.\n Insulin 11. Linezolid 12. Magnesium Sulfate\n 13. Meropenem 14. Micafungin 15. Midodrine 16. Miconazole Powder 2% 17.\n Ondansetron 18. Pantoprazole\n 19. Rifaximin 20. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n 52 cm.\n MULTI LUMEN - STOP 09:35 PM\n Post operative day:\n POD#24 - ex lap duod ulcer repair\n POD#21 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Micafungin - 04:00 PM\n Meropenem - 11:20 PM\n Linezolid - 12:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:03 AM\n Hydromorphone (Dilaudid) - 01:30 AM\n Other medications:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.6\n T current: 36.1\nC (97\n HR: 117 (100 - 117) bpm\n BP: 106/55(72) {103/46(65) - 138/73(93)} mmHg\n RR: 22 (15 - 32) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 102.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 1 (1 - 106) mmHg\n Total In:\n 5,161 mL\n 1,196 mL\n PO:\n Tube feeding:\n 3,260 mL\n 719 mL\n IV Fluid:\n 1,350 mL\n 368 mL\n Blood products:\n 200 mL\n 50 mL\n Total out:\n 6,575 mL\n 2,094 mL\n Urine:\n 760 mL\n 194 mL\n NG:\n Stool:\n Drains:\n 5,815 mL\n 1,900 mL\n Balance:\n -1,414 mL\n -898 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 118 K/uL\n 9.8 g/dL\n 163 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.0 mEq/L\n 114 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.5 %\n 19.5 K/uL\n [image002.jpg]\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n WBC\n 12.2\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n Hct\n 27.6\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n Plt\n 156\n 142\n 147\n 121\n 105\n 101\n 102\n 118\n Creatinine\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n TCO2\n 14\n Glucose\n 165\n 183\n 156\n 127\n 115\n 136\n 153\n 157\n 163\n Other labs: PT / PTT / INR:24.8/83.7/2.4, ALT / AST:33/69, Alk-Phos / T\n bili:119/15.9, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:169 IU/L, Ca:8.3 mg/dL,\n Mg:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n .\n Plan: Neuro: Dilaudid prn, awake and following commands\n CVS: Hemodynamically stable will use albumin for intravascular fluid\n replacement\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal syndrome worsening, will continue to\n monitor, replacements currently on hold for his ostomy and Jtube\n outputs\n FEN/GI: 1.8 negative now . Currently not transplant candidate d/t\n peritoneal infection. protonix 40\", TF changed renal impact with fiber\n strenght . Rifaximin & lactulose for hepatic encephalopathy.\n Octreotide d/ced for now due to LLE erythema. abdominal collection ?\n ir perc drain. Start regular diet .\n ID: Being treated for Candda glabrata fungemia as well as peritonitis\n along with VRE with Micafungin, Meropenem and Linezolid, leukocytosis\n HEME: Hct stable. Trending platelets for downward trend, concern for\n HIT awaiting HIT panel JP ascitic replacements held up until 1-2 L\n negative. will restart when -2L WITH 0.5 CC/1CC.\n ENDO: RISS\n Psych: s/p consult\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, R IJ triple lumen ()removed sent tip\n for cx. , PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Nutrition:\n NovaSource Renal () - 11:52 PM 125 mL/hour\n Lines:\n Arterial Line - 01:20 PM\n PICC Line - 07:00 PM\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2164-12-06 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 711006, "text": "24 Hour Events:\n BLOOD CULTURED - At 11:58 PM\n periph stick cultures\n ARTERIAL LINE - STOP 01:17 AM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:34 AM\n pt self dc'd arterial line. Dr & here to eval pt. Wrist\n restraints applied & attempt to reorient pt .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 09:26 PM\n Micafungin - 01:38 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:15 AM\n Other medications:\n Flowsheet Data as of 02:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.6\nC (96\n HR: 85 (79 - 93) bpm\n BP: 102/45(57) {87/45(57) - 108/66(76)} mmHg\n RR: 16 (14 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.3 kg (admission): 107.2 kg\n Total In:\n 1,299 mL\n 36 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,019 mL\n 36 mL\n Blood products:\n 100 mL\n Total out:\n 1,935 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n 1,925 mL\n Balance:\n -636 mL\n 36 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n 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\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, confused at times\n Labs / Radiology\n 177 K/uL\n 8.5 g/dL\n 64 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 71 mg/dL\n 87 mEq/L\n 126 mEq/L\n 24.8 %\n 14.8 K/uL\n [image002.jpg]\n 04:30 AM\n 02:07 AM\n 02:27 AM\n 03:17 AM\n WBC\n 25.9\n 25.2\n 14.8\n Hct\n 26.6\n 25.2\n 24.8\n Plt\n 220\n 241\n 177\n Cr\n 5.7\n 6.3\n 6.5\n TCO2\n 17\n Glucose\n 81\n 71\n 64\n Other labs: PT / PTT / INR:27.1/78.3/2.1, ALT / AST:63/189, Alk Phos /\n T Bili:97/28.5, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:3.0 g/dL,\n LDH:269 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n HEPATIC FAILURE, FULMINANT, HYPOTENSION (NOT SHOCK), FEVER\n (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS)\n 52M with ETOH Child C cirrhosis c/b esophageal and rectal varices with\n prior episodes of bleeding admitted with painless BRBPR and\n hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy,now with hypotension, increasing\n abdominal pain/distension/fevers.\n .\n Plan:\n Neuro: A&Ox 3, Slightly confused and agitated. Dilaudid prn. PT asking\n for no further intervention- will clarify goals of care and DNR/DNI\n status. Benadryl for pruritis.\n Patient refusing therapies.\n CVS: Fluid boluses, albumin and Neo gtt to maintain map > 55\n PULM: Stable on RA\n RENAL: /CRF/hepatorenal, on HD (holding per renal)\n GI: protonix 40'', increasing abdominal pain/distention, recently self\n d/c'd j tube ? fistula vs SBP on broad spectrum abx,? CT with po\n contrast.\n HEME: Holding on blood draws per pt wishes, pt is s/p x 2 admissions to\n SICU this hospital stay for GIB\n ENDO: Holding on fingersticks due to pt wishes\n ID: tmax 100, Hx of VRE and Stenotrophamonas has been off all abx\n except prophylactic bactrim wbc 25.9 today currently on\n linezolid/zosym and micafungin. Bl Cultures GNR 3/3 bottles\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full?\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:40 AM\n Dialysis Catheter - 07:24 AM\n :\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710746, "text": "Hepatic failure, fulminant\n Assessment:\n AAO x 3, although makes comments incongruent to conversation\n at hand. Pleasant, cooperative. Afebrile. Upper extremities move\n against resistance, lower extremities barely move on bed (partially due\n to prior knee surgeries and/or anasarca. Sclera icteric.\n Remains on Neosynephrine. Titrated down from 4mcg to\n 2mcg/kg/min. Midodrine and albumin given today. MAP in 60s for most\n of shift.\n Lungs clear in upper airways, diminished in bases. O2 sat\n > 95% on RA.\n Abdomen distended with ascites. Hypoactive BS. Some pain\n upon movement. Treated with Dilaudid 0.25mg IV.\n Skin jaundiced/bronze. Stage II (broken excoriation) to\n inner thighs near gluteal folds. Cleaned with foam cleanser and\n barrier cream applied.\n Long discussion with wife and patient regarding DNR/DNI\n status, continuation of care, etc. Pt wishes to remain full code at\n this time. Also would like to receive dialysis treatment knowing that\n he is not a candidate for a liver transplant. Pt understands with with\n dialysis but without a liver, life expectancy is approximately 3 months\n (per Dr. . Explained to patient and wife that decision does not\n need to be made immediately, but that constant/frequent conversation\n needs to occur in revisiting the issue.\n Plan:\n Maintain MAP between 55-60. Titrate Neo off as tolerated. Continue to\n turn and position for comfort being observant of excoriation to inner\n thighs/gluteal folds. Possible HD tomorrow (per Dr. .\n" }, { "category": "Physician ", "chartdate": "2164-12-04 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 710642, "text": "TITLE:\n 24 Hour Events:\n PICC LINE - START 12:40 AM\n ARTERIAL LINE - START 12:47 AM\n : Family meeting to asses goals of care-> will proceed status quo;\n GNR from blood cultures, Neo at 4.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:30 PM\n Linezolid - 10:29 PM\n Infusions:\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 AM\n Dextrose 50% - 10:23 AM\n Hydromorphone (Dilaudid) - 03:30 PM\n Other medications:\n Flowsheet Data as of 01:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.7\n HR: 101 (95 - 108) bpm\n BP: 87/42(60) {75/38(53) - 92/50(206)} mmHg\n RR: 24 (17 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109.8 kg (admission): 107.2 kg\n Total In:\n 6,279 mL\n 63 mL\n PO:\n TF:\n IVF:\n 4,454 mL\n 63 mL\n Blood products:\n Total out:\n 130 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 30 mL\n Drains:\n Balance:\n 6,149 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: scleral icterus\n Head, Ears, Nose, Throat: Normocephalic, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : )\n Abdominal: Distended, Area of former abscess opened and dressed\n with gauze, erythema at all former insicion/ tube site\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 220 K/uL\n 8.8 g/dL\n 81 mg/dL\n 5.7 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 58 mg/dL\n 91 mEq/L\n 131 mEq/L\n 26.6 %\n 25.9 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 25.9\n Hct\n 26.6\n Plt\n 220\n Cr\n 5.7\n Glucose\n 81\n Other labs: PT / PTT / INR:24.1/62.8/2.3, ALT / AST:49/169, Alk Phos /\n T Bili:167/30.4, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:2.8 g/dL,\n LDH:262 IU/L, Ca++:8.8 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Imaging: none\n Microbiology: GNR 3/3 bottles\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF\n UNKNOWN ORIGIN), .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Neuro: A&Ox 3, Dilaudid prn. PT asking for no further intervention-\n will clarify goals of care and DNR/DNI status. Benadryl for pruritis.\n CVS: Fluid boluses and Neo gtt to maintain map > 55\n PULM: Stable on 2L\n RENAL: /CRF/hepatorenal, on HD which was held yesterday given\n hemodynamic instability.\n GI: protonix 40'', increasing abdominal pain/distention, recently self\n d/c'd j tube ? fistula vs SBP on broad spectrum abx,? CT with po\n contrast\n HEME: Holding on blood draws per pt wishes, pt is s/p x 2 admissions to\n SICU this hospital stay for GIB, hct 26.6, plt 220, inr 2.3\n ENDO: Holding on fingersticks due to pt wishes\n ID: tmax 100, Hx of VRE and Stenotrophamonas has been off all abx\n except prophylactic bactrim wbc 25.9 today currently on\n linezolid/zosym. Bl Cultures GNR 2/2 bottles\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:40 AM\n Arterial Line - 12:47 AM\n Dialysis Catheter - 07:24 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Social Work", "chartdate": "2164-12-05 00:00:00.000", "description": "Social Work Progress Note", "row_id": 710896, "text": "Social Work Progress Note, transplant service\n Clinical data: Contact by SICU because pt is refusing all treatment\n and staff requesting code status discussion with pt and family. SW met\n with pt briefly. He presented reclined in bed, fully alert and oriented\n x1. He had soft restraints on. Pt reported that he did not recognize\n SW nor did he remember our conversation from yesterday. He abruptly\n ended the meeting. SW contact pt\ns wife via phone who reported that\n she is planning to come to the hospital this afternoon. She noted that\n she has several phone calls to make to manage her affairs and that her\n dtr is having difficulty focusing on her school work, but attended\n school today so that she could meet with a school counselor for\n emotional support. SW informed pt\ns wife about yesterday meeting,\n conveying pt\ns wish to spend time with his family. She reported that\n the pt called her last evening to inform her of this. SW also informed\n pt\ns wife of his current condition and the team\ns wish to address goals\n of care at this time. Pt\ns wife reported that she will come to\n hospital later this afternoon. SW encouraged pt\ns wife to include her\n dtr to allow for time visiting with pt.\n Clinical Assessment/plan: Pt appears to be more confused that during\n meeting with him yesterday. Pt\ns wife appears to be coping more\n appropriately, though still remains overwhelmed with circumstances. She\n seems to be considering more directly the pt\ns circumstances and the\n impact that it is having on their family. Further, she seems more able\n to retain information provided to her. SW will f/u with Dr and\n palliative care service re:possible meeting with pt and his family\n later this afternoon.\n \n Transplant Social Worker\n #\n" }, { "category": "Nutrition", "chartdate": "2164-12-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 710444, "text": "Subjective: Did not speak with patient.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 107.2 kg\n Pertinent medications: Neosynephrine, noted\n Labs:\n Value\n Date\n Glucose\n 81 mg/dL\n 04:30 AM\n Glucose Finger Stick\n 94\n 11:00 AM\n BUN\n 58 mg/dL\n 04:30 AM\n Creatinine\n 5.7 mg/dL\n 04:30 AM\n Sodium\n 131 mEq/L\n 04:30 AM\n Potassium\n 3.7 mEq/L\n 04:30 AM\n Chloride\n 91 mEq/L\n 04:30 AM\n TCO2\n 19 mEq/L\n 04:30 AM\n Albumin\n 2.8 g/dL\n 04:30 AM\n Calcium non-ionized\n 8.8 mg/dL\n 04:30 AM\n Phosphorus\n 1.3 mg/dL\n 04:30 AM\n Magnesium\n 1.8 mg/dL\n 04:30 AM\n ALT\n 49 IU/L\n 04:30 AM\n Alkaline Phosphate\n 167 IU/L\n 04:30 AM\n AST\n 169 IU/L\n 04:30 AM\n Amylase\n 83 IU/L\n 04:30 AM\n Total Bilirubin\n 30.4 mg/dL\n 04:30 AM\n WBC\n 25.9 K/uL\n 04:30 AM\n Hgb\n 8.8 g/dL\n 04:30 AM\n Hematocrit\n 26.6 %\n 04:30 AM\n Current diet order / nutrition support: DIet: NPO\n GI: abd firm, distended, liquid stool, c/o abd pain\n Assessment of Nutritional Status\n Patient readm to SICU with hypotension and high temps, now on\n Neosynephrine drip. Patient pulled out his proximal J-tube, but still\n has his feeding/distal J-tube. Patient is currently NPO until blood\n pressure is more stable. Team/family discussing hospice. If tube\n feeds are restarted, recommend previous tube feeding goal of Nutren 2.0\n @ 45mL/hr + 40g protein (2267kcals, 112g protein). Will follow plan.\n #\n" }, { "category": "Social Work", "chartdate": "2164-12-04 00:00:00.000", "description": "Social Work Progress Note", "row_id": 710728, "text": "Social Work Progress Note, Transplant Service\n Clinical Data: Continuing to follow pt in SICU. After two meetings\n with family and pt yesterday to discuss goals of care, SW met with pt\n to provide further emotional support around progressing illness and\n education around end of life planning/decision-making. Pt presented\n reclined in bed, oriented x2. Possible AH/VH demonstrated by thinking\n TV was on when it was not, hearing music, hearing voice of a friend.\n Also present for conversation was pt\ns SICU nurse, . SW prompted\n conversation around several areas including 1) pt\ns understanding of\n his current circumstances-\nI can\nt have a transplant\nI have limited\n time.\n 2) How pt wants to spend his remaining time-\nI want to spend as\n much time with my daughter, wife, mother, sister, and other family as I\n can.\n 3) pt\ns understanding of course of care. Pt clearly stated that\n he would like to spend time with his family and articulated what he\n would like to say to them, especially his dtr, wife, and mother. Pt\n asked 2 or 3 times throughout hour-long conversation where there were\n any options for him to have a liver transplant. SW reinforced with pt\n that he has clearly communicated with the team with words and actions\n that he did not want to have a liver transplant and that he was unable\n to tolerate the many medical interventions involved. Pt noted,\n know, I did this to myself.\n SW and RN discussed impact of continuing\n current level of care vs reducing interventions. Also discussed\n remaining in hospital vs potential for hospice care in the community.\n Finally discussed difference between full code status vs DNR/DNI. Pt\n once again stated that he would like to spend as much time with his\n family as possible. SW and RN encouraged pt to consider conversation\n in the context of his medical condition.\n Clinical assessment: Pt demonstrated more clarity of thought than\n yesterday. Pt seems to want family present for visitation. SW will\n contact pt\ns wife tomorrow to discuss this. Pt seemed to process\n content of conversation more easily. SW will return to conversation\n with pt tomorrow, hopefully with wife present. Recommend steady f/u\n with pt and wife to reinforce and reassess care plan. SW will f/u with\n Dr. and palliative care service.\n \n Transplant Social Work\n #\n" }, { "category": "Physician ", "chartdate": "2164-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 710882, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.S/P transfusion of\n multiple 30+ units pRBC, FFP in MICU. To OR for ex-lap for duodenal\n arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo\n vasopressin intraop. Since admission grew C.glabra in ascities and\n completed course of micafungin, then grew Stenothrophamonas currently\n on bactrim and VRE currently on daptomycin. With a readmission and\n discharge fromt SICU with re-ocurance of GIB. Now readmitted to SICU\n with high temps and hypotension.\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with UGIB,\n hypotension during dialysis\n PMHx:\n ETOH cirrhosis, portalHTN/esophageal/rectal varices, duodenal ulcer,\n internal hemorrhoids\n Current medications:\n Linezolid 600 mg IV Q12H Order date: @ 0024, Midodrine 10 mg PO\n TID Order date: @ 0024, Albumin 25% (12.5g / 50mL) 25 g IV Q6H\n Duration: 48 Hours Order date: @ 0634, Micafungin 100 mg IV Q24H\n Order date: @ 1044, Nystatin Oral Suspension 5 mL PO QID Order\n date: @ 0024, Artificial Tears 1-2 DROP BOTH EYES PRN dryness\n Order date: @ 2320, Octreotide Acetate 100 mcg SC Q8H Order\n date: @ 0024, Calcium Acetate 1334 mg PO TID W/MEALS Order date:\n @ 0024, Ondansetron 4 mg IV Q8H:PRN nausea Order date: @\n 0024, Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 0024, Pantoprazole 40 mg IV Q12H Order date: @ 0024,\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\n 0024, Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>55 Order\n date: @ 0106, HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain\n Order date: @ 0024, Piperacillin-Tazobactam 2.25 g IV Q8H Order\n date: @ 0024, Rifaximin 400 mg PO TID OK to give via J-tube\n Order date: @ 0024, Sarna Lotion 1 Appl TP QID:PRN itch Order\n date: @ 0024, Simethicone 40-80 mg PO/NG QID:PRN bloating Order\n date: @ 0024, Insulin SC (per Insulin Flowsheet) Sliding Scale\n Order date: @ 0024, Sucralfate 1 gm PO QID Order date: @\n 0024, Lactulose 30 mL PO/NG Q4H:PRN encephalopathy Order date: @\n 0024\n 24 Hour Events:\n BLOOD CULTURED - At 11:58 PM\n periph stick cultures\n ARTERIAL LINE - STOP 01:17 AM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:34 AM\n pt self dc'd arterial line. Dr & here to eval pt. Wrist\n restraints applied & attempt to reorient pt .\n : albumin prn for hypotension, wean neo. Now full code. HD .\n Encephalopathic. Agitated o/n. Refusing all medications. Self-removed\n a-line. Neo at 2\n Post operative day:\n POD 49 / 45 s/p ex lap, gastrotomy, duodenotomy w/suturing of bleeding\n vessel, draining jejunostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 09:26 PM\n Micafungin - 01:38 AM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Hydromorphone (Dilaudid) - 02:54 PM\n Other medications:\n Flowsheet Data as of 05:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.2\nC (97.2\n HR: 82 (82 - 100) bpm\n BP: 108/66(76) {82/46(54) - 110/69(76)} mmHg\n RR: 16 (15 - 27) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.8 kg (admission): 107.2 kg\n Total In:\n 1,876 mL\n 216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,496 mL\n 116 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,876 mL\n 216 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Anxious, Encephalopathic\n HEENT: Scleral icterus\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Drain\n in place\n Left Extremities: (Edema: 2+, 3+), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+, 3+), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: Jaundice, (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 177 K/uL\n 8.5 g/dL\n 64 mg/dL\n 6.3 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 71 mg/dL\n 87 mEq/L\n 126 mEq/L\n 24.8 %\n 14.8 K/uL\n [image002.jpg]\n 04:30 AM\n 02:07 AM\n 02:27 AM\n 03:17 AM\n WBC\n 25.9\n 25.2\n 14.8\n Hct\n 26.6\n 25.2\n 24.8\n Plt\n 220\n 241\n 177\n Creatinine\n 5.7\n 6.3\n TCO2\n 17\n Glucose\n 81\n 71\n 64\n Other labs: PT / PTT / INR:28.6/71.0/2.8, ALT / AST:63/189, Alk-Phos /\n T bili:97/30.7, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:3.0 g/dL,\n LDH:269 IU/L, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n HEPATIC FAILURE, FULMINANT, HYPOTENSION (NOT SHOCK), FEVER\n (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 52M with ETOH Child C cirrhosis c/b esophageal and\n rectal varices with prior episodes of bleeding admitted with painless\n BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy with\n suturing of bleeding vessel, draining jejunostomy,now with hypotension,\n increasing abdominal pain/distension/fevers.\n Assesment and Plan:\n 52yo M with end stage ETOH cirrhosis\n Neuro: Ax1, Encephalopathic overnight; self dc\nd a-line. Confused and\n agitated. Needing restraints overnight. Pt refusing meds. Will clarify\n goals of care and DNR/DNI status with pt\ns family. Prior to pt\n encephalopathy, he had expressed desire to have no further care. When\n confused, he later expressed desire to have care but is now refusing\n that care, pulling lines, refusing meds etc. I have told nurse it would\n be inappropriate to force care on the patient. I would normally deal\n with this directly with the family, but Dr. has expressed desire\n to handle all family communications himself.\n CVS: Fluid boluses, albumin and Neo gtt to maintain map > 55\n PULM: Stable on RA\n RENAL: /CRF/hepatorenal/ESRD, (holding off on HD) as pt\ns goals of\n care must be clarified.\n GI: protonix 40'', increasing abdominal pain/distention, recently self\n d/c'd j tube ? fistula vs SBP on broad spectrum abx,? CT with po\n contrast.\n HEME: Holding on blood draws per pt wishes, pt is s/p x 2 admissions to\n SICU this hospital stay for GIB\n ENDO: Holding on fingersticks due to pt wishes\n ID: tmax 100, Hx of VRE and Stenotrophamonas has been off all abx\n except prophylactic bactrim wbc 14.8 today currently on\n linezolid/zosym and micafungin. Bl Cultures GNR 3/3 bottles\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full?\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n Glycemic Control: RISS, refusing\n Lines:\n PICC Line - 12:40 AM\n Dialysis Catheter - 07:24 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer : PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition:\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710989, "text": "HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. With a readmission and discharge fromt SICU with\n re-ocurance of GIB. Now readmitted to SICU with high temps and\n hypotension\n Chief complaint:\n hypotension\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Hepatic failure, fulminant\n Assessment:\n Patient appears jaundice, sclera icteric and bilateral\n asterisxis.\n Alert and oriented X2. Patient from start of shift\n consistently declining all care.\n MD /MD and from social work notified.\n Abdomen: Grossly distended, +BSX4,S, tenderness with\n palpation. Abdominal incision well healed, small open area, drainage\n bag intact with serous drainage.\n Currently on Neo at 1.75mcg/kg/min.\n Action:\n from social work in to speak with patient\n regarding refusal of care. Contact patient\ns wife. family\n meeting this afternoon to discuss code status and POC.\n Patient throughout shift refusing all IV/PO medications, HD\n and all routine care.\n Patient stating\nI wish to spend time with daughter.\n Response:\n becoming increasingly encephalopathic throughout\n shift. Currently A+OX1.\n Patient continues to decline care.\n /MD family arrival to discuss code\n status and POC.\n Plan:\n Continue to respect patient\ns decision to decline all care.\n Wife and daughter to visit this afternoon and meet with\n and MD to readdress code status and POC.\n" }, { "category": "Physician ", "chartdate": "2164-12-04 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 710546, "text": "TITLE:\n 24 Hour Events:\n PICC LINE - START 12:40 AM\n ARTERIAL LINE - START 12:47 AM\n : Family meeting to asses goals of care-> will proceed status quo;\n GNR from blood cultures, Neo at 4.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:30 PM\n Linezolid - 10:29 PM\n Infusions:\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 AM\n Dextrose 50% - 10:23 AM\n Hydromorphone (Dilaudid) - 03:30 PM\n Other medications:\n Flowsheet Data as of 01:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.7\n HR: 101 (95 - 108) bpm\n BP: 87/42(60) {75/38(53) - 92/50(206)} mmHg\n RR: 24 (17 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109.8 kg (admission): 107.2 kg\n Total In:\n 6,279 mL\n 63 mL\n PO:\n TF:\n IVF:\n 4,454 mL\n 63 mL\n Blood products:\n Total out:\n 130 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 30 mL\n Drains:\n Balance:\n 6,149 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: scleral icterus\n Head, Ears, Nose, Throat: Normocephalic, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : )\n Abdominal: Distended, Area of former abscess opened and dressed\n with gauze, erythema at all former insicion/ tube site\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 220 K/uL\n 8.8 g/dL\n 81 mg/dL\n 5.7 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 58 mg/dL\n 91 mEq/L\n 131 mEq/L\n 26.6 %\n 25.9 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 25.9\n Hct\n 26.6\n Plt\n 220\n Cr\n 5.7\n Glucose\n 81\n Other labs: PT / PTT / INR:24.1/62.8/2.3, ALT / AST:49/169, Alk Phos /\n T Bili:167/30.4, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:2.8 g/dL,\n LDH:262 IU/L, Ca++:8.8 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Imaging: none\n Microbiology: GNR 3/3 bottles\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF\n UNKNOWN ORIGIN), .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Neuro: A&Ox 3, Dilaudid prn. PT asking for no further intervention-\n will clarify goals of care and DNR/DNI status. Benadryl for pruritis.\n CVS: Fluid boluses and Neo gtt to maintain map > 55\n PULM: Stable on 2L\n RENAL: /CRF/hepatorenal, on HD\n GI: protonix 40'', increasing abdominal pain/distention, recently self\n d/c'd j tube ? fistula vs SBP on broad spectrum abx,? CT with po\n contrast\n HEME: Holding on blood draws per pt wishes, pt is s/p x 2 admissions to\n SICU this hospital stay for GIB, hct 26.6, plt 220, inr 2.3\n ENDO: Holding on fingersticks due to pt wishes\n ID: tmax 100, Hx of VRE and Stenotrophamonas has been off all abx\n except prophylactic bactrim wbc 25.9 today currently on\n linezolid/zosym. Bl Cultures GNR 2/2 bottles\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:40 AM\n Arterial Line - 12:47 AM\n Dialysis Catheter - 07:24 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2164-12-06 00:00:00.000", "description": "Generic Note", "row_id": 711093, "text": "TITLE: PT/Rehab Services\n Attempted to see for follow-up. Case discussed with RN who reports\n patient not currently appropriate for PT treatment and likely\n transferring to hospice later today. Will sign off. Please re-consult\n if status changes.\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710857, "text": "TITLE:\n Hepatic failure, fulminant\n Assessment:\n PERL 4mm brisk A& O x 2, calm at begin of shift. Vague\n oriented to place\nhospital\n and person. Not to time-\n\n Increasingly confused, combative, refusing care ~ 2330\n Neo at 2mcg/kg/min goal mbp > 55\n Grossly jaundiced, sclera icteric. + asterisxis. Abd soft,\n large amts of ascites.\n Old drain site putting out large amts of dk yellow/\n clear drng\n Anuric\n Action:\n Drainage bag appliance placed over drain site and continues\n to drain copious amts of serous fld.\n Continues on q6h albumin\n Antibx as ordered, time delays in dosing d/t pt refusal to\n let staff give meds.\n With increased agitation pt refusing meds.Pt pulling iv\n tubings and iv pole, attempting to dc. Dr and made aware of\n increased agitation- >per transplant\n no meds for agitation, just\n continue to reorient.\n 0120 am pt self dc\nd art line, combative, Dr and \n paged. Soft restraints applied and pressure held over art line site.\n Attempted art line aborted by Dr as pt increasingly agitated,\n combative. Following cuff bp\n Attempted lactulose dosing , pt refused\n Response:\n Disoriented, w + asterisxis. encephalopathic\n Remains on neo, goal bp maintained > 55\n Plan:\n Plan to revisit w SW and Team -plan of care , code status.\n ? dialysis today.\n Attempt to give lactulose for ammonia clearance via jtube\n" }, { "category": "Social Work", "chartdate": "2164-12-06 00:00:00.000", "description": "Social Work Progress Note", "row_id": 711082, "text": "Social Work Progress Note, Transplant Service\n Clinical Data: Continuing to follow pt while hospitalized. Pt now DNR\n and continues to refuse all care. Case manager working to secure bed\n in hospice home on for later today. SW met with pt briefly\n and informed him of likely plan for hospice later today. He was\n agreeable. SW contact pt\ns wife re:plan and she was also agreeable\n and requested that she be contact by cell phone to inform her when\n plans are finalized. She stated that should he go to hospice today,\n she will not come to hospital but will see him after he is moved.\n Clinical assessment/plan: Pt and his wife appear agreeable with plan\n for move to hospice home on . Pls contact pt\ns wife on her\n cell # if needed. SW will continue to follow until\n discharge.\n \n Transplant Social Work\n #\n" }, { "category": "Physician ", "chartdate": "2164-12-06 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 711087, "text": "24 Hour Events:\n BLOOD CULTURED - At 11:58 PM\n periph stick cultures\n ARTERIAL LINE - STOP 01:17 AM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:34 AM\n pt self dc'd arterial line. Dr & here to eval pt. Wrist\n restraints applied & attempt to reorient pt .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 09:26 PM\n Micafungin - 01:38 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:15 AM\n Other medications:\n Flowsheet Data as of 02:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.6\nC (96\n HR: 85 (79 - 93) bpm\n BP: 102/45(57) {87/45(57) - 108/66(76)} mmHg\n RR: 16 (14 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.3 kg (admission): 107.2 kg\n Total In:\n 1,299 mL\n 36 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,019 mL\n 36 mL\n Blood products:\n 100 mL\n Total out:\n 1,935 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n 1,925 mL\n Balance:\n -636 mL\n 36 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n 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\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, confused at times\n Labs / Radiology\n 177 K/uL\n 8.5 g/dL\n 64 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 71 mg/dL\n 87 mEq/L\n 126 mEq/L\n 24.8 %\n 14.8 K/uL\n [image002.jpg]\n 04:30 AM\n 02:07 AM\n 02:27 AM\n 03:17 AM\n WBC\n 25.9\n 25.2\n 14.8\n Hct\n 26.6\n 25.2\n 24.8\n Plt\n 220\n 241\n 177\n Cr\n 5.7\n 6.3\n 6.5\n TCO2\n 17\n Glucose\n 81\n 71\n 64\n Other labs: PT / PTT / INR:27.1/78.3/2.1, ALT / AST:63/189, Alk Phos /\n T Bili:97/28.5, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:3.0 g/dL,\n LDH:269 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 52M with ETOH Child C cirrhosis c/b esophageal and rectal varices with\n prior episodes of bleeding admitted with painless BRBPR and\n hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy,now with hypotension, increasing\n abdominal pain/distension/fevers.\n .\n Plan:\n Neuro: confused and agitated. Prior to becoming confused, PT had asked\n ask for no further intervention\n Patient refusing therapies.\n CVS: hypotension, pt refusing phenylephrine gtt.\n PULM: Stable on RA\n RENAL: ESRD/hepatorenal, no HD given pt\ns goals of care\n GI: recently self d/c'd j tube\n HEME: Holding on blood draws per pt wishes, pt is s/p x 2 admissions to\n SICU this hospital stay for GIB\n ENDO: Holding on fingersticks due to pt wishes\n ID: pt refusing abx\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: DNR/DNI\n after evaluation by Lockland , director of\n medical ethics; pt\ns DNR/DNI status has been confirmed.\n CONTACT: , wife, \n DISPO: Hospice\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:40 AM\n Dialysis Catheter - 07:24 AM\n :\n Code status: DNR/DNI\n Disposition: Hospice\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2164-12-03 00:00:00.000", "description": "Intensivist Note", "row_id": 710420, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. it. S/P transfusion\n of multiple 30+ units pRBC, FFP in MICU. To OR for ex-lap for duodenal\n arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo\n vasopressin intraop. Since admission grew C.glabra in ascities and\n completed course of micafungin, then grew Stenothrophamonas currently\n on bactrim and VRE currently on daptomycin. With a readmission and\n discharge fromt SICU with re-ocurance of GIB. Now readmitted to SICU\n with high temps and hypotension\n Chief complaint:\n hypotension\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Artificial Tears 5. Calcium Acetate 6. Dextrose 50% 7. Glucagon\n 8. HYDROmorphone (Dilaudid) 9. Insulin 10. Lactulose 11. Linezolid 12.\n Midodrine 13. Nystatin Oral Suspension 14. Octreotide Acetate 15.\n Ondansetron 16. Pantoprazole 17. Phenylephrine 18.\n Piperacillin-Tazobactam 19. Rifaximin 20. Sarna Lotion 21. Simethicone\n 22. Sucralfate\n 24 Hour Events:\n PICC LINE - START 12:40 AM\n ARTERIAL LINE - START 12:47 AM\n - bolus 1.25 liters crystalloid\n - started neo gtt to maintin MAPs\n - started on Linezolid/Zosyn\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:09 AM\n Infusions:\n Phenylephrine - 3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100\n HR: 101 (97 - 108) bpm\n BP: 85/43(60) {68/25(2) - 92/50(66)} mmHg\n RR: 20 (16 - 24) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,697 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,897 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,597 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, infrequently moans in discomfort\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bases)\n Abdominal: Distended\n Left Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice, (Incision: No(t) Clean / Dry / Intact), icteric sclera\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 220 K/uL\n 8.8 g/dL\n 81 mg/dL\n 5.7 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 58 mg/dL\n 91 mEq/L\n 131 mEq/L\n 26.6 %\n 25.9 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 25.9\n Hct\n 26.6\n Plt\n 220\n Creatinine\n 5.7\n Glucose\n 81\n Other labs: PT / PTT / INR:24.1/62.8/2.3, ALT / AST:49/169, Alk-Phos /\n T bili:167/30.4, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:2.8 g/dL,\n LDH:262 IU/L, Ca:8.8 mg/dL, Mg:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF\n UNKNOWN ORIGIN), .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with hypotension, increasing\n abdominal pain/distension/fevers\n Neurologic: AAOx3, pain well controlled.\n Cardiovascular: MAP goal of 55mmHg requires crystalloids and\n neosynephrine. We would add albumin. Stop midodrine.\n Pulmonary: Stable on RA.\n Gastrointestinal / Abdomen: Worsening cirrhosis with peritonitis vs\n abdominal wall abcess. We will inquire about his suitability of the\n transplant in near future. CT scan today after HD stable.\n Nutrition: NPO.\n Renal: Worsening hepatorenal syndrome, anuric, treated with chronic\n hemodialysis. Scheduled on T, W, Sat. But we will postpone HD b/o HD\n instability.\n Hematology: Follow Hct & platelets & coagulation parameters. INR\n elevated as surrogate of liver dysfunction.\n Endocrine: RISS with satisfactory serum glucose control. Chronic\n hyponatremia.\n Infectious Disease: Septic shock picture secondary to the peritonitis.\n We will investigate further causes by performing CT, and send blood\n cultures. On linbezolid and zosyn for VRE. Add CRP to assess progress\n of infection.\n Imaging: CT today\n Fluids: KVO, prn boluses\n Consults: Transplant\n Billing Diagnosis: Sepsis\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:40 AM\n Arterial Line - 12:47 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: Comments: Pt might benefit most acutely by I&D of Rt\n sided abdominal wall abscess. Will discuss with transplant svc.\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710516, "text": "Hypotension (not Shock)\n Assessment:\n Pt received on 3 mcg Neo gtt, transplant goal MAP>55\n Abdomen firmly distended, tender\n Area marked where pt self-discontinued G-J tube, reddened\n Positive bld cx\ns for gram (-) rods\n Pt having several small loose brown stools this shift\n Moving all extremities on the bed\n Pt appropriate but at times making confused statements,\n reorients on own quickly\n Pt stating\nStop the antibiotics, stop everything. \n want to do this anymore.\n Action:\n Neo gtt titrated up to 4mcg/kg/min\n Abd CT held d/t pt stating he no longer wanted aggressive\n treatment (as pt had previously been stating through out week\n hospitalization per Ethics/SW notes in OMR)\n Pipercillin and linezolid IV given as ordered as 1x doses as\n still awaiting ID approval for ?cont course of abx\n Transplant called and small meeting held at bedside with\n resident and RN re: and decision to make pt \n Ethics MD following pt and SW for transplant team, \n , and meeting held (RN, MD, SW) with wife re:pt\ns \n Planned mtg at 1700 with Dr. (attng physician for pt),\n SW, Ethics MD, RN, and wife at bedside to include pt in decision\n making\n Response:\n BP continues to be pressor dependent, SBP~high 70s-80s with\n MAPs at goal 55-65\n Plan:\n According to meeting with Dr. this evening, pt is to\n continue on Abx and neo gtt overnoc but to endure NO INVASIVE\n procedures/treatments\n ?SICU resident to acquire DNR status prior to wife\ns leaving\n tonight if okay with transplant\n Reassess in AM pt\ns wishes\n" }, { "category": "Nursing", "chartdate": "2164-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710707, "text": "Hepatic failure, fulminant\n Assessment:\n AAO x 3, although makes comments incongruent to conversation\n at hand. Pleasant, cooperative. Afebrile. Upper extremities move\n against resistance, lower extremities barely move on bed (partially due\n to prior knee surgeries and/or anasarca. Sclera icteric.\n Remains on Neosynephrine. Titrated down from 4mcg to\n 2mcg/kg/min.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710710, "text": "Hepatic failure, fulminant\n Assessment:\n AAO x 3, although makes comments incongruent to conversation\n at hand. Pleasant, cooperative. Afebrile. Upper extremities move\n against resistance, lower extremities barely move on bed (partially due\n to prior knee surgeries and/or anasarca. Sclera icteric.\n Remains on Neosynephrine. Titrated down from 4mcg to\n 2mcg/kg/min. Midodrine and albumin given today. MAP in 60s for most\n of shift.\n Lungs clear in upper airways, diminished in bases. O2 sat\n > 95% on RA.\n Abdomen distended with ascites. Hypoactive BS. Some pain\n upon movement. Treated with Dilaudid 0.25mg IV.\n Skin jaundiced/bronze. Stage II (broken excoriation) to\n inner thighs near gluteal folds. Cleaned with foam cleanser and\n barrier cream applied.\n Long discussion with wife and patient regarding DNR/DNI\n status, continuation of care, etc. Pt wishes to remain full code at\n this time. Also would like to receive dialysis treatment knowing that\n he is not a candidate for a liver transplant. Pt understands with with\n dialysis but without a liver, life expectancy is approximately 3 months\n (per Dr. . Explained to patient and wife that decision does not\n need to be made immediately, but that constant/frequent conversation\n needs to occur in revisiting the issue.\n Plan:\n Maintain MAP between 55-60. Titrate Neo off as tolerated. Continue to\n turn and position for comfort being observant of excoriation to inner\n thighs/gluteal folds. Possible HD tomorrow (per Dr. .\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710942, "text": "Hepatic failure, fulminant\n Assessment:\n Patient appears jaundice, sclera icteric and bilateral\n asterisxis.\n Alert and oriented X2. Patient from start of shift\n consistently declining all care.\n MD /MD and from social work notified.\n Abdomen: Grossly distended, +BSX4,S, tenderness with\n palpation. Abdominal incision well healed, small open area, drainage\n bag intact with serous drainage.\n Currently on Neo at 1.75mcg/kg/min.\n Action:\n from social work in to speak with patient\n regarding refusal of care. Contact patient\ns wife. family\n meeting this afternoon to discuss code status and POC.\n Patient throughout shift refusing all IV/PO medications, HD\n and all routine care.\n Patient stating\nI wish to spend time with daughter.\n Response:\n becoming increasingly encephalopathic throughout\n shift. Currently A+OX1.\n Patient continues to decline care.\n /MD family arrival to discuss code\n status and POC.\n Plan:\n Continue to respect patient\ns decision to decline all care.\n Wife and daughter to visit this afternoon and meet with\n and MD to readdress code status and POC.\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710944, "text": "HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. With a readmission and discharge fromt SICU with\n re-ocurance of GIB. Now readmitted to SICU with high temps and\n hypotension\n Chief complaint:\n hypotension\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Hepatic failure, fulminant\n Assessment:\n Patient appears jaundice, sclera icteric and bilateral\n asterisxis.\n Alert and oriented X2. Patient from start of shift\n consistently declining all care.\n MD /MD and from social work notified.\n Abdomen: Grossly distended, +BSX4,S, tenderness with\n palpation. Abdominal incision well healed, small open area, drainage\n bag intact with serous drainage.\n Currently on Neo at 1.75mcg/kg/min.\n Action:\n from social work in to speak with patient\n regarding refusal of care. Contact patient\ns wife. family\n meeting this afternoon to discuss code status and POC.\n Patient throughout shift refusing all IV/PO medications, HD\n and all routine care.\n Patient stating\nI wish to spend time with daughter.\n Response:\n becoming increasingly encephalopathic throughout\n shift. Currently A+OX1.\n Patient continues to decline care.\n /MD family arrival to discuss code\n status and POC.\n Plan:\n Continue to respect patient\ns decision to decline all care.\n Wife and daughter to visit this afternoon and meet with\n and MD to readdress code status and POC.\n" }, { "category": "Nursing", "chartdate": "2164-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710697, "text": "Hepatic failure, fulminant\n Assessment:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710834, "text": "TITLE:\n Hepatic failure, fulminant\n Assessment:\n PERL 4mm brisk A& O x 2, calm at begin of shift. Vague\n oriented to place\nhospital\n and person. Not to time-\n\n Increasingly confused, combative, refusing care ~ 2330\n Neo at 2mcg/kg/min goal mbp > 55\n Grossly jaundiced, sclera icteric. + asterisxis. Abd soft,\n large amts of ascites.\n Old drain site putting out large amts of dk yellow/\n clear drng\n Anuric\n Action:\n Drainage bag appliance placed over drain site and continues\n to drain copious amts of serous fld.\n Continues on q6h albumin\n Antibx as ordered, time delays in dosing d/t pt refusal to\n let staff give meds.\n With increased agitation pt refusing meds.Pt pulling iv\n tubings and iv pole, attempting to dc. Dr and made aware of\n increased agitation- >per transplant\n no meds for agitation, just\n continue to reorient.\n 0120 am pt self dc\nd art line, combative, Dr and \n paged. Soft restraints applied and pressure held over art line site.\n Attempted art line aborted by Dr as pt increasingly agitated,\n combative. Following cuff bp\n Attempted lactulose dosing , pt refused\n Response:\n Disoriented, w + asterisxis. encephalopathic\n Remains on neo, goal bp maintained > 55\n Plan:\n Plan to revisit w SW and Team -plan of care , code status.\n ? dialysis today.\n Attempt to give lactulose for ammonia clearance via jtube\n" }, { "category": "Nursing", "chartdate": "2164-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711021, "text": "Hepatic failure, fulminant\n Assessment:\n Patient consistently declining all care from onset of\n shift\nrefusing temperature monitoring, BP monitoring, full body\n assessment, bath, changing of gown/fitted sheet/pad, any meds including\n IV abx, and pain med\n Pt with significant jaundice, sclera icteric and bilateral\n asterisxis\n Orientation waxes and wanes, pt making occasional confused\n statement, occasionally having auditory/visual hallucinations\n Transplant team aware of refusal of care/ICU monitoring\n Abd remains firmly distended, +tenderness/guarding\n Abd with small open area to drainage bag at start of shift\n with serous drainage\n Received on Neo at 1.8mcg/kg/min\n Action:\n Neo weaned to off, BP consistently at time WNL for pt \n >/=55-65)\n Patient throughout shift refusing all IV/PO medications and\n all routine care, threatening members of staff\n Patient\ns family in to see pt for ~1-2 hrs\n Emotional support given\n Response:\n Plan:\n Continue to respect patient\ns decision to decline all care\n Wife and daughter need to meet with SW and MD\n to readdress code status and POC\n If DNR obtained, Case management to facilitate\n pt getting hospice bed and leaving ICU as pt is refusing most elements\n of critical care\n" }, { "category": "Nursing", "chartdate": "2164-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710496, "text": "Hypotension (not Shock)\n Assessment:\n Pt received on 3 mcg Neo gtt, transplant goal MAP>55\n Abdomen firmly distended, tender\n Area marked where pt self-discontinued G-J tube, reddened\n Pt having several small loose brown stools this shift\n Moving all extremities on the bed\n Pt appropriate but at times making confused statements,\n reorients on own quickly\n Pt stating\nStop the antibiotics, stop everything. \n want to do this anymore.\n Action:\n Neo gtt titrated up to 4mcg/kg/min\n Abd CT held d/t pt stating he no longer wanted aggressive\n treatment (as pt had previously been stating through out week\n hospitalization on 10)\n Pipercillin and linezolid iv given as ordered as 1x doses as\n still awaiting ID approval for ?cont course of abx\n Transplant called and small meeting held at bedside with\n resident and RN re: and decision to make pt \n Ethics MD following pt and SW for transplant team, \n , and meeting held (RN, MD, SW) with wife re:pt\ns \n Planned mtg at 1700 with Dr. (attng physician for pt),\n SW, Ethics MD, RN, and wife at bedside to include pt in decision\n making\n Response:\n Bp continues to be pressor dependent, SBP~high 70s-80s with\n MAPs at goal 55-65\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710825, "text": "TITLE:\n Hepatic failure, fulminant\n Assessment:\n PERL 4mm brisk A& O x 2, calm at begin of shift. Vague\n oriented to place\nhospital\n and person. Not to time-\n\n Increasingly confused, combative, refusing care ~ 2330\n Neo at 2mcg/kg/min goal mbp > 55\n Grossly jaundiced, sclera icteric. + asterisxis. Abd soft,\n large amts of ascites.\n Old drain site putting out large amts of dk yellow/\n clear drng\n Anuric\n Action:\n Drainage bag appliance placed over drain site and continues\n to drain copious amts of serous fld.\n Continues on q6h albumin\n Antibx as ordered, time delays in dosing d/t pt refusal to\n let staff give meds.\n With increased agitation pt refusing meds.Pt pulling iv\n tubings and iv pole, attempting to dc. Dr and made aware of\n increased agitation- >per transplant\n no meds for agitation, just\n continue to reorient.\n 0120 am pt self dc\nd art line, combative, Dr and \n paged. Soft restraints applied and pressure held over art line site.\n Attempted art line aborted by Dr as pt increasingly agitated,\n combative. Following cuff bp\n Attempted lactulose dosing , pt refused\n Response:\n Disoriented, w + asterisxis. encephalopathic\n Remains on neo, goal bp maintained > 55\n Plan:\n Plan to revisit w SW and Team -plan of care , code status.\n ? dialysis today.\n ? ngt placement to give lactulose for ammonia clearance.\n" }, { "category": "Physician ", "chartdate": "2164-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710384, "text": "HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. With a readmission and discharge fromt SICU with\n re-ocurance of GIB. Now readmitted to SICU with high temps and\n hypotension\n Chief complaint:\n hypotension\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Hypotension (not Shock)\n Assessment:\n Admitted to the sicu from 10, bp on floor 68/39 heart rate 103\n Abdomen firmly distended and complaining of pain\n Resp rate 20-30\n Skin jaundiced.\n Legs edematous.\n Bp in the sicu 80-90\ns with mean 54-60.\n Alert and oriented\n Moving all extremities on the bed.\n Action:\n 500cc normal saline fluid bolus given on floor\n 25occ normal saline fluid bolus x2 during the first hour of arrival.\n Aline inserted.\n Neo gtt initiated and titrated up to 3mcg/kg/min.\n Pipercillin and linezolid iv given as ordered.\n Response:\n Bp continues to be in the low 80;s despite neo gtt. And fluid bolus\n Transplant team notified and will be see on rounds.\n Plan:\n Monitor bp closely\n To have an abdominal ct scan with contrast today\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Fever on floor up to 102\n Upon arrival to the floor , temp 97.7\n Temp during the nite 100.6 and 100.0\n Action:\n Tepid bath given.\n Response:\n Temp 100 po presentlyl\n Plan:\n Monitor closely.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen firmly distended.\n Patient complains of pain when turning in the bed.\n Action:\n Head of bed elevated to help relieve pressure off abdomen.\n Response:\n Patient complains of abdominal pain when turning in the bed .\n Plan:\n Monitor abd pain\n To cat scan today for abdominal ct with contrast.\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710932, "text": "Hepatic failure, fulminant\n Assessment:\n Patient appears jaundice, sclera icteric and bilateral\n asterisxis.\n Alert and oriented X2. Patient from start of shift\n consistently declining all care.\n MD /MD and from social work notified.\n Abdomen: Grossly distended, +BSX4,S, tenderness with\n palpation. Abdominal incision well healed, small open area, drainage\n bag intact with serous drainage.\n Action:\n from social work in to speak with patient\n regarding refusal of care. Contact patient\ns wife. family\n meeting this afternoon to discuss code status and POC.\n Response:\n Plan:\n Hepatic failure, fulminant\n Assessment:\n PERL 4mm brisk A& O x 2, calm at begin of shift. Vague\n oriented to place\nhospital\n and person. Not to time-\n\n Increasingly confused, combative, refusing care ~ 2330\n Neo at 2mcg/kg/min goal mbp > 55\n Grossly jaundiced, sclera icteric. + asterisxis. Abd soft,\n large amts of ascites.\n Old drain site putting out large amts of dk yellow/\n clear drng\n Anuric\n Action:\n Drainage bag appliance placed over drain site and continues\n to drain copious amts of serous fld.\n Continues on q6h albumin\n Antibx as ordered, time delays in dosing d/t pt refusal to\n let staff give meds.\n With increased agitation pt refusing meds.Pt pulling iv\n tubings and iv pole, attempting to dc. Dr and made aware of\n increased agitation- >per transplant\n no meds for agitation, just\n continue to reorient.\n 0120 am pt self dc\nd art line, combative, Dr and \n paged. Soft restraints applied and pressure held over art line site.\n Attempted art line aborted by Dr as pt increasingly agitated,\n combative. Following cuff bp\n Attempted lactulose dosing , pt refused\n Response:\n Disoriented, w + asterisxis. encephalopathic\n Remains on neo, goal bp maintained > 55\n Plan:\n Plan to revisit w SW and Team -plan of care , code status.\n ? dialysis today.\n Attempt to give lactulose for ammonia clearance via jtube\n" }, { "category": "Physician ", "chartdate": "2164-12-03 00:00:00.000", "description": "Intensivist Note", "row_id": 710376, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. With a readmission and discharge fromt SICU with\n re-ocurance of GIB. Now readmitted to SICU with high temps and\n hypotension\n Chief complaint:\n hypotension\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Artificial Tears 5. Calcium Acetate 6. Dextrose 50% 7. Glucagon\n 8. HYDROmorphone (Dilaudid) 9. Insulin 10. Lactulose 11. Linezolid 12.\n Midodrine 13. Nystatin Oral Suspension\n 14. Octreotide Acetate 15. Ondansetron 16. Pantoprazole 17.\n Phenylephrine 18. Piperacillin-Tazobactam\n 19. Rifaximin 20. Sarna Lotion 21. Simethicone 22. Sucralfate\n 24 Hour Events:\n PICC LINE - START 12:40 AM\n ARTERIAL LINE - START 12:47 AM\n - bolus 1.25 liters crystalloid\n - started neo gtt to maintin MAPs\n - started on Linezolid/Zosyn\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 12:09 AM\n Infusions:\n Phenylephrine - 3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100\n HR: 101 (97 - 108) bpm\n BP: 85/43(60) {68/25(2) - 92/50(66)} mmHg\n RR: 20 (16 - 24) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,697 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,897 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,597 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, infrequently moans in discomfort\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bases)\n Abdominal: Distended\n Left Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice, (Incision: No(t) Clean / Dry / Intact), icteric sclera\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 220 K/uL\n 8.8 g/dL\n 81 mg/dL\n 5.7 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 58 mg/dL\n 91 mEq/L\n 131 mEq/L\n 26.6 %\n 25.9 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 25.9\n Hct\n 26.6\n Plt\n 220\n Creatinine\n 5.7\n Glucose\n 81\n Other labs: PT / PTT / INR:24.1/62.8/2.3, ALT / AST:49/169, Alk-Phos /\n T bili:167/30.4, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:2.8 g/dL,\n LDH:262 IU/L, Ca:8.8 mg/dL, Mg:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF\n UNKNOWN ORIGIN), .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy,now with hypotension, increasing\n abdominal pain/distension/fevers\n Neurologic: alert and oriented x 3, stable for past 24 hours, Dilaudid\n prn per primary team for pain\n Cardiovascular: Fluid boluses and Neo gtt to maintain map > 55\n Pulmonary: Sats good on RA\n Gastrointestinal / Abdomen: protonix 40'', increasing abdominal\n pain/distention, recently self d/c'd j tube ? fistula vs SBP on broad\n spectrum abx, when hemodynamically stable will do CT with po contrast\n Nutrition: NPO\n Renal: /CRF/hepatorenal, on HD cr 5.7\n Hematology: will trend hct/plts/coags, pt is s/p x 2 admissions to SICU\n this hospital stay for GIB, hct 26.6, plt 220, inr 2.3\n Endocrine: RISS, goal BS <150, sodium 131\n Infectious Disease: Check cultures, tmax 100, Hx of VRE and\n Stenotrophamonas has been off all abx except prophylactic bactrim wbc\n 25.9 todayhypotension, febrile on floor, septic picture, most likely\n source is intra-abdominal started zosyn/linezolid, will do CT to\n better evaluate intra-abdominal process\n Lines / Tubes / Drains:\n Wounds:\n Imaging: CXR today\n Fluids: KVO, prn boluses\n Consults: Transplant\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:40 AM\n Arterial Line - 12:47 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: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2164-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710377, "text": "Hypotension (not Shock)\n Assessment:\n Admitted to the sicu from 10, bp on floor 68/39 heart rate 103\n Abdomen firmly distended and complaining of pain\n Resp rate 20-30\n Skin jaundiced.\n Legs edematous.\n Bp in the sicu 80-90\ns with mean 54-60.\n Alert and oriented\n Moving all extremities on the bed.\n Action:\n 500cc normal saline fluid bolus given on floor\n 25occ normal saline fluid bolus x2 during the first hour of arrival.\n Aline inserted.\n Neo gtt initiated and titrated up to 3mcg/kg/min.\n Pipercillin and linezolid iv given as ordered.\n Response:\n Bp continues to be in the low 80;s despite neo gtt. And fluid bolus\n Transplant team notified and will be see on rounds.\n Plan:\n Monitor bp closely\n To have an abdominal ct scan with contrast today\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Fever on floor up to 102\n Upon arrival to the floor , temp 97.7\n Temp during the nite 100.6 and 100.0\n Action:\n Tepid bath given.\n Response:\n Temp 100 po presentlyl\n Plan:\n Monitor closely.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdomen firmly distended.\n Patient complains of pain when turning in the bed.\n Action:\n Head of bed elevated to help relieve pressure off abdomen.\n Response:\n Abdomonial pain\n Plan:\n Monitor abd pain\n To cat scan today for abdominal ct with contrast.\n" }, { "category": "Nursing", "chartdate": "2164-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710577, "text": "Hypotension (not Shock)\n Assessment:\n Pt A&Ox2-3, occasionally with odd statements and sometimes\n appearing confused. Pt quickly reorients self. Forgetful. Otherwise\n appropriate in conversation\n MAE, following all commands\n Pt cooperative with care throughout shift, making needs\n known\n HR 90-100, SR, no ectopy. BP continues to be pressor\n dependant, MAP 54-67, goal 55-60, aline damped, following cuff\n pressures\n Pt c/o general discomfort in ABD region and c/o itchiness\nall over\n Action:\n Providing care as discussed in family meeting in previous\n shift, continuing with abx and BP meds. Pt remains full code\n Neo gtt as ordered to maintain MAP 55-60\n Benadryl x1 for itchiness\n Dialudid prn pain\n Response:\n MAP remains 54-67\n No change in mental status\n Pt expressing adequate relief from benadryl and dilaudid\n Plan:\n Wean neo gtt as tolerated\n Continue with care as planned until further decisions\n regarding pt\ns status is made\n Family meeting today to discuss pt wanting to make himself\n \n Provide pt and family with emotional support\n" }, { "category": "Physician ", "chartdate": "2164-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 710819, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.S/P transfusion of\n multiple 30+ units pRBC, FFP in MICU. To OR for ex-lap for duodenal\n arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo\n vasopressin intraop. Since admission grew C.glabra in ascities and\n completed course of micafungin, then grew Stenothrophamonas currently\n on bactrim and VRE currently on daptomycin. With a readmission and\n discharge fromt SICU with re-ocurance of GIB. Now readmitted to SICU\n with high temps and hypotension.\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with UGIB,\n hypotension during dialysis\n PMHx:\n ETOH cirrhosis, portalHTN/esophageal/rectal varices, duodenal ulcer,\n internal hemorrhoids\n Current medications:\n Linezolid 600 mg IV Q12H Order date: @ 0024, Midodrine 10 mg PO\n TID Order date: @ 0024, Albumin 25% (12.5g / 50mL) 25 g IV Q6H\n Duration: 48 Hours Order date: @ 0634, Micafungin 100 mg IV Q24H\n Order date: @ 1044, Nystatin Oral Suspension 5 mL PO QID Order\n date: @ 0024, Artificial Tears 1-2 DROP BOTH EYES PRN dryness\n Order date: @ 2320, Octreotide Acetate 100 mcg SC Q8H Order\n date: @ 0024, Calcium Acetate 1334 mg PO TID W/MEALS Order date:\n @ 0024, Ondansetron 4 mg IV Q8H:PRN nausea Order date: @\n 0024, Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date:\n @ 0024, Pantoprazole 40 mg IV Q12H Order date: @ 0024,\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: @\n 0024, Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>55 Order\n date: @ 0106, HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain\n Order date: @ 0024, Piperacillin-Tazobactam 2.25 g IV Q8H Order\n date: @ 0024, Rifaximin 400 mg PO TID OK to give via J-tube\n Order date: @ 0024, Sarna Lotion 1 Appl TP QID:PRN itch Order\n date: @ 0024, Simethicone 40-80 mg PO/NG QID:PRN bloating Order\n date: @ 0024, Insulin SC (per Insulin Flowsheet) Sliding Scale\n Order date: @ 0024, Sucralfate 1 gm PO QID Order date: @\n 0024, Lactulose 30 mL PO/NG Q4H:PRN encephalopathy Order date: @\n 0024\n 24 Hour Events:\n BLOOD CULTURED - At 11:58 PM\n periph stick cultures\n ARTERIAL LINE - STOP 01:17 AM\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 01:34 AM\n pt self dc'd arterial line. Dr & here to eval pt. Wrist\n restraints applied & attempt to reorient pt .\n : albumin prn for hypotension, wean neo. Now full code. HD .\n Encephalopathic. Agitated o/n. Refusing all medications. Self-removed\n a-line. Neo at 2\n Post operative day:\n POD 49 / 45 s/p ex lap, gastrotomy, duodenotomy w/suturing of bleeding\n vessel, draining jejunostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 09:26 PM\n Micafungin - 01:38 AM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Hydromorphone (Dilaudid) - 02:54 PM\n Other medications:\n Flowsheet Data as of 05:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.2\nC (97.2\n HR: 82 (82 - 100) bpm\n BP: 108/66(76) {82/46(54) - 110/69(76)} mmHg\n RR: 16 (15 - 27) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.8 kg (admission): 107.2 kg\n Total In:\n 1,876 mL\n 216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,496 mL\n 116 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,876 mL\n 216 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Anxious, Encephalopathic\n HEENT: Scleral icterus\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Drain\n in place\n Left Extremities: (Edema: 2+, 3+), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+, 3+), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: Jaundice, (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 177 K/uL\n 8.5 g/dL\n 64 mg/dL\n 6.3 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 71 mg/dL\n 87 mEq/L\n 126 mEq/L\n 24.8 %\n 14.8 K/uL\n [image002.jpg]\n 04:30 AM\n 02:07 AM\n 02:27 AM\n 03:17 AM\n WBC\n 25.9\n 25.2\n 14.8\n Hct\n 26.6\n 25.2\n 24.8\n Plt\n 220\n 241\n 177\n Creatinine\n 5.7\n 6.3\n TCO2\n 17\n Glucose\n 81\n 71\n 64\n Other labs: PT / PTT / INR:28.6/71.0/2.8, ALT / AST:63/189, Alk-Phos /\n T bili:97/30.7, Amylase / Lipase:83/51, Differential-Neuts:72.0 %,\n Band:11.0 %, Lymph:3.0 %, Mono:9.0 %, Eos:1.0 %, Albumin:3.0 g/dL,\n LDH:269 IU/L, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n HEPATIC FAILURE, FULMINANT, HYPOTENSION (NOT SHOCK), FEVER\n (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), .H/O ABDOMINAL\n PAIN (INCLUDING ABDOMINAL TENDERNESS)\n Assessment and Plan: 52M with ETOH Child C cirrhosis c/b esophageal and\n rectal varices with prior episodes of bleeding admitted with painless\n BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy with\n suturing of bleeding vessel, draining jejunostomy,now with hypotension,\n increasing abdominal pain/distension/fevers.\n Plan:\n Neuro: Ax1, Encephalopathic. Confused and agitated. Needing restraints.\n Dilaudid prn. PT asking for no further intervention- will clarify goals\n of care and DNR/DNI status. Benadryl for pruritis.\n CVS: Fluid boluses, albumin and Neo gtt to maintain map > 55\n PULM: Stable on RA\n RENAL: /CRF/hepatorenal, on HD (holding per renal\n will reassess)\n GI: protonix 40'', increasing abdominal pain/distention, recently self\n d/c'd j tube ? fistula vs SBP on broad spectrum abx,? CT with po\n contrast.\n HEME: Holding on blood draws per pt wishes, pt is s/p x 2 admissions to\n SICU this hospital stay for GIB\n ENDO: Holding on fingersticks due to pt wishes\n ID: tmax 100, Hx of VRE and Stenotrophamonas has been off all abx\n except prophylactic bactrim wbc 14.8 today currently on\n linezolid/zosym and micafungin. Bl Cultures GNR 3/3 bottles\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full?\n CONTACT: , wife, \n DISPO: SICU\n ICU Care\n Nutrition:\n Glycemic Control: RISS, refusing\n Lines:\n PICC Line - 12:40 AM\n Dialysis Catheter - 07:24 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer : PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition:\n Total time spent: 30\n" }, { "category": "Physician ", "chartdate": "2164-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710374, "text": "Hypotension (not Shock)\n Assessment:\n Admitted to the sicu from 10, bp on floor 68/39 heart rate 103\n Abdomen firmly distended and complaining of pain\n Resp rate 20-30\n Skin jaundiced.\n Legs edematous.\n Bp in the sicu 80-90\ns with mean 54-60.\n Alert and oriented\n Moving all extremities on the bed.\n Action:\n 500cc normal saline fluid bolus given on floor\n 25occ normal saline fluid bolus x2 during the first hour of arrival.\n Aline inserted.\n Neo gtt initiated and titrated up to 3mcg/kg/min.\n Pipercillin and linezolid iv given as ordered.\n Response:\n Bp continues to be in the low 80;s despite neo gtt. And fluid bolus\n Transplant team notified and will be see on rounds.\n Plan:\n Monitor bp closely\n To have an abdominal ct scan with contrast today\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Fever on floor up to 102\n Upon arrival to the\n Action:\n Response:\n Plan:\n Monitor closely.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710922, "text": "Hepatic failure, fulminant\n Assessment:\n Patient appears jaundice, sclera icteric and bilateral\n asterisxis.\n Alert and oriented X2. Patient from start of shift\n consistently declining all care.\n MD /MD and from social work notified.\n Abdomen: Grossly distended, +BSX4,S, tenderness with\n palpation. Abdominal incision well healed with small open area with\n drainage bag with serous drainage.\n Action:\n from social work in to speak with patient\n regarding refusal of care. Contact patient\ns wife. family\n meeting this afternoon to discuss code status and POC.\n Response:\n Plan:\n Hepatic failure, fulminant\n Assessment:\n PERL 4mm brisk A& O x 2, calm at begin of shift. Vague\n oriented to place\nhospital\n and person. Not to time-\n\n Increasingly confused, combative, refusing care ~ 2330\n Neo at 2mcg/kg/min goal mbp > 55\n Grossly jaundiced, sclera icteric. + asterisxis. Abd soft,\n large amts of ascites.\n Old drain site putting out large amts of dk yellow/\n clear drng\n Anuric\n Action:\n Drainage bag appliance placed over drain site and continues\n to drain copious amts of serous fld.\n Continues on q6h albumin\n Antibx as ordered, time delays in dosing d/t pt refusal to\n let staff give meds.\n With increased agitation pt refusing meds.Pt pulling iv\n tubings and iv pole, attempting to dc. Dr and made aware of\n increased agitation- >per transplant\n no meds for agitation, just\n continue to reorient.\n 0120 am pt self dc\nd art line, combative, Dr and \n paged. Soft restraints applied and pressure held over art line site.\n Attempted art line aborted by Dr as pt increasingly agitated,\n combative. Following cuff bp\n Attempted lactulose dosing , pt refused\n Response:\n Disoriented, w + asterisxis. encephalopathic\n Remains on neo, goal bp maintained > 55\n Plan:\n Plan to revisit w SW and Team -plan of care , code status.\n ? dialysis today.\n Attempt to give lactulose for ammonia clearance via jtube\n" }, { "category": "Nutrition", "chartdate": "2164-11-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706133, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 98.2 kg\n 102.3 kg ( 05:00 AM)\n 28.5\n Pertinent medications: rifaximin, RISS, ABx, others noted\n Labs:\n Value\n Date\n Glucose\n 157 mg/dL\n 02:27 AM\n Glucose Finger Stick\n 161\n 10:00 AM\n BUN\n 107 mg/dL\n 02:27 AM\n Creatinine\n 3.4 mg/dL\n 02:27 AM\n Sodium\n 138 mEq/L\n 02:27 AM\n Potassium\n 3.4 mEq/L\n 02:27 AM\n Chloride\n 109 mEq/L\n 02:27 AM\n TCO2\n 14 mEq/L\n 02:27 AM\n PO2 (arterial)\n 81. mm Hg\n 03:27 AM\n PCO2 (arterial)\n 22 mm Hg\n 03:27 AM\n pH (arterial)\n 7.41 units\n 03:27 AM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 14 mEq/L\n 03:27 AM\n Albumin\n 3.2 g/dL\n 02:27 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:27 AM\n Phosphorus\n 5.4 mg/dL\n 02:27 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:27 AM\n Magnesium\n 2.0 mg/dL\n 02:27 AM\n ALT\n 29 IU/L\n 02:27 AM\n Alkaline Phosphate\n 95 IU/L\n 02:27 AM\n AST\n 59 IU/L\n 02:27 AM\n Amylase\n 132 IU/L\n 02:58 AM\n Total Bilirubin\n 18.8 mg/dL\n 02:27 AM\n WBC\n 20.1 K/uL\n 02:27 AM\n Hgb\n 10.0 g/dL\n 02:27 AM\n Hematocrit\n 30.0 %\n 02:27 AM\n Current diet order / nutrition support: Tube Feeds: stregth\n Novasource Renal @ 150mL/hr (5400kcals, 200g protein)\n GI: abd firm, distended, bowel sounds present\n Assessment of Nutritional Status\n Patient continues on tube feeds for nutrition support, which has been\n running at goal, meeting 100% of estimated needs. Tube feeds were\n changed last night by team to a diluted renal formula. This formula is\n twice calorie dense (2kcals/mL versus 1kcal/ml), thus current tube feed\n order is providing well over twice patient\ns calorie needs. Recommend\n decreasing goal to\n strength Novasource Renal @ 60mL/hr + 40g\n Beneprotein (2303kcals, 114g protein). Please note that phos is high,\n but all over lab values do not indicate the need for a renal formula.\n Will follow - #\n" }, { "category": "Respiratory ", "chartdate": "2164-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703043, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 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 / 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 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\n Reason for continuing current ventilatory support: Cannot protect\n airway; Comments: Not responding. No spont resp.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Unable to do RSBI due to no spont resp.Will cont to monitor\n resp status.\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703240, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remained on vent , CMV mode, no change in vent settings\n overnight,\n Action:\n Patient on Triadyne bed, on continuous rotation form side to side, ABG\n sent, CXR done this morning. VAP care done.\n Response:\n LS clear and diminished at bases, O2 sat 97-98%, weak productive cough.\n RSBI this morning is 47, team aware, waiting for morning rounds for\n changes.\n Plan:\n Cont to monitor, pulm hygiene, mouth care q4h, ? Wean vent if\n tolerates\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining dark bloody drainage early shift and now more\n clear but blood tinged, Abdomen softly distended, No BS, JP\nS draining\n ascitic fluid, +++ generalized edema.\n Action:\n JP drainage replaced with NS 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2.\n Response:\n stable HCT 34.6, patient is opening eyes to call, not following any\n commands or moving any extremities, PERL, off sedation more than 24\n hours now.\n Plan:\n Cont to monitor, replace alb for 1L of JP out put\n" }, { "category": "Nursing", "chartdate": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706241, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. MAE. Following commands.\n Abdomen firm and distended. + BS. Loose golden/green BM x3.\n NPO. Novasource\n strength infusing via J-tube. Receiving\n banana flakes every 8 hours. Upper J-tube remains clamped.\n Medial JP with moderate amounts (150-350cc/hr) of ascetic\n drainage. sump with scant amounts of ascetic drainage. Pigtail\n drain putting out 300-450cc every 4 hours with small amounts of blood\n present primarily yellow in coloring.\n Afebrile. HR ST 100-112. No ectopy. BP remains stable with\n MAP >65. WBC 20.1. PICC line confirmed by x-ray and CVL removed.\n Pt with mild c/o pain in left thigh around area of\n cellulitis as well as abdominal pain. Pt with hiccups lasting a few\n hours over night.\n Foley patent. Icteric. Clear. Making 25-45cc/hour.\n Action:\n Emptying JP drain hourly replacing output in addition of\n sump output with Albumin for every liter out.\n CVL tip sent for culture. Continues on IV antibiotics.\n Dilaudid given for pain control. Turned and repositioned to\n comfort.\n Response:\n Pt -1.4L at Midnight. Received total of Albumin 12.5g x for\n evening.\n Pain improved after interventions.\n WBC 19.5\n Plan:\n Continue to replace JP and sump outputs with Albumin\n for every 1L removed.\n Monitor fluid balance closely.\n Monitor pain/comfort treating as needed.\n F/u culture results.\n" }, { "category": "Physician ", "chartdate": "2164-11-13 00:00:00.000", "description": "Intensivist Note", "row_id": 706899, "text": "SICU\n HPI:\n POD 27 / 24 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: micafungin (), Meropenum (), Linezolid ()\n PPx: boots, PPI \n TLD: foley, R IJ triple lumen (), PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis\n Current medications:\n Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5. Bicitra 6.\n Calcium Gluconate 7. HYDROmorphone (Dilaudid) 8. HYDROmorphone\n (Dilaudid) 9. Heparin Flush (10 units/ml) 10. 11. Insulin 12. Linezolid\n 13. Magnesium Sulfate 14. Meropenem 15. Micafungin 16. Miconazole\n Powder 2% 17. Ondansetron\n 18. Pantoprazole 19. Rifaximin 20. Sodium Bicarbonate\n 24 Hour Events:\n NASAL SWAB - At 09:00 AM\n ARTERIAL LINE - STOP 07:00 PM\n Post operative day:\n POD#27 - ex lap duod ulcer repair\n POD#24 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:00 PM\n Meropenem - 10:00 PM\n Linezolid - 12:32 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 09:29 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.5\nC (97.7\n HR: 95 (84 - 107) bpm\n BP: 97/54(64) {97/54(64) - 112/69(88)} mmHg\n RR: 20 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.8 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 3,124 mL\n 465 mL\n PO:\n 1,524 mL\n 120 mL\n Tube feeding:\n 230 mL\n IV Fluid:\n 1,150 mL\n 345 mL\n Blood products:\n 100 mL\n Total out:\n 3,855 mL\n 305 mL\n Urine:\n 920 mL\n 105 mL\n NG:\n Stool:\n Drains:\n 2,935 mL\n 200 mL\n Balance:\n -731 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\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:\n Diminished: bilateral lung base), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 122 K/uL\n 9.5 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.3 mEq/L\n 119 mg/dL\n 99 mEq/L\n 129 mEq/L\n 28.6 %\n 21.6 K/uL\n [image002.jpg]\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n 03:00 AM\n 03:25 AM\n WBC\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n 22.4\n 21.6\n Hct\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n 28.4\n 28.6\n Plt\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n 115\n 122\n Creatinine\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n 3.2\n TCO2\n 12\n Glucose\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n 86\n 122\n Other labs: PT / PTT / INR:20.9/49.6/1.9, ALT / AST:47/116, Alk-Phos /\n T bili:112/21.7, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:2.9 g/dL, LDH:169 IU/L, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:7.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia, S/P IR drainage of abdmoninal fluid collection\n Plan:\n Neurologic: AAOx3, pain well controlled and PRN bases. We will talk\n about discontinuing refaximin.\n Cardiovascular: BP stable off the pressor, HR well controlled.\n Pulmonary: IS, OOB\n Gastrointestinal / Abdomen: not on the list for liver transplant\n secondary to the infection. Change protonix to daily dosing.\n Nutrition: po diet, calorie count. ALT/ASP stable. Rising bilirubin\n represent intrahepatic stasis 2 s\n Renal: renal function stable with elevated CREA. We will continue.\n Fluid restriction for hyponatremia. Sodium bicarbonate for metabolic\n acidosis.\n Hematology: H/H stable\n Endocrine: RISS (2units / 24hrs), blood glucose below desired goal\n 1500mg%.\n Infectious Disease: WBC stable at to 21.6 but febrile. Currently, being\n treated for fungemia as well as peritonitis along with\n VRE with Micafungin, Meropenem and Linezolid,. Will consider\n discontinuing micafungin 2 weeks after negative cultures that were sent\n yesterday.\n Lines / Tubes / Drains: PICC placed foley, PIV x1, JP x2, J-tube x2,\n A-line\n Imaging: none\n Fluids: Replace ascites with 25% albumin\n Consults: renal,\n Billing Diagnosis: Acute kidney failure, acute liver failure,\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 07:00 PM\n Prophylaxis:\n DVT: Boots (not indicated)\n Stress ulcer: PPI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2164-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 706901, "text": "HPI: 52M with ETOH cirrhosis c/b esophageal and rectal varices. Prior\n episodes of bleeding admit with painless BRBPR and hypotension.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm >> to OR for ex-lap for duodenal arterial bleed. (EBL\n 8L. 12U PRBC. 12U FFP. 3 6-packs of platelets. neo vasopressin\n Intraop).\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis . Duodenal ulcer. Internal hemorrhoids. s/p\n bilateral knee replacements\n .\n SICU course significant events:\n : On Neo. Given albumin. 3units FFP given prior to removal of\n femoral sheath by IR. Rec replacing drain loss cc:cc. No need for HD at\n this time.\n : OR for closure of abdominal wound. Right femoral art line pulled\n s/p blood products.\n : Droppped BP to 50s in AM, noted bloody stool >> given 2U PRBCs\n and increased Neo gtt to 4 >>SBP increased to 110s. At same time desat\n to 70%s on CPAP >> FiO2 inc to 100% and CXR revealed diffuse opacity of\n L lung consistent with mucus plug. Bedside bronch to remove thick mucus\n plug, O2 sats recovered to high 90%s, vent weaned back to 50% FiO2.\n : Rigors. Afebrile. Recultured. EEG performed, results pending.\n : Removed L femoral without complication. Vit K x 1 dose.\n : Weaned vent to min settings. High output around JP drains.\n Ascities replacement schedule adjusted.\n : Continued high JP output. Intermittent fluid boluses throughout\n day with LR as needed for BP / UOP.\n : Extubated. Continuing goal of fluid status being 2 liters\n negative.\n : Stable. Trauma line pulled. Started Caspiofungin.\n : Ascites cx and blood cx from growing yeast> changed to\n Micafungin and restarted vanc/zosyn/flagyl pending further culture\n data. Re-sited CVL and changed A-line over wire. Increased ascites\n repletion to 1cc:1cc. Transient decreases in UOP and SBP responded to\n fluid boluses initially> started on Neo gtt overnight for hypotension.\n : Hypotension requiring progressive increases in Neo drip.\n Albumin bolus x1. ID consulted. Aline replaced.\n : Switched to Dilaudid for pain. Following cx were negative: UA,\n peritoneal fluid, and aline tip.\n : C/o of intermittent LLQ pain, given small doses of Dilaudid with\n some improvement. 1U PRBCs. Weaning Neo gtt.\n : Stool cx sent. Prn albumin for hypotension\n : Bld cx sent. Lateral JP removed.\n : Abdominal US.\n : CT pelvis/abdomen. LLE erythemia.\n : PICC placed. CVL removed.\n : Started Regular diet. TF discontinued.\n both j-tubes clamped on calorie count tolerating soft solids 24\n hour urine started\n having loose stools c-diff sent\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient alert and orientated X 3 abd soft + bowel sounds + flatus\n tolerating soft solids having loose stools c/o of some left sided pain.\n Heart rate90-100\ns sinus tach and systolic 90-100\ns over 50\n Action:\n Continue to replace one liter of drain fluid with albumin\n tolerating well Continue with current antibiotics\n Response:\n Patient remains stable\n Plan:\n Transfer to 10 notify team of any changes provide\n comfort and support as needed.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 98.2 kg\n Daily weight:\n 98.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH, GI Bleed\n CV-PMH:\n Additional history: s/p Bilateral knee replacements OA, Chronic GIB\n internal hemorrhoids, grade 1 esophageal varices seen in ,\n bleeding duodenal ulcer\n Surgery / Procedure and date: - Embolization in IR\n - Ex. Lap for duodenal ulcer repair\n S/P abdominal closure, placement of feeding J tube (draining\n jtube in place already)\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:54\n Temperature:\n 99\n Arterial BP:\n S:112\n D:69\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,533 mL\n 24h total out:\n 2,640 mL\n Pertinent Lab Results:\n Sodium:\n 129 mEq/L\n 03:25 AM\n Potassium:\n 3.3 mEq/L\n 03:25 AM\n Chloride:\n 99 mEq/L\n 03:25 AM\n CO2:\n 14 mEq/L\n 03:25 AM\n BUN:\n 119 mg/dL\n 03:25 AM\n Creatinine:\n 3.3 mg/dL\n 03:25 AM\n Glucose:\n 122 mg/dL\n 03:25 AM\n Hematocrit:\n 28.6 %\n 03:25 AM\n Finger Stick Glucose:\n 144\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu A\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2164-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702172, "text": "HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use.\n He was hospitalized at from to for UGIB due to\n duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n Transferred from OSH, hypotensive with HCT 17. After receiving\n multiple blood products in the MICU here at , as well as a failed\n attempt to stop duodenal bleeding in IR (), he was sent to the\n OR. Received 12 units of PRBCs in OR, duodenal ulcer oversewn, came to\n SICU intubated, paralyzed, sedated, with open abdomen.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pts temp 95-97 orally. HR ranging from 100-130\ns, sinus. BP gradually\n decreasing to 80\ns systolic, Map 60, groin line and radial a-line\n corresponding, verified with cuff as well. CVP trending down, ranging\n from . Lungs clear bilat, suctioned a few times for no sputum. Pt\n has no cough, no gag, and not over breathing set rate on vent due to\n adequate dose of Cisatricurium. Sedated on Propofol as well as Fentanyl\n for pain. Abdominal dressing intact with various areas of leakage.\n Leakage pooling under dressing in some areas, 2 JPs with only one\n holding suction and draining large amounts of serosang. Tubing placed\n under dressing on right side and connected to very low intermittent\n suction with large amounts of serosang/ascitic output. One small drain\n on left side of abdomen connected to low intermittent suction,\n appearing bilious. NG tube placed on med suction and draining only\n scant blood drainage. BS varying all shift from 130-200\ns. Insulin gtt\n on hold for now, Dr. notified, will cover most recent with\n sliding scale. Uop decreasing throughout the night ranging from\n 10-20cc/ hr of dark yellow urine. Flexiseal in place with brb in\n drainage bag, however no further output since admission.\n Action:\n Bair hugger placed for a few hours, currently off. Labs drawn Q 4\n hours, all values reported to Dr. , 2 units of PRBCs given and 1\n bag of Plts. Neo started at .5-.75 mcgs, Vasopressin currently off.\n Low UOP, Bp and decreasing CVP indicating that pt may be in need of\n fluid. Abdominal dressing leaking through sheets, large amount of\n insensible loss, shown to resident. Albumin 25 g given x 1, 500cc of\n D5\n NS given x 2, and maintainence fluid started at a gentle rate.\n Maintenance fluid stopped this am and D5\n NS running for\n cc per cc\n replacement of peritioneal drainage. Pt came from OR with full\n paralysis, had no twitches at baseline upon arrival. Cisatricurium\n started at .2 mcgs per Dr. and twitches reevaluated throughout\n the night. When pt still without twitches this am, gtt decreased\n titrated down by 25% and will continue to decrease until pt responds.\n Abdominal drainage sent for albumin, NG tube drainage sent for pH,\n however output minimal, unable to send Q 2 hours as requested and Dr.\n notified.\n Response:\n Pt currently normothermic. Hct stable, mag 1.5, no treatment per\n resident. No response to Albumin, however pt responding well to fluid\n boluses, BP and UOP increased, HR currently in 90\n Plan:\n Continue to monitor labs Q 4 hours, transfuse for HCT less than 30. Pt\n to remain paralyzed and sedated, monitor for adequate pain control.\n Monitor for any signs of increased bleeding.\n" }, { "category": "Nutrition", "chartdate": "2164-11-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 706708, "text": "Subjective: Appetite is improving.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 98.2 kg\n 98.8 kg ( )\n 28.5\n Pertinent medications: RISS, Protonix, rifaximin, Alb, others noted\n Labs:\n Value\n Date\n Glucose\n 86 mg/dL\n 03:00 AM\n Glucose Finger Stick\n 137\n 10:00 AM\n BUN\n 112 mg/dL\n 03:00 AM\n Creatinine\n 3.2 mg/dL\n 03:00 AM\n Sodium\n 127 mEq/L\n 03:00 AM\n Potassium\n 3.9 mEq/L\n 03:00 AM\n Chloride\n 99 mEq/L\n 03:00 AM\n TCO2\n 14 mEq/L\n 03:00 AM\n PO2 (arterial)\n 123 mm Hg\n 08:35 PM\n PCO2 (arterial)\n 18 mm Hg\n 08:35 PM\n pH (arterial)\n 7.42 units\n 08:35 PM\n pH (urine)\n 5.0 units\n 06:37 PM\n CO2 (Calc) arterial\n 12 mEq/L\n 08:35 PM\n Albumin\n 2.9 g/dL\n 03:00 AM\n Calcium non-ionized\n 8.6 mg/dL\n 03:00 AM\n Phosphorus\n 7.5 mg/dL\n 03:00 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:27 AM\n Magnesium\n 1.8 mg/dL\n 03:00 AM\n ALT\n 46 IU/L\n 03:00 AM\n Alkaline Phosphate\n 92 IU/L\n 01:53 AM\n AST\n 115 IU/L\n 03:00 AM\n Amylase\n 132 IU/L\n 02:58 AM\n Total Bilirubin\n 19.8 mg/dL\n 03:00 AM\n WBC\n 22.4 K/uL\n 03:00 AM\n Hgb\n 9.8 g/dL\n 03:00 AM\n Hematocrit\n 28.4 %\n 03:00 AM\n Current diet order / nutrition support: Diet: soft/ renal, with 1L\n fluid restriction\n Assessment of Nutritional Status\n 52 y.o. Male with ETOH cirrhosis c/b esophageal and rectal varices with\n prior episodes of bleeding admitted with painless BRBPR and\n hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, and feeding jejunostomy, now\n with fungemia, S/P IR drainage of fluid collection, resolving acute on\n chronic renal failure. Patient\ns tube feeds have been off since ,\n and diet is advanced to soft with renal restrictions. Team would like\n calorie counts done to assess patient\ns po intake. Will do calorie\n counts , will follow up with results. Patient already\n receiving Ensure supplements. Team would like to restrict fluid to 1L\n due to hyponatremia today. Recommend starting Phos binder (Ca Carb) to\n help with hyperphosphatemia.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2164-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 706893, "text": "HPI: 52M with ETOH cirrhosis c/b esophageal and rectal varices. Prior\n episodes of bleeding admit with painless BRBPR and hypotension.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm >> to OR for ex-lap for duodenal arterial bleed. (EBL\n 8L. 12U PRBC. 12U FFP. 3 6-packs of platelets. neo vasopressin\n Intraop).\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis . Duodenal ulcer. Internal hemorrhoids. s/p\n bilateral knee replacements\n .\n SICU course significant events:\n : On Neo. Given albumin. 3units FFP given prior to removal of\n femoral sheath by IR. Rec replacing drain loss cc:cc. No need for HD at\n this time.\n : OR for closure of abdominal wound. Right femoral art line pulled\n s/p blood products.\n : Droppped BP to 50s in AM, noted bloody stool >> given 2U PRBCs\n and increased Neo gtt to 4 >>SBP increased to 110s. At same time desat\n to 70%s on CPAP >> FiO2 inc to 100% and CXR revealed diffuse opacity of\n L lung consistent with mucus plug. Bedside bronch to remove thick mucus\n plug, O2 sats recovered to high 90%s, vent weaned back to 50% FiO2.\n : Rigors. Afebrile. Recultured. EEG performed, results pending.\n : Removed L femoral without complication. Vit K x 1 dose.\n : Weaned vent to min settings. High output around JP drains.\n Ascities replacement schedule adjusted.\n : Continued high JP output. Intermittent fluid boluses throughout\n day with LR as needed for BP / UOP.\n : Extubated. Continuing goal of fluid status being 2 liters\n negative.\n : Stable. Trauma line pulled. Started Caspiofungin.\n : Ascites cx and blood cx from growing yeast> changed to\n Micafungin and restarted vanc/zosyn/flagyl pending further culture\n data. Re-sited CVL and changed A-line over wire. Increased ascites\n repletion to 1cc:1cc. Transient decreases in UOP and SBP responded to\n fluid boluses initially> started on Neo gtt overnight for hypotension.\n : Hypotension requiring progressive increases in Neo drip.\n Albumin bolus x1. ID consulted. Aline replaced.\n : Switched to Dilaudid for pain. Following cx were negative: UA,\n peritoneal fluid, and aline tip.\n : C/o of intermittent LLQ pain, given small doses of Dilaudid with\n some improvement. 1U PRBCs. Weaning Neo gtt.\n : Stool cx sent. Prn albumin for hypotension\n : Bld cx sent. Lateral JP removed.\n : Abdominal US.\n : CT pelvis/abdomen. LLE erythemia.\n : PICC placed. CVL removed.\n : Started Regular diet. TF discontinued.\n both j-tubes clamped on calorie count tolerating soft solids 24\n hour urine started\n having loose stools c-diff sent\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient alert and orientated X 3 abd soft + bowel sounds + flatus\n tolerating soft solids having loose stools c/o of some left sided pain.\n Heart rate90-100\ns sinus tach and systolic 90-100\ns over 50\n Action:\n Continue to replace one liter of drain fluid with albumin\n tolerating well Continue with current antibiotics\n Response:\n Patient remains stable\n Plan:\n Transfer to 10 notify team of any changes provide\n comfort and support as needed.\n" }, { "category": "Nursing", "chartdate": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706215, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. MAE. Following commands.\n Abdomen firm and distended. + BS. Loose golden/green BM x3.\n NPO. Novasource\n strength infusing via J-tube. Receiving\n banana flakes every 8 hours. Upper J-tube remains clamped.\n Medial JP with moderate amounts (150-350cc/hr) of ascetic\n drainage. sump with scant amounts of ascetic drainage. Pigtail\n drain putting out 300-400cc every 4 hours with small amounts of blood\n present primarily yellow in coloring.\n Afebrile. HR ST 100-112. No ectopy. BP remains stable with\n MAP >65. WBC . PICC line confirmed by x-ray and CVL removed.\n Pt with mild c/o pain in left thigh around area of\n cellulitis as well as abdominal pain. Pt with hiccups lasting a few\n hours over night.\n Foley patent. Icteric. Clear. Making 25-45cc/hour.\n Action:\n Emptying JP drain hourly replacing output in addition of\n sump output with Albumin for every liter out.\n CVL tip sent for culture.\n Dilaudid given for pain control. Turned and repositioned to\n comfort.\n Response:\n Pt -1.4L at Midnight. Received total of Albumin 12.5g x for\n evening.\n Pain improved after interventions.\n WBC\n Plan:\n Continue to replace JP and sump outputs with Albumin\n for every 1L removed.\n Monitor fluid balance closely.\n Monitor pain/comfort treating as needed.\n F/u culture results.\n Consider unclamping upper J-tube.\n" }, { "category": "Respiratory ", "chartdate": "2164-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703234, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 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: Rusty / 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 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: RSBI done on 0 peep/ 5 ips 47.Pt overbreathing vent may\n consider going to cpap.\n" }, { "category": "Physician ", "chartdate": "2164-11-09 00:00:00.000", "description": "Intensivist Note", "row_id": 706087, "text": "SICU\n HPI:\n POD 23 / 20 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: micafungin (), Meropenum (), Linezolid ()\n PPx: boots, PPI \n TLD: foley, R IJ triple lumen (), PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n .\n Current medications:\n 2. Albumin 25% (12.5g / 50mL) 3. Artificial Tear Ointment 4. Bicitra 5.\n Calcium Gluconate 6. HYDROmorphone (Dilaudid)\n 7. Insulin 8. Linezolid 9. Magnesium Sulfate 10. Meropenem 11.\n Micafungin 12. Midodrine 13. Miconazole Powder 2%\n 14. Ondansetron 15. Pantoprazole 16. Rifaximin 17. Sodium Chloride 0.9%\n Flush 18. Tetracaine HCl\n 24 Hour Events:\n CT abdomen/pelvis: 14 cm subhepatic mixed air and fluid collection\n in the lesser sac, in the setting of recent perforated duodenal ulcer,\n concerning for infected collection. Wall thickening of ascending colon,\n a nonspecific finding\n : LLE erythema concerning for infection, Octreotide and fluid\n replecements d/ced for goal of negative I/O's\n Post operative day:\n POD#23 - ex lap duod ulcer repair\n POD#20 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Micafungin - 03:37 PM\n Linezolid - 12:35 AM\n Meropenem - 06:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:36 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.4\nC (97.6\n HR: 103 (99 - 121) bpm\n BP: 112/53(71) {80/49(61) - 126/65(86)} mmHg\n RR: 27 (15 - 33) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 102.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 2 (2 - 7) mmHg\n Total In:\n 6,729 mL\n 1,551 mL\n PO:\n Tube feeding:\n 2,494 mL\n 867 mL\n IV Fluid:\n 2,771 mL\n 574 mL\n Blood products:\n 200 mL\n 50 mL\n Total out:\n 6,020 mL\n 1,875 mL\n Urine:\n 1,195 mL\n 400 mL\n NG:\n 975 mL\n Stool:\n 350 mL\n Drains:\n 3,500 mL\n 1,475 mL\n Balance:\n 709 mL\n -324 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished\n BS B/L, but CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended, Tender: LLQ\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 102 K/uL\n 10.0 g/dL\n 157 mg/dL\n 3.4 mg/dL\n 14 mEq/L\n 3.4 mEq/L\n 107 mg/dL\n 109 mEq/L\n 138 mEq/L\n 30.0 %\n 20.1 K/uL\n [image002.jpg]\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n WBC\n 12.2\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n Hct\n 27.6\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n Plt\n 156\n 142\n 147\n 121\n 105\n 101\n 102\n Creatinine\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n TCO2\n 12\n 14\n Glucose\n 165\n 183\n 156\n 127\n 115\n 136\n 153\n 157\n Other labs: PT / PTT / INR:26.2/55.6/2.5, ALT / AST:29/59, Alk-Phos / T\n bili:95/18.8, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:3.2 g/dL, LDH:169 IU/L, Ca:8.6 mg/dL,\n Mg:2.0 mg/dL, PO4:5.4 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA,\n BRBPR, GI BLEED, GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n .\n Plan:\n Neuro: Dilaudid PRN pain, awake and following commands\n CVS: HD stable for now, will use albumin for intravascular fluid\n replacement PRN\n PULM: No Issues\n RENAL:\n 1. /CRF/hepatorenal syndrome worsening will continue to\n monitor.\n 2. NS Fluid replacements currently on hold for his ostomy and\n Jtube outputs\n FEN/GI:\n 1. Currently not transplant candidate d/t peritoneal infection.\n 2. TF Novasource Renal\n strength\n 3. Continue ascetic fluid replacement- 1L output with 12.5g\n Albumin.\n 4. Primary team considering drainage of fluid collection in\n lesser sac.\n 5. Rifaximin and Lactulose for hepatic encephalopathy\n 6. Octreotide discontinued for now due to LLE erythema.\n ID:\n 1. Candda glabrata fungemia being treated with Micafungin.\n 2. Peritoneal Fluid with GNR/VRE on Meropenum and Linezolid\n 3. After review of thigh CT scan, lenticular collection along\n fascial plain in left thigh. benefit by exploration. MRI can be\n considered, but will unlikely affect management.\n HEME:\n 1. Hct stable.\n 2. Trending platelets for downward trend, concern for HIT\n awaiting HIT panel\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen (), PIV x1, JP x2, J-tube x2,\n A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Consults: Transplant\n Billing Diagnosis: GI Bleed, Hepatic Failure\n ICU Care\n Nutrition:\n NovaSource Renal () - 06:00 PM 150 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Respiratory ", "chartdate": "2164-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703320, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 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": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706360, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative\n Abdomen firmly distended. Distant BS.\n J-tubes clamped.\n Medial JP/sump/pigtail drain draining moderate amts ascetic\n drainage.\n K 3.0\n Amber urine 30-50 cc/hr.\n Small amts liquid green stool. Guaic positive stools x2.\n Action:\n JP drainage checked q 2\n Albumin given per q 1 liter drain output\n\n cc per cc repletion continued when pt reached 2 liters\n output\n Diet advanced to regular\n K repleted with 60 meq\n TF\ns off\n Renal following-ordered 24 hour urine collection. No\n containers in lab. Will call again tomorrow.\n Dilaudid prn pain\n Response:\n Hemodynamically stable\n Fluid balance=\n K\n Plan:\n Continue\n cc per cc repletion and closely monitor drain\n output.\n Albumin per q liter output\n Continue guaic stools as ordered\n Cont aggressive skin care. ?wound care consult Monday.\n Cont antibiotics as ordered\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706575, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative\n Abdomen firmly distended. +BS. Small amts liquid brown\n stool.\n J-tubes clamped. Tolerating clears.\n Medial JP/sump/pigtail drains draining moderate amts ascitic\n drainage.\n Amber urine 30-60 cc/hr.\n Action:\n JP drainage checked q 2-3 hours\n Albumin given per q 1 liter drain output\n Diet advanced to regular/soft solids\n Renal following-ordered 24 hour urine collection. No\n containers in lab.\n Dilaudid prn pain\n Oob to chair\n Response:\n Hemodynamically stable\n Fluid balance currently even\n Pt tolerating clears/thick liquids\n Plan:\n Continue holding repletion for drain output\n Albumin per q liter output\n Cont follow labs\n Cont aggressive skin care, frequent repositioning. ?wound\n care consult Monday.\n Cont OOB as tolerated/PT/OT consults\n Cont antibiotics as ordered per ID team\n Transfer to floor if pt remains stable\n" }, { "category": "Nursing", "chartdate": "2164-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706795, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt very pleasant and cooperative, A&Ox3\n Abd firm, pos BS, pos flatus and stool\n Pt on calorie count\n Jtube x2 clamped\n Medial JP and sump drain to wall suction, serous acites\n fluid draining in mod amounts\n Pigtail drain in LLQ with serous drainage in small amounts\n Multiple stools, brown loose, guiac pos\n Afebrile\n Skin very excoriated on coccyx and buttocks\n L leg cellulitis improving, pt c/o pain x1\n Pt remains oliguric\n VSS\n Action:\n Dilaudid 0.5mg IV x1\n Abx as ordered\n 24 hr urine collection\n Monitoring drain output\n Pt on fluid restriction\n Albumin 25% 12.5g given for every 1L output of acites\n drainage\n Turn and reposition Q2-3hrs\n \n Cdiff spec sent\n Response:\n Pt expressing adequate pain relief from pain meds\n No change in u/o\n No change in JP outputs\n Pt fluid balance approx 700cc negative as of MN\n Pt remains afebrile\n VSS\n Plan:\n Continue with abx as ordered\n 24 urine collection until 0800 \n Pain management\n PT/OT consults\n Albumin prn\n \n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706194, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Serum K 3.4, Chloride 109, phosphorous 5.4. BUN/CR elevated at 107/3.4\n respectively. Albumin level 3.2. Receiving nova source renal\n strength\n at 150cc/hr. RLQ drain attached to LWS draining moderate amounts and\n JP drain putting out lg amounts of ascetic fluid. Uo icteric and foley\n draining 25-4-cc/hr. HR persistently in low 100s\n and MAP is >60. Pt is\n alert and oriented x 3 and able to converse appropriately.\n Action:\n Renal service consulted for worsening renal function and no repletion\n ordered for K/Phos. Albumin repletion per for every 1L fluid out\n JP. Tube feed rate decreased to 125cc/hr as ordered.\n Response:\n Pt remained hemodynamically stable and neurologically intact. Albumin\n replaced x2.\n Plan:\n Lytes as ordered, note renal service reccs and continue albumin\n replacement as ordered. Observe for arrhythmias, Hemodynamic\n instability or change in neuro assessment. Nutrition following.\n" }, { "category": "Physician ", "chartdate": "2164-11-11 00:00:00.000", "description": "Intensivist Note", "row_id": 706421, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n GI bleed, ascitis\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular Order date: @ 1311 12. Magnesium Sulfate IV Sliding\n Scale Order date: @ 0813\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1736 13. Meropenem 500 mg IV\n Q12H\n Changed according to ID rec Order date: @ 1108\n 3. Albumin 25% (12.5g / 50mL) 12.5 g IV Q2H Duration: 48 Hours\n give 12.5g albumin for each Liter of ascites from drains Order date:\n @ 1024 14. Micafungin 100 mg IV DAILY Order date: @ 0917\n 4. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758 15. Midodrine 7.5 mg PO TID\n via J tube Order date: @ 1216\n 5. Bicitra 15 mL PO/NG TID\n Please give per feeding tube Order date: @ 0758 16. Miconazole\n Powder 2% 1 Appl TP :PRN rash Order date: @ 2239\n 6. Calcium Gluconate IV Sliding Scale Order date: @ 1703 17.\n Ondansetron 4 mg IV Q8H:PRN N/V Order date: @ 0447\n 7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q2H:PRN pain\n please hold for oversedation or rr<8 Order date: @ 1340 18.\n Pantoprazole 40 mg IV Q12H Order date: @ 0946\n 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1736 19.\n Potassium Chloride (Powder) 40 mEq PO/NG Duration: 2 Doses\n Hold for K >3.5 Order date: @ 1308\n 9. IV access request: PICC Place Urgency: Urgent Order date: @\n 1236 20. Rifaximin 400 mg PO TID\n can crush and administer via J-tube per pharmacy Order date: @\n 0919\n 10. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703 21. Sodium Chloride 0.9%\n Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1703\n 11. Linezolid 600 mg IV Q12H Order date: @ 1211\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n 52 cm.\n MULTI LUMEN - STOP 09:35 PM\n :Started on regular diet/ meropenem switched from q6h to q12h by\n ID\n Post operative day:\n POD#25 - ex lap duod ulcer repair\n POD#22 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:31 PM\n Meropenem - 12:02 AM\n Linezolid - 12:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:02 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 03:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.2\n T current: 36\nC (96.8\n HR: 91 (84 - 117) bpm\n BP: 94/55(68) {94/53(68) - 139/70(92)} mmHg\n RR: 17 (16 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.1 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 5,759 mL\n 1,021 mL\n PO:\n 2,080 mL\n 500 mL\n Tube feeding:\n 1,007 mL\n IV Fluid:\n 2,282 mL\n 521 mL\n Blood products:\n 150 mL\n Total out:\n 5,304 mL\n 427 mL\n Urine:\n 804 mL\n 127 mL\n NG:\n Stool:\n Drains:\n 4,500 mL\n 300 mL\n Balance:\n 455 mL\n 594 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: 7.42/18/123/14/-9\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended, Appropriately tender\n Left Extremities: (Edema: No(t) Trace), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 120 K/uL\n 9.8 g/dL\n 92 mg/dL\n 3.0 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 115 mg/dL\n 102 mEq/L\n 129 mEq/L\n 28.5 %\n 20.2 K/uL\n [image002.jpg]\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n WBC\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n Hct\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n Plt\n 142\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n Creatinine\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n TCO2\n 12\n Glucose\n 183\n 156\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n Other labs: PT / PTT / INR:22.7/55.4/2.1, ALT / AST:45/106, Alk-Phos /\n T bili:92/18.4, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:169 IU/L, Ca:8.8 mg/dL,\n Mg:1.7 mg/dL, PO4:6.6 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia, S/P IR\n drainage of fluid collection\n Neurologic: Neuro: A & O X3, Q4H neurochek, Dilaudid prn\n Cardiovascular: Hemodynamically stable will use albumin for\n intravascular fluid replacement\n Pulmonary: Sats good on RA\n Gastrointestinal / Abdomen: Currently not transplant candidate d/t\n peritoneal infection. protonix 40\", TF stopped beacuse tolerating\n regular diet very well. Rifaximin & lactulose for hepatic\n encephalopathy. s/p IR perc drain for abdominal collection \n Nutrition: Regular diet\n Renal: /CRF/hepatorenal syndrome worsening, will continue to\n monitor, replacements currently on hold for his ostomy and Jtube\n outputs, Creatinine improving but BUN increasing we will follow the\n trend, JP ascitic replacements held up until 1-2 L negative. will\n restart when -2L WITH 0.5 CC/1CC.\n Hematology: Serial Hct, Hct stable. Trending platelets for downward\n trend, concern for HIT awaiting HIT panel\n Endocrine: RISS\n Infectious Disease: Check cultures, Being treated for Candda glabrata\n fungemia as well as peritonitis along with VRE with Micafungin,\n Meropenem and Linezolid, leukocytosis\n Lines / Tubes / Drains: PICC placed foley, PIV x1, JP x2, J-tube x2,\n A-line\n Wounds:\n Imaging:\n Fluids:\n Consults: Transplant, ID dept, Nephrology\n Billing Diagnosis: Sepsis, Peritonitis, Liver failure, Acute renal\n failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:20 PM\n PICC Line - 07:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to the floor\n Total time spent: 30 minutes\n" }, { "category": "Respiratory ", "chartdate": "2164-10-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702157, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Tube Type\n 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: 26 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: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2164-10-20 00:00:00.000", "description": "Intensivist Note", "row_id": 702625, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n Fluconazole\n Octreotide gtt\n Pantoprazole gtt\n Cisatra\n Zosyn\n ISS\n 24 Hour Events:\n On phenylephrine, given albumin.Planning on going back to OR on .\n 3 units FFP given prior to removal of femoral sheath by IR.Renal\n consulted, FeNa<0.1. Rec replacing drain loss cc per cc. No need for HD\n at this time.\n : Ca repletion.\n SHEATH - STOP 07:02 PM\n Post operative day:\n POD#3 - ex lap duod ulcer repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Vancomycin - 08:00 PM\n Fluconazole - 10:55 PM\n Piperacillin - 04:17 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Octreotide - 50 mcg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Propofol - 50 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.1\nC (97\n HR: 80 (77 - 96) bpm\n BP: 114/64(79) {66/40(48) - 134/70(92)} mmHg\n RR: 18 (18 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.6 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 15 (5 - 214) mmHg\n Total In:\n 7,262 mL\n 1,762 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,355 mL\n 1,762 mL\n Blood products:\n 908 mL\n Total out:\n 5,414 mL\n 1,560 mL\n Urine:\n 439 mL\n 185 mL\n NG:\n 150 mL\n 275 mL\n Stool:\n Drains:\n 4,825 mL\n 1,100 mL\n Balance:\n 1,848 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 650) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SPO2: 98%\n ABG: 7.43/27/107/19/-4\n Ve: 10.9 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress\n HEENT: Icteric sclera\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: decreased BS on R base\n Abdominal: No(t) Non-distended, Distended\n Left Extremities: (Edema: No(t) 1+, 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 72 K/uL\n 10.6 g/dL\n 138 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.0 %\n 13.6 K/uL\n [image002.jpg]\n 06:14 AM\n 08:37 AM\n 08:53 AM\n 11:08 AM\n 02:07 PM\n 02:14 PM\n 07:51 PM\n 12:00 AM\n 12:45 AM\n 02:48 AM\n WBC\n 15.7\n 17.3\n 14.2\n 12.2\n 13.2\n 13.6\n Hct\n 31.5\n 31.6\n 29.8\n 28.6\n 27.9\n 30.0\n Plt\n 92\n 108\n 86\n 71\n 69\n 72\n Creatinine\n 2.4\n 2.5\n 2.6\n 2.6\n TCO2\n 19\n 19\n 20\n 19\n Glucose\n 140\n 140\n 133\n 138\n Other labs: PT / PTT / INR:18.5/41.2/1.7, ALT / AST:22/45, Alk-Phos / T\n bili:57/6.9, Amylase / Lipase:58/81, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:187 mg/dL, Lactic\n Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:199 IU/L, Ca:7.8 mg/dL, Mg:1.8\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, INEFFECTIVE\n COPING, GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n Neurologic: Intubated and sedated propofol gtt, fentanyl gtt,\n paralyzed with cisatracurium\n Cardiovascular: On neo gtt; albumin boluses as needed\n Pulmonary: intubated and sedated, paralyzed. Watch for . Vent\n setting to inverse I:E\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt. follow\n LFTs q 6 hours, likely pancreatitis superimposed\n Nutrition: NPO\n Renal: Foley, Foley, follow UOP, follow lytes; replacing ascites drain\n output 1 to 1 with D51/2 NS with 50 of Bicarb. Hx of hepatorenal\n syndrome, renal following. No HD at this time\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: renal following. No HD at this time\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds:\n Imaging: CXR today\n Fluids: Other, fluid repletion per renal recs\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2164-11-12 00:00:00.000", "description": "Intensivist Note", "row_id": 706624, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis c/b esophageal and rectal varices with prior\n episodes of bleeding admitted with painless BRBPR and hypotension, s/p\n ex lap, gastrotomy, duodenotomy with suturing of bleeding vessel,\n draining jejunostomy, now with fungemia, S/P IR drainage of fluid\n collection, resolving acute on chronic renal failure\n Chief complaint:\n managment of hemodynamics/infection in setting of massive GI bleed and\n liver failure\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n RISS, Linezolid. Magnesium Sulfate IV Sliding Meropenem, Albumin 25%,\n Midodrine . Miconazole Powder , Calcium Gluconate IV Sliding Scale .\n Dilaudid. Pantoprazole\n 24 Hour Events:\n - stable no issues\n Post operative day:\n POD#26 - ex lap duod ulcer repair\n POD#23 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:00 PM\n Meropenem - 12:12 AM\n Linezolid - 12:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 AM\n Hydromorphone (Dilaudid) - 02:00 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: 36.2\nC (97.1\n T current: 35.9\nC (96.7\n HR: 81 (78 - 96) bpm\n BP: 110/56(72) {96/53(68) - 127/65(86)} mmHg\n RR: 20 (13 - 23) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.8 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 2,848 mL\n 1,051 mL\n PO:\n 1,340 mL\n 480 mL\n Tube feeding:\n IV Fluid:\n 1,168 mL\n 461 mL\n Blood products:\n 100 mL\n 50 mL\n Total out:\n 3,797 mL\n 865 mL\n Urine:\n 1,077 mL\n 260 mL\n NG:\n 400 mL\n Stool:\n Drains:\n 2,320 mL\n 605 mL\n Balance:\n -949 mL\n 186 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases)\n Abdominal: Distended, Tender: mild diffuse tenderness\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), drains in place\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 115 K/uL\n 9.8 g/dL\n 86 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.9 mEq/L\n 112 mg/dL\n 99 mEq/L\n 127 mEq/L\n 28.4 %\n 22.4 K/uL\n [image002.jpg]\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n 03:00 AM\n WBC\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n 22.4\n Hct\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n 28.4\n Plt\n 142\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n 115\n Creatinine\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n 3.2\n TCO2\n 12\n Glucose\n 156\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n 86\n Other labs: PT / PTT / INR:21.5/52.3/2.0, ALT / AST:46/115, Alk-Phos /\n T bili:92/19.8, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:2.9 g/dL, LDH:169 IU/L, Ca:8.6 mg/dL,\n Mg:1.8 mg/dL, PO4:7.5 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia, S/P IR drainage of fluid collection\n .\n Plan: Neuro: Q4H neurochek, Dilaudid prn, A & O X3\n CVS: Hemodynamically stable will use albumin for intravascular fluid\n replacement\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal improving cr, will continue to monitor,\n replacements currently on hold for his ostomy and Jtube outputs\n FEN/GI: tolerating po Currently not transplant candidate d/t peritoneal\n infection. protonix 40\", TF changed renal impact with fiber \n strenght . Rifaximin & lactulose for hepatic encephalopathy. s/p IR\n perc drain for abdominal collection \n ID: Being treated for Candda glabrata fungemia as well as peritonitis\n along with VRE with Micafungin, Meropenem and Linezolid, leukocytosis\n HEME: Hct stable, plt stable HIT pending JP ascitic replacements held\n up until 1-2 L negative. will restart when -2L WITH 0.5 CC/1CC.\n ENDO: RISS\n Psych: s/p consult\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: to floor\n Total time spent: 30 min\n" }, { "category": "Nursing", "chartdate": "2164-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 706871, "text": "HPI: 52M with ETOH cirrhosis c/b esophageal and rectal varices. Prior\n episodes of bleeding admit with painless BRBPR and hypotension.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm >> to OR for ex-lap for duodenal arterial bleed. (EBL\n 8L. 12U PRBC. 12U FFP. 3 6-packs of platelets. neo vasopressin\n Intraop).\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis . Duodenal ulcer. Internal hemorrhoids. s/p\n bilateral knee replacements\n .\n SICU course significant events:\n : On Neo. Given albumin. 3units FFP given prior to removal of\n femoral sheath by IR. Rec replacing drain loss cc:cc. No need for HD at\n this time.\n : OR for closure of abdominal wound. Right femoral art line pulled\n s/p blood products.\n : Droppped BP to 50s in AM, noted bloody stool >> given 2U PRBCs\n and increased Neo gtt to 4 >>SBP increased to 110s. At same time desat\n to 70%s on CPAP >> FiO2 inc to 100% and CXR revealed diffuse opacity of\n L lung consistent with mucus plug. Bedside bronch to remove thick mucus\n plug, O2 sats recovered to high 90%s, vent weaned back to 50% FiO2.\n : Rigors. Afebrile. Recultured. EEG performed, results pending.\n : Removed L femoral without complication. Vit K x 1 dose.\n : Weaned vent to min settings. High output around JP drains.\n Ascities replacement schedule adjusted.\n : Continued high JP output. Intermittent fluid boluses throughout\n day with LR as needed for BP / UOP.\n : Extubated. Continuing goal of fluid status being 2 liters\n negative.\n : Stable. Trauma line pulled. Started Caspiofungin.\n : Ascites cx and blood cx from growing yeast> changed to\n Micafungin and restarted vanc/zosyn/flagyl pending further culture\n data. Re-sited CVL and changed A-line over wire. Increased ascites\n repletion to 1cc:1cc. Transient decreases in UOP and SBP responded to\n fluid boluses initially> started on Neo gtt overnight for hypotension.\n : Hypotension requiring progressive increases in Neo drip.\n Albumin bolus x1. ID consulted. Aline replaced.\n : Switched to Dilaudid for pain. Following cx were negative: UA,\n peritoneal fluid, and aline tip.\n : C/o of intermittent LLQ pain, given small doses of Dilaudid with\n some improvement. 1U PRBCs. Weaning Neo gtt.\n : Stool cx sent. Prn albumin for hypotension\n : Bld cx sent. Lateral JP removed.\n : Abdominal US.\n : CT pelvis/abdomen. LLE erythemia.\n : PICC placed. CVL removed.\n : Started Regular diet. TF discontinued.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702622, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient has a open abdomen\n Hct 27.9-30\n Patient intubated and paralyzed. Patient on cistacurium\n Action:\n Response:\n Hct drawn q6hrs goal 28 hct 27.9-30\n Plan:\n Monitor vital signs closely titrate neo gtt\n Continue to monitor the fentanyl,propofol and cistacurium gtts\n Monitor labs hcts q4-6hrs\n Monitor abd drainage\n Cc/cc repletion\n Monitor urine output and creatinine\n Continue with protonix and octreotide gtts\n To or today to have abdomen closed.\n Impaired Physical Mobility\n Assessment:\n Patient is unresponsive\n Patient is on cistacurium,fentanyl and propofol gtts\n Pupils #2 bilaterally and reacts briskly\n Patient is intubated and presently on cmv mode 60%-600-18 and 5 peep.\n Action:\n Turned from side to side q2-3 hrs but only slighltly due drop in bp\n Skin checked for redness.\n Range of motion done while being washed.\n Multipodus boots on to prevent foot drop\n Response:\n While being turned slightly , patient\ns bp drops\n Neo gtt infusing and being titrated to keep bp > 100syst.\n Plan:\n Continue to check skin\n Continue with total care regimen\n Patient to be transferred to a tyradyne bed after the or today.\n" }, { "category": "Nursing", "chartdate": "2164-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702780, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Returned from the or at 1700.\n Remains intubated and suctioned for scant amt white sputum\n Remains on cmv 60%-600-16-5\n Abd closed with transparent dsg intact .some visable bloody drainage\n noted.\n Jp medial and lateral intact and draining serous- pink serous\n drainage. Amt of drainage via jp decreased over the nite.\n Jejunostomy tubes to gravity and draining bilious drainage.\n Remains on neo gtt and titrated for map > 65\n Protonix gtt infusing,\n Ngt intact with bloody drainage present/ DONOT IRRIGATE md team.\n Fentanyl, propofol and octreotide gtt infusing.\n Urine output 20-45 ccq1hrs. urine dark amber in color.\n Hct 33.9 bun 55, creat 2.9 lactate 3.2 ionized calicium1.11\n Action:\n Suctioned prn\n Tyrndyne bed with rotation\n Labs prn\n Ngt to lcws .\n Continues on propofol, protonix , fentanyl and neo gtts.\n Jp medial and lateral drainage being repleted for 1/2cc/cc..\n On iv pipercillin and fluconazole\n Response:\n Remains on propofol, fentanyl, neo and octreitide gtts.\n Hct 33.9 today\n Wbc elevated 19.9\n Lactate acid up to 3.2 today\n Aline dampens easily and requires frequently adjusting\n Bp via cuff > 90\n Plan:\n Monitor condition closely\n Update family on patient\ns condition.\n 0545 am dropped o2sat down to the 80\ns down to 79. bp dropped to the\n low 80\ns. bed rotating . suctioned for scant amt of sputum. Bp and sat\n slowly up to 90\n 0610 am dropped o2sat to the 80;s bp 80 70\ns abg\ns drawn\n 7.37-30-49-18- -6 neo increased tto 4.5 mcg, placed on 100% via\n ventilator sicu team present in room\n" }, { "category": "Physician ", "chartdate": "2164-11-13 00:00:00.000", "description": "Intensivist Note", "row_id": 706790, "text": "SICU\n HPI:\n POD 27 / 24 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: micafungin (), Meropenum (), Linezolid ()\n PPx: boots, PPI \n TLD: foley, R IJ triple lumen (), PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis\n Current medications:\n Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5. Bicitra 6.\n Calcium Gluconate\n 7. HYDROmorphone (Dilaudid) 8. HYDROmorphone (Dilaudid) 9. Heparin\n Flush (10 units/ml) 10. 11. Insulin\n 12. Linezolid 13. Magnesium Sulfate 14. Meropenem 15. Micafungin 16.\n Miconazole Powder 2% 17. Ondansetron\n 18. Pantoprazole 19. Rifaximin 20. Sodium Bicarbonate\n 24 Hour Events:\n NASAL SWAB - At 09:00 AM\n ARTERIAL LINE - STOP 07:00 PM\n Post operative day:\n POD#27 - ex lap duod ulcer repair\n POD#24 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:00 PM\n Meropenem - 10:00 PM\n Linezolid - 12:32 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 09:29 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.5\nC (97.7\n HR: 95 (84 - 107) bpm\n BP: 97/54(64) {97/54(64) - 112/69(88)} mmHg\n RR: 20 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.8 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 3,124 mL\n 465 mL\n PO:\n 1,524 mL\n 120 mL\n Tube feeding:\n 230 mL\n IV Fluid:\n 1,150 mL\n 345 mL\n Blood products:\n 100 mL\n Total out:\n 3,855 mL\n 305 mL\n Urine:\n 920 mL\n 105 mL\n NG:\n Stool:\n Drains:\n 2,935 mL\n 200 mL\n Balance:\n -731 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\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:\n Diminished: bilateral lung base), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 122 K/uL\n 9.5 g/dL\n 122 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.3 mEq/L\n 119 mg/dL\n 99 mEq/L\n 129 mEq/L\n 28.6 %\n 21.6 K/uL\n [image002.jpg]\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n 03:00 AM\n 03:25 AM\n WBC\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n 22.4\n 21.6\n Hct\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n 28.4\n 28.6\n Plt\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n 115\n 122\n Creatinine\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n 3.2\n TCO2\n 12\n Glucose\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n 86\n 122\n Other labs: PT / PTT / INR:20.9/49.6/1.9, ALT / AST:47/116, Alk-Phos /\n T bili:112/21.7, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:2.9 g/dL, LDH:169 IU/L, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:7.8 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia, S/P IR drainage of abdmoninal fluid collection\n .\n Plan:\n Neuro: alert and oriented, stable for past 24 hours, Dilaudid prn\n CVS: Hemodynamically stable, hasnt required any fluid/pressor support\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal, cr has plateaued for now around 3.0, will\n continue to monitor, replacements currently on hold for his ostomy and\n Jtube outputs, will monitor his hyponateremia and address with Sodium\n bicarbonate via J tube\n GI: tolerating po, encouraging more PO intake. Currently not transplant\n candidate d/t peritoneal infection. protonix 40\", currently on\n Rifaximin for hepatic encephalopathy\n ID: WBC trending upwards to 21.6, currently being treated for \n fungemia as well as peritonitis along with VRE with\n Micafungin, Meropenem and Linezolid,. Will consider discontinuing\n micafungin 2 weeks after negative cultures.\n HEME: Hct stable, plt stable\n ENDO: RISS for strict glycemic control\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: to floor\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 07:00 PM\n Prophylaxis:\n DVT: Boots (not indicated)\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: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2164-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702406, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains paralyzed and sedated\n Abd remains open, multiple drains to wall suction, copious\n amounts of serosang drainage\n NGT to LCS, sump port backing up frequently, bloody drainage\n J tube to LCS, min amounts bilious drainage\n MAP 65-70, SBP 90-112\n Plt 77\n Hct stable, coags stable\n Remains on CMV 60% FiO2, PEEP 5, TV 500, R 20\n Abg at start of shift 7.34/40/79/-\n LS clear, diminished at bases\n Remains oliguric, u/o 10-20cc/hr\n Cr 2.2\n Pt wgt up 14kg\n Lactate 2.7\n Action:\n Octreotide and protonix gtt\n NGT flushed by MD\ns x3\n Neo gtt to keep MAP >65\n Fluid bolus x1\n Received Plts x1\n 1/2cc:cc repletion for wound output\n Tidal volume increased to 650 from 500 MD despite\n conversation about increasing PEEP or FiO2\n Response:\n Plt 114, 104\n Able to slowly wean neo gtt\n Abg worsening to 7.41-7.43/29-31/67-73/-, MD ,\n MD , and MD Concchi notified, discussed with chief on transplant\n team, no changes made to vent settings, despite voicing concerns.\n Monitoring abg\ns closely\n Cr 2.4\n Lactate up to 3.8\n Hct and coags remain stable\n Plan:\n Monitor abg\ns closely, discuss vent setting in rounds this\n AM with attendings present\n Monitor outputs\n Continue with 1/2cc:cc repletion\n Monitor labs\n Monitor NGT\n Wean neo as tolerated\n OR or for abd closure\n Keep pt sedated and paralyzed\n Provide pt and family with emotional support\n" }, { "category": "Respiratory ", "chartdate": "2164-10-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702724, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Diagnostic lab\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / 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 went to OR for abdominal closure back in unit and placed back\n on vent. Has periods of desaturation, suctioned without secretion. FI02\n increased to 70% I.T is 1.5 for better recruitment of alveoli; if\n sedation is withdrawn fine turning parameters on vent.\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706408, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. Pleasant in conversation and cooperative in\n care.\n Abdomen firm/distended. + BS. + flatulus. TF continue to be\n off with J-tubes clamped. Tolerating Pos well. Small green loose BM x1.\n Medial JP/sump/pigtail drains with scant to small amounts of\n ascetic drainage.\n Foley patent. Amber clear urine 20-50cc/hr.\n Pt with c/o mild abdominal and left leg pain.\n Afebrile. VSS. WBC 19.5\n Action:\n JP/sump drainage monitored every 2 hours and replacing with\n LR\n c:cc over 2 hours. Albumin administered for every 1L drain output.\n Giving Dilaudid as needed for pain. Turning/repositioning to\n comfort.\n Receiving IV antibiotics as ordered.\n Response:\n Hemodynamically remains stable.\n Pt +400 at MN. Dr aware.\n Pt with adequate pain relief.\n WBC\n Plan:\n Continue with\n cc:cc repletions and closely monitor drain\n output. Administer Albumin when 1L drainage out from JP/Sump.\n Monitor labs and treat as needed.\n Maintain skin integrity and cont aggressive skin care.\n Consider wound consult on Monday.\n F/u with Renal as to 24hr urine collection.\n" }, { "category": "Nursing", "chartdate": "2164-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702338, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt is POD#1 s/p exploratory lap for duodenal bleed with EBL 8000\n replaced with 12 units PRBC, 12 units FFP, plts 3 units , cellsaver\n 250ml, crystaolloids 1000ml. Pt received as follows\n -pt unresponsive on propofol, fentynal and cisatracurium for sedation,\n pain and paralytic. PERRLA, no movement to command, TOF no twitches.\n -pt in SR no ectopics, SBP88-100 MAP 62-75, CVP 9-12, PPV 5\n -ET-Tube to vent FIO@ 60%, CMV 20, PEEP 5, TV 500, bilateral breath\n sounds clear to auscultation.\n No secretions when suctioned.\n -GI-Abd open JPdrain draining large am\nt of serosang drg. Second JP\n draining ) will not stay compressed as is\n asurface drain. 3^rd drain also a surface drain. Replacing this 3^rd\n drain\n cc/cc with D51/2 NS with 50meq\n Na bicarb\n Protonix and octreotide drips infusing\n -J-tube to 20cm intermittent wall suction draining bilious in scant\n am\n -NGT to lcws draining BRB in small am\nts. Lab will not run PH of\n gastric contents due to viscosity of specimen.\n -Foley to BSD draining concentrated yellow urine. u/o decreased to zero\n x 2 hrs.\n -HCT 36.7 WBC up to 15.6, PT 18, PTT 40.2 , INR 1.5 Magnesium 1.5,\n lactic acid 2.2 ABGs 7.33, 41, 80, 23\n -4, blood sugars 131-148.\n -pt high risk to bleed given coags INR and open abd s/p ulcer repair\n -Skin right lateral abd skin with small yellowish blisters found\n beneath previous dsg.\n Action:\n Labs q 6 hrs due at 2100\n Cisatracurium titrated down to .06\n Fentynal and propofol doses unchanged.\n Neo as high as 3mcg/kg/min to maintain MAP>65\n Protonix and octreotide gtt doses unchanged.\n Surface drains place right and left lateral abd skin to control\n leakage and maintain dry skin (by -CNS)\n Pt\ns pads changed q 2hrs and skin massaged q2hrs. pt tilted slightly to\n do this.\n Bed in reverse trendlenberg 30 degrees.\n Albumin 25%(500ml) given for low uop.\n Response:\n Fairly stable on neo 2mcg/kg/min\n LOC, paralyzed, sedated and pain treated. VSS on current doses of\n propofol, cisatraurium and fentynal\n No major only residual blood from GI tract, HCT stable at 36.7.\n Skin clean and dry.\n Slight increase in uop.\n Plan:\n OR Saturday per Dr .\n Maintain skin Integrity\n Prevent bleeding\n VAP protocol\n Prevent infection use aseptic techniques with all lines\n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702610, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Patient is unresponsive\n Patient is on cistacurium,fentanyl and propofol gtts\n Pupils #2 bilaterally and reacts briskly\n Patient is intubated and presently on cmv mode 60%-600-18 and 5 peep.\n Action:\n Turned from side to side q2-3 hrs but only slighltly due drop in bp\n Skin checked for redness.\n Range of motion done while being washed.\n Multipodus boots on to prevent foot drop\n Response:\n While being turned slightly , patient\ns bp drops\n Neo gtt infusing and being titrated to keep bp > 100syst.\n Plan:\n Continue to check skin\n Continue with total care regimen\n Patient to be transferred to a tyradyne bed after the or today.\n" }, { "category": "Nursing", "chartdate": "2164-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702401, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains paralyzed and sedated\n Abd remains open, multiple drains to wall suction, copious\n amounts of serosang drainage\n NGT to LCS, sump port backing up frequently, bloody drainage\n J tube to LCS, min amounts bilious drainage\n MAP 65-70, SBP 90-112\n Plt 77\n Hct stable, coags stable\n Remains on CMV 60% FiO2, PEEP 5, TV 500, R 20\n Abg at start of shift 7.34/40/79/-\n LS clear, diminished at bases\n Remains oliguric, u/o 10-20cc/hr\n Cr 2.2\n Pt wgt up 14kg\n Lactate 2.7\n Action:\n Octreotide and protonix gtt\n NGT flushed by MD\ns x3\n Neo gtt to keep MAP >65\n Fluid bolus x1\n Received Plts x1\n 1/2cc:cc repletion for wound output\n Tidal volume increased to 650 from 500 MD despite\n conversation about increasing PEEP or FiO2\n Response:\n Plt 114, 104\n Able to slowly wean neo gtt\n Abg worsening to 7.41-7.43/29-31/67-73/-, MD ,\n MD , and MD Concchi notified, discussed with chief on transplant\n team, no changes made to vent settings, despite voicing concerns.\n Monitoring abg\ns closely\n Cr 2.4\n Lactate up to 3.8\n Hct and coags remain stable\n Plan:\n Monitor abg\ns closely, discuss vent setting in rounds this\n AM with attendings present\n Monitor outputs\n Continue with 1/2cc:cc repletion\n Monitor labs\n Wean neo as tolerated\n OR or for abd closure\n Keep pt sedated and paralyzed\n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702605, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702862, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n ~ 0730 this morning, O2 Sats quickly dropped to 70\n Hypotensive to SBP 60\n No air exchange auscultated right lung\n Peak airway pressures elevated to 36\n ABG showing PaO2 in 40\n X-ray done prior to rounds @ 0500 showed no signs of right\n lung collapse\n Action:\n Neo gtt increased to 5 mcg/kg/min\n Ambu by respiratory therapist\n Chest x-ray done showing right lung no air exchange\n Bronchoscopy done, suctioned for thick, tenatous secretions\n Bronchial lavage specimens sent for culture\n FIO2 increased to 100%\n Bed rotation continuously for optimal lung health\n HOB in reverse T- as patient will tolerate\n VAP protocol\n Protonix gtt\n Response:\n Blood pressure improved to goal MAP >65\n O2 sats improved to low 90\n Follow up chest x-ray showing effective aeration of right\n and left lung fields\n Initial ABG showing improvement with a compensated metabolic\n acidosis 7.40, 29, 78, -4, 19 and improved but not optimal\n oxygenation. One amp of Sodium Bicarb given, fluid given,.\n Most recent ABG showing a respiratory alkalosis with 7.46,\n 29, 78, -4, 19.\n Plan:\n Respiratory rate decreased to 16 from 18\n FIo2 decreased to 70% from 80%\n Continue to closely monitor respiratory status\n Repeat ABG\ns as needed.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n At the same time as above respiratory episode, patient noted\n to have melanous stool around flexiseal.\n Prior HCT was 31\n No tachycardia or other S+S of acute bleeding, other than\n the hypotension and events noted above.\n Bladder pressure 16\n Both Jejunostomy tubes to gravity drainage with bilious\n drainage (these drains are the closest drains to the duodenal ulcer\n that had bled prior to the last surgery).\n Ionized calcium continues to run low\n Action:\n 2 units PRBC\n One liter LR fluid bolus\n Neo gtt increased to 5 mcg/kg/min\n Patient cleaned and flexiseal irrigated\n Albumin q 8 hours x 3 doses\n D51/2 ns @ 100 cc maintenance, assist with preventing\n hypoglycemia as well\n CC per CC fluid replacement from JP drain output with Normal\n Saline\n Calcium gluconate x 2 this shift\n Protonix and octreotide gtts continue\n Fentanyl gtt for pain control\n Propofol gtt decreased to 40 however due to instability was\n not weaned further\n Renal consulted, urine electrolytes sent\n Response:\n Repeat HCT 34.5\n Continues to have\n melanous stool from rectum\n Impression is that patient is not actively bleeding, and\n that the episode was precipitated by a mucous plug and hypoxia, not\n acute blood loss\n Neo attempted to wean several times unsuccessfully, will\n continue to attempt to wean\n Fluid balance MN\n 1700 even\n Plan:\n Wean Neo for goal MAP >65\n Repeat labs, electrolytes, and follow HCT. Replace\n electrolytes as needed.\n Patient and family support\n Social work consult as patient\ns wife is in need of their\n services.\n" }, { "category": "Physician ", "chartdate": "2164-11-11 00:00:00.000", "description": "Intensivist Note", "row_id": 706486, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n GI bleed, ascitis\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular Order date: @ 1311 12. Magnesium Sulfate IV Sliding\n Scale Order date: @ 0813\n 2. IV access: PICC, heparin dependent Location: Left basilic, Date\n inserted: Order date: @ 1736 13. Meropenem 500 mg IV\n Q12H\n Changed according to ID rec Order date: @ 1108\n 3. Albumin 25% (12.5g / 50mL) 12.5 g IV Q2H Duration: 48 Hours\n give 12.5g albumin for each Liter of ascites from drains Order date:\n @ 1024 14. Micafungin 100 mg IV DAILY Order date: @ 0917\n 4. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes Order date:\n @ 0758 15. Midodrine 7.5 mg PO TID\n via J tube Order date: @ 1216\n 5. Bicitra 15 mL PO/NG TID\n Please give per feeding tube Order date: @ 0758 16. Miconazole\n Powder 2% 1 Appl TP :PRN rash Order date: @ 2239\n 6. Calcium Gluconate IV Sliding Scale Order date: @ 1703 17.\n Ondansetron 4 mg IV Q8H:PRN N/V Order date: @ 0447\n 7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q2H:PRN pain\n please hold for oversedation or rr<8 Order date: @ 1340 18.\n Pantoprazole 40 mg IV Q12H Order date: @ 0946\n 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1736 19.\n Potassium Chloride (Powder) 40 mEq PO/NG Duration: 2 Doses\n Hold for K >3.5 Order date: @ 1308\n 9. IV access request: PICC Place Urgency: Urgent Order date: @\n 1236 20. Rifaximin 400 mg PO TID\n can crush and administer via J-tube per pharmacy Order date: @\n 0919\n 10. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703 21. Sodium Chloride 0.9%\n Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1703\n 11. Linezolid 600 mg IV Q12H Order date: @ 1211\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n 52 cm.\n MULTI LUMEN - STOP 09:35 PM\n :Started on regular diet/ meropenem switched from q6h to q12h by\n ID\n Post operative day:\n POD#25 - ex lap duod ulcer repair\n POD#22 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 02:31 PM\n Meropenem - 12:02 AM\n Linezolid - 12:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:02 AM\n Hydromorphone (Dilaudid) - 12:02 AM\n Other medications:\n Flowsheet Data as of 03:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.2\n T current: 36\nC (96.8\n HR: 91 (84 - 117) bpm\n BP: 94/55(68) {94/53(68) - 139/70(92)} mmHg\n RR: 17 (16 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.1 kg (admission): 98.2 kg\n Height: 73 Inch\n Total In:\n 5,759 mL\n 1,021 mL\n PO:\n 2,080 mL\n 500 mL\n Tube feeding:\n 1,007 mL\n IV Fluid:\n 2,282 mL\n 521 mL\n Blood products:\n 150 mL\n Total out:\n 5,304 mL\n 427 mL\n Urine:\n 804 mL\n 127 mL\n NG:\n Stool:\n Drains:\n 4,500 mL\n 300 mL\n Balance:\n 455 mL\n 594 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: 7.42/18/123/14/-9\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Distended, Appropriately tender\n Left Extremities: (Edema: No(t) Trace), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 120 K/uL\n 9.8 g/dL\n 92 mg/dL\n 3.0 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 115 mg/dL\n 102 mEq/L\n 129 mEq/L\n 28.5 %\n 20.2 K/uL\n [image002.jpg]\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n 08:35 PM\n 01:53 AM\n WBC\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n 20.2\n Hct\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n 28.5\n Plt\n 142\n 147\n 121\n 105\n 101\n 102\n 118\n 120\n Creatinine\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n 3.0\n TCO2\n 12\n Glucose\n 183\n 156\n 127\n 115\n 136\n 153\n 157\n 163\n 92\n Other labs: PT / PTT / INR:22.7/55.4/2.1, ALT / AST:45/106, Alk-Phos /\n T bili:92/18.4, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:169 IU/L, Ca:8.8 mg/dL,\n Mg:1.7 mg/dL, PO4:6.6 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia, S/P IR\n drainage of fluid collection\n Neurologic: Neuro: A & O X3, Q4H neurochek, Dilaudid prn\n Cardiovascular: Hemodynamically stable will use albumin for\n intravascular fluid replacement\n Pulmonary: Sats good on RA\n Gastrointestinal / Abdomen: Currently not transplant candidate d/t\n peritoneal infection. protonix 40\", TF stopped beacuse tolerating\n regular diet very well. Rifaximin & lactulose for hepatic\n encephalopathy. s/p IR perc drain for abdominal collection \n Nutrition: Regular diet\n Renal: /CRF/hepatorenal syndrome worsening, will continue to\n monitor, replacements currently on hold for his ostomy and Jtube\n outputs, Creatinine improving but BUN increasing we will follow the\n trend, JP ascitic replacements held up until 1-2 L negative. will\n restart when -2L WITH 0.5 CC/1CC.\n Hematology: Serial Hct, Hct stable. Trending platelets for downward\n trend, concern for HIT awaiting HIT panel\n Endocrine: RISS\n Infectious Disease: Check cultures, Being treated for Candda glabrata\n fungemia as well as peritonitis along with VRE with Micafungin,\n Meropenem and Linezolid, leukocytosis\n Lines / Tubes / Drains: PICC placed foley, PIV x1, JP x2, J-tube x2,\n A-line\n Wounds:\n Imaging:\n Fluids:\n Consults: Transplant, ID dept, Nephrology\n Billing Diagnosis: Sepsis, Peritonitis, Liver failure, Acute renal\n failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:20 PM\n PICC Line - 07:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Could be transferred to the floor\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 706590, "text": "TITLE:\n HPI: 52M with ETOH cirrhosis c/b esophageal and rectal varices. Prior\n episodes of bleeding admit with painless BRBPR and hypotension.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm >> to OR for ex-lap for duodenal arterial bleed. (EBL\n 8L. 12U PRBC. 12U FFP. 3 6-packs of platelets. neo vasopressin\n Intraop).\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis . Duodenal ulcer. Internal hemorrhoids. s/p\n bilateral knee replacements\n .\n SICU course significant events:\n : On Neo. Given albumin. 3units FFP given prior to removal of\n femoral sheath by IR. Rec replacing drain loss cc:cc. No need for HD at\n this time.\n : OR for closure of abdominal wound. Right femoral art line pulled\n s/p blood products.\n : Droppped BP to 50s in AM, noted bloody stool >> given 2U PRBCs\n and increased Neo gtt to 4 >>SBP increased to 110s. At same time desat\n to 70%s on CPAP >> FiO2 inc to 100% and CXR revealed diffuse opacity of\n L lung consistent with mucus plug. Bedside bronch to remove thick mucus\n plug, O2 sats recovered to high 90%s, vent weaned back to 50% FiO2.\n : Rigors. Afebrile. Recultured. EEG performed, results pending.\n : Removed L femoral without complication. Vit K x 1 dose.\n : Weaned vent to min settings. High output around JP drains.\n Ascities replacement schedule adjusted.\n : Continued high JP output. Intermittent fluid boluses throughout\n day with LR as needed for BP / UOP.\n : Extubated. Continuing goal of fluid status being 2 liters\n negative.\n : Stable. Trauma line pulled. Started Caspiofungin.\n : Ascites cx and blood cx from growing yeast> changed to\n Micafungin and restarted vanc/zosyn/flagyl pending further culture\n data. Re-sited CVL and changed A-line over wire. Increased ascites\n repletion to 1cc:1cc. Transient decreases in UOP and SBP responded to\n fluid boluses initially> started on Neo gtt overnight for hypotension.\n : Hypotension requiring progressive increases in Neo drip.\n Albumin bolus x1. ID consulted. Aline replaced.\n : Switched to Dilaudid for pain. Following cx were negative: UA,\n peritoneal fluid, and aline tip.\n : C/o of intermittent LLQ pain, given small doses of Dilaudid with\n some improvement. 1U PRBCs. Weaning Neo gtt.\n : Stool cx sent. Prn albumin for hypotension\n : Bld cx sent. Lateral JP removed.\n : Abdominal US.\n : CT pelvis/abdomen. LLE erythemia.\n : PICC placed. CVL removed.\n : Started Regular diet. TF discontinued.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706591, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative in care. Mild c/o abdominal\n and left leg pain.\n Abdomen firmly distended. +BS. Small amts liquid green/brown\n stool.\n J-tubes clamped. Tolerating clears. have regular/soft\n solids as tolerates.\n Medial JP/sump/pigtail drains draining moderate amts ascetic\n drainage.\n Amber urine 40-60 cc/hr.\n Action:\n JP drainage checked every 2 hours\n Albumin given for every 1 liter drain output\n Renal following-ordered 24 hour urine collection. No\n containers in lab.\n Dilaudid given as needed for pain.\n Receiving IV antibiotics as ordered.\n Response:\n Hemodynamically stable\n Fluid balance -950 at midnight. Currently\n WBC\n Plan:\n Continue holding repletion for drain output.\n Administer Albumin for every 1 liter output form JP/sump\n drains.\n Monitor labs treating as needed.\n Continue aggressive skin care and frequent repositioning.\n Consider wound care consult today.\n Cont OOB as tolerates. PT/OT consults\n Continue antibiotics as ordered per ID team\n Transfer to floor if pt remains stable\n" }, { "category": "Respiratory ", "chartdate": "2164-10-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702855, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n Patient desaturated to low 70s this AM associated with hypotension and\n bradycardia. Ambu for a while then placed back on vent. Bronchoscopic\n procedure done mucous plug removed.CXR RUL collapse resoled,RLL\n collapsed improved with small bilateral pleural effusion. ETT advanced\n 3 cm now @ 24 cm.\n" }, { "category": "Nursing", "chartdate": "2164-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702909, "text": "OH cirrhosis complicated by esophageal and rectal varices with prior\n episodes of bleeding admitted with painless BRBPR and hypotension.\n Presented to Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct\n 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd incision clean and dry\n New dsg applied\n Jejuostomy tubes patent and draining bilous drainage\n medial and lateral to bulb suction and draining pink\n serous drainage\n Ngt patent and draining 50cc bloody drainage DO NOT IRRIGATE\n Flexiseal patent and draining melena stool\n Hct 34 k 3.4-3.5 ion calicium 1.1\n Heart rate sinus brady tonite 54-60 bp 100-115 syst.\n Action:\n Protonix gtt infusing\n Ocreotide gtt infusing\n Fenatnyl and propofol gtt infusing and being titrated\n Neo gtt infusing and being weaned slowly\n Kcl 20meq iv x1 given\n Calicium gluconate 2 gms iv given as per sliding scale\n Iv d51/2ns at 100cc/hr\n Jp\ns being repleted with normal saline cc/ccq1hr\n Iv fluconazole and pipercillin\n Albumin iv 25% iv given as ordered.\n Flexeseal to rectum\n Skin checks q2-3 hrs tyrdyne bed with rotation.\n Response:\n Stable post op tonite\n Weaning fentanyl, propofol and neo gtts slowly\n Tolerating the rotating bed.\n Hct stable tonite.\n Plan:\n Monitor patient\ns condition closely\n Update family on patient\ns condition\n Consult social service\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On cmv mode 70% 650-16-5\n Suctioned for small amt of white sputum\n Breath sounds clear in the upper lobes but diminished in lower bases\n O2sats > 94%\n Abg 7.42-28-104-19 -4 7.40-29-109-19 -4\n Weight currently is up to 107.7 kg dry weight 98.2 kg.\n Action:\n Chest xray done this am\n Suctioned prn.\n Vap mouthcare as per protocol\n Protonix gtt infusing\n Head in reverse trendelenberg position\n Tyrdyne bed with rotation\n Abgs drawn\n Response:\n No episodes of desating\n Resp rate 16.\n O2sat > 94%.\n Plan:\n Monitor resp status closely\n Abg\ns as ordered\n Attempt to wean ventilator.\n Impaired Physical Mobility\n Assessment:\n No spontaneous movements\n Patient is unresponsive and intubated\n Perla # 3 bilaterally and reacts briskly\n On fentanyl and propofol gtts.\n Action:\n Weaning propofol and fentanyl gtts.\n Complete care.\n Skin care\n Tyradyne bed with rotation.\n Response:\n Overall generalized edema wgt up to 107.7\n No red pressure areas or pressure sores\n Tolerating the tyradyne bed with rotation.\n Weaning fentanyl and propofol gtts slowly patient continues to be\n unresponsive.\n Plan:\n Complete care\n Maintain skin integrity\n Continue with the tynadyne bed.\n" }, { "category": "Physician ", "chartdate": "2164-10-22 00:00:00.000", "description": "Intensivist Note", "row_id": 702911, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n Chief complaint:\n BRBPR\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Internal\n Jugular Order date: @ 1703\n 12. Fluconazole 200 mg IV Q24H Order date: @ 1703\n 2. IV access: Temporary central access (ICU) Location: Right Subclavian\n Order date: @ 1703\n 13. Insulin 100 Units/100 ml NS @ 0.5 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1703\n 3. IV access: Temporary central access (ICU) Location: Left Femoral\n Order date: @ 1703\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 4. 1000 mL D5 1/2NS\n Continuous at 100 ml/hr Order date: @ 1243\n 15. Octreotide Acetate 50 mcg/hr IV DRIP INFUSION Order date: @\n 1703\n 5. 1000 mL NS\n Continuous at 0 ml/hr for 0 ml\n please give cc / cc JP output repletion Order date: @ 1316\n 16. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 1703\n 6. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 1243\n 17. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>65 Order\n date: @ 1703\n 7. Albumin 25% (12.5g / 50mL) 12.5 g IV Q 8H Duration: 3 Doses Order\n date: @ 1316\n 18. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 1703\n 8. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 1703\n 19. Potassium Chloride 20 mEq / 50 ml SW IV ONCE Duration: 1 Doses\n Order date: @ 2055\n 9. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 20. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 1703\n 10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1703\n 21. 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: @ 1703\n 11. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1703\n 22. Sodium Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date:\n @ 1243\n 24 Hour Events:\n Droppped BP to 50s in AM, noted bloody stool; given 2U PRBCs and\n increased neo gtt to 4, SBP increased to 110s. At same time, desat to\n 70%s on CPAP; FiO2 increased to 100% and CXR revealed diffuse opacity\n of L lung consistent with mucus plug. Bedside bronchoscopy to remove\n thick mucus plug, O2 sats recovered to high 90%s, vent weaned back to\n 50% FiO2.\n BRONCHOSCOPY - At 08:10 AM\n Post operative day:\n POD#5 - ex lap duod ulcer repair\n POD#2 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:26 AM\n Fluconazole - 10:17 PM\n Piperacillin/Tazobactam (Zosyn) - 04:03 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Phenylephrine - 3 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 12:51 PM\n Other medications:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.5\n HR: 57 (56 - 92) bpm\n BP: 106/57(72) {67/39(47) - 155/85(109)} mmHg\n RR: 16 (14 - 23) insp/min\n SPO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 109.6 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 14 (0 - 323) mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 8,665 mL\n 2,835 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,982 mL\n 2,785 mL\n Blood products:\n 633 mL\n 50 mL\n Total out:\n 7,602 mL\n 2,580 mL\n Urine:\n 707 mL\n 320 mL\n NG:\n 875 mL\n 350 mL\n Stool:\n 300 mL\n 200 mL\n Drains:\n 5,720 mL\n 1,710 mL\n Balance:\n 1,063 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 97%\n ABG: 7.40/29/109/18/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: PERRL, EOMI, does not track with eyes\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: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated, unresponsive to voice even with propofol off; does not follow\n commands; withdraws to pain\n Labs / Radiology\n 90 K/uL\n 12.1 g/dL\n 118 mg/dL\n 2.6 mg/dL\n 18 mEq/L\n 3.5 mEq/L\n 58 mg/dL\n 112 mEq/L\n 134 mEq/L\n 34.4 %\n 13.6 K/uL\n [image002.jpg]\n 06:52 AM\n 07:30 AM\n 07:34 AM\n 11:05 AM\n 11:24 AM\n 04:05 PM\n 07:09 PM\n 07:10 PM\n 03:06 AM\n 03:16 AM\n WBC\n 18.1\n 18.1\n 14.6\n 13.6\n Hct\n 31.5\n 34\n 35.4\n 36.3\n 34.4\n Plt\n 118\n 111\n 101\n 90\n Creatinine\n 3.0\n 2.7\n 2.6\n TCO2\n 18\n 19\n 19\n 19\n 19\n 19\n Glucose\n 81\n 78\n 102\n 103\n 118\n Other labs: PT / PTT / INR:19.3/51.8/1.8, ALT / AST:22/69, Alk-Phos / T\n bili:75/8.3, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:240 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.0 g/dL, LDH:214 IU/L, Ca:7.8 mg/dL, Mg:1.8\n mg/dL, PO4:6.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan:\n Neurologic: Intubated and sedated propofol gtt, fentanyl gtt, s/p\n cisatracurium. Attempt to wean sedation.\n Cardiovascular: On neo gtt; albumin boluses as needed. Wean neo as\n tolerated.\n Pulmonary: Intubated and sedated, s/p bronch for mucus plug .\n Increased inspiratory time to maximize MAP and goal 9cc/kg TV. Daily\n ABG, CXR. Continue tidal volume 600mL, low PEEP, wean FiO2 as\n tolerated.\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt, likely\n pancreatitis superimposed s/p staged closure.\n Nutrition: NPO\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Hx of hepatorenal syndrome, renal following. No HD\n at this time.\n Hematology: Hct stable in setting of melenotic stool, type and crossed\n for 4 units.\n Endocrine: Insulin gtt\n Infectious Disease: Zosyn; vanc held per transplant team.\n Lines / Tubes / Drains: ETT, foley, L IJ triple lumen, R SC trauma\n line, PIV x1, JP x2, NGT, J-tube\n Wounds: abdominal wound, now closed; clean / dry / intact\n Imaging: CXR\n Fluids: D51/2NS @100mL/hr plus\n cc/cc repletion of ascites output\n Consults: transplant surgery\n Billing Diagnosis: lower GI bleed\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Physician ", "chartdate": "2164-10-22 00:00:00.000", "description": "Intensivist Note", "row_id": 702921, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n Chief complaint:\n BRBPR\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Internal\n Jugular Order date: @ 1703\n 12. Fluconazole 200 mg IV Q24H Order date: @ 1703\n 2. IV access: Temporary central access (ICU) Location: Right Subclavian\n Order date: @ 1703\n 13. Insulin 100 Units/100 ml NS @ 0.5 UNIT/HR IV DRIP INFUSION\n Fingersticks every hour Order date: @ 1703\n 3. IV access: Temporary central access (ICU) Location: Left Femoral\n Order date: @ 1703\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1703\n 4. 1000 mL D5 1/2NS\n Continuous at 100 ml/hr Order date: @ 1243\n 15. Octreotide Acetate 50 mcg/hr IV DRIP INFUSION Order date: @\n 1703\n 5. 1000 mL NS\n Continuous at 0 ml/hr for 0 ml\n please give cc / cc JP output repletion Order date: @ 1316\n 16. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 1703\n 6. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 1243\n 17. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>65 Order\n date: @ 1703\n 7. Albumin 25% (12.5g / 50mL) 12.5 g IV Q 8H Duration: 3 Doses Order\n date: @ 1316\n 18. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 1703\n 8. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Order date: \n @ 1703\n 19. Potassium Chloride 20 mEq / 50 ml SW IV ONCE Duration: 1 Doses\n Order date: @ 2055\n 9. Calcium Gluconate IV Sliding Scale Order date: @ 1703\n 20. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 1703\n 10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1703\n 21. 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: @ 1703\n 11. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1703\n 22. Sodium Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date:\n @ 1243\n 24 Hour Events:\n Droppped BP to 50s in AM, noted bloody stool; given 2U PRBCs and\n increased neo gtt to 4, SBP increased to 110s. At same time, desat to\n 70%s on CPAP; FiO2 increased to 100% and CXR revealed diffuse opacity\n of L lung consistent with mucus plug. Bedside bronchoscopy to remove\n thick mucus plug, O2 sats recovered to high 90%s, vent weaned back to\n 50% FiO2.\n BRONCHOSCOPY - At 08:10 AM\n Post operative day:\n POD#5 - ex lap duod ulcer repair\n POD#2 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:26 AM\n Fluconazole - 10:17 PM\n Piperacillin/Tazobactam (Zosyn) - 04:03 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Phenylephrine - 3 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 12:51 PM\n Other medications:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.5\n HR: 57 (56 - 92) bpm\n BP: 106/57(72) {67/39(47) - 155/85(109)} mmHg\n RR: 16 (14 - 23) insp/min\n SPO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 109.6 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 14 (0 - 323) mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 8,665 mL\n 2,835 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,982 mL\n 2,785 mL\n Blood products:\n 633 mL\n 50 mL\n Total out:\n 7,602 mL\n 2,580 mL\n Urine:\n 707 mL\n 320 mL\n NG:\n 875 mL\n 350 mL\n Stool:\n 300 mL\n 200 mL\n Drains:\n 5,720 mL\n 1,710 mL\n Balance:\n 1,063 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 97%\n ABG: 7.40/29/109/18/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: PERRL, EOMI, does not track with eyes\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: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated, unresponsive to voice even with propofol off; does not follow\n commands; withdraws to pain\n Labs / Radiology\n 90 K/uL\n 12.1 g/dL\n 118 mg/dL\n 2.6 mg/dL\n 18 mEq/L\n 3.5 mEq/L\n 58 mg/dL\n 112 mEq/L\n 134 mEq/L\n 34.4 %\n 13.6 K/uL\n [image002.jpg]\n 06:52 AM\n 07:30 AM\n 07:34 AM\n 11:05 AM\n 11:24 AM\n 04:05 PM\n 07:09 PM\n 07:10 PM\n 03:06 AM\n 03:16 AM\n WBC\n 18.1\n 18.1\n 14.6\n 13.6\n Hct\n 31.5\n 34\n 35.4\n 36.3\n 34.4\n Plt\n 118\n 111\n 101\n 90\n Creatinine\n 3.0\n 2.7\n 2.6\n TCO2\n 18\n 19\n 19\n 19\n 19\n 19\n Glucose\n 81\n 78\n 102\n 103\n 118\n Other labs: PT / PTT / INR:19.3/51.8/1.8, ALT / AST:22/69, Alk-Phos / T\n bili:75/8.3, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:240 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.0 g/dL, LDH:214 IU/L, Ca:7.8 mg/dL, Mg:1.8\n mg/dL, PO4:6.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan:\n Neurologic: Intubated and sedated propofol gtt, fentanyl gtt, s/p\n cisatracurium. Attempt to wean sedation.\n Cardiovascular: On neo gtt; albumin boluses as needed. Wean neo as\n tolerated.\n Pulmonary: Intubated and sedated, s/p bronch for mucus plug .\n Increased inspiratory time to maximize MAP and goal . Will drop FI02\n to .5. For now, his Plat pressure is fine on present tidal volumes.\n Daily ABG, CXR. Continue tidal volume 600mL, low PEEP, wean FiO2 as\n tolerated.\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt, likely\n pancreatitis superimposed s/p staged closure.\n Nutrition: NPO\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Hx of hepatorenal syndrome, renal following. No HD\n at this time.\n Hematology: Hct stable in setting of melenotic stool, type and crossed\n for 4 units.\n Endocrine: Insulin gtt\n Infectious Disease: Zosyn; vanc held per transplant team.\n Lines / Tubes / Drains: ETT, foley, L IJ triple lumen, R SC trauma\n line, PIV x1, JP x2, NGT, J-tube\n Wounds: abdominal wound, now closed; clean / dry / intact\n Imaging: CXR\n Fluids: D51/2NS @100mL/hr plus\n cc/cc repletion of ascites output\n Consults: transplant surgery\n Billing Diagnosis: lower GI bleed\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2164-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702771, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Returned from the or at 1700.\n Remains intubated and suctioned for scant amt white sputum\n Remains on cmv 60%-600-16-5\n Abd closed with transparent dsg intact .some visable bloody drainage\n noted.\n Jp medial and lateral intact and draining serous- pink serous\n drainage. Amt of drainage via jp decreased over the nite.\n Jejunostomy tubes to gravity and draining bilious drainage.\n Remains on neo gtt and titrated for map > 65\n Protonix gtt infusing,\n Ngt intact with bloody drainage present/ DONOT IRRIGATE md team.\n Fentanyl, propofol and octreotide gtt infusing.\n Urine output 20-45 ccq1hrs. urine dark amber in color.\n Hct 33.9 bun 55, creat 2.9 lactate 3.2 ionized calicium1.11\n Action:\n Suctioned prn\n Tyrndyne bed with rotation\n Response:\n Remains on propofol, fentanyl, neo and octreitide gtts.\n Hct 33.9 today\n Wbc elevated 19.9\n Lactate acid up to 3.2 today\n Aline dampens easily and requires frequently adjusting\n Bp via cuff > 90\n Plan:\n Monitor condition closely\n Update family on patient\ns condition.\n" }, { "category": "Physician ", "chartdate": "2164-11-10 00:00:00.000", "description": "Intensivist Note", "row_id": 706254, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged RBC scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for duodenal arterial bleed, EBL 8L,\n 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin intraop.\n Chief complaint:\n Liver failure\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5.\n Bicitra 6. Calcium Gluconate\n 7. HYDROmorphone (Dilaudid) 8. Heparin Flush (10 units/ml) 9. 10.\n Insulin 11. Linezolid 12. Magnesium Sulfate\n 13. Meropenem 14. Micafungin 15. Midodrine 16. Miconazole Powder 2% 17.\n Ondansetron 18. Pantoprazole\n 19. Rifaximin 20. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n PICC LINE - START 07:00 PM\n 52 cm.\n MULTI LUMEN - STOP 09:35 PM\n Post operative day:\n POD#24 - ex lap duod ulcer repair\n POD#21 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Micafungin - 04:00 PM\n Meropenem - 11:20 PM\n Linezolid - 12:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:03 AM\n Hydromorphone (Dilaudid) - 01:30 AM\n Other medications:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.6\n T current: 36.1\nC (97\n HR: 117 (100 - 117) bpm\n BP: 106/55(72) {103/46(65) - 138/73(93)} mmHg\n RR: 22 (15 - 32) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 102.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 1 (1 - 106) mmHg\n Total In:\n 5,161 mL\n 1,196 mL\n PO:\n Tube feeding:\n 3,260 mL\n 719 mL\n IV Fluid:\n 1,350 mL\n 368 mL\n Blood products:\n 200 mL\n 50 mL\n Total out:\n 6,575 mL\n 2,094 mL\n Urine:\n 760 mL\n 194 mL\n NG:\n Stool:\n Drains:\n 5,815 mL\n 1,900 mL\n Balance:\n -1,414 mL\n -898 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 118 K/uL\n 9.8 g/dL\n 163 mg/dL\n 3.2 mg/dL\n 14 mEq/L\n 3.0 mEq/L\n 114 mg/dL\n 108 mEq/L\n 136 mEq/L\n 29.5 %\n 19.5 K/uL\n [image002.jpg]\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n 02:27 AM\n 01:22 AM\n WBC\n 12.2\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n 20.1\n 19.5\n Hct\n 27.6\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n 30.0\n 29.5\n Plt\n 156\n 142\n 147\n 121\n 105\n 101\n 102\n 118\n Creatinine\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n 3.4\n 3.2\n TCO2\n 14\n Glucose\n 165\n 183\n 156\n 127\n 115\n 136\n 153\n 157\n 163\n Other labs: PT / PTT / INR:24.8/83.7/2.4, ALT / AST:33/69, Alk-Phos / T\n bili:119/15.9, Amylase / Lipase:132/63, Differential-Neuts:86.1 %,\n Band:0.0 %, Lymph:6.4 %, Mono:3.6 %, Eos:3.6 %, Fibrinogen:207 mg/dL,\n Lactic Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:169 IU/L, Ca:8.3 mg/dL,\n Mg:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, MOTOR FUNCTION, IMPAIRED,\n TRANSFERS, IMPAIRED, ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED\n PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE,\n FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n .\n Plan: Neuro: Dilaudid prn, awake and following commands\n CVS: Hemodynamically stable will use albumin for intravascular fluid\n replacement\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal syndrome worsening, will continue to\n monitor, replacements currently on hold for his ostomy and Jtube\n outputs\n FEN/GI: 1.8 negative now . Currently not transplant candidate d/t\n peritoneal infection. protonix 40\", TF changed renal impact with fiber\n strenght . Rifaximin & lactulose for hepatic encephalopathy.\n Octreotide d/ced for now due to LLE erythema. abdominal collection ?\n ir perc drain\n ID: Being treated for Candda glabrata fungemia as well as peritonitis\n along with VRE with Micafungin, Meropenem and Linezolid, leukocytosis\n HEME: Hct stable. Trending platelets for downward trend, concern for\n HIT awaiting HIT panel JP ascitic replacements held up until 1-2 L\n negative. will restart when -2L WITH 0.5 CC/1CC.\n ENDO: RISS\n Psych: s/p consult\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, R IJ triple lumen ()removed sent tip\n for cx. , PIV x1, JP x2, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Nutrition:\n NovaSource Renal () - 11:52 PM 125 mL/hour\n Lines:\n Arterial Line - 01:20 PM\n PICC Line - 07:00 PM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706438, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. Pleasant in conversation and cooperative in\n care.\n Abdomen firm/distended. + BS. + flatulus. TF continue to be\n off with J-tubes clamped. Tolerating Pos well. Small green loose BM x1.\n Medial JP/sump/pigtail drains with scant to small amounts of\n ascetic drainage.\n Foley patent. Amber clear urine 20-50cc/hr.\n Pt with c/o mild abdominal and left leg pain.\n Afebrile. VSS. WBC 19.5\n Action:\n JP/sump drainage monitored every 2 hours and replacing with\n LR\n c:cc over 2 hours. Albumin administered for every 1L drain output.\n Giving Dilaudid as needed for pain. Turning/repositioning to\n comfort.\n Receiving IV antibiotics as ordered.\n Response:\n Hemodynamically remains stable.\n Pt +400 at MN and currently +750. Dr aware.\n Pt with adequate pain relief.\n WBC 20.2\n Plan:\n Continue with\n cc:cc repletions and closely monitor drain\n output. Administer Albumin when 1L drainage out from JP/Sump.\n Monitor labs and treat as needed.\n Maintain skin integrity and cont aggressive skin care.\n Consider wound consult on Monday.\n F/u with Renal as to 24hr urine collection.\n" }, { "category": "Physician ", "chartdate": "2164-10-23 00:00:00.000", "description": "Intensivist Note", "row_id": 703051, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n EGD showed 1 cord of non-bleeding grade II varices at 36 cm, 2 linear\n non-bleeding ulcers (6-7 mm) in the distal duodenal bulb, clotted blood\n in the antrum, and slight ulceration of the ampulla of Vater with a\n small amount of blood on it.\n PMHx:\n ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1000 mL NS\n Albumin 25% (12.5g / 50mL)\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Fentanyl Citrate\n Fluconazole\n Insulin\n Octreotide Acetate\n Pantoprazole\n Phenylephrine\n Piperacillin-Tazobactam\n Potassium Chloride\n Propofol\n Vancomycin\n 24 Hour Events:\n weaned neo\n continued replacement of each liter of ascites with 12.5g (25%)\n albumin\n TPN started\n TF started at 10 cc/hr\n PAN CULTURE - At 12:00 PM\n EEG - At 05:30 PM\n Post operative day:\n POD#6 - ex lap duod ulcer repair\n POD#3 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:26 AM\n Vancomycin - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Fluconazole - 10:29 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 106 (56 - 106) bpm\n BP: 111/57(73) {71/44(52) - 142/77(98)} mmHg\n RR: 16 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.4 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 10 (6 - 182) mmHg\n Total In:\n 10,368 mL\n 1,460 mL\n PO:\n Tube feeding:\n 16 mL\n 51 mL\n IV Fluid:\n 10,014 mL\n 1,054 mL\n Blood products:\n 200 mL\n 143 mL\n Total out:\n 9,033 mL\n 2,435 mL\n Urine:\n 1,173 mL\n 220 mL\n NG:\n 1,100 mL\n 250 mL\n Stool:\n 500 mL\n Drains:\n 6,260 mL\n 1,965 mL\n Balance:\n 1,335 mL\n -975 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 99%\n ABG: 7.39/27/91./18/-6\n Ve: 10.9 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: No acute distress, occassional rigors\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, JP drains\n serosanginous\n Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm), (Pulse\n - Dorsalis 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: Sedated\n Labs / Radiology\n 72 K/uL\n 11.3 g/dL\n 137 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 56 mg/dL\n 113 mEq/L\n 140 mEq/L\n 33.8 %\n 12.2 K/uL\n [image002.jpg]\n 03:06 AM\n 03:16 AM\n 09:30 AM\n 09:42 AM\n 03:40 PM\n 03:48 PM\n 08:06 PM\n 08:15 PM\n 02:07 AM\n 02:17 AM\n WBC\n 13.6\n 13.0\n 13.1\n 12.8\n 12.2\n Hct\n 34.4\n 34.2\n 34.5\n 35.5\n 33.8\n Plt\n 90\n 81\n 84\n 78\n 72\n Creatinine\n 2.6\n 2.5\n 2.3\n 2.1\n 2.0\n TCO2\n 19\n 15\n 18\n 18\n 17\n Glucose\n 118\n 119\n 100\n 114\n 119\n 137\n Other labs: PT / PTT / INR:20.1/53.0/1.8, ALT / AST:15/51, Alk-Phos / T\n bili:69/8.6, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.0 g/dL, LDH:179 IU/L, Ca:7.7 mg/dL, Mg:1.8\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated, rigors, f/u EEG. Off sedation.\n CVS: On neo gtt weaning down\n wean as tolerated; albumin 12.5g per 1L\n ascites\n PULM: Intubated, Daily ABG, CXR. Continue tidal volume 600mL, low PEEP,\n wean FiO2 as tolerated.\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Hx of hepatorenal syndrome, renal following. No HD at\n this time.\n FEN/GI: NPO, protonix drip, octreotide gtt, TPN, TF nutren renal at\n 10cc/hr\n ID: vanc / zosyn / fluc; f/u cx\n HEME: Hct stable in setting of melenotic stool, type and crossed for 4\n units.\n ENDO: Insulin RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, s/p R IJ triple lumen, L fem , R SC trauma line\n (considering changing line for dialysis), PIV x1, JP x2, NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Consults: West 1\n Billing Diagnosis: Duodenal bleed\n ICU Care\n Nutrition:\n TPN without Lipids - 08:40 PM 41. mL/hour\n NovaSource Renal () - 10:25 PM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703338, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant thick, white secretions.\n Action:\n ABGs x2.\n Response:\n Transplant Team and SICU Team aware of current ABG.\n No changes to ventilator settings.\n Plan:\n C\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706243, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3. MAE. Following commands.\n Abdomen firm and distended. + BS. Loose golden/green BM x3.\n NPO. Novasource\n strength infusing via J-tube. Receiving\n banana flakes every 8 hours. Upper J-tube remains clamped.\n Medial JP with moderate amounts (150-350cc/hr) of ascetic\n drainage. sump with scant amounts of ascetic drainage. Pigtail\n drain putting out 300-450cc every 4 hours with small amounts of blood\n present primarily yellow in coloring.\n Afebrile. HR ST 100-112. No ectopy. BP remains stable with\n MAP >65. WBC 20.1. PICC line confirmed by x-ray and CVL removed.\n Pt with mild c/o pain in left thigh around area of\n cellulitis as well as abdominal pain. Pt with hiccups lasting a few\n hours over night.\n Foley patent. Icteric. Clear. Making 25-45cc/hour.\n Action:\n Emptying JP drain hourly replacing output in addition of\n sump output with Albumin for every liter out.\n CVL tip sent for culture. Continues on IV antibiotics.\n Dilaudid given for pain control. Turned and repositioned to\n comfort.\n Response:\n Pt -1.4L at Midnight. Received total of Albumin 12.5g x for\n evening.\n Pain improved after interventions.\n WBC 19.5\n Plan:\n Continue to replace JP and sump outputs with Albumin\n for every 1L removed.\n Monitor fluid balance closely.\n Monitor pain/comfort treating as needed.\n F/u culture results.\n" }, { "category": "Nursing", "chartdate": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706327, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative\n Abdomen firmly distended. Distant BS.\n J-tubes clamped.\n Medial JP/sump/pigtail drain draining moderate amts ascetic\n drainage.\n K 3.0\n Amber urine 30-50 cc/hr.\n Action:\n JP drainage checked q 2\n Albumin given per q 1 liter drain output\n\n cc per cc repletion continued when pt reached 2 liters\n output\n Diet advanced to regular\n K repleted with 60 meq\n TF\ns off\n Renal following-ordered 24 hour urine collection. No\n containers in lab. Will call again tomorrow.\n Dilaudid prn pain\n Response:\n Hemodynamically stable\n Fluid balance=\n K\n Plan:\n Continue\n cc per cc repletion and closely monitor drain\n output.\n Albumin per q liter output\n Cont aggressive skin care. ?wound care consult Monday.\n Cont antibiotics as ordered\n" }, { "category": "Nursing", "chartdate": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706328, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative\n Abdomen firmly distended. Distant BS.\n J-tubes clamped.\n Medial JP/sump/pigtail drain draining moderate amts ascetic\n drainage.\n K 3.0\n Amber urine 30-50 cc/hr.\n Action:\n JP drainage checked q 2\n Albumin given per q 1 liter drain output\n\n cc per cc repletion continued when pt reached 2 liters\n output\n Diet advanced to regular\n K repleted with 60 meq\n TF\ns off\n Renal following-ordered 24 hour urine collection. No\n containers in lab. Will call again tomorrow.\n Dilaudid prn pain\n Response:\n Hemodynamically stable\n Fluid balance=\n K\n Plan:\n Continue\n cc per cc repletion and closely monitor drain\n output.\n Albumin per q liter output\n Continue guaic stools\n Cont aggressive skin care. ?wound care consult Monday.\n Cont antibiotics as ordered\n" }, { "category": "Nursing", "chartdate": "2164-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706390, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed,\n GIB), Hepatorenal failure\n Assessment:\n AOx3. Pleasant and cooperative\n Abdomen firmly distended. +BS.\n J-tubes clamped.\n Medial JP/sump/pigtail drains draining moderate amts ascitic\n drainage.\n K 3.0 this am\n Amber urine 30-50 cc/hr.\n Small amts liquid green stool. Guaic positive stools x2.\n Action:\n JP drainage checked q 2\n Albumin given per q 1 liter drain output\n\n cc per cc repletion continued when pt reached 2 liters\n output\n Diet advanced to regular\n K repleted with 60 meq\n TF\ns off\n Renal following-ordered 24 hour urine collection. No\n containers in lab. Will call again tomorrow.\n Dilaudid prn pain\n Response:\n Hemodynamically stable\n Fluid balance=negative 80 currently\n Pt tolerating clears/thick liquids\n Plan:\n Continue\n cc per cc repletion and closely monitor drain\n output.\n Albumin per q liter output\n Cont follow labs\n Cont aggressive skin care, frequent repositioning. ?wound\n care consult Monday.\n Cont antibiotics as ordered per ID team\n" }, { "category": "Nursing", "chartdate": "2164-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702126, "text": "HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use.\n He was hospitalized at from to for UGIB due to\n duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n Transferred from OSH, hypotensive with HCT 17. After receiving\n multiple blood products in the MICU here at , as well as a failed\n attempt to stop duodenal bleeding in IR (), he was sent to the\n OR. Received 12 units of PRBCs in OR, duodenal site for bleeding\n repaired, came to SICU intubated, paralyzed, sedated, with open\n abdomen.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702393, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains paralyzed and sedated\n Abd remains open, multiple drains to wall suction, copious\n amounts of serosang drainage\n NGT to LCS, sump port backing up frequently, bloody drainage\n J tube to LCS, min amounts bilious drainage\n MAP 65-70, SBP 90-112\n Plt 77\n Action:\n Octreotide and protonix gtt\n NGT flushed by MD\ns x3\n Neo gtt to keep MAP >65\n Fluid bolus x1\n Plt x1\n 1/2cc:cc repletion for wound output\n Response:\n Plt 114, 104\n Able to slowly wean neo gtt\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2164-10-19 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 702496, "text": "Subjective: Unable to speak with patient, no family available.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 98.2 kg\n 112 kg ( 01:00 AM)\n 28.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 83.5 kg\n 118%\n Diagnosis: Upper GIB\n PMHx: -ETOH cirrhosis complicated by portal hypertension esophageal &\n rectal varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Cisatracurium, Octreotide acetate, protonix,\n phenylephrine, fentanyl, propofol, Dextrose 5% NaCl 0.45% with\n NaBicarb, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 140 mg/dL\n 08:37 AM\n Glucose Finger Stick\n 138\n 11:00 AM\n BUN\n 42 mg/dL\n 08:37 AM\n Creatinine\n 2.4 mg/dL\n 08:37 AM\n Sodium\n 140 mEq/L\n 08:37 AM\n Potassium\n 4.1 mEq/L\n 08:37 AM\n Chloride\n 110 mEq/L\n 08:37 AM\n TCO2\n 18 mEq/L\n 08:37 AM\n PO2 (arterial)\n 71 mm Hg\n 08:53 AM\n PCO2 (arterial)\n 27 mm Hg\n 08:53 AM\n pH (arterial)\n 7.45 units\n 08:53 AM\n pH (urine)\n 5.0 units\n 05:28 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 08:53 AM\n Albumin\n 2.2 g/dL\n 08:37 AM\n Calcium non-ionized\n 8.0 mg/dL\n 08:37 AM\n Phosphorus\n 5.6 mg/dL\n 08:37 AM\n Ionized Calcium\n 1.09 mmol/L\n 08:53 AM\n Magnesium\n 1.8 mg/dL\n 08:37 AM\n ALT\n 23 IU/L\n 08:37 AM\n Alkaline Phosphate\n 47 IU/L\n 08:37 AM\n AST\n 49 IU/L\n 08:37 AM\n Amylase\n 58 IU/L\n 11:14 PM\n Total Bilirubin\n 6.6 mg/dL\n 08:37 AM\n WBC\n 17.3 K/uL\n 11:08 AM\n Hgb\n 11.3 g/dL\n 11:08 AM\n Hematocrit\n 31.6 %\n 11:08 AM\n Current diet order / nutrition support: Diet: NPO\n GI: abd open, soft, + ascites, bowel sounds absent\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: ETOH, ESLD, extensive bowel surgery\n Estimated Nutritional Needs\n Calories: -2455 (20-25 cal/kg)\n Protein: 98-137 (1-1.4 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate (NPO)\n Specifics:\n 52 y.o. Male with ETOH cirrhosis complicated by esophageal and rectal\n varices with prior episodes of bleeding, admitted with painless BRBPR\n and hypotension. EGD showed 1 cord of non-bleeding grade II varices, 2\n linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it. Patient went to OR for\n ex-lap, gastrostomy, duodenotomy with suturing of bleeding vessel and\n draining jejunostomy. Abd is open, and plan is to go back to OR\n . Patient is intubated, sedated, paralyzed and on pressor\n support. Due to extensive abd surgeries, patient may require TPN for\n nutrition support. Recommendations below.\n Medical Nutrition Therapy Plan - Recommend the Following\n If TPN indicated, recommend start with day 1 standard TPN.\n Check triglycerides, hold if greater than 400.\n TPN goal: 80kg 3-in-1: 2036kcals and 120g protein.\n Following plan/progress - #\n" }, { "category": "Respiratory ", "chartdate": "2164-10-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702598, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 83.5\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / 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: Not triggering\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2164-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705975, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Vitals remain stable despite rising wbc and concern for intraabdominal\n sepsis. Abd. Soft, ascetic. Multiple guiac negative stools today.\n Proximal JT to gravity this a.m., distal JT with feedings as\n documented. Medial JP to bulb suction with large serosang. Output.\n sump tube within abd. Dressing draining additional ascetic\n weeping fluid to low wall suction.\n Action:\n Pt. taken for Abd. CT this afternoon. Antibiotics adjusted per ID\n recs. Proximal JT clamed per orders. TF\ns to be adjusted this\n afternoon. Intially 3/4cc NS/1cc ascetic fluid (via JP/sump)\n administered, then decreased to 1/2cc/1cc, then placed on HOLD due to\n goal negative balance (one liter) by the end of today. 12.5gm albumin\n given this afternoon when JP output reached one liter. Pain control as\n documented.\n Response:\n Pt. afebrile, VSS. CT results pending. All outputs as documented.\n Fluid balance remains positive.\n Plan:\n Continue to monitor hemodynamics, support as indicated. Antibiotic\n therapy per ID. Strict I\ns and O\ns, continue to hold NS replacement\n for now. Change TF when available. F/u CT results.\n Knowledge, Impaired\n Assessment:\n Pt. has been stating he wants to go home all day. He is oriented x 3,\n and states he understands the severity of his illness, but this\n afternoon is threatening to sign out AMA. He states his wife is coming\n to pick him up. ?Some delusional element to this behavior.\n Action:\n Reality of situation presented. Discussed with psych and all\n medical/surgical teams today.\n Response:\n At present, pt. is still saying he\ns going home. He remains oriented\n but very unrealistic.\n Plan:\n Pending, awaiting pt\ns wife. Continue to present reality and redirect\n as needed.\n Impaired Skin Integrity\n Assessment:\n Left upper anterior thigh appearing cellulitic today. The area is\n warm, red, swollen and very tender to touch. ?If this is due to sc\n injections (pt. weeps from all sites) vs. complication from left groin\n trauma line pt. has upon admission.\n Action:\n Antibiotic therapy. Legs/thighs included in CT. Warm packs offered.\n Octreotide held, per liver and transplant teams. Medicated for pain as\n documented.\n Response:\n Leg unchanged. CT results pending.\n Plan:\n Continue present antibiotic regimen. Cont. to monitor.\n" }, { "category": "Physician ", "chartdate": "2164-10-24 00:00:00.000", "description": "Intensivist Note", "row_id": 703252, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension, now s/p exploratory laparotomy, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy.\n Chief complaint:\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n Vit K\n albumin\n vanco\n Fluconazole\n zosyn\n ISS\n Nexium gtt\n Octreotide gtt\n 24 Hour Events:\n : Tubefeeds changed to Nepro 1/2 strength, ordered for urine 24hr\n Cr clearance. Removed L femoral without complication. Vit K x 1\n dose\n TRAUMA LINE - STOP 11:07 AM\n Post operative day:\n POD#7 - ex lap duod ulcer repair\n POD#4 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:01 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Fluconazole - 10:00 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:59 AM\n Other medications:\n Flowsheet Data as of 06:15 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: 37\nC (98.6\n HR: 121 (91 - 123) bpm\n BP: 104/55(70) {88/50(63) - 137/77(96)} mmHg\n RR: 18 (14 - 20) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101.2 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 11 (0 - 270) mmHg\n Total In:\n 8,224 mL\n 2,007 mL\n PO:\n Tube feeding:\n 385 mL\n 120 mL\n IV Fluid:\n 6,267 mL\n 1,463 mL\n Blood products:\n 500 mL\n 150 mL\n Total out:\n 11,903 mL\n 4,010 mL\n Urine:\n 988 mL\n 270 mL\n NG:\n 750 mL\n 450 mL\n Stool:\n 300 mL\n Drains:\n 10,165 mL\n 2,990 mL\n Balance:\n -3,679 mL\n -2,003 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 65 (65 - 650) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 47\n PIP: 19 cmH2O\n Plateau: 19 cmH2O\n Compliance: 46.4 cmH2O/mL\n SPO2: 97%\n ABG: 7.38/29/94./16/-6\n Ve: 12.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), Transmitted breath sounds\n bilaterally\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli, No(t) Unresponsive), Slight\n mov't with noxious stimuli. No spont mov't\n Labs / Radiology\n 69 K/uL\n 11.8 g/dL\n 154 mg/dL\n 1.8 mg/dL\n 16 mEq/L\n 3.6 mEq/L\n 60 mg/dL\n 117 mEq/L\n 142 mEq/L\n 34.6 %\n 12.9 K/uL\n [image002.jpg]\n 08:06 PM\n 08:15 PM\n 02:07 AM\n 02:17 AM\n 10:03 AM\n 02:06 PM\n 02:13 PM\n 08:11 PM\n 02:05 AM\n 02:24 AM\n WBC\n 12.8\n 12.2\n 14.1\n 13.4\n 12.9\n Hct\n 35.5\n 33.8\n 35.3\n 33.8\n 34.6\n Plt\n 78\n 72\n 80\n 74\n 69\n Creatinine\n 2.1\n 2.0\n 1.9\n 1.8\n TCO2\n 18\n 17\n 19\n 19\n 18\n Glucose\n 119\n 137\n 133\n 145\n 154\n Other labs: PT / PTT / INR:21.0/65.6/2.0, ALT / AST:9/36, Alk-Phos / T\n bili:65/8.5, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:213 IU/L, Ca:7.4 mg/dL, Mg:1.9\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n Neurologic: Intubated and of sedation\n Cardiovascular: On neo gtt; albumin 12.5g per 1L ascites. Wean neo as\n tolerated.\n Pulmonary: Intubated, s/p bronch for mucus plug . Increased\n inspiratory time to maximize MAP and goal 9cc/kg TV. Daily ABG, CXR.\n Continue tidal volume 600mL, low PEEP, wean FiO2 as tolerated.\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt, TPN, TF\n nepro 1/2 strength at 20 cc/hr (not advancing)\n Nutrition: TPN\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Hx of hepatorenal syndrome, renal following. No HD at\n this time. 24 hr urine creatinine ordered\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: vanc / zosyn / fluc; f/u cx\n Lines / Tubes / Drains: Foley, NGT, J-Tube, ETT, Surgical drains\n (hemovac, JP)\n Wounds: c/d/i\n Imaging:\n Fluids: Repleting every cc of JP output with 1/2 cc NS\n Consults: General surgery, Transplant, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 05:53 PM 20 mL/hour\n TPN without Lipids - 08:21 PM 45.5 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703253, "text": "52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension, now s/p exploratory laparotomy, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remained on vent , CMV mode, no change in vent settings\n overnight,\n Action:\n Patient on Triadyne bed, on continuous rotation form side to side, ABG\n sent, CXR done this morning. VAP care done.\n Response:\n LS clear and diminished at bases, O2 sat 97-98%, weak productive cough.\n RSBI this morning is 47, team aware, waiting for morning rounds for\n changes.\n Plan:\n Cont to monitor, pulm hygiene, mouth care q4h, ? Wean vent if\n tolerates\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining dark bloody drainage early shift and now more\n clear but blood tinged, Abdomen softly distended, No BS, JP\nS draining\n ascitic fluid, +++ generalized edema.\n Action:\n JP drainage replaced with NS 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2.\n Response:\n stable HCT 34.6, patient is opening eyes to call, not following any\n commands or moving any extremities, PERL, off sedation more than 24\n hours now.\n Plan:\n Cont to monitor, replace alb for 1L of JP out put\n" }, { "category": "Physician ", "chartdate": "2164-10-21 00:00:00.000", "description": "Intensivist Note", "row_id": 702760, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n .\n MEDICATIONS (per d/c summary )\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n 1000 mL NS 5. Albumin 25% (12.5g / 50mL) 6. Albumin 25% (12.5g / 50mL)\n 7. Artificial Tears\n 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Fentanyl Citrate 11. Fluconazole\n 12. Insulin 13. Insulin 14. Octreotide Acetate 15. Pantoprazole 16.\n Phenylephrine 17. Piperacillin-Tazobactam\n 18. Propofol\n 24 Hour Events:\n Pt to OR for closure of abdominal wound. Procedure well tolerated.\n Requiring increased MAP to maintain oxygenation. Albumin x1. Right\n femoral art line pulled s/p blood products\n OR SENT - At 01:30 PM\n OR RECEIVED - At 05:00 PM\n Post operative day:\n POD#4 - ex lap duod ulcer repair\n POD#1 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Fluconazole - 10:56 PM\n Piperacillin - 03:26 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 3.5 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 78 (78 - 87) bpm\n BP: 105/60(75) {80/50(60) - 132/73(95)} mmHg\n RR: 16 (16 - 18) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.6 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 11 (8 - 17) mmHg\n Total In:\n 7,664 mL\n 500 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,770 mL\n 475 mL\n Blood products:\n 1,894 mL\n 25 mL\n Total out:\n 4,915 mL\n 325 mL\n Urine:\n 490 mL\n 110 mL\n NG:\n 525 mL\n 175 mL\n Stool:\n Drains:\n 2,600 mL\n 40 mL\n Balance:\n 2,749 mL\n 175 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 40 cmH2O/mL\n SPO2: 94%\n ABG: 7.38/33/94./19/-4\n Ve: 9.6 L/min\n PaO2 / FiO2: 157\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-tender, Distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 127 K/uL\n 12.3 g/dL\n 84 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 106 mEq/L\n 138 mEq/L\n 33.9 %\n 19.9 K/uL\n [image002.jpg]\n 06:05 AM\n 06:23 AM\n 10:00 AM\n 10:14 AM\n 02:58 PM\n 03:24 PM\n 05:41 PM\n 06:09 PM\n 02:58 AM\n 03:09 AM\n WBC\n 14.2\n 19.9\n Hct\n 28.8\n 29.0\n 33\n 35\n 34.5\n 33.9\n Plt\n 72\n 96\n 127\n Creatinine\n 2.5\n 2.9\n TCO2\n 19\n 22\n 22\n 21\n 22\n 20\n Glucose\n 99\n 93\n 101\n 82\n 84\n Other labs: PT / PTT / INR:18.3/39.2/1.7, ALT / AST:22/60, Alk-Phos / T\n bili:66/8.0, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:226 mg/dL, Lactic\n Acid:3.2 mmol/L, Albumin:2.4 g/dL, LDH:214 IU/L, Ca:8.0 mg/dL, Mg:1.9\n mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, INEFFECTIVE\n COPING, GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated and sedated propofol gtt, fentanyl gtt, s/p\n cisatracurium\n CVS: On neo gtt; albumin boluses as needed\n PULM: intubated and sedated, paralyzed. Watch for . Vent setting to\n inverse I:E. Daily ABG, CXR\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 1 to 1 with D51/2 NS with 50 of Bicarb. Hx of hepatorenal syndrome,\n renal following. No HD at this time\n FEN/GI: NPO, protonix drip, octreotide gtt, likely pancreatitis\n superimposed s/p staged closure\n ID: zosyn\n HEME: Hct stable,but type and crossed for 4 units.\n ENDO:insulin gtt-->RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, R IJ triple lumen, R SC trauma line (considering\n changing line for dialysis), L EJ (will eb d/c'd), PIV x1, ascites\n drain, JP (adjacent to duodenum), NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI gtt\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705276, "text": "Ineffective Coping\n Assessment:\n Pt alert and oriented X3 most of night\n maintain BP > 110\ns with Map >60\n Having LLQ pain intermittently\n Pt very anxious with periods of agitation\n Crying following Octreotide dose\n Action:\n Weaned neo off at 0200\n Med with Dilaudid .5 Q3 hrs\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705408, "text": "SICU\n HPI:\n POD 19 / 16 s/p ex lap, gastrotomy, duodenotomy w/suturing of\n bleeding vessel, draining jejunostomy\n Abx: vanc, micafungin \n PPx: boots, PPI \n TLD: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube\n .\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n s/p GI bleed\n Assessment:\n Patient alert and oriented x 3 , yet at the same time confused with a\n crazed look at times.\n Paranoid questions to nursing staff.\n Patient continues w/\n cc/cc jp drainage replacement\n Tube feeds remain\n impact w/ fiber @ 125cc hr\n Belly firm, distended, yet fairly dry due to sump to suction\n Urine output remains low.\n Action:\n Pshyc. Into see patient today\n Patient OOB to chair,tolerated well\n Taking some ice chips/water, immediately drains out jtube to gravity.\n No family call or visited at this point.\n Response:\n Continues to improve.\n ?Goal of transfer to floor in next couple of days.\n Plan:\n OOb again today if able.\n Haldol for sleep (Psych recommendations)\n Continue with fluid replacement\n Call ho/liver team w/ any changes.\n" }, { "category": "Nutrition", "chartdate": "2164-11-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 705758, "text": "Subjective: Did not speak with patient.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 98.2 kg\n 103.5 kg ( )\n 28.5\n Pertinent medications: RISS, Micafungin, Protonix, rifaximin, ABx,\n others noted\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 01:43 AM\n Glucose Finger Stick\n 155\n 10:00 AM\n BUN\n 99 mg/dL\n 01:43 AM\n Creatinine\n 3.8 mg/dL\n 01:43 AM\n Sodium\n 139 mEq/L\n 01:43 AM\n Potassium\n 4.1 mEq/L\n 01:43 AM\n Chloride\n 109 mEq/L\n 01:43 AM\n TCO2\n 16 mEq/L\n 01:43 AM\n PO2 (arterial)\n 81. mm Hg\n 03:27 AM\n PCO2 (arterial)\n 22 mm Hg\n 03:27 AM\n pH (arterial)\n 7.41 units\n 03:27 AM\n pH (urine)\n 5.0 units\n 08:30 AM\n CO2 (Calc) arterial\n 14 mEq/L\n 03:27 AM\n Albumin\n 3.2 g/dL\n 01:43 AM\n Calcium non-ionized\n 8.3 mg/dL\n 01:43 AM\n Phosphorus\n 5.9 mg/dL\n 01:43 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:27 AM\n Magnesium\n 1.6 mg/dL\n 01:43 AM\n ALT\n 24 IU/L\n 01:43 AM\n Alkaline Phosphate\n 64 IU/L\n 01:43 AM\n AST\n 49 IU/L\n 01:43 AM\n Amylase\n 132 IU/L\n 02:58 AM\n Total Bilirubin\n 13.7 mg/dL\n 01:43 AM\n WBC\n 14.3 K/uL\n 01:43 AM\n Hgb\n 8.5 g/dL\n 01:43 AM\n Hematocrit\n 25.4 %\n 01:43 AM\n Current diet order / nutrition support: Tube Feeds: 3/4 strength Impact\n with Fiber @125mL/hr (2250kcals, 126g protein)\n Diet: NPO\n GI: abd firm, bowel sounds present, golden loose stools\n Assessment of Nutritional Status\n 52 y.o. Male with ETOH cirrhosis c/b esophageal and rectal varices with\n prior episodes of bleeding admitted with painless BRBPR and\n hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, and feeding jejunostomy, now\n with fungemia. Patient\ns diluted tube feeds are at goal, which meets\n 100% of estimated needs. Noted increasing BUN/Cr. Patient\ns tube\n feeds provide 1.3g protein/kg.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with tube feeds at goal.\n Monitor renal function, may need to adjust tube feeds if\n this worsens.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2164-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705838, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt A&Ox2, but occasionally confused as expressed by some\n comments that are made\n Pt continuing to drain approx 300cc serous fluid from medial\n JP\n Small amount of drainage from sump drain\n Upper J tube (red) to gravity with mod amount of bilious\n drainage\n Lower J tube to tube feeds, currently at goal\n Golden soft stools\n Abd firm, pos bs, c/o pain on L side of ABD\n Pt complains of thirst frequently\n SBP 98-130\ns, MAP\ns >65 throughout shift\n Action:\n Monitoring JP, sump drain and J tube outputs\n 3/4cc:cc NS repletion for JP outputs\n 25% Albumin given for every 1L output from drains\n 0.5mg IVP Dilaudid given prn\n Midodrine as ordered\n Response:\n Pt expressing adequate pain relief from Dilaudid\n No change in outputs\n Pt fluid status even as of MN\n Plan:\n Continue to monitor drain outputs\n Pain management\n Keep Map >65\n Continue with Albumin as ordered\n Attempt to get pt 1-2L negative\n Ineffective Coping\n Assessment:\n Pt very labile emotionally\n Aggressive towards staff intermittently\n Pt continuously stating he wants to go home\n Pt unable to acknowledge current condition\n Uncooperative with care\n Action:\n Continue to provide pt with emotional support\n Continue to reorient pt to current condition\n Acknowledge and validate pt\ns frustrations\n Response:\n Pt more cooperative after recieving nursing support and\n acknowledgement of pt\ns frustrations\n Pt continues to have moments of aggression and lashing out\n at staff, but more dirctable\n Plan:\n Psych consult, social work consult\n Continue to provide pot with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703350, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant thick, white secretions.\n Weak cough.\n Gag weak to absent.\n Negative 2\n Liters.\n Action:\n ABGs x2.\n Response:\n Transplant Team and SICU Team aware of current ABG.\n No changes to ventilator settings.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Incisions CDI.\n JP\ns with star\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702380, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-10-19 00:00:00.000", "description": "Intensivist Note", "row_id": 702454, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 24 Hour Events:\n - Remains intubated, sedated/paralyzed, open abd\n - Continued to require Neo for BP support\n - Received albumin for volume resuscitation\n Post operative day:\n POD#2 - ex lap duod ulcer repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Vancomycin - 08:00 PM\n Fluconazole - 10:40 PM\n Piperacillin - 02:09 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Fentanyl (Concentrate) - 75 mcg/hour\n Propofol - 50 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.4\nC (97.6\n HR: 88 (85 - 95) bpm\n BP: 115/62(78) {86/48(61) - 115/66(81)} mmHg\n RR: 20 (15 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112 kg (admission): 98.2 kg\n CVP: 11 (9 - 273) mmHg\n Total In:\n 7,382 mL\n 2,652 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,600 mL\n 2,580 mL\n Blood products:\n 781 mL\n 72 mL\n Total out:\n 5,471 mL\n 2,060 mL\n Urine:\n 331 mL\n 110 mL\n NG:\n 160 mL\n 100 mL\n Stool:\n Drains:\n 4,980 mL\n 1,850 mL\n Balance:\n 1,911 mL\n 592 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (500 - 650) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Neuromusc Block\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n SPO2: 97%\n ABG: 7.43/28/69/20/-3\n Ve: 13 L/min\n PaO2 / FiO2: 115\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear,\n diminished bilat bases : )\n Abdominal: Soft, Ioban in place, with JP drains in place\n Left Extremities: (Edema: 3+), (Temperature: Cool)\n Right Extremities: (Edema: 3+), (Temperature: Cool)\n Skin: Jaundiced\n Neurologic: Sedated, Chemically paralyzed,\n Labs / Radiology\n 104 K/uL\n 11.4 g/dL\n 139 mg/dL\n 2.4 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 39 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.5 %\n 13.7 K/uL\n [image002.jpg]\n 03:06 PM\n 04:00 PM\n 08:14 PM\n 08:24 PM\n 12:10 AM\n 12:16 AM\n 12:57 AM\n 01:04 AM\n 02:58 AM\n 06:14 AM\n WBC\n 13.2\n 13.7\n Hct\n 32.4\n 32.5\n Plt\n 77\n 114\n 104\n Creatinine\n 2.2\n 2.4\n TCO2\n 23\n 23\n 20\n 19\n 20\n 19\n Glucose\n 131\n 158\n 139\n Other labs: PT / PTT / INR:18.7/42.3/1.7, ALT / AST:18/47, Alk-Phos / T\n bili:40/6.5, Amylase / Lipase:58/81, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:187 mg/dL, Lactic\n Acid:4.0 mmol/L, Albumin:2.4 g/dL, LDH:174 IU/L, Ca:8.2 mg/dL, Mg:1.9\n mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy\n Neurologic: Neuro checks Q: 1 hr, Continue sedation, paralysis for now\n Cardiovascular: Requires Neo for BP support; wean as tolerated. If\n volume needed, will favor colloids including albumin.\n Pulmonary: Cont ETT and keep TV ~8ml / kg IBW for , but will\n minimize PEEP given Liver Failure.\n Gastrointestinal / Abdomen: Check bladder pressure, NPO. Drains in\n place.\n Nutrition: NPO\n Renal: Foley, Severe Oliguria. Will contact Renal in case pt needs\n . Lytes q 6h.\n Hematology: Cont serial Hct and maintain active T&C.\n Endocrine: RISS\n Infectious Disease: Cont empiric GI antibx per primary team. And\n follow Vanco level QD.\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n d/c EJ and Fem CVL and change Left SC to HD catheter. Will also need\n to address Fem A-line.\n Wounds: Ioband / Open abdomen.\n Imaging: CXR today\n Fluids: Replcing JP output 1/2cc per 1 cc.\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure),\n Post-op hypotension; Acute Renal Failure; Liver failure\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Sheath - 08:00 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots, no Heparin.\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2164-10-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702755, "text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 83.5\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / 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: Not triggering\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2164-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705481, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements. Mild c/o abdominal pain.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n JP x2 to self suction with sump to LCWS. Medial drain\n with moderate amounts ascetic output. Lateral drain and sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65.\n Action:\n Reorientating pt as needed. Dilaudid given for pain control.\n Repositioning pt to comfort.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Adequate pain relief.\n Pt positive 1.5L at midnight.\n Remains off Neo (x24 hrs) maintaining MAP >65\n Plan:\n Reorient pt frequently. Treat pain/comfort as needed.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n" }, { "category": "Physician ", "chartdate": "2164-11-07 00:00:00.000", "description": "Intensivist Note", "row_id": 705732, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with sepsis\n secondary to fungemia\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1. 2. 1000 mL NS 3. Albumin 25% (12.5g / 50mL) 4. Albumin 25% (12.5g /\n 50mL) 5. Artificial Tear Ointment\n 6. Bicitra 7. Calcium Gluconate 8. HYDROmorphone (Dilaudid) 9. Insulin\n 10. Lidocaine 2% 11. Micafungin\n 12. Midodrine 13. Miconazole Powder 2% 14. Octreotide Acetate 15.\n Ondansetron 16. Pantoprazole 17. Rifaximin\n 18. Sodium Chloride 0.9% Flush 19. Tetracaine HCl 20. Vancomycin\n 24 Hour Events:\n : Blood cx sent, Lateral jp d/ced, neg fluid balance 1l/24h\n Post operative day:\n POD#21 - ex lap duod ulcer repair\n POD#18 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:19 AM\n Micafungin - 02:00 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.6\nC (97.8\n HR: 109 (95 - 151) bpm\n BP: 139/69(92) {105/49(67) - 156/81(108)} mmHg\n RR: 24 (16 - 34) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.5 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 8 (1 - 11) mmHg\n Total In:\n 8,221 mL\n 2,122 mL\n PO:\n 1,470 mL\n 480 mL\n Tube feeding:\n 3,008 mL\n 729 mL\n IV Fluid:\n 3,283 mL\n 743 mL\n Blood products:\n 100 mL\n 50 mL\n Total out:\n 9,084 mL\n 2,845 mL\n Urine:\n 689 mL\n 205 mL\n NG:\n 4,400 mL\n 1,700 mL\n Stool:\n Drains:\n 3,995 mL\n 940 mL\n Balance:\n -863 mL\n -723 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///16/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: No(t) CTA bilateral : , Crackles :\n at the base, No(t) Diminished: )\n Abdominal: Soft, Distended, appropriately tender\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 121 K/uL\n 8.5 g/dL\n 115 mg/dL\n 3.8 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 99 mg/dL\n 109 mEq/L\n 139 mEq/L\n 25.4 %\n 14.3 K/uL\n [image002.jpg]\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n WBC\n 18.1\n 17.1\n 15.8\n 12.2\n 12.9\n 13.5\n 14.3\n Hct\n 28.1\n 27.5\n 28.5\n 27.6\n 26.4\n 25.8\n 25.4\n Plt\n 56\n 142\n 147\n 121\n Creatinine\n 3.1\n 3.3\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n TCO2\n 12\n 14\n Glucose\n 140\n 122\n 165\n 183\n 156\n 127\n 115\n Other labs: PT / PTT / INR:24.8/55.4/2.4, ALT / AST:24/49, Alk-Phos / T\n bili:64/13.7, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.2 g/dL, LDH:173 IU/L, Ca:8.3 mg/dL, Mg:1.6\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE, FUNGAL INFECTION, OTHER,\n HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n Neurologic: Neuro checks Q: 4 hr, Dilaudid prn, awake and following\n commands\n Cardiovascular: Hypotension, now off neo x 48 hours, fluid repletion\n 3/4:1\n Pulmonary: sats mid 90's on RA\n Gastrointestinal / Abdomen: protonix 40\", Rifaximin for hepatic\n encephalopathy.\n Nutrition: TF impact 3/4 strength at 125ml/hr.\n Renal: Foley, follow UOP, replacing ascites output 3/4:1 with NS.\n Albumin 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not\n believe this is related to micafungin. Giving boluses with albumin PRN\n for BP / UOP. D5W with 150 Sod Bicarb @ 150/hr\n Hematology: Post op anemia, per Primary Team Request 2U pRBC\n Endocrine: RISS, Goal BS<150\n Infectious Disease: Check cultures, micafungin started continue\n for 2 weeks after 1st negative cx blood/ascites; vanc\n for coag neg staph tip cx; ophthalmology exam negative. All lines\n changed out. Follow vanco level\n Lines / Tubes / Drains: foley, R IJ triple lumen (), PIV x1, JP\n x1, J-tube x2, A-line\n Prophylaxis: PPI and pneumoboots\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: transplant surgery , hepatology\n Billing Diagnosis: GI Bleed with alcoholic cirrhosis\n ICU Care\n Nutrition:\n Impact with Fiber () - 10:44 PM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 706034, "text": "Ineffective Coping\n Assessment:\n Pt agitated at times, saying\nm going home\n , asking to call his\n wife. Oriented x 3, however has periods of delusions.\n Action:\n Pt reoriented when necessary. Wife called and will be in today\n Response:\n Pt resting comfortably most of the night, less agitation\n Plan:\n Continue to monitor for confusion, bed alarm for safety, offer\n emotional support\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd firm and distended, remaining the same over night, + BS. Sump drain\n decreased and draining only minimally to wall suction. JP in place\n draining 300-400ccs of ascitic fluid every two hours. VSS, tachy to 115\n at times, BP stable with Map above 65. C/o pain in left thigh in area\n of cellulitis. Area remains red and inflamed within traced margins. UOP\n 40-60cc/hr. Loose, guiac + stool continues. TF at goal with Banana\n Flakes added TID.\n Action:\n JP emptied Q 2 hours, replacement with NS dc\nd at this time, goal for\n pt to be 1.5l neg. Albumin 12.5g given a few times per shift for every\n 1l of ascitic fluid out of the drains. Dilaudid .5mg given for pain\n Response:\n Pt unchanged\n Plan:\n Continue to monitor fluid balance, Albumin x 48 hours as ordered.\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703343, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant thick, white secretions.\n Weak cough.\n Gag weak to absent.\n Action:\n ABGs x2.\n Response:\n Transplant Team and SICU Team aware of current ABG.\n No changes to ventilator settings.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702897, "text": "OH cirrhosis complicated by esophageal and rectal varices with prior\n episodes of bleeding admitted with painless BRBPR and hypotension.\n Presented to Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct\n 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On cmv mode 70% 650-16-5\n Suctioned for small amt of white sputum\n Breath sounds clear in the upper lobes but diminished in lower bases\n O2sats > 94%\n Abg 7.42-28-104-19 -4 7.40-29-109-19 -4\n Weight currently is up to 107.7 kg dry weight 98.2 kg.\n Action:\n Chest xray done this am\n Suctioned prn.\n Vap mouthcare as per protocol\n Protonix gtt infusing\n Head in reverse trendelenberg position\n Tyrdyne bed with rotation\n Abgs drawn\n Response:\n No episodes of desating\n Resp rate 16.\n O2sat > 94%.\n Plan:\n Monitor resp status closely\n Abg\ns as ordered\n Attempt to wean ventilator.\n Impaired Physical Mobility\n Assessment:\n No spontaneous movements\n Patient is unresponsive and intubated\n Perla # 3 bilaterally and reacts briskly\n On fentanyl and propofol gtts.\n Action:\n Weaning propofol and fentanyl gtts.\n Complete care.\n Skin care\n Tyradyne bed with rotation.\n Response:\n Overall generalized edema wgt up to 107.7\n No red pressure areas or pressure sores\n Tolerating the tyradyne bed with rotation.\n Weaning fentanyl and propofol gtts slowly patient continues to be\n unresponsive.\n Plan:\n Complete care\n Maintain skin integrity\n Continue with the tynadyne bed.\n" }, { "category": "Physician ", "chartdate": "2164-11-02 00:00:00.000", "description": "Intensivist Note", "row_id": 704735, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Albumin 25% (12.5g / 50mL) 6. Artificial Tear Ointment 7. Calcium\n Gluconate 8. Fentanyl Citrate 9. HYDROmorphone (Dilaudid) 10. Insulin\n 11. Micafungin\n 12. Pantoprazole 13. Phenylephrine 14. Phytonadione 15. Sodium Chloride\n 0.9% Flush 16. Sodium Chloride 0.9% Flush 17. Tetracaine HCl\n 18.Vancomycin\n 24 Hour Events:\n : Switched to dilaudid for pain. Fractionated bilirubin Tbili=8.8,\n Dbili=4.8. Not obstructed. Following cx were negative: UA, peritoneal\n fluid, and tip.\n : Dry heaving, no emesis or blood. Started zofran.\n Post operative day:\n POD#16 - ex lap duod ulcer repair\n POD#13 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Micafungin - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 01:14 PM\n Pantoprazole (Protonix) - 12:30 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 04:58 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: 36\nC (96.8\n HR: 112 (100 - 127) bpm\n BP: 106/51(70) {85/44(60) - 128/65(85)} mmHg\n RR: 20 (16 - 28) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.3 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 2 (2 - 185) mmHg\n Total In:\n 11,314 mL\n 2,129 mL\n PO:\n Tube feeding:\n 3,000 mL\n 592 mL\n IV Fluid:\n 7,367 mL\n 1,537 mL\n Blood products:\n 947 mL\n Total out:\n 9,707 mL\n 1,939 mL\n Urine:\n 492 mL\n 99 mL\n NG:\n 400 mL\n Stool:\n 50 mL\n Drains:\n 8,685 mL\n 1,840 mL\n Balance:\n 1,607 mL\n 190 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: 7.43/22/96./16/-6\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, Tender: to touch on LLQ\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: No(t) x 3), Follows simple\n commands\n Labs / Radiology\n 210 K/uL\n 9.1 g/dL\n 136 mg/dL\n 2.8 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 86 mg/dL\n 104 mEq/L\n 131 mEq/L\n 28.1 %\n 18.1 K/uL\n [image002.jpg]\n 02:45 AM\n 08:38 AM\n 06:46 PM\n 02:00 AM\n 04:45 AM\n 01:58 AM\n 01:59 AM\n 08:25 AM\n 02:03 AM\n 02:11 AM\n WBC\n 26.0\n 21.9\n 26.1\n 25.5\n 19.6\n 18.1\n Hct\n 33.7\n 32.1\n 32.5\n 32.6\n 28.8\n 28.1\n Plt\n 130\n 140\n 192\n 244\n 222\n 210\n Creatinine\n 2.0\n 1.9\n 2.0\n 2.2\n 2.4\n 2.8\n TCO2\n 18\n 15\n 16\n 15\n Glucose\n 102\n 128\n 155\n 162\n 125\n 136\n Other labs: PT / PTT / INR:23.8/54.0/2.3, ALT / AST:19/43, Alk-Phos / T\n bili:96/8.7, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.8 g/dL, LDH:209 IU/L, Ca:7.5 mg/dL, Mg:1.3\n mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION,\n OTHER, HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n Neurologic: Dilaudid prn, awake and following commands\n Cardiovascular: Vasodilatory shock, fluid repletion 3/4:1, on neo gtt\n for hypotension\n Pulmonary: on NC, no issues; pulm toilet, IS\n Gastrointestinal / Abdomen: protonix 40\", TF impact 3/4 strength at\n 125ml/hr. Continues to be tender to palp over LLQ, Transplant\n following.\n Nutrition: Tube feeding, advance to full strength.\n Renal: Foley, adequate UOP; creat rising, check urine lytes now, urine\n sediment.; hyponatremic, check serum osms.\n Hematology: stable Hct; INR elevated, received FFP yesterday.\n Endocrine: RISS, adequate control.\n Infectious Disease: micafungin started \n blood/ascites; vanc for coag neg staph tip cx; ophthalmology exam\n negative. Daily surv cx. All lines changed out. Follow vanco level\n prior to 4th dose (tonight). Ascites gram stain (-), cx pending.\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), J tube,\n , \n Wounds: c/d/i/\n Imaging:\n Fluids: NS, 3/4:1 of JP output\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:51 PM 125 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2164-10-19 00:00:00.000", "description": "Intensivist Note", "row_id": 702440, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 24 Hour Events:\n - Remains intubated, sedated/paralyzed, open abd\n - Continued to require Neo for BP support\n - Received albumin for volume resuscitation\n Post operative day:\n POD#2 - ex lap duod ulcer repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Vancomycin - 08:00 PM\n Fluconazole - 10:40 PM\n Piperacillin - 02:09 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Fentanyl (Concentrate) - 75 mcg/hour\n Propofol - 50 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.4\nC (97.6\n HR: 88 (85 - 95) bpm\n BP: 115/62(78) {86/48(61) - 115/66(81)} mmHg\n RR: 20 (15 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112 kg (admission): 98.2 kg\n CVP: 11 (9 - 273) mmHg\n Total In:\n 7,382 mL\n 2,652 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,600 mL\n 2,580 mL\n Blood products:\n 781 mL\n 72 mL\n Total out:\n 5,471 mL\n 2,060 mL\n Urine:\n 331 mL\n 110 mL\n NG:\n 160 mL\n 100 mL\n Stool:\n Drains:\n 4,980 mL\n 1,850 mL\n Balance:\n 1,911 mL\n 592 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (500 - 650) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Neuromusc Block\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n SPO2: 97%\n ABG: 7.43/28/69/20/-3\n Ve: 13 L/min\n PaO2 / FiO2: 115\n Physical Examination\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Ioban in place, with JP drains in place\n Left Extremities: (Edema: 2+), (Temperature: Cool)\n Right Extremities: (Edema: 2+), (Temperature: Cool)\n Skin: Jaundiced\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 104 K/uL\n 11.4 g/dL\n 139 mg/dL\n 2.4 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 39 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.5 %\n 13.7 K/uL\n [image002.jpg]\n 03:06 PM\n 04:00 PM\n 08:14 PM\n 08:24 PM\n 12:10 AM\n 12:16 AM\n 12:57 AM\n 01:04 AM\n 02:58 AM\n 06:14 AM\n WBC\n 13.2\n 13.7\n Hct\n 32.4\n 32.5\n Plt\n 77\n 114\n 104\n Creatinine\n 2.2\n 2.4\n TCO2\n 23\n 23\n 20\n 19\n 20\n 19\n Glucose\n 131\n 158\n 139\n Other labs: PT / PTT / INR:18.7/42.3/1.7, ALT / AST:18/47, Alk-Phos / T\n bili:40/6.5, Amylase / Lipase:58/81, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:187 mg/dL, Lactic\n Acid:4.0 mmol/L, Albumin:2.4 g/dL, LDH:174 IU/L, Ca:8.2 mg/dL, Mg:1.9\n mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy\n Neurologic: Neuro checks Q: 1 hr, Continue sedation, paralysis for now\n Cardiovascular: Requires Neo for BP support; wean as tolerated. If\n volume needed, will discuss albumin.\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen: Check bladder pressure, NPO. Drains in\n place.\n Nutrition: NPO\n Renal: Foley, Small amt UOP, HRS. Will contact Renal in case pt needs\n . Lytes q 6h.\n Hematology: Stable anemia.\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: Replcing JP output 1/2cc per 1 cc.\n Consults: Transplant, Nephrology\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress:\n Insufficiency / Post-op), Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Sheath - 08:00 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705823, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt continuing to drain approx 300cc serous fluid from medial\n JP\n Small amount of drainage from sump drain\n Upper J tube (red) to gravity with mod amount of bilious\n drainage\n Lower J tube to tube feeds, currently at goal\n Golden soft stools\n Abd soft, pos bs, c/o pain on L side of ABD\n NPO\n SBP 98-130\ns, MAP\ns >65 throughout shift\n Action:\n Monitoring JP, sump drain and J tube outputs\n 25% Albumin given for every 1L output from drains\n 0.5mg IVP Dilaudid given prn\n Midodrine as ordered\n Response:\n Pt expressing adequate pain relief from Dilaudid\n No change in outputs\n Pt fluid status even as of MN\n Plan:\n Continue to monitor drain outputs\n Pain management\n Keep Map >65\n Continue with Albumin as ordered\n Ineffective Coping\n Assessment:\n Pt very labile emotionally\n Aggressive towards staff intermittently\n Pt continuously stating he wants to go home\n Pt unable to acknowledge current condition\n Uncooperative with care\n Action:\n Continue to provide pt with emotional support\n Continue to reorient pt to current condition\n Acknowledge and validate pt\ns frustrations\n Response:\n Pt more cooperative after recieving nursing support and\n acknowledgement of pt\ns frustrations\n Pt continues to have moments of aggression and lashing out\n at staff, but more dirctable\n Plan:\n Psych consult, social work consult\n Continue to provide pot with emotional support\n" }, { "category": "Rehab Services", "chartdate": "2164-11-08 00:00:00.000", "description": "Physical Therapy Re-evaluation Note", "row_id": 705953, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 571.1 /\n Reason of referral: re-eval\n History of Present Illness / Subjective Complaint: 52 y/o M with etoh\n cirrhosis with variceal bleed, ascites, and encephalopthy, admitted\n from OSH with hematochezia and hypotension. Underwent angio and\n found to have GDA pseudoaneurysm, went to OR for ex-lap for\n duodenal arterial bleed, gastrotomy, duodenotomy, and draining\n jejunostomy. Extubated .\n Past Medical / Surgical History: see eval\n Medications: Insulin, dilaudid, albumin, meropenem, linezolid\n Radiology: CXR : bibasilar subsegmental atelectasis, low lung\n volumes; L LE US : (-) DVT\n Labs:\n 28.5\n 10.0\n 101\n 19.3\n [image002.jpg]\n Other labs:\n Activity Orders: as tolerated\n Social / Occupational History: see eval\n Living Environment: see eval\n Prior Functional Status / Activity Level: see eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, flat affect,\n following all commands\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 108\n 118/61\n 20\n 99% RA\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n 106\n 121/64\n 26\n 98% RA\n Total distance walked: n/a\n Minutes:\n Pulmonary Status: NARD, even and coordinated breathing\n Integumentary / Vascular: PEG, abdominal incision with drain to suction\n and large bulb drain, R IJ line; L thigh errythema, B knee incisions\n well-healed from TKR, (+) jaundice\n Sensory Integrity: intact to LT\n Pain / Limiting Symptoms: c/o 7/10 L sided abdominal pain and L thigh\n pain; worsens with activity despite IV dilaudid during re-eval\n Posture: supine in bed\n Range of Motion\n Muscle Performance\n WFL except L shoulder flexion limited to 75%, L knee/thigh limited to\n 25% ROM secondary to pain\n B grasp moderately strong, B elbow flexion 4+/5, B shoulder flexion\n 3-/5\n B DF , R quads 3+/5, L quads > , R hip flex > , L hip flex -\n pt unable to attempt secondary to pain\n Motor Function: moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Clarification:\n Patient was severely limited by abdominal pain and L thigh pain;\n patient was unable to roll onto side. Patient required max A to move R\n LE laterally on bed and total A to move L LE laterally on bed; once B\n LE off EOB, patient attempted to sit up with max A x 2 but only\n achieved sitting.\n Rolling:\n n/a\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n n/a\n\n\n\n\n\n\n Sit to Stand:\n n/a\n\n\n\n\n\n\n Ambulation:\n n/a\n\n\n\n\n\n\n Stairs:\n n/a\n\n\n\n\n\n\n Balance: Seated: unable to achieve secondary to pain\n Education / Communication: Educated patient as to role of PT,\n importance of mobility.\n Communicated with RN as to limited PT secondary to pain.\n Intervention: n/a\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Transfers, Impaired\n Clinical impression / Prognosis: 52 y/o male adm with GIB s/p multiple\n surgeries and prolonged hospital course. Patient presents with\n deficits consistent with deconditioning. Patient was severely limited\n by pain today. Patient is going for a CT scan which may reveal source\n of L thigh pain. Patient continues to need aggressive rehab on\n discharge to maximize functional mobility and independence.\n Goals\n Time frame: 1 week\n 1.\n Sup to sit with max A x 1\n 2.\n Sit EOB with B UE support and CG\n 3.\n Sit to stand with max A x 2\n 4.\n Assess transfers\n 5.\n L hip/knee ROM 50%\n 6.\n Supervision with HEP\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/week x 1 week\n Transfer assessment and training\n Balance training\n ROM L hip and knee\n strengthening ther-ex\n education\n RN Recommendations: Bed to chair with lift or slideboard to\n stretcher chair ONLY\n Face Time: 12:05-12:40\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2164-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704819, "text": "Shock, septic\n Assessment:\n Alert, oriented x3\n Pt follows commands\n Remains on neio\n Medial Jp switch back to self suction\n Lateral jp remains to self suction\n Medial jp output less than than this morning, dr. \n aware\n Pt c/o pain\n Hr 110-125\ns dr. , dr. aware\n Hct 28.1\n Na 131\n Magnesium 1.3\n Urine output 15-20cc/hr\n Action:\n Pt received dilaudid for pain\n Continue replacement of\n strength ns with jp output\n Pt is receiving one unit of blood\n Neo titrated to keep mean arterial pressure greater than 65\n Response:\n Pt with adequate relief of pain\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702888, "text": "OH cirrhosis complicated by esophageal and rectal varices with prior\n episodes of bleeding admitted with painless BRBPR and hypotension.\n Presented to Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct\n 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Physical Mobility\n Assessment:\n Patient is unresponsive and being sedated with propofol gtt and\n fentanyl gtt.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704821, "text": "Shock, septic\n Assessment:\n Alert, oriented x3\n Pt follows commands\n Remains on neo\n Medial Jp switch back to self suction\n Lateral jp remains to self suction\n Medial jp output less than than this morning, dr. \n aware\n Pt c/o pain\n Hr 110-125\ns dr. , dr. aware\n Hct 28.1\n Na 131\n Magnesium 1.3\n Urine output 15-20cc/hr , dr. , dr. aware\n Action:\n Pt received dilaudid for pain\n Continue replacement of\n strength ns with jp output, Giving\n 25% Albumin for every 1L of JP drainage out.\n Pt is receiving one unit of blood\n Neo titrated to keep mean arterial pressure greater than 65\n Response:\n Pt with adequate relief of pain\n Mean arterial pressure greater 65\n Plan:\n Continue to monitor\n Titrate neo to keep mean arterial pressure greater than 65\n A\n" }, { "category": "Respiratory ", "chartdate": "2164-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 703150, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL / Air\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: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on ventilator support.\n" }, { "category": "Physician ", "chartdate": "2164-11-08 00:00:00.000", "description": "Intensivist Note", "row_id": 705910, "text": "SICU\n HPI:\n HPI: 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior\n episodes of bleeding admit w/painless BRBPR and hypotension. At \n Hospital where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Chief complaint:\n Chief complaint:\n 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and drainage for\n massive UGIB secondary to pseudoaneurysm now with sepsis\n secondary to fungemia\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 1000 mL NS 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear\n Ointment 5. Bicitra 6. Calcium Gluconate 7. HYDROmorphone (Dilaudid) 8.\n Insulin 9. Meropenem 10. Micafungin 11. Midodrine 12. Miconazole Powder\n 2%\n 13. Octreotide Acetate 14. Ondansetron 15. Pantoprazole 16. Rifaximin\n 17. Sodium Chloride 0.9% Flush 18. Tetracaine HCl 19. Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 06:40 PM\n Post operative day:\n POD#22 - ex lap duod ulcer repair\n POD#19 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Micafungin - 02:10 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Hydromorphone (Dilaudid) - 02:12 AM\n Other medications:\n Flowsheet Data as of 05:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 117 (98 - 124) bpm\n BP: 105/51(71) {98/46(67) - 147/69(92)} mmHg\n RR: 17 (17 - 35) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.5 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 11 (1 - 11) mmHg\n Total In:\n 8,837 mL\n 1,438 mL\n PO:\n 960 mL\n Tube feeding:\n 3,000 mL\n 594 mL\n IV Fluid:\n 3,560 mL\n 705 mL\n Blood products:\n 897 mL\n 50 mL\n Total out:\n 8,478 mL\n 1,365 mL\n Urine:\n 1,058 mL\n 265 mL\n NG:\n 3,525 mL\n 475 mL\n Stool:\n Drains:\n 3,895 mL\n 625 mL\n Balance:\n 359 mL\n 73 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///14/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n mild)\n Abdominal: Distended, Tender: Left l abd flank thigh\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 101 K/uL\n 10.0 g/dL\n 153 mg/dL\n 3.6 mg/dL\n 14 mEq/L\n 3.8 mEq/L\n 106 mg/dL\n 112 mEq/L\n 141 mEq/L\n 28.5 %\n 19.3 K/uL\n [image002.jpg]\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n 02:29 PM\n 03:56 AM\n 01:36 AM\n 01:43 AM\n 05:29 PM\n 02:52 AM\n WBC\n 15.8\n 12.2\n 12.9\n 13.5\n 14.3\n 14.1\n 19.3\n Hct\n 28.5\n 27.6\n 26.4\n 25.8\n 25.4\n 29.0\n 28.5\n Plt\n 179\n 156\n 142\n 147\n 121\n 105\n 101\n Creatinine\n 3.3\n 3.0\n 3.0\n 3.0\n 3.3\n 3.8\n 3.8\n 3.6\n TCO2\n 12\n 14\n Glucose\n 122\n 165\n 183\n 156\n 127\n 115\n 136\n 153\n Other labs: PT / PTT / INR:26.3/95.8/2.5, ALT / AST:26/55, Alk-Phos / T\n bili:62/18.0, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.4 g/dL, LDH:161 IU/L, Ca:8.4 mg/dL, Mg:1.5\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB), ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, ACTIVITY INTOLERANCE, FUNGAL INFECTION, OTHER,\n HYPOMAGNESEMIA (LOW MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy, now with\n fungemia\n .\n Plan:\n Neuro:\n 1. AAOx3 but labile. On rafixim for prevention of the liver\n encephalopathy.\n 2. Pain well controlled on PRN diluadid\n CVS:\n 1. Vasodilator shock resolved\n 2. Use 25% albumin for fluid repletion\n PULM:Stable\n RENAL/FEN:\n 1. /CRF/hepatorenal syndrome worseining but UOP still\n satisfactory. We will continue to monitor CREA & BUN. Worsening RF is\n not believed to be due to the microfunging.\n 2. Replacing ascites output 1:1 with NS and 25% albumin\n 3. UA(-). Worsening renal fx, ID does not believe this is related\n to micafungin.\n 4. Magnesium replacement\n GI:\n 1. Rifaximin & lactulose for hepatic encephalopathy. Stop\n octeotride\n 2. Fluid repletion 3/4:1, dx lat DRESSING SUMP 150/8hrs and\n Medial JP 300/2hr NH4 79.\n 3. Change TF to full strength.\n ID:\n 1. On microfungin for \n will inquire for\n duration of treatment micafungin started continue for 2 weeks\n after 1st negative cx blood/ascites\n 2. Tip positive for Coag neg on Vancomycin (Vanc trough 21.9).\n All lines changed out. Need stop date.\n 3. Started on Vanc/meropenum, (Vanc trough 21.9) for peritoneal\n fluid;GNR and enterococci positive but sparse - sensitivities pending\n started on Meropenum.\n 4. Cellulites develop on the thigh. Schedule for CT scan to\n evaluate depth by primary service. Stop octreatride and skin breakdown.\n Awaiting final read of USG.\n HEME:\n 1. Hct stable.\n 2. He received Vit K\n 3. INR & aPTT raising secondary to ALF\n 4. Thrombocytopenia with HIT panel sent on ^nd pending\n ENDO: RISS. Glucose satisfactory controlled. Baseline cortisol level\n 14.4\n Psych: consult. Patient voices willingness to go to other facility.\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen (), PIV x1, JP x2, J-tube x2,\n A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Nutrition:\n Impact with Fiber () - 10:25 PM 125 mL/hour\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\n Total time spent: 38min\n" }, { "category": "Nursing", "chartdate": "2164-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704665, "text": "Shock, septic\n Assessment:\n Pt slept well majority of evening. Easy to arouse oriented\n x3. Asking to call family remaining want to go home. MAE. c/o abdominal\n and generalized pain.\n JPx2 with moderate amounts of ascetic/sersang drainage.\n Upper J-Tube to gravity. Moderate amounts of bilious output.\n Feeding lower J-Tube, at goal rate. Loose golden brown stool via FIB\n bag.\n Lungs clear diminished in bases. Strong productive cough.\n Sat\ns 94-96% RA. Using IS pulling about 1000-1350cc.\n Afebrile. NSR/ST 95-115. Continues on Neo.\n Action:\n Giving Dilaudid IVP for pain. Repositioning to comfort.\n Replacing JPx2 outputs with NS\n cc:cc. Giving 25% Albumin\n for every 1L of JP drainage out.\n Encouraging c/db.\n Titrating Neo for goal MAP >65.\n Response:\n Pt stating pain tolerable and improved. Continues to be able\n to rest well.\n Maintaining MAP >65.\n Pt 1.6L up at midnight.\n WBC\n Plan:\n Continue to monitor pain/comfort treating as needed and\n provide emotional support.\n Continue with NS\n cc:cc repletions with JP drain outputs\n and Albumin administration after 1L out.\n Titrate Neo to goal MAP >65.\n Encourage activity. Pt had stated yesterday ambition to\n pivot to chair today, requires max assist. PT/OT following pt.\n" }, { "category": "Nursing", "chartdate": "2164-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704816, "text": "Shock, septic\n Assessment:\n Alert, oriented x3\n Pt follows commands\n Neo at 1.5mcg/kg/min\n Medial Jp switch back to self suction\n Lateral jp remains to self suction\n Pt c/o pain\n Hr 110-125\ns dr. \n Hct 28.1\n Na 131\n Magnesium 1.3\n Urine output 15-20cc/hr\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702576, "text": "Impaired Physical Mobility\n Assessment:\n Pt intubated on mechanical ventilation sedated with propofol, paralyzed\n with ciasatracurium and fentynal gtt for pain. Pt unresponsive, no\n movement, TOF no response, PERRLA 2mm each.\n Action:\n Slight turns side to side q 2 hrs\n Complete care\n Response:\n Hypotensive x 3 with turns SBP 66, neo increased to 3mcg now back to\n 1.5, 500ml NS given.\n Plan:\n Slight turns only to change pressure points\n Assess skin a 4 hrs\n Complete care\n Impaired Skin Integrity\n Assessment:\n Beneath tegaderm on right lateral abd skin raised blisters noted on\n Thurs, since covered and incorporated into wound dsg.\n Action:\n Wound dsg reinforced by CNS\n Response:\n no further skin breakdown\n Plan:\n Continue plan of care.\n Ineffective Coping\n Assessment:\n Repeat ETOH/GI bleed, wife called today for update, brother in law at\n bedside to see pt and gives updates to wife. Wife lives near .\n Wife aware for .\n Action:\n emotional and informational support for family given.\n Response:\n family appropriately concerned\n Plan:\n Continue to provide information and emotional support to family.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n POD#2 s/p repair of duodenal ulcer EBL8000ml.\n Hct down slightly 29. 8\n Ionized calcium 1.6\n INR 1.7\n hypotensive with positionchanges\n open abd\n vent changes per Dr TV not PEEP changed rate\n Action:\n No PRBCs today want HCT >=28\n Calcium Gluconate 2 GMs PB given\n FFP total 3 units then Rt fem aline d/c\nd by IR\n Neo increased to 3mcg/kg and 500ml NS bolus for hypotension\n paralytic, pain med and sedative for open abd to prevent bleeding\n ABGs stable on current vent settings\n Response:\n unstable /critically ill\n Plan:\n Continue plan of care\n OR Sat for closure (KCI bed in OR already)\n q 6 hr labs\n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702645, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient has a open abdomen\n Hct 27.9-30\n Drains draining pink serous fluid\n Patient intubated and paralyzed. Patient on cistacurium and propofol\n gtts\n u/o 20-45cc/hr\n flexiseal in place and draining bloody liquid stool.\n ngt draining bloody drainage and per team DO NOT IRRIGATE\n breath sounds diminished in lower bases.\n Ionized caicium 1.01\n Action:\n Remains on neo gtt and titratrated to keep map > 65\n Hct drawn q6hrs\n Suctioned prn\n Cc/cc repletition iv given as ordered.\n Remains paralyzed and on citacurium gtt, fentanyl and propofol gtt.\n Protonix gtt infusing at 8mg/hr..\n Pipercillin iv given as ordered.\n Octreotide gtt infusing.\n Interventional radiology resident in and d/c\nd right femoral arterial\n sheath\n Site intact with good femoral and pedal pulses via Doppler.\n TOF done with no twitches.\n Response:\n Hct drawn q6hrs goal 28 hct 27.9-30\n Remains on neo for bp control\n Cc/cc repleteition for abd drainage\n To or today for abd closure.\n Plan:\n Monitor vital signs closely titrate neo gtt\n Continue to monitor the fentanyl,propofol and cistacurium gtts\n Monitor labs hcts q4-6hrs\n Monitor abd drainage\n Cc/cc repletion\n Monitor urine output and creatinine\n Continue with protonix and octreotide gtts\n To or today to have abdomen closed.\n Impaired Physical Mobility\n Assessment:\n Patient is unresponsive\n Patient is on cistacurium,fentanyl and propofol gtts\n Pupils #2 bilaterally and reacts briskly\n Patient is intubated and presently on cmv mode 60%-600-18 and 5 peep.\n Action:\n Turned from side to side q2-3 hrs but only slighltly due drop in bp\n Skin checked for redness.\n Range of motion done while being washed.\n Multipodus boots on to prevent foot drop\n Response:\n While being turned slightly , patient\ns bp drops\n Neo gtt infusing and being titrated to keep bp > 100syst.\n Plan:\n Continue to check skin\n Continue with total care regimen\n Patient to be transferred to a tyradyne bed after the or today.\n" }, { "category": "Echo", "chartdate": "2164-10-29 00:00:00.000", "description": "Report", "row_id": 89089, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Fungal bacteremia.\nHeight: (in) 72\nWeight (lb): 202\nBSA (m2): 2.14 m2\nBP (mm Hg): 130/52\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 16:16\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 and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: 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: Small pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. Regional left ventricular wall\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary\nartery systolic pressure could not be determined. There is a very small\ncircumferential pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity size with normal regional and\nhyperdynamic global systolic function. Very small circumferential pericardial\neffusion. No valvular pathology or pathologic flow identified.\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": "Respiratory ", "chartdate": "2164-10-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702567, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: No response sedated.\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:\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 on mechanical ventilation sedated with open abdomen.\n I.T 1.5 to allow better oxygenation due to open abdomen. MD do not want\n to increase PEEP. GI MDs do not want change on vent without their\n intervention please take notice.\n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702634, "text": "HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GIB\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient has a open abdomen\n Hct 27.9-30\n Patient intubated and paralyzed. Patient on cistacurium\n Action:\n Response:\n Hct drawn q6hrs goal 28 hct 27.9-30\n Plan:\n Monitor vital signs closely titrate neo gtt\n Continue to monitor the fentanyl,propofol and cistacurium gtts\n Monitor labs hcts q4-6hrs\n Monitor abd drainage\n Cc/cc repletion\n Monitor urine output and creatinine\n Continue with protonix and octreotide gtts\n To or today to have abdomen closed.\n Impaired Physical Mobility\n Assessment:\n Patient is unresponsive\n Patient is on cistacurium,fentanyl and propofol gtts\n Pupils #2 bilaterally and reacts briskly\n Patient is intubated and presently on cmv mode 60%-600-18 and 5 peep.\n Action:\n Turned from side to side q2-3 hrs but only slighltly due drop in bp\n Skin checked for redness.\n Range of motion done while being washed.\n Multipodus boots on to prevent foot drop\n Response:\n While being turned slightly , patient\ns bp drops\n Neo gtt infusing and being titrated to keep bp > 100syst.\n Plan:\n Continue to check skin\n Continue with total care regimen\n Patient to be transferred to a tyradyne bed after the or today.\n" }, { "category": "Nursing", "chartdate": "2164-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703024, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains unarousable, all sedation remains off, no response from deep\n painful stimuli or sternal rub. Pupils equal, appearing sluggish at\n times. Continues to have periods of rigors, resident witnessed and\n updated. Bp dropping briefly at the beginning of the shift to 80\n without obvious cause, pt became slightly tachy at that time as well.\n Neo continues for MAP greater than 65. HR 80\ns-90\ns all shift, NSR\n with occasional PVCs. CVP 8-11. Lungs clear, O2 sat 96-99%. Pt has BRB\n from NG tube, residents aware. UOP adequate. Melena stool from\n flexiseal.\n Action:\n When Bp decreased abruptly at beginning of the night, fluids bolused,\n Neo temporarily increased to 5 mcgs , labs sent and resident paged to\n room. JPs to bulb suction and emptied every hour with\n cc per cc\n replacement of NS. Lytes repleted overnight. Neo titrated down and\n currently at 1 mcg. Albumin 12.5 g given for every 1000cc of acitic\n fluid drained from JPs. Trophic TF started at 10cc/hr via J tube with\n the red J tube remaining to gravity and draining bilious drainage. TPN\n started and maintenance fluid kvo\nd. Pt on Triadyne bed with rotation\n all shift.\n Response:\n Pt stable following one brief episode of hypotension. HCT stable\n despite blood drainage from NG tube and melena stool.\n Plan:\n Continue to replace JP drainage Q 1 hour with NS repletion. Albumin to\n be given for every liter of ascites drained. Monitor TF and if pt\n tolerates may advance and discontinue TPN.\n" }, { "category": "Nutrition", "chartdate": "2164-10-23 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 703126, "text": "Subjective: Patient is tolerating tube feeds so far, RN.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185 cm\n 98.2 kg\n 100.4 kg ( )\n 28.5\n Pertinent medications: octreotide, protonix, neosynephrine drip, Kcl\n repletions, others noted\n Labs:\n Value\n Date\n Glucose\n 133 mg/dL\n 10:03 AM\n Glucose Finger Stick\n 150\n 04:00 AM\n BUN\n 56 mg/dL\n 02:07 AM\n Creatinine\n 2.0 mg/dL\n 02:07 AM\n Sodium\n 140 mEq/L\n 02:07 AM\n Potassium\n 3.2 mEq/L\n 10:03 AM\n Chloride\n 113 mEq/L\n 02:07 AM\n TCO2\n 18 mEq/L\n 02:07 AM\n PO2 (arterial)\n 95. mm Hg\n 10:03 AM\n PCO2 (arterial)\n 32 mm Hg\n 10:03 AM\n pH (arterial)\n 7.36 units\n 10:03 AM\n pH (urine)\n 5.0 units\n 11:23 AM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:03 AM\n Albumin\n 2.0 g/dL\n 02:07 AM\n Calcium non-ionized\n 7.7 mg/dL\n 02:07 AM\n Phosphorus\n 5.0 mg/dL\n 02:07 AM\n Ionized Calcium\n 1.13 mmol/L\n 10:03 AM\n Magnesium\n 1.8 mg/dL\n 02:07 AM\n ALT\n 15 IU/L\n 02:07 AM\n Alkaline Phosphate\n 69 IU/L\n 02:07 AM\n AST\n 51 IU/L\n 02:07 AM\n Amylase\n 132 IU/L\n 02:58 AM\n Total Bilirubin\n 8.6 mg/dL\n 02:07 AM\n WBC\n 12.2 K/uL\n 02:07 AM\n Hgb\n 11.3 g/dL\n 02:07 AM\n Hematocrit\n 33.8 %\n 02:07 AM\n Current diet order / nutrition support: Tube Feeds: 3/4 strength\n Novasource Renal @ 50mL/hr (1800kcal, 67g protein)\n TPN: Day 2 standard with non-standard lytes.\n GI: abd soft, distended, absent bowel sounds, NGT, feeding J-tube and\n draining J-tube\n Assessment of Nutritional Status\n 52 y.o. Male with ETOH cirrhosis complicated by esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, now s/p exploratory laparotomy, gastrotomy,\n duodenotomy with suturing of bleeding vessel, draining jejunostomy and\n feeding jejunostomy. Patient remains intubated, not sedated. TPN was\n started , and advanced to Day 2 standard today. Will provide goal\n TPN recommendations below. Tube feeds have also been started via\n feeding jejunostomy (distal to draining jejunostomy), and patient is\n tolerating trophic rate thus far. Patient does likely not need renal\n formula at this time. Goal tube feeding recommendations below.\n Medical Nutrition Therapy Plan - Recommend the Following\n Goal TPN will only be needed if tube feeds need to be\n stopped due to intolerance. Goal TPN: 80 kg 3-in-1: 2036kcals, 120g\n protein)\n Recommend changing tube feeding goal to Nutren 2.0 @ 45mL/hr\n + 30g Beneprotein (2267kcals, 112g protein).\n If diluted tube feeds are desired by team, recommend goal of\n strength Nutren 2.0 @ 60mL/hr + 30g Beneprotein.\n Monitor tolerance to tube feeds with abd exam; no residual\n checks with J-tube.\n Monitor lytes and hydration.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2164-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704926, "text": "52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in stomach, blood in 2nd part\n of duodenum, and large visible vessel in the proximal duodenum.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt awake all night\n Having abdominal/incisional pain\n Large amount of ascites drainage from JP tube\n Low urine out put all night\n Having several soft BM\n BUN and Creat increased\n Total bili up to 14 today\n Action:\n Med Q3hr with Dilaudid .5mg for pain\n Cont with\n cc:cc replacement\n Received albumen approx Q2-3 hrs for ascites drainage >1000cc\n Response:\n minimal pain relief from dilaudid\n Plan:\n Cont with current plan\n Emotional support for family and patient\n ? further investigation for pain/ increased Total bili\n" }, { "category": "Physician ", "chartdate": "2164-10-20 00:00:00.000", "description": "Intensivist Note", "row_id": 702632, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n Fluconazole\n Octreotide gtt\n Pantoprazole gtt\n Cisatra\n Zosyn\n ISS\n 24 Hour Events:\n On phenylephrine, given albumin.Planning on going back to OR on .\n 3 units FFP given prior to removal of femoral sheath by IR.Renal\n consulted, FeNa<0.1. Rec replacing drain loss cc per cc. No need for HD\n at this time.\n : Ca repletion.\n SHEATH - STOP 07:02 PM\n Post operative day:\n POD#3 - ex lap duod ulcer repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Vancomycin - 08:00 PM\n Fluconazole - 10:55 PM\n Piperacillin - 04:17 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Octreotide - 50 mcg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Propofol - 50 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.1\nC (97\n HR: 80 (77 - 96) bpm\n BP: 114/64(79) {66/40(48) - 134/70(92)} mmHg\n RR: 18 (18 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.6 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 15 (5 - 214) mmHg\n Total In:\n 7,262 mL\n 1,762 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,355 mL\n 1,762 mL\n Blood products:\n 908 mL\n Total out:\n 5,414 mL\n 1,560 mL\n Urine:\n 439 mL\n 185 mL\n NG:\n 150 mL\n 275 mL\n Stool:\n Drains:\n 4,825 mL\n 1,100 mL\n Balance:\n 1,848 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 650) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SPO2: 98%\n ABG: 7.43/27/107/19/-4\n Ve: 10.9 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: Icteric sclera\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: decreased BS on R base\n Abdominal: soft, open chevron incision with ioband,\n Left Extremities: (Edema: 3+)\n Right Extremities: (Edema: 3+)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 72 K/uL\n 10.6 g/dL\n 138 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.0 %\n 13.6 K/uL\n [image002.jpg]\n 06:14 AM\n 08:37 AM\n 08:53 AM\n 11:08 AM\n 02:07 PM\n 02:14 PM\n 07:51 PM\n 12:00 AM\n 12:45 AM\n 02:48 AM\n WBC\n 15.7\n 17.3\n 14.2\n 12.2\n 13.2\n 13.6\n Hct\n 31.5\n 31.6\n 29.8\n 28.6\n 27.9\n 30.0\n Plt\n 92\n 108\n 86\n 71\n 69\n 72\n Creatinine\n 2.4\n 2.5\n 2.6\n 2.6\n TCO2\n 19\n 19\n 20\n 19\n Glucose\n 140\n 140\n 133\n 138\n Other labs: PT / PTT / INR:18.5/41.2/1.7, ALT / AST:22/45, Alk-Phos / T\n bili:57/6.9, Amylase / Lipase:58/81, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:187 mg/dL, Lactic\n Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:199 IU/L, Ca:7.8 mg/dL, Mg:1.8\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, INEFFECTIVE\n COPING, GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n Neurologic: Intubated and sedated propofol gtt, fentanyl gtt,\n paralyzed with cisatracurium\n Cardiovascular: On neo gtt; albumin boluses as needed\n Pulmonary: intubated and sedated, paralyzed. Would cont to recommend\n controlling TV to prevent overdistension by maintaining TV\ns less than\n 10ml/kg of IBW.\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt. follow\n LFTs q 6 hours, likely pancreatitis superimposed\n Nutrition: NPO\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 1 to 1 with D51/2 NS with 50 of Bicarb. Hx of hepatorenal syndrome,\n renal following. No HD at this time\n Hematology: Serial Hct and coags and tx for unstable blood volume or\n obvious bleeding.\n Endocrine: RISS\n Infectious Disease: renal following. No HD at this time\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP)\n Wounds: Ioband with drains to suction\n Imaging: CXR today\n Fluids: Other, fluid repletion per renal recs\n Consults: Transplant\n Billing Diagnosis: Respiratory Failure; Acute Renal Failure; Post-op\n Hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 14 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2164-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702964, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: 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: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilator support.\n" }, { "category": "Rehab Services", "chartdate": "2164-11-02 00:00:00.000", "description": "Occupational Therapy Evaluation Note", "row_id": 704798, "text": "History\n Attending M.D.: \n Referral Date: \n Reason for Referral: Eval and treat\n Medical Dx / ICD - 9: 571.1\n Activity Orders: activity as tolerated\n HPI / Subjective Complaint: 52 yo M with etoh cirrhosis with variceal\n bleed, ascites, and encephalopthy, admitted from OSH with\n hematochezia and hypotension. Underwent angio and found to have GDA\n pseudoaneurysm, went to OR for ex-lap for duodenal arterial\n bleed, gastrotomy, duodenotomy, and draining jejunostomy. Extubated\n .\n Past Medical / Surgical History: Etoh cirrhosis, etoh hepatitis, upper\n GIB duodenal ulcer s/p clipping, OA s/p B TKA, chronic GIB \n internal hemorrhoids\n Medications: vanco, dilaudid, albumin,\n Labs\n Hematocrit (serum): 28.1 ...\n Hematocrit (whole blood - calculated): 34 ...\n Hemoglobin: 9.1 ... g/dl\n WBC: 18.1 ...\n Platelet Count: 210 ...\n Occupational History\n Performance Patterns: lives with wife and 16 year old daughter\n Baseline Occupational Performance: I ADLS, I adls, active\n Environmental History: a few stairs to enter\n Current Activities of Daily Living\n Self Feeding: (Dependent)\n Grooming: (mod A)\n UE Bathing: (mod A)\n LE Bathing: (max A)\n UE Dressing: (mod A)\n LE Dressing: (max A)\n Toileting: (Dependent)\n Performance Skills\n Process Skills: pt AO x3, able to attend to conversation and task, able\n to follow step commands, fiar insight, good safety awareness\n Communication / Interactive Skills: Able to make needs known,\n appropriate conversation, ableto make and maintain eye contact\n Motor Skills - Functional Transfers\n Rolling: (max A)\n Supine / Side-lying to Sit: (mod A)\n Functional Transfers Clarification: Pt requires mod A x1 and min A x1\n to go from supine-sit. Assist needed to get legs off bed and push up\n from side lying.\n Functional Balance: Pt able to sit EOB approximately 8 minutes with min\n A initially but able to progress to CG. Pt limited by tachycardia at\n EOB and pt returned to supine, deferred transfer\n Aerobic Capacity: Rest\n Rest HR: 117\n Rest BP: 106/54\n Rest RR: 21\n Rest O2 sat: 94 %\n Aerobic Capacity: Activity\n Activity HR: 144\n Activity RR: 27\n Activity O2 sat: 96 %\n Aerobic Capacity: Recovery\n Recovery HR: 122\n Recovery BP: 125/59\n Recovery RR: 27\n Recovery O2 sat: 98 %\n Range of Motion\n Range of Motion: B UE WFL\n Muscle Performance: strength, power, endurance\n Muscle Performance: B UE 4/5 strength\n Additional Performance Skills\n Motor Control: no abnormal movements noted\n Coordination: NT\n Pain (0 - 10): 8 / 10\n Limiting Symptoms: pt limited at EOB by tachycardia so transfer not\n assessed\n Sensation: Intact B UE\n Integumentary: central line, foley, flexiseal, JP drain, abd drain\n Team Communication: with RN, co-treat with PT\n Education: role of OT\n Diagnosis\n Diagnosis 1: decreased adls\n Diagnosis 2: decreased balance\n Diagnosis 3: decreased activity tolerance\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: 52 year old male with GDA\n pseudoaneurysm who presents as above. Pt demonstrates deconditioning,\n decreased balance and decreased activity tolerance. Pt limited today\n by tachycardia at EOB so further functional mobility/adls deferred. Pt\n is functioning well below baseline at this time and will need intense\n rehab once medically stable.\n Goals: patient / family, objective, measurable\n Goal 1: mod a le adls\n Goal 2: sit eob Ily for 5 minutes for adls\n Goal 3: min a rolling for hygiene\n Anticipated Discharge: Rehab\n Treatment Plan: Interventions; patient / family education, community\n resources\n Treatment Plan: f/u for adls, balance, functional mobility, d/c\n planning\n Frequency / Duration: x week\n Therapist Information\n Therapist's Name: \n Date: \n Time: 11-1140\n Pager #: \n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702734, "text": "Impaired Physical Mobility\n Assessment:\n Patient chemically paralyzed, no spontaneous movements, no\n cough\n 4 eye twitches noted on TOF however the goals of the\n treatment: to be compliant with the ventilator and to prevent\n evisceration of abdominal wound, are being met, so paralytics were not\n increased.\n Action:\n check TOF q 4 hours\n Sedated on Propofol\n Pain treated with Fentanyl gtt\n Response:\n remained chemically paralyzed when sent to OR for possible\n abdominal closure\n Plan:\n Post\n op patient returned not reversed from paralytics\n Will not restart , not keep paralyzed\n post-op\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n HCT ~29\n No S+S of active bleeding\n Neo gtt to maintain MAP > 65\n Propofol for sedation while paralyzed\n Fentanyl gtt for pain control\n Protonix and Octreotide drips\n Paralyzed, on , no spontaneous movements, not\n breathing over the vent\n Action:\n To OR for abdominal closure\n In OR 1 unit platelets, 2 units FFP, 2 units PRBC, 2 doses\n Albumin, 1700 cc crystaloid given. EBL 500 cc\ns, urine output 600.\n Response:\n Returned from OR with closed abdomen\n NGT to low wall suction\n X2 Abdominal JP drains to bulb suction. Will do\n cc per cc\n fluid replacement for JP drains q 2 hours with NS, surgical team will\n order albumin for every liter of JP output.\n X2 Jejunostomy tubes\n together to gravity drainage\n Continues on Neo gtt for MAP > 65\n discontinued\n Propofol, fentanyl, octreotide, protonix drips continue\n HCT 34\n ABG showing mild metabolic acidosis\\\n Ventilated\n Plan:\n Continue close monitoring and management as outlined in the\n response part of the note.\n Patient and family support\n" }, { "category": "Respiratory ", "chartdate": "2164-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702874, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 83.5\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / 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: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated, Underlying\n illness not resolved\n" }, { "category": "Physician ", "chartdate": "2164-10-24 00:00:00.000", "description": "Intensivist Note", "row_id": 703284, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension, now s/p exploratory laparotomy, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy.\n Chief complaint:\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n Vit K\n albumin\n vanco\n Fluconazole\n zosyn\n ISS\n Nexium gtt\n Octreotide gtt\n 24 Hour Events:\n : Tubefeeds changed to Nepro 1/2 strength, ordered for urine 24hr\n Cr clearance. Removed L femoral without complication. Vit K x 1\n dose\n TRAUMA LINE - STOP 11:07 AM\n Post operative day:\n POD#7 - ex lap duod ulcer repair\n POD#4 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:01 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Fluconazole - 10:00 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 09:59 AM\n Other medications:\n Flowsheet Data as of 06:15 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: 37\nC (98.6\n HR: 121 (91 - 123) bpm\n BP: 104/55(70) {88/50(63) - 137/77(96)} mmHg\n RR: 18 (14 - 20) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101.2 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 11 (0 - 270) mmHg\n Total In:\n 8,224 mL\n 2,007 mL\n PO:\n Tube feeding:\n 385 mL\n 120 mL\n IV Fluid:\n 6,267 mL\n 1,463 mL\n Blood products:\n 500 mL\n 150 mL\n Total out:\n 11,903 mL\n 4,010 mL\n Urine:\n 988 mL\n 270 mL\n NG:\n 750 mL\n 450 mL\n Stool:\n 300 mL\n Drains:\n 10,165 mL\n 2,990 mL\n Balance:\n -3,679 mL\n -2,003 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 65 (65 - 650) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 47\n PIP: 19 cmH2O\n Plateau: 19 cmH2O\n Compliance: 46.4 cmH2O/mL\n SPO2: 97%\n ABG: 7.38/29/94./16/-6\n Ve: 12.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), Transmitted breath sounds\n bilaterally\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli, No(t) Unresponsive), Slight\n mov't with noxious stimuli. No spont mov't\n Labs / Radiology\n 69 K/uL\n 11.8 g/dL\n 154 mg/dL\n 1.8 mg/dL\n 16 mEq/L\n 3.6 mEq/L\n 60 mg/dL\n 117 mEq/L\n 142 mEq/L\n 34.6 %\n 12.9 K/uL\n [image002.jpg]\n 08:06 PM\n 08:15 PM\n 02:07 AM\n 02:17 AM\n 10:03 AM\n 02:06 PM\n 02:13 PM\n 08:11 PM\n 02:05 AM\n 02:24 AM\n WBC\n 12.8\n 12.2\n 14.1\n 13.4\n 12.9\n Hct\n 35.5\n 33.8\n 35.3\n 33.8\n 34.6\n Plt\n 78\n 72\n 80\n 74\n 69\n Creatinine\n 2.1\n 2.0\n 1.9\n 1.8\n TCO2\n 18\n 17\n 19\n 19\n 18\n Glucose\n 119\n 137\n 133\n 145\n 154\n Other labs: PT / PTT / INR:21.0/65.6/2.0, ALT / AST:9/36, Alk-Phos / T\n bili:65/8.5, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:213 IU/L, Ca:7.4 mg/dL, Mg:1.9\n mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n Neurologic: Intubated and of sedation\n Cardiovascular: On neo gtt; albumin 12.5g per 1L ascites. Wean neo as\n tolerated.\n Pulmonary: Intubated, s/p bronch for mucus plug . Now on PSV\n Will try on .\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt, TPN, TF\n nepro 1/2 strength at 20 cc/hr (not advancing)\n Nutrition: TPN\n Renal: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Change to RL given the hyperchloremic acidosis Hx of\n hepatorenal syndrome, renal following. No HD at this time. 24 hr urine\n creatinine ordered\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: vanc / zosyn / fluc; f/u cx\n Lines / Tubes / Drains: Foley, NGT, J-Tube, ETT, Surgical drains\n (hemovac, JP)\n Wounds: c/d/i\n Imaging:\n Fluids: Repleting every cc of JP output with 1/2 cc NS\n Consults: General surgery, Transplant, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n NovaSource Renal () - 05:53 PM 20 mL/hour\n TPN without Lipids - 08:21 PM 45.5 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots,\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2164-10-21 00:00:00.000", "description": "Intensivist Note", "row_id": 702783, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n GI Bleed\n PMHx:\n PAST MEDICAL & SURGICAL HISTORY:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n .\n MEDICATIONS (per d/c summary )\n ursodeoxycholic acid 200 mg TID\n protonix 40 mg \n lactulose 30 ml \n furosemide 40 mg daily\n spironolactone 50 mg daily\n nadolol 20 mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY: Currently disabled. Lives with wife and daughter. Drank\n 1/2-1 pint of vodka daily for many years until quitting in .\n Non-smoker. Never used IVD. No tattoos.\n .\n FAMILY HISTORY: Dad died of ETOH cirrhosis.\n Current medications:\n 1000 mL NS 5. Albumin 25% (12.5g / 50mL) 6. Albumin 25% (12.5g / 50mL)\n 7. Artificial Tears\n 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Fentanyl Citrate 11. Fluconazole\n 12. Insulin 13. Insulin 14. Octreotide Acetate 15. Pantoprazole 16.\n Phenylephrine 17. Piperacillin-Tazobactam\n 18. Propofol\n 24 Hour Events:\n Pt to OR for closure of abdominal wound. Procedure well tolerated.\n Frequent desats with turning. Albumin x1. Right femoral art line\n pulled s/p blood products\n OR SENT - At 01:30 PM\n OR RECEIVED - At 05:00 PM\n Post operative day:\n POD#4 - ex lap duod ulcer repair\n POD#1 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Fluconazole - 10:56 PM\n Piperacillin - 03:26 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Phenylephrine - 3.5 mcg/Kg/min\n Propofol - 50 mcg/Kg/min\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 78 (78 - 87) bpm\n BP: 105/60(75) {80/50(60) - 132/73(95)} mmHg\n RR: 16 (16 - 18) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.6 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 11 (8 - 17) mmHg\n Total In:\n 7,664 mL\n 500 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,770 mL\n 475 mL\n Blood products:\n 1,894 mL\n 25 mL\n Total out:\n 4,915 mL\n 325 mL\n Urine:\n 490 mL\n 110 mL\n NG:\n 525 mL\n 175 mL\n Stool:\n Drains:\n 2,600 mL\n 40 mL\n Balance:\n 2,749 mL\n 175 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 40 cmH2O/mL\n SPO2: 94%\n ABG: 7.38/33/94/19/-4\n Ve: 9.6 L/min\n PaO2 / FiO2: 157\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-tender, Distended\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Intubated, sedated,\n Labs / Radiology\n 127 K/uL\n 12.3 g/dL\n 84 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 106 mEq/L\n 138 mEq/L\n 33.9 %\n 19.9 K/uL\n [image002.jpg]\n 06:05 AM\n 06:23 AM\n 10:00 AM\n 10:14 AM\n 02:58 PM\n 03:24 PM\n 05:41 PM\n 06:09 PM\n 02:58 AM\n 03:09 AM\n WBC\n 14.2\n 19.9\n Hct\n 28.8\n 29.0\n 33\n 35\n 34.5\n 33.9\n Plt\n 72\n 96\n 127\n Creatinine\n 2.5\n 2.9\n TCO2\n 19\n 22\n 22\n 21\n 22\n 20\n Glucose\n 99\n 93\n 101\n 82\n 84\n Other labs: PT / PTT / INR:18.3/39.2/1.7, ALT / AST:22/60, Alk-Phos / T\n bili:66/8.0, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:226 mg/dL, Lactic\n Acid:3.2 mmol/L, Albumin:2.4 g/dL, LDH:214 IU/L, Ca:8.0 mg/dL, Mg:1.9\n mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY, IMPAIRED SKIN INTEGRITY, INEFFECTIVE\n COPING, GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,\n GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated and sedated propofol gtt, fentanyl gtt\n wean off as\n tolerated; Cisatracurium now off.\n CVS: Hypotension\n remains on neo gtt; albumin boluses as needed\n PULM: intubated and sedated. Presumably in . Cont to have\n hypoxemia, however, minimizing PEEP per primary team to minimize Liver\n and variceal congestion; Cont with increased inspiratory times but\n would limit TV to ~8ml/kg and keep Pplat < 30. Daily ABG, CXR\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 1 to 1 with D51/2 NS with 50 of Bicarb. Hx of hepatorenal syndrome,\n renal following. No HD at this time\n FEN/GI: NPO, protonix drip, octreotide gtt, likely pancreatitis\n superimposed s/p staged closure\n ID: zosyn\n HEME: Hct stable,but type and crossed for 4 units\n follow serial\n Hct\n ENDO:RISS or insulin gtt for glucose control < 150.\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, R IJ triple lumen, R SC trauma line (considering\n changing line for dialysis), ascites drain, JP (adjacent to duodenum),\n NGT, J-tube; L Fem (would d/c today).\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis: Respiratory Failure; Acute Renal Failure; Liver\n Failure; GI Bleed; Post-op Hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI gtt\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31\n" }, { "category": "Physician ", "chartdate": "2164-10-23 00:00:00.000", "description": "Intensivist Note", "row_id": 703090, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n EGD showed 1 cord of non-bleeding grade II varices at 36 cm, 2 linear\n non-bleeding ulcers (6-7 mm) in the distal duodenal bulb, clotted blood\n in the antrum, and slight ulceration of the ampulla of Vater with a\n small amount of blood on it.\n PMHx:\n ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n 1000 mL NS\n Albumin 25% (12.5g / 50mL)\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Fentanyl Citrate\n Fluconazole\n Insulin\n Octreotide Acetate\n Pantoprazole\n Phenylephrine\n Piperacillin-Tazobactam\n Potassium Chloride\n Propofol\n Vancomycin\n 24 Hour Events:\n weaned neo\n continued replacement of each liter of ascites with 12.5g (25%)\n albumin\n TPN started\n TF started at 10 cc/hr\n PAN CULTURE - At 12:00 PM\n EEG - At 05:30 PM\n Post operative day:\n POD#6 - ex lap duod ulcer repair\n POD#3 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:26 AM\n Vancomycin - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Fluconazole - 10:29 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 1.5 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 106 (56 - 106) bpm\n BP: 111/57(73) {71/44(52) - 142/77(98)} mmHg\n RR: 16 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.4 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 10 (6 - 182) mmHg\n Total In:\n 10,368 mL\n 1,460 mL\n PO:\n Tube feeding:\n 16 mL\n 51 mL\n IV Fluid:\n 10,014 mL\n 1,054 mL\n Blood products:\n 200 mL\n 143 mL\n Total out:\n 9,033 mL\n 2,435 mL\n Urine:\n 1,173 mL\n 220 mL\n NG:\n 1,100 mL\n 250 mL\n Stool:\n 500 mL\n Drains:\n 6,260 mL\n 1,965 mL\n Balance:\n 1,335 mL\n -975 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 99%\n ABG: 7.39/27/91./18/-6\n Ve: 10.9 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: No acute distress, occassional rigors\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, JP drains\n serosanginous\n Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm), (Pulse\n - Dorsalis 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: Sedated\n Labs / Radiology\n 72 K/uL\n 11.3 g/dL\n 137 mg/dL\n 2.0 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 56 mg/dL\n 113 mEq/L\n 140 mEq/L\n 33.8 %\n 12.2 K/uL\n [image002.jpg]\n 03:06 AM\n 03:16 AM\n 09:30 AM\n 09:42 AM\n 03:40 PM\n 03:48 PM\n 08:06 PM\n 08:15 PM\n 02:07 AM\n 02:17 AM\n WBC\n 13.6\n 13.0\n 13.1\n 12.8\n 12.2\n Hct\n 34.4\n 34.2\n 34.5\n 35.5\n 33.8\n Plt\n 90\n 81\n 84\n 78\n 72\n Creatinine\n 2.6\n 2.5\n 2.3\n 2.1\n 2.0\n TCO2\n 19\n 15\n 18\n 18\n 17\n Glucose\n 118\n 119\n 100\n 114\n 119\n 137\n Other labs: PT / PTT / INR:20.1/53.0/1.8, ALT / AST:15/51, Alk-Phos / T\n bili:69/8.6, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:1.8 mmol/L, Albumin:2.0 g/dL, LDH:179 IU/L, Ca:7.7 mg/dL, Mg:1.8\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, INEFFECTIVE COPING, GASTROINTESTINAL BLEED,\n LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, now s/p exploratory laparotomy,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining\n jejunostomy.\n .\n Plan:\n Neuro: Intubated, rigors, f/u EEG. Off sedation.\n CVS: On neo gtt weaning down\n wean as tolerated; albumin 12.5g per 1L\n ascites\n PULM: Intubated, Daily ABG, CXR. Continue tidal volume 600mL, low PEEP,\n wean FiO2 as tolerated.\n RENAL: Foley, follow UOP, follow lytes; replacing ascites drain output\n 0.5 to 1 with NS. Hx of hepatorenal syndrome, renal following. No HD at\n this time. Cr improving.\n FEN/GI: NPO, protonix drip, octreotide gtt, TPN, TF nutren renal at\n 10cc/hr\n ID: vanc / zosyn / fluc; f/u cx\n HEME: Hct stable in setting of melenotic stool, type and crossed for 4\n units.\n ENDO: Insulin RISS\n PPX: PPI IV gtt, pneumoboots\n ACCESS: ETT, foley, s/p R IJ triple lumen, L fem , R SC trauma line\n (considering changing line for dialysis), PIV x1, JP x2, Remove\n femoral line. NGT, J-tube\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Consults: West 1\n Billing Diagnosis: Duodenal bleed\n ICU Care\n Nutrition:\n TPN without Lipids - 08:40 PM 41. mL/hour\n NovaSource Renal () - 10:25 PM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:19 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703353, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant thick, white secretions.\n Weak cough.\n Gag weak to absent.\n Negative 2\n Liters.\n Action:\n ABGs x2.\n Response:\n Transplant Team and SICU Team aware of current ABG.\n No changes to ventilator settings.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining clear, thick drainage. Abdomen softly\n distended,\n BS present.\n JP\nS draining ascitic fluid.\n +++ generalized edema.\n Hemodynamically stable.\n Pain as e/b HR 115-120\n Action:\n JP drainage replaced with LR 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2.\n Response:\n Stable HCT 34.6, patient is opening eyes to call, not following any\n commands or moving any extremities, PERL, off sedation more than 24\n hours now. Fluid balance of -3.6L by MN. Maintaining map >60, still\n tachycardic 110-123,TF at 20ml/hr, do not advance till further order.\n JP drained 9855 ml in 24 hours and replaced with 10bags of 12.5gm H\n alb. Creat 1.8 this morning, liver enzymes wnl.\n Plan:\n Cont to monitor, replace alb for 1L of JP out put, monitor neuro ,\n renal and liver status, and S& S of bleeding.\n" }, { "category": "Respiratory ", "chartdate": "2164-10-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702065, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 1400\n Comments: Pt intubated in IR during procedure for airway protection and\n due to active bleeding. Pt now in OR and will be transferred to SICU\n service.\n" }, { "category": "Physician ", "chartdate": "2164-10-18 00:00:00.000", "description": "Intensivist Note", "row_id": 702230, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n Upper and lower GI bleed\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n CeftriaXONE 6. Cisatracurium Besylate 7. Fentanyl Citrate 8.\n Fluconazole 9. Fluconazole 10. Insulin\n 11. Octreotide Acetate 12. Pantoprazole 13. Phenylephrine 14.\n Piperacillin-Tazobactam 15. Piperacillin-Tazobactam\n 16. Propofol 17. Vancomycin\n 24 Hour Events:\n ENDOSCOPY - At 08:00 AM\n INTUBATION - At 02:00 PM\n intubated in IR\n INVASIVE VENTILATION - START 02:00 PM\n SHEATH - START 08:00 PM\n ARTERIAL LINE - START 08:20 PM\n TRAUMA LINE - START 08:20 PM\n TRAUMA LINE - START 09:05 PM\n OR RECEIVED - At 09:14 PM\n Post operative day:\n POD#1 - ex lap duod ulcer repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Fluconazole - 09:49 PM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Octreotide - 50 mcg/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Cisatracurium - 0.15 mg/Kg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 50.2 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 08:00 AM\n Fentanyl - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:45 PM\n Other medications:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.1\nC (97\n HR: 96 (87 - 133) bpm\n BP: 104/53(67) {83/49(61) - 141/88(110)} mmHg\n RR: 20 (16 - 30) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 9 (4 - 19) mmHg\n Bladder pressure: 38 (30 - 38) mmHg\n Total In:\n 27,373 mL\n 1,822 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,258 mL\n 1,722 mL\n Blood products:\n 18,965 mL\n 100 mL\n Total out:\n 10,203 mL\n 1,732 mL\n Urine:\n 378 mL\n 102 mL\n NG:\n 425 mL\n Stool:\n 350 mL\n Drains:\n 250 mL\n 1,630 mL\n Balance:\n 17,170 mL\n 90 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): 506 (506 - 630) mL\n PS : 10 cmH2O\n RR (Set): 20\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Neuromusc Block\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n SPO2: 100%\n ABG: 7.30/44/98/22/-4\n Ve: 9.6 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : bases, Diminished:\n bases)\n Abdominal: open laparotomy with ioban covering\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Sedated, paralyzed\n Labs / Radiology\n 89 K/uL\n 10.8 g/dL\n 189\n 1.6 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 117 mEq/L\n 144 mEq/L\n 30.7 %\n 6.9 K/uL\n [image002.jpg]\n 07:22 PM\n 07:30 PM\n 08:20 PM\n 08:27 PM\n 11:08 PM\n 11:14 PM\n 12:13 AM\n 03:36 AM\n 03:52 AM\n 04:00 AM\n WBC\n 3.2\n 3.5\n 5.6\n 6.9\n Hct\n 24.7\n 28\n 28.9\n 37\n 34.0\n 30.7\n Plt\n 95\n 76\n 114\n 89\n Creatinine\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 22\n 20\n 23\n Glucose\n 249\n 233\n 144\n 170\n 130\n 292\n 189\n Other labs: PT / PTT / INR:17.9/47.3/1.6, ALT / AST:19/47, Alk-Phos / T\n bili:30/6.1, Amylase / Lipase:58/81, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:161 mg/dL, Lactic\n Acid:2.7 mmol/L, Albumin:2.1 g/dL, LDH:151 IU/L, Ca:8.5 mg/dL, Mg:1.5\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, to OR for duodenal artery ulceration\n Neurologic: Intubated and sedated propofol gtt, fentanyl gtt, paralyzed\n with cisatracurium,\n Cardiovascular: BRBPR and UGI bleeding: Intraop: EBL 8 liters, 12U\n pRBC, 12U FFP, 3 6-packs of platelets\n -x-fuse PRN PRBC, Platelets\n -PRN neo, vasopressin\n -Aline, right femoral arterial sheath, right SCL . Follow CBC &\n Coags q4 hours,\n Pulmonary: intubated and sedated, paralyzed\n lung protective vent with\n TV ml/kg IBW with Pplat < 30.\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt, gastric\n ph q2hours (must stay above 5),\n Nutrition: NPO\n Renal: Foley, Follow UOP, follow Calcium, potassium, magnesium, UOP 25\n mls for past 2 hours, replacing drain output 0.5 to 1 with D51/2 NS\n with 50 of Bicarb\n may need CVVH to remove volume.\n Hematology: Monitor CBC q 4 hours HCT stable, s/p 2 U PRBC in SICU and\n 1 unit platelets\n maintain T&C of PRBC and FFP\n Endocrine: RISS, Insulin drip if necessary to keep Glucose < 150.\n Infectious Disease: Fluconazole 400 mg IV Q24H, CeftriaXONE 1 gm IV\n Q24H, Vancomycin, zosyn, duodenum spilled into surgical field upon\n opening\n cont antibx for now and d/w per primary team\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n 18 g R AC, , LIJ triple lumen, right radial a line, left\n femoral , right femoral arterial sheath\n Wounds: ioban dressing over open laparotomy\n Imaging:\n Fluids: D5 1/2 NS, replacing drain output 0.5 to 1 with D51/2 NS with\n 50 of Bicarb\n Consults: Transplant\n Billing Diagnosis: Respiratory Failure; Post-op hypotension.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Sheath - 08:00 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 37 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702400, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains paralyzed and sedated\n Abd remains open, multiple drains to wall suction, copious\n amounts of serosang drainage\n NGT to LCS, sump port backing up frequently, bloody drainage\n J tube to LCS, min amounts bilious drainage\n MAP 65-70, SBP 90-112\n Plt 77\n Hct stable, coags stable\n Remains on CMV 60% FiO2, PEEP 5, TV 500, R 20\n Abg at start of shift 7.34/40/79/-\n LS clear, diminished at bases\n Remains oliguric, u/o 10-20cc/hr\n Cr 2.2\n Pt wgt up 14kg\n Action:\n Octreotide and protonix gtt\n NGT flushed by MD\ns x3\n Neo gtt to keep MAP >65\n Fluid bolus x1\n Received Plts x1\n 1/2cc:cc repletion for wound output\n Tidal volume increased to 650 from 500 MD despite\n conversation about increasing PEEP or FiO2\n Response:\n Plt 114, 104\n Able to slowly wean neo gtt\n Abg worsening to 7.41-7.43/29-31/67-73/-, MD ,\n MD , and MD Concchi notified, discussed with chief on transplant\n team, no changes made to vent settings, despite voicing concerns.\n Monitoring abg\ns closely\n Cr 2.4\n Labs remain stable\n Plan:\n Monitor abg\ns closely, discuss vent setting in rounds this\n Am with attendings present\n Monitor outputs\n Continue with 1/2cc:cc repletion\n Monitor labs\n Wean neo as tolerated\n OR or for abd closure\n" }, { "category": "Nursing", "chartdate": "2164-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705090, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Total CO2 critically low 10.\n JP drains x2 continue to drain large amounts serosanguinous fluid.\n Abdominal sump draining small amt serous fluid.\n Passing copious amounts loose stool on bedpan and incontinent during\n evening.\n Proximal j-tube draining large amounts yellowish bile.\n Diminished hourly urine output.\n Action:\n Bicarb 150cc in 500cc ns bolus, then Bicarb in D5W gtts started.\n Cc/cc NS replacement of total JP drainage.\n Urine sent for creatinine clearance.\n Ascites fluid sent for lytes.\n Mag and calcium repleted.\n Flexiseal system applied to quantify stool and protect skin.\n Response:\n Total CO2 slow to improve, 14 this am.\n Mg and Ca improved, no repletion required this am.\n Plan:\n Ongoing bicarb replacement.\n Continue cc/cc jp drainage replacement.\n Replete lytes.\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705094, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Total CO2 critically low 10.\n JP drains x2 continue to drain large amounts serosanguinous fluid.\n Abdominal sump draining small amt serous fluid.\n Passing copious amounts loose stool on bedpan and incontinent during\n evening.\n Proximal j-tube draining large amounts yellowish bile.\n Diminished hourly urine output.\n Action:\n Bicarb 150cc in 500cc ns bolus, then Bicarb in D5W gtts started.\n Cc/cc NS replacement of total JP drainage.\n Urine sent for creatinine clearance.\n Ascites fluid sent for lytes.\n Mag and calcium repleted.\n Flexiseal system applied to quantify stool and protect skin.\n Response:\n Total CO2 slow to improve, 14 this am.\n Mg and Ca improved, no repletion required this am.\n Approximately 500cc positive fluid balance at this time.\n Plan:\n Ongoing bicarb replacement.\n Continue cc/cc jp drainage replacement.\n Replete lytes as indicated.\n Shock, septic\n Assessment:\n Afebrile.\n BP requiring pressor support.\n Action:\n Neo gtts titrated as tolerated.\n Albumin administered as ordered.\n Vanco held due to elevated trough.\n Response:\n Unable to wean neo below 0.6mcg/kg/min as tachycardia>130 resulted\n followed by hypotensive map<60.\n WBC continues to decrease.\n Plan:\n Draw vanco trough this evening prior to scheduled dose.\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703258, "text": "52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension, now s/p exploratory laparotomy, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remained on vent , CMV mode, no change in vent settings\n overnight,\n Action:\n Patient on Triadyne bed, on continuous rotation form side to side, ABG\n sent, CXR done this morning. VAP care done.\n Response:\n LS clear and diminished at bases, O2 sat 97-98%, weak productive cough.\n RSBI this morning is 47, team aware, waiting for morning rounds for\n changes. Noted 5 beat run of Vtach at 0610, Dr. notified ,\n potassium 2mmol for K+ 3.6 with morning lab given.\n Plan:\n Cont to monitor, pulm hygiene, mouth care q4h, ? Wean vent if\n tolerates, VAP care. Cont with rotation.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining dark bloody drainage early shift and now more\n clear but blood tinged, Abdomen softly distended, No BS, JP\nS draining\n ascitic fluid, +++ generalized edema.\n Action:\n JP drainage replaced with NS 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2.NEO gtt off from 4am,\n Response:\n Stable HCT 34.6, patient is opening eyes to call, not following any\n commands or moving any extremities, PERL, off sedation more than 24\n hours now. Fluid balance of -3.6L by MN. Maintaining map >60, still\n tachycardic 110-123,TF at 20ml/hr, do not advance till further order.\n JP drained 9855 ml in 24 hours and replaced with 10bags of 12.5gm H\n alb. Creat 1.8 this morning, liver enzymes wnl.\n Plan:\n Cont to monitor, replace alb for 1L of JP out put, monitor neuro ,\n renal and liver status, and S& S of bleeding.\n" }, { "category": "Physician ", "chartdate": "2164-10-18 00:00:00.000", "description": "Intensivist Note", "row_id": 702194, "text": "SICU\n HPI:\n 52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension. Presented to Hospital where BP 85/43 HR 102 (BP nadir\n 68/36) Hct 17.6% INR 1.9. EKG unremarkable, CXR clear.\n In the ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP ordered but not yet given. Vital signs prior to transfer\n 88 102/48 24 100%RA. Upon arrival in the MICU, patient without\n complaints. EGD showed 1 cord of non-bleeding grade II varices at 36\n cm, 2 linear non-bleeding ulcers (6-7 mm) in the distal duodenal bulb,\n clotted blood in the antrum, and slight ulceration of the ampulla of\n Vater with a small amount of blood on it.\n Recently hospitalized at for UGIB due to duodenal\n ulcer, alcoholic hepatitis treated with corticosteroids, hepatorenal\n syndrome, and respiratory failure requiring mechanical ventilation.\n EGD showed esophageal varices, blood in the stomach, blood in the\n second part of the duodenum, and a large visible vessel in the proximal\n duodenum.\n S/P transfusion of multiple 30+ units pRBC, FFP in MICU\n tagged red cell scan then to IR, on angio found to have GDA\n pseudoaneurysm, To OR for ex-lap for dueodenal arterial bleed, EBL 8\n liters, 12U pRBC, 12U FFP, 3 6-packs of platelets, neo vasopressin\n intraop.\n Chief complaint:\n Upper and lower GI bleed\n PMHx:\n -ETOH cirrhosis complicated by portal hypertension esophageal & rectal\n varices last paracentesis \n -duodenal ulcer\n -internal hemorrhoids\n -s/p bilateral knee replacements\n Current medications:\n CeftriaXONE 6. Cisatracurium Besylate 7. Fentanyl Citrate 8.\n Fluconazole 9. Fluconazole 10. Insulin\n 11. Octreotide Acetate 12. Pantoprazole 13. Phenylephrine 14.\n Piperacillin-Tazobactam 15. Piperacillin-Tazobactam\n 16. Propofol 17. Vancomycin\n 24 Hour Events:\n ENDOSCOPY - At 08:00 AM\n INTUBATION - At 02:00 PM\n intubated in IR\n INVASIVE VENTILATION - START 02:00 PM\n SHEATH - START 08:00 PM\n ARTERIAL LINE - START 08:20 PM\n TRAUMA LINE - START 08:20 PM\n TRAUMA LINE - START 09:05 PM\n OR RECEIVED - At 09:14 PM\n Post operative day:\n POD#1 - ex lap duod ulcer repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 AM\n Fluconazole - 09:49 PM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Octreotide - 50 mcg/hour\n Phenylephrine - 0.8 mcg/Kg/min\n Cisatracurium - 0.15 mg/Kg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 50.2 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 08:00 AM\n Fentanyl - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 12:45 PM\n Other medications:\n Flowsheet Data as of 06:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.1\nC (97\n HR: 96 (87 - 133) bpm\n BP: 104/53(67) {83/49(61) - 141/88(110)} mmHg\n RR: 20 (16 - 30) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 9 (4 - 19) mmHg\n Bladder pressure: 38 (30 - 38) mmHg\n Total In:\n 27,373 mL\n 1,822 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,258 mL\n 1,722 mL\n Blood products:\n 18,965 mL\n 100 mL\n Total out:\n 10,203 mL\n 1,732 mL\n Urine:\n 378 mL\n 102 mL\n NG:\n 425 mL\n Stool:\n 350 mL\n Drains:\n 250 mL\n 1,630 mL\n Balance:\n 17,170 mL\n 90 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): 506 (506 - 630) mL\n PS : 10 cmH2O\n RR (Set): 20\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Neuromusc Block\n PIP: 22 cmH2O\n Plateau: 18 cmH2O\n SPO2: 100%\n ABG: 7.30/44/98./22/-4\n Ve: 9.6 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : bases, Diminished:\n bases)\n Abdominal: open laparotomy with ioban covering\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n 89 K/uL\n 10.8 g/dL\n 189\n 1.6 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 117 mEq/L\n 144 mEq/L\n 30.7 %\n 6.9 K/uL\n [image002.jpg]\n 07:22 PM\n 07:30 PM\n 08:20 PM\n 08:27 PM\n 11:08 PM\n 11:14 PM\n 12:13 AM\n 03:36 AM\n 03:52 AM\n 04:00 AM\n WBC\n 3.2\n 3.5\n 5.6\n 6.9\n Hct\n 24.7\n 28\n 28.9\n 37\n 34.0\n 30.7\n Plt\n 95\n 76\n 114\n 89\n Creatinine\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 22\n 20\n 23\n Glucose\n 249\n 233\n 144\n 170\n 130\n 292\n 189\n Other labs: PT / PTT / INR:17.9/47.3/1.6, ALT / AST:19/47, Alk-Phos / T\n bili:30/6.1, Amylase / Lipase:58/81, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:161 mg/dL, Lactic\n Acid:2.7 mmol/L, Albumin:2.1 g/dL, LDH:151 IU/L, Ca:8.5 mg/dL, Mg:1.5\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis complicated by esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, to OR for duodenal artery ulceration\n Neurologic: Intubated and sedated propofol gtt, fentanyl gtt, paralyzed\n with cisatracurium,\n Cardiovascular: BRBPR and UGI bleeding: Intraop: EBL 8 liters, 12U\n pRBC, 12U FFP, 3 6-packs of platelets\n -x-fuse PRN PRBC, Platelets\n -PRN neo, vasopressin\n -Aline, right femoral arterial sheath, right SCL , transfuse 2 UpRBC\n immediately. Follow CBC & Coags q4 hours,\n Pulmonary: intubated and sedated, paralyzed\n Gastrointestinal / Abdomen: NPO, protonix drip, octreotide gtt, gastric\n ph q2hours (must stay above 5), follow LFTs q 4 hours, likely\n pancreatitis superimposed.\n Nutrition: NPO\n Renal: Foley, Follow UOP, follow Calcium, potassium, magnesium, UOP 25\n mls for past 2 hours, replacing drain output 0.5 to 1 with D51/2 NS\n with 50 of Bicarb\n Hematology: Monitor CBC q 4 hours HCT stable, s/p 2 U PRBC in SICU and\n 1 unit platelets\n Endocrine: RISS, Insulin drip\n Infectious Disease: Fluconazole 400 mg IV Q24H, CeftriaXONE 1 gm IV\n Q24H, Vancomycin, zosyn, duodenum spilled into surgical field upon\n opening\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n 18 g R AC, , LIJ triple lumen, right radial a line, left\n femoral , right femoral arterial sheath\n Wounds: ioban dressing over open laparotomy\n Imaging:\n Fluids: D5 1/2 NS, replacing drain output 0.5 to 1 with D51/2 NS with\n 50 of Bicarb\n Consults: Transplant\n Billing Diagnosis: (Shock), Other: GI Bleed\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion\n Lines:\n 18 Gauge - 05:09 PM\n Multi Lumen - 09:19 PM\n Sheath - 08:00 PM\n Arterial Line - 08:20 PM\n Trauma line - 09:05 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702135, "text": "HPI:\n 52yo man with a h/o EtOH-induced cirrhosis with esophageal and rectal\n varices with prior episodes of bleeding admitted with painless brbpr\n and hypotension. He had multiple episodes of bright red blood in his\n stool starting this morning. With this brbpr . He denies any NSAID or\n EtOH use.\n He was hospitalized at from to for UGIB due to\n duodenal ulcer, alcoholic hepatitis treated with corticosteroids,\n hepatorenal syndrome, and respiratory failure requiring mechanical\n ventilation. His last EGD was on and showed esophageal varices,\n blood in the stomach, blood in the second part of the duodenum, and a\n large visible vessel in the proximal duodenum. C-scope showed\n medium non-bleeding grade 2 internal hemorrhoids and two 4mm non-\n bleeding ulcers noted on the hemorrhoid at a site of previous banding.\n Transferred from OSH, hypotensive with HCT 17. After receiving\n multiple blood products in the MICU here at , as well as a failed\n attempt to stop duodenal bleeding in IR (), he was sent to the\n OR. Received 12 units of PRBCs in OR, duodenal ulcer oversewn, came to\n SICU intubated, paralyzed, sedated, with open abdomen.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pts temp 95-97 orally. HR ranging from 100-130\ns, sinus. BP gradually\n decreasing to 80\ns systolic, Map 60, groin line and radial a-line\n corresponding, verified with cuff as well. CVP trending down, ranging\n from . Lungs clear bilat, suctioned a few times for no sputum. Pt\n has no cough, no gag, and not over breathing set rate on vent due to\n adequate dose of Cisatricurium. Sedated on Propofol as well as Fentanyl\n for pain. Abdominal dressing intact with various areas of leakage.\n Leakage pooling under dressing in some areas, 2 JPs with only one\n holding suction and draining large amounts of serosang. Tubing placed\n under dressing on right side and connected to very low intermittent\n suction with large amounts of serosang/ascitic output. One small drain\n on left side of abdomen connected to low intermittent suction,\n appearing bilious. NG tube placed on med suction and draining only\n scant blood drainage. Uop decreasing throughout the night ranging from\n 10-20cc/ hr of dark yellow urine. Flexiseal in place with brb in\n drainage bag, however no further output since admission.\n Action:\n Bair hugger placed for a few hours, currently off. Labs drawn Q 4\n hours, all values reported to Dr. , 2 units of PRBCs given and 1\n bag of Plts. Neo started at .5-.75 mcgs, Vasopressin currently off.\n Low UOP, Bp and decreasing CVP indicating that pt may be in need of\n fluid. Abdominal dressing leaking through sheets, large amount of\n insensible loss, shown to resident. Albumin 25 g given x 1, 500cc of\n D5\n NS and maintainence fluid started at a gentle rate. Pt came from\n OR with full paralysis, had no twitches at baseline upon arrival.\n Cisatricurium started at .2 mcgs per Dr. and twitches\n reevaluated throughout the night. Abdominal drainage sent for albumin,\n NG tube drainage sent for pH, however output minimal, unable to send Q\n 2 hours as requested and Dr. notified.\n Response:\n Pt currently normothermic. Hct stable, mag 1.6, no treatment per\n resident. No response to Albumin, however pt responding well to fluid\n bolus, BP and UOP increased, HR currently in 90\n Plan:\n Continue to monitor labs Q 4 hours. Pt to remain paralyzed and sedated,\n monitor for adequate pain control. Monitor for any signs of increased\n bleeding.\n" }, { "category": "Nursing", "chartdate": "2164-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703005, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Cough reflex impaired. Pt did cough once after fentynal and Propofol\n off x 4 hrs. Congested cough and then pt bit on his ET-Tube when\n ET-tube attempted to be suctioned. Hco3 15\n Action:\n Oral airway inserted\n VAP protocol done\n FiO2 decreased from 70% down to 60%\n Suctioned ET-Tube q 3-4hrs\n Sodium bicarb 1 amp IVPB given.\n Response:\n O2 sats on 60% were 97%/FIO2 weaned down to 50%\n Plan:\n Monitor closely for signs of mucous plugging\n Suction ET-Tube q 2-3 hrs as needed\n Ineffective Coping\n Assessment:\n Pt\ns wife in to visit, more conversive tonight, states I just \n know what to do whether to get a hotel, stay at the hospital or go\n home, wife admits to being streesed, has 16year old daughter at home.\n Wife also concerned about parking.\n Action:\n Wife told that if she needs to be with her daughter she can always call\n us and of course we would notify her of any change in pt\ns condition.\n Response:\n Wife seemed more at ease\n Plan:\n Continue to give information and emotional support to pt\ns wife.\n Email Social worker for .\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt continues to have BRB from NGT 750 ml, maroon liquid from flexiseal,\n bilious Jejunotomy tubes.\n Neo weaned down to 2.6 unable to wean further\n Low albumin 2.0\n Ionized calcium 1.0\n HCO3 15\n Action:\n Serial hcts checked\n c/cc NS replacement changed to\n cc NS replacement of JP drains\n Neo at 2,.6\n Albumin 25% (12.5GM) to be given q 8hrs for each liter pt puts out of\n JPs\n Calcium repleted with calcium gluconate 4 GMs IVPB\n Sodium bicarb 50MEQ IVP given as ordered\n Response:\n HCT stable at 32\n MAP>65\n Plan:\n Continue plan of care/follow action plan as above.\n Keep MAP>65\n Do not irrigate NGT.\n Start TF as ordered though yellow JTube\n Start TPN as ordered.\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703360, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant thick, white secretions.\n Weak cough.\n Gag weak to absent.\n Negative 2\n Liters.\n Action:\n ABGs x2.\n Response:\n Transplant Team and SICU Team aware of current ABG.\n No changes to ventilator settings.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining clear, thick drainage. Abdomen softly\n distended,\n BS present.\n JP\nS draining ascitic fluid.\n +++ generalized edema.\n Hemodynamically stable.\n Pain as e/b HR 115-120\n Action:\n JP drainage replaced with LR 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2. AM K+ 3.3, repleted\n with 20K.\n Response:\n Patient is opening eyes to call, following simple commands and moving\n all extremities, PERL, Continued off sedation Fentanyl bolus PRN for\n pain\n Maintaining map >60, still tachycardic 110-123,\n TF at 30ml/hr.\n JP\ns @1630 started with copious draininage around JP insert site and no\n suction to JP bulb.\n SICU Resident and Transplant Chief Resident aware.\n ? JP migrated out of site. Tegaderms to contain drainage from tube,\n awaiting stitch to be placed.\n No repletion since 1630.\n Plan:\n Continue to replete JP output as ordered with LR and albumin as\n indicated,\n Monitor resp and hemodynamics.\n ? D/C NGT.\n" }, { "category": "Physician ", "chartdate": "2164-11-04 00:00:00.000", "description": "Intensivist Note", "row_id": 705087, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension. At Hospital\n where BP 85/43 HR 102 (BP nadir 68/36) Hct 17.6% INR 1.9. EKG\n unremarkable, CXR clear.\n In ED, initial VS 98.3 100 89/48 100%RA. Hct 25.5%. Given 3U\n PRBC, 2 U FFP. Upon arrival in the MICU, EGD showed 1 cord of\n non-bleeding grade II varices at 36 cm, 2 linear non-bleeding ulcers\n (6-7 mm) in distal duodenal bulb, clotted blood in the antrum, and\n slight ulceration of ampulla of Vater with a small amount of blood on\n it.\n PMHx:\n PMH: ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n 1000 mL NS\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W\n Albumin 25% (12.5g / 50mL)\n Calcium Gluconate\n Cosyntropin\n HYDROmorphone (Dilaudid)\n Insulin\n Magnesium Sulfate\n Micafungin\n Midodrine\n Miconazole Powder 2%\n Octreotide Acetate\n Ondansetron\n Pantoprazole\n Phenylephrine\n Rifaximin\n Sodium Bicarbonate\n Tetracaine HCl\n Vancomycin\n 24 Hour Events:\n NaBicarb given\n weaned neo\n Post operative day:\n POD#18 - ex lap duod ulcer repair\n POD#15 - S/P abdominal closure, placement of feeding jejunostomy tube\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Micafungin - 02:21 PM\n Infusions:\n Phenylephrine - 0.6 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Hydromorphone (Dilaudid) - 03:45 AM\n Other medications:\n Flowsheet Data as of 05:32 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\nC (98.6\n HR: 120 (110 - 136) bpm\n BP: 100/51(68) {87/43(61) - 136/74(97)} mmHg\n RR: 19 (16 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.4 kg (admission): 98.2 kg\n Height: 73 Inch\n CVP: 5 (4 - 10) mmHg\n Total In:\n 11,036 mL\n 4,157 mL\n PO:\n Tube feeding:\n 3,017 mL\n 683 mL\n IV Fluid:\n 7,369 mL\n 3,374 mL\n Blood products:\n 600 mL\n 100 mL\n Total out:\n 9,881 mL\n 4,080 mL\n Urine:\n 528 mL\n 130 mL\n NG:\n 2,525 mL\n 750 mL\n Stool:\n 600 mL\n Drains:\n 6,828 mL\n 2,600 mL\n Balance:\n 1,155 mL\n 77 mL\n Respiratory support\n SPO2: 96%\n ABG: 7.41/22/81./14/-7\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: , JP drains\n in place\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: Jaundice, (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 156 K/uL\n 9.2 g/dL\n 165 mg/dL\n 3.0 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 95 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.6 %\n 12.2 K/uL\n [image002.jpg]\n 01:59 AM\n 08:25 AM\n 02:03 AM\n 02:11 AM\n 04:11 PM\n 02:35 AM\n 08:19 PM\n 10:34 PM\n 03:13 AM\n 03:27 AM\n WBC\n 19.6\n 18.1\n 18.1\n 17.1\n 15.8\n 12.2\n Hct\n 28.8\n 28.1\n 28.1\n 27.5\n 28.5\n 27.6\n Plt\n 222\n 210\n 210\n 194\n 179\n 156\n Creatinine\n 2.4\n 2.8\n 3.1\n 3.3\n 3.0\n TCO2\n 16\n 15\n 12\n 14\n Glucose\n 125\n 136\n 140\n 122\n 165\n Other labs: PT / PTT / INR:25.1/59.2/2.4, ALT / AST:19/48, Alk-Phos / T\n bili:61/12.9, Amylase / Lipase:132/63, Differential-Neuts:81.6 %,\n Lymph:12.9 %, Mono:4.5 %, Eos:0.4 %, Fibrinogen:207 mg/dL, Lactic\n Acid:2.4 mmol/L, Albumin:3.1 g/dL, LDH:164 IU/L, Ca:8.5 mg/dL, Mg:1.7\n mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, IMPAIRED PHYSICAL MOBILITY,\n IMPAIRED SKIN INTEGRITY, FUNGAL INFECTION, OTHER, HYPOMAGNESEMIA (LOW\n MAGNESEIUM), SHOCK, SEPTIC\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy, now with fungemia\n .\n Plan:\n Neuro: Dilaudid prn, awake and following commands\n CVS: Vasodilatory shock, fluid repletion 3/4:1, on neo gtt for\n hypotension\n PULM: on NC now\n RENAL: Foley, follow UOP, replacing ascites output 1:1 with NS. Albumin\n 12.5g per 1L ascites. UA(-). Worsening renal fx, ID does not believe\n this is related to micafungin. Giving boluses with albumin PRN for BP /\n UOP.\n FEN/GI: protonix 40\", TF impact 3/4 strength at 125ml/hr. Rifaximin for\n hepatic encephalopathy.\n ID: micafungin started blood/ascites; vanc for\n coag neg staph tip cx; ophthalmology exam negative. Daily surv cx. All\n lines changed out. Follow vanco level prior to 4th dose. Ascites gs(-)\n HEME: Hct stable\n ENDO: RISS\n PPX: PPI , pneumoboots\n ACCESS: foley, R IJ triple lumen, PIV x1, JP x2, NGT, J-tube x2, A-line\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis: Duodenal bleed s/p ex lap, repair\n ICU Care\n Nutrition:\n Impact with Fiber () - 11:17 PM 125 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:06 PM\n Arterial Line - 01:20 PM\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": "Nursing", "chartdate": "2164-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703066, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains unarousable, all sedation remains off, no response from deep\n painful stimuli or sternal rub. Pupils equal, appearing sluggish at\n times. Continues to have periods of rigors, resident witnessed and\n updated. Bp dropping briefly at the beginning of the shift to 80\n without obvious cause, pt became slightly tachy at that time as well.\n Neo continues for MAP greater than 65. HR 80\ns-90\ns most of the shift,\n however began to increase to 100-110 early this am. NSR with occasional\n PVCs. CVP 8-11. Lungs clear, O2 sat 96-99%. Pt has BRB from NG tube,\n residents aware. UOP adequate. Melena stool from flexiseal.\n Action:\n When Bp decreased abruptly at beginning of the night, fluids bolused,\n Neo temporarily increased to 5 mcgs , labs sent and resident paged to\n room. JPs to bulb suction and emptied every hour with\n cc per cc\n replacement of NS. Lytes repleted overnight. Neo titrated down and\n currently at 1 mcg. Fentanyl 50mcgs x 1 given for questionable pain\n when HR increased this am. Albumin 12.5 g given for every 1000cc of\n acitic fluid drained from JPs. Trophic TF started at 10cc/hr via J tube\n with the red J tube remaining to gravity and draining bilious drainage.\n TPN started and maintenance fluid kvo\nd. Pt on Triadyne bed with\n rotation all shift. Suctioning requiring during rotation of bed, sputum\n increasing with repositioning and pt beginning to cough\n Response:\n Pt stable following one brief episode of hypotension. HCT decreasing\n slightly throughout the night, however remains stable despite blood\n drainage from NG tube and melena stool. HR decreasing significantly\n following pain med, currently in 80\ns. Ectopy resolving with lyte\n repletion\n Plan:\n Continue to replace JP drainage Q 1 hour with NS repletion. Albumin to\n be given for every liter of ascites drained. Monitor TF and if pt\n tolerates may advance and discontinue TPN. Follow up on chest xray\n results, ? wean vent. Continue to decrease Neo as tolerated for MAP >\n 65. Offer emotional support to family and follow up with social work\n regarding support for wife\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703255, "text": "52M with ETOH cirrhosis complicated by esophageal and rectal varices\n with prior episodes of bleeding admitted with painless BRBPR and\n hypotension, now s/p exploratory laparotomy, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remained on vent , CMV mode, no change in vent settings\n overnight,\n Action:\n Patient on Triadyne bed, on continuous rotation form side to side, ABG\n sent, CXR done this morning. VAP care done.\n Response:\n LS clear and diminished at bases, O2 sat 97-98%, weak productive cough.\n RSBI this morning is 47, team aware, waiting for morning rounds for\n changes.\n Plan:\n Cont to monitor, pulm hygiene, mouth care q4h, ? Wean vent if\n tolerates, VAP care. Cont with rotation.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining dark bloody drainage early shift and now more\n clear but blood tinged, Abdomen softly distended, No BS, JP\nS draining\n ascitic fluid, +++ generalized edema.\n Action:\n JP drainage replaced with NS 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2.NEO gtt off from 4am,\n Response:\n Stable HCT 34.6, patient is opening eyes to call, not following any\n commands or moving any extremities, PERL, off sedation more than 24\n hours now. Fluid balance of -3.6L by MN. Maintaining map >60, still\n tachycardic 110-123,TF at 20ml/hr, do not advance till further order.\n JP drained 9855 ml in 24 hours and replaced with 10bags of 12.5gm H\n alb. Creat 1.8 this morning, liver enzymes wnl.\n Plan:\n Cont to monitor, replace alb for 1L of JP out put, monitor neuro neuro,\n renal and liver status, and S& S of bleeding.\n" }, { "category": "Respiratory ", "chartdate": "2164-10-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702323, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum 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 Comments: Pt received on AC as noted with no vent changes this shift.\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: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Pt has an open abdomen.\n" }, { "category": "Respiratory ", "chartdate": "2164-10-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 702392, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n 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: 27 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: /\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 Comments: orders to make the vent change to 650 Vt resulted in\n hypocarbia and hypoxygenation,\n Assessment of breathing comfort: No claim of dyspnea (sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: follow up with team on plan of care for pt and\n determine ABG goals as well as PEEP and VT parameters\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2164-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702707, "text": "Impaired Physical Mobility\n Assessment:\n Patient chemically paralyzed, no spontaneous movements, no\n cough\n 4 eye twitches noted on TOF however the goals of the\n treatment: to be compliant with the ventilator and to prevent\n evisceration of abdominal wound, are being met, so paralytics were not\n increased.\n Action:\n check TOF q 4 hours\n Sedated on Propofol\n Pain treated with Fentanyl gtt\n Response:\n remained chemically paralyzed when sent to OR for possible\n abdominal closure\n Plan:\n follow up with SICU team regarding goals of paralytics when\n patient returns from surgery.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n H\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705637, "text": "TITLE:\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt oriented x3 when engaged in conversation however\n occasionally confused in statements. Mild c/o abdominal pain.\n Abdomen firm. + BS. Small/mod loose golden stools. TF\n infusing at goal via lower J-tube. Upper J-tube to gravity with Large\n amounts of bilious drainage.\n Medial JP to self suction with sump to LCWS. Medial\n drain with moderate amounts ascetic output. Lateral drain removed by\n Transplant team at change of shift with sutures placed. sump with\n scant amounts of ascetic output.\n Lungs clear, diminished in bases. Sats >96% RA. Strong\n productive cough.\n Afebrile. SR/ST HR 90-110. MAP >65. WBC 13.5\n Action:\n Reorientating pt as needed. Dilaudid given for pain control.\n Repositioning pt to comfort.\n Closely monitoring I&Os.\n Replacing JP and sump outputs with NS\n cc:cc hourly.\n Response:\n Adequate pain relief.\n Pt -900cc at midnight.\n Plan:\n Reorient pt frequently. Treat pain/comfort as needed.\n Continue with NS\n cc:cc repletions.\n Encourage increased activity and OOB with pt as tolerates.\n f/u with blood and JP output cultures.\n" }, { "category": "Nursing", "chartdate": "2164-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703199, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n In morning, in a metabolic acidosis with respiratory\n alkalosis\n Minimal cough reflex\n No gag\n Not breathing over the vent\n Action:\n Respiratory rate decreased from 18 to 16\n One amp of sodium bicarb given\n VAP\n Rotating triadyne bed\n Fluid balance MN\n 1700 negative 3 liters\n Response:\n Improving acid base balance with ABG: 7.40, 30, 89, -4, 19,\n 96.\n Plan:\n Continue with VAP protocol\n Continue with rotating bed\n Continue to allow for fluid negative balance without\n allowing patient to become intervascularly dry.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n HR tachy at times, 105\n 123\n NGT with concerning output, dark red blood ~ 200 cc\ns this\n shift\n JP drains with large sero-sang output\n Fluid balance MN\n 1700\n 3 liters\n Urine output 30-50 c\ns/hr\n K+ 3.2\n Vanco 11.7\n Patient neuro status slowly improving, attempting to open\n eyes when asked, coughing, no gag, PERL.\n Action:\n Hourly\n cc per cc fluid replacement with NS from JP drains\n 24 hour urine collection started @ 1600 for Creatinine\n clearance. Per lab, no preservative needed in collection bottle, just\n place container in a bucket of ice.\n Tube feeds changed to\n strength renal @ 20 cc\ns/hr, do not\n advance\n TPN as ordered\n Albumin 12.5 grams for every liter of JP drain output.\n Since MN patient has received albumin 8 times.\n Potassium given\n Neo weaned to 1 mcg/kg/min\n Response:\n Repeat HCT 35.3, INR 1.9\n Repeat K+ 3.8\n Creatinine 1.9 (2.3)\n Improved acid base balance as noted above\n Plan:\n Continue to wean neo for goal MAP > 65\n Continue to monitor neuro status, renal status, resp status,\n and S+S bleeding\n Continue to monitor HCT, coags, electrolytes, and ABG\n Social work involved\n" }, { "category": "Nursing", "chartdate": "2164-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703355, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to CPAP 5/5 and FiO2 50%.\n LSCTA with diminished bases.\n O2 SAT 98-100%.\n Scant thick, white secretions.\n Weak cough.\n Gag weak to absent.\n Negative 2\n Liters.\n Action:\n ABGs x2.\n Response:\n Transplant Team and SICU Team aware of current ABG.\n No changes to ventilator settings.\n Plan:\n Continue pt on current vent settings.\n ABGs when indicated.\n ? attempt extubation within next 24-48 hours\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Patient NGT was draining clear, thick drainage. Abdomen softly\n distended,\n BS present.\n JP\nS draining ascitic fluid.\n +++ generalized edema.\n Hemodynamically stable.\n Pain as e/b HR 115-120\n Action:\n JP drainage replaced with LR 1/2 cc / cc out put, H.Alb 125.gm for\n every 1L of JP drainage given, Labs checked x2. AM K+ 3.3, repleted\n with 20K.\n Response:\n Patient is opening eyes to call, following simple commands and moving\n all extremities, PERL, Continued off sedation Fentanyl bolus PRN for\n pain\n Maintaining map >60, still tachycardic 110-123,\n TF at 30ml/hr.\n JP\ns @ 1700 started with copious\n Plan:\n Cont to monitor, replace alb for 1L of JP out put, monitor neuro ,\n renal and liver status, and S& S of bleeding.\n" }, { "category": "Nursing", "chartdate": "2164-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702125, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711118, "text": "Hepatic failure, fulminant\n Assessment:\n Patient consistently declining all interventions from onset\n of shift.\n Pt with significant jaundice, sclera icteric and bilateral\n asterisxis\n Orientation waxes and wanes, occasionally makes confused\n statement. Intermittent auditory/visual hallucinations that reside with\n reorientation.\n Transplant team aware of refusal of care/ICU monitoring\n Abdomen: Firmly distended, + BSX4, tenderness/guarding with\n palpation. Abdomen with small open area at old incision site with\n serous drainage.\n Action:\n Patient throughout shift declining all IV/PO medications and\n all routine care\n MD to address code status with patient. \n from social work notified of change in code status to DNR. Wife\n updated regarding code status and plan to discharge to Hospice.\n Emotional support given to patient.\n Response:\n Patient resting comfortably and awaiting transfer to The\n Care Center.\n Denies pain.\n Plan:\n Continue to respect patient\ns wishes to decline all care.\n Wife notified of patient\ns transfer and plans to meet him at\n The Care Center.\n Emotional support given to patient-continue to respect\n patient\ns wishes and maintain comfort.\n" }, { "category": "Nursing", "chartdate": "2164-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711113, "text": "Hepatic failure, fulminant\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708142, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Melena stool x 1, hct >26\n Action:\n Npo pt only able to drink sucralfate\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 708295, "text": "HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. Readmitted to SICU with re-ocurance of GIB.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Admit to sicu from floor with lower gi bleed, tx with 3 u pc\n 1 bag platelets in icu, endoscopy done in icu, no active bleeding\n noted, esophagitis found, pt started on carafate slurry QID, also on iv\n protonix & sc octreotide TID, pt with stable VS since admission, HD\n done today x 3 hrs with no drop in sbp, 0.5 liters fluid removed, pt\n npo, g-tube & j-tube clamped, no maintenance ivf\n Action:\n HCT q 8 hrs today, po midodrine given as ordered, protonix, octreotide,\n carafate given as ordered, cl lix diet started this pm\n Response:\n 1500 hct stable @ 28.5, BM x 1 this pm, guiac +, mod amt liquid\n green/black stool, no BRB noted, no N/V, c/o mild abdominal pain,\n states does not need pain med, tolerating cl lix well\n Plan:\n Tx to floor on , advance to regular diet, resume tube feed,\n continue to monitor for GI bleed\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708296, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Admit to sicu from floor with lower gi bleed, tx with 3 u pc\n 1 bag platelets in icu, endoscopy done in icu, no active bleeding\n noted, esophagitis found, pt started on carafate slurry QID, also on iv\n protonix & sc octreotide TID, pt with stable VS since admission, HD\n done today x 3 hrs with no drop in sbp, 0.5 liters fluid removed, pt\n npo, g-tube & j-tube clamped, no maintenance ivf\n Action:\n HCT q 8 hrs today, po midodrine given as ordered, protonix, octreotide,\n carafate given as ordered, cl lix diet started this pm\n Response:\n 1500 hct stable @ 28.5, BM x 1 this pm, guiac +, mod amt liquid\n green/black stool, no BRB noted, no N/V, c/o mild abdominal pain,\n states does not need pain med, tolerating cl lix well\n Plan:\n Tx to floor on , advance to regular diet, resume tube feed,\n continue to monitor for GI bleed\n" }, { "category": "Nursing", "chartdate": "2164-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711137, "text": "Hepatic failure, fulminant\n Assessment:\n Patient consistently declining all interventions from onset\n of shift.\n Pt with significant jaundice, sclera icteric and bilateral\n asterisxis\n Orientation waxes and wanes, occasionally makes confused\n statement. Intermittent auditory/visual hallucinations that reside with\n reorientation.\n Transplant team aware of refusal of care/ICU monitoring\n Abdomen: Firmly distended, + BSX4, tenderness/guarding with\n palpation. Abdomen with small open area at old incision site with\n serous drainage.\n Action:\n Patient throughout shift declining all IV/PO medications and\n all routine care\n MD to address code status with patient. \n from social work notified of change in code status to DNR. Wife\n updated regarding code status and plan to discharge to Hospice.\n Emotional support given to patient.\n Response:\n Patient resting comfortably and awaiting transfer to The\n Care Center.\n Denies pain.\n Plan:\n Continue to respect patient\ns wishes to decline all care.\n Wife notified of patient\ns transfer and plans to meet him at\n The Care Center.\n Emotional support given to patient-continue to respect\n patient\ns wishes and maintain comfort.\n Page I,II and III prepared and sent with patient. Report given to\n accepting RN. Wife updated regarding transfer.\n" }, { "category": "Nursing", "chartdate": "2164-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711132, "text": "Hepatic failure, fulminant\n Assessment:\n Patient consistently declining all interventions from onset\n of shift.\n Pt with significant jaundice, sclera icteric and bilateral\n asterisxis\n Orientation waxes and wanes, occasionally makes confused\n statement. Intermittent auditory/visual hallucinations that reside with\n reorientation.\n Transplant team aware of refusal of care/ICU monitoring\n Abdomen: Firmly distended, + BSX4, tenderness/guarding with\n palpation. Abdomen with small open area at old incision site with\n serous drainage.\n Action:\n Patient throughout shift declining all IV/PO medications and\n all routine care\n MD to address code status with patient. \n from social work notified of change in code status to DNR. Wife\n updated regarding code status and plan to discharge to Hospice.\n Emotional support given to patient.\n Response:\n Patient resting comfortably and awaiting transfer to The\n Care Center.\n Denies pain.\n Plan:\n Continue to respect patient\ns wishes to decline all care.\n Wife notified of patient\ns transfer and plans to meet him at\n The Care Center.\n Emotional support given to patient-continue to respect\n patient\ns wishes and maintain comfort.\n Page I,II and III prepared and sent with patient. Report given to\n accepting RN.\n" }, { "category": "Nursing", "chartdate": "2164-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 710549, "text": "Hypotension (not Shock)\n Assessment:\n Pt A&Ox2-3, occasionally with odd statements and sometimes\n appearing confused. Pt quickly reorients self. Forgetful. Otherwise\n appropriate in conversation\n MAE, following all commands\n Pt cooperative with care throughout shift, making needs\n known\n HR 90-100, SR, no ectopy. BP continues to be pressor\n dependant, MAP 54-67, goal 55-60, aline damped\n Pt c/o general discomfort in ABD region and c/o itchiness\nall over\n Action:\n Providing care as discussed in family meeting in previous\n shift, continuing with abx and BP meds. Pt remains full code\n Neo gtt as ordered to maintain MAP 55-60\n Benadryl x1 for itchiness\n Dialudid prn pain\n Response:\n MAP remains 54-67\n No change in mental status\n Pt expressing adequate relief from benadryl and dilaudid\n Plan:\n Wean neo gtt as tolerated\n Continue with care as planned until further decisions\n regarding pt\ns status is made\n Family meeting today to discuss pt wanting to make himself\n \n Provide pt and family with emotional support\n" }, { "category": "Nursing", "chartdate": "2164-11-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708141, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708132, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-11-22 00:00:00.000", "description": "Intensivist Note", "row_id": 708133, "text": "SICU - Admission note\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. Readmitted to SICU with re-ocurance of LGIB.\n Chief complaint:\n LGIB\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n Current medications:\n Active Medications , W\n 1. 2. 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5.\n Calcium Acetate 6. Cepacol (Menthol)\n 7. Daptomycin 8. Fentanyl Citrate 9. HYDROmorphone (Dilaudid) 10.\n Heparin Flush (10 units/ml) 11. Heparin Flush (10 units/ml)\n 12. 13. Insulin 14. Miconazole Powder 2% 15. Midodrine 16. Midazolam\n 17. Nystatin Oral Suspension\n 18. Octreotide Acetate 19. Ondansetron 20. Pantoprazole 21. Rifaximin\n 22. Simethicone 23. Sodium Chloride 0.9% Flush 24. Sodium Bicarbonate\n 25. Sodium Chloride 26. Sodium Chloride 0.9% Flush 27.\n Sulfameth/Trimethoprim 28. Sucralfate\n 24 Hour Events:\n EVENTS:\n readmitted to SICU for LGIB, on HD x 2 courses so far for renal\n failure. Transfused 2UPRBC.\n PARACENTESIS\n EGD\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:41 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 35.9\nC (96.6\n HR: 80 (79 - 91) bpm\n BP: 98/56(66) {85/43(56) - 105/69(77)} mmHg\n RR: 17 (15 - 24) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,957 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 1,176 mL\n Total out:\n 0 mL\n 2,512 mL\n Urine:\n 12 mL\n NG:\n Stool:\n Drains:\n 2,500 mL\n Balance:\n 0 mL\n -555 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 72 K/uL\n 8.4 g/dL\n 23.9 %\n 12.1 K/uL\n [image002.jpg]\n 12:43 PM\n WBC\n 12.1\n Hct\n 23.9\n Plt\n 72\n Assessment and Plan\n .H/O ASCITES, .H/O GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR,\n GI BLEED, GIB)\n Assessment and Plan: 52M with ETOH cirrhosis c/b esophageal and rectal\n varices with prior episodes of bleeding admitted with painless BRBPR\n and hypotension, s/p ex lap, gastrotomy, duodenotomy with suturing of\n bleeding vessel, draining jejunostomy,to SICU for recurrent L GIB\n .\n Plan:\n Neuro: alert and oriented x 3, stable for past 24 hours, Dilaudid prn\n pr primary team.\n CVS: Hemodynamically stable, off pressors.\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal, on HD, held on due to active bleeding\n GI: protonix 4'', US guided paracentesis: 2.5L GI/hepatology\n consulted for EGD : severe esophagitis , protonix, carafate slurry ,\n Nystatin slush NPO.\n ID: VRE on Daptomycin till , and Stenotrophamonas on bactrim till\n \n HEME: LGIB, HCT 21 -> received 2uPRBC & 1pack platelets-> HCT 23 ->\n received another 2PRBC.\n [ ]f/u CBC (ordered for q8h)\n ENDO: RISS for strict glycemic control\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Billing Diagnosis: CIRRHOSIS /LGIB\n Lines:\n Dialysis Catheter - 09:00 AM\n PICC Line - 09:12 AM\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2164-11-23 00:00:00.000", "description": "Intensivist Note", "row_id": 708208, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. Readmitted to SICU with re-ocurance of GIB.\n Chief complaint:\n Melena\n Oesophagitis\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5.\n Calcium Acetate 6. Cepacol (Menthol)\n 7. Daptomycin 8. Fentanyl Citrate 9. HYDROmorphone (Dilaudid) 10.\n Heparin Flush (10 units/ml) 11. Heparin Flush (10 units/ml)\n 12. 13. Insulin 14. Miconazole Powder 2% 15. Midodrine 16. Midazolam\n 17. Nystatin Oral Suspension\n 18. Octreotide Acetate 19. Ondansetron 20. Pantoprazole 21. Rifaximin\n 22. Simethicone 23. Sodium Chloride 0.9% Flush\n 24. Sodium Bicarbonate 25. Sodium Chloride 26. Sodium Chloride 0.9%\n Flush 27. Sulfameth/Trimethoprim\n 28. Sucralfate\n 24 Hour Events:\n DIALYSIS CATHETER - START 09:00 AM\n PICC LINE - START 09:12 AM\n PARACENTESIS - At 03:30 PM\n readmitted to SICU for LGIB, on HD x 2 courses so far for renal\n failure. Transfused 2UPRBC.\n PARACENTESIS\n EGD\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36\nC (96.8\n HR: 78 (78 - 91) bpm\n BP: 106/68(78) {85/43(56) - 106/69(78)} mmHg\n RR: 14 (14 - 24) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,957 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 1,176 mL\n Total out:\n 2,527 mL\n 0 mL\n Urine:\n 27 mL\n NG:\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -570 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 51 K/uL\n 9.6 g/dL\n 78 mg/dL\n 5.1 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 96 mg/dL\n 92 mEq/L\n 135 mEq/L\n 27.2 %\n 11.4 K/uL\n [image002.jpg]\n 12:43 PM\n 07:48 PM\n 01:37 AM\n WBC\n 12.1\n 11.4\n Hct\n 23.9\n 26.8\n 27.2\n Plt\n 72\n 51\n Creatinine\n 5.1\n Glucose\n 78\n Other labs: PT / PTT / INR:21.3/43.4/2.0, ALT / AST:64/294, Alk-Phos /\n T bili:105/23.3, Ca:9.5 mg/dL, Mg:1.9 mg/dL, PO4:7.0 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE), .H/O ASCITES, .H/O GASTROINTESTINAL BLEED, LOWER\n (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy,to SICU for\n recurrent LGIB\n .\n Plan:\n Neuro: alert and oriented x 3, stable for past 24 hours, Dilaudid prn\n pr primary team for abd pain.\n CVS: Hemodynamically stable, off pressors.\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal, on HD, held on due to active bleeding\n GI: protonix 4'', US guided paracentesis: 2.5L GI/hepatology\n consulted for EGD : severe esophagitis , protonix, carafate slurry ,\n Nystatin slush NPO. Melena x3\n ID: VRE on Daptomycin till , and Stenotrophamonas on bactrim till\n \n HEME: LGIB, HCT 21 -> received 2uPRBC & 1pack platelets-> HCT 23 ->\n received another 2PRBC. 26.9> 27.2\n ENDO: RISS for strict glycemic control\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Consults: Neurosurg\n Lines:\n Dialysis Catheter - 09:00 AM\n PICC Line - 09:12 AM\n Total time spent: 30 MINTS\n" }, { "category": "Physician ", "chartdate": "2164-11-23 00:00:00.000", "description": "Intensivist Note", "row_id": 708209, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. Readmitted to SICU with re-ocurance of GIB.\n Chief complaint:\n Melena\n Oesophagitis\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5.\n Calcium Acetate 6. Cepacol (Menthol)\n 7. Daptomycin 8. Fentanyl Citrate 9. HYDROmorphone (Dilaudid) 10.\n Heparin Flush (10 units/ml) 11. Heparin Flush (10 units/ml)\n 12. 13. Insulin 14. Miconazole Powder 2% 15. Midodrine 16. Midazolam\n 17. Nystatin Oral Suspension\n 18. Octreotide Acetate 19. Ondansetron 20. Pantoprazole 21. Rifaximin\n 22. Simethicone 23. Sodium Chloride 0.9% Flush\n 24. Sodium Bicarbonate 25. Sodium Chloride 26. Sodium Chloride 0.9%\n Flush 27. Sulfameth/Trimethoprim\n 28. Sucralfate\n 24 Hour Events:\n DIALYSIS CATHETER - START 09:00 AM\n PICC LINE - START 09:12 AM\n PARACENTESIS - At 03:30 PM\n readmitted to SICU for LGIB, on HD x 2 courses so far for renal\n failure. Transfused 2UPRBC.\n PARACENTESIS\n EGD\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36\nC (96.8\n HR: 78 (78 - 91) bpm\n BP: 106/68(78) {85/43(56) - 106/69(78)} mmHg\n RR: 14 (14 - 24) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,957 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 1,176 mL\n Total out:\n 2,527 mL\n 0 mL\n Urine:\n 27 mL\n NG:\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -570 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 51 K/uL\n 9.6 g/dL\n 78 mg/dL\n 5.1 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 96 mg/dL\n 92 mEq/L\n 135 mEq/L\n 27.2 %\n 11.4 K/uL\n [image002.jpg]\n 12:43 PM\n 07:48 PM\n 01:37 AM\n WBC\n 12.1\n 11.4\n Hct\n 23.9\n 26.8\n 27.2\n Plt\n 72\n 51\n Creatinine\n 5.1\n Glucose\n 78\n Other labs: PT / PTT / INR:21.3/43.4/2.0, ALT / AST:64/294, Alk-Phos /\n T bili:105/23.3, Ca:9.5 mg/dL, Mg:1.9 mg/dL, PO4:7.0 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE), .H/O ASCITES, .H/O GASTROINTESTINAL BLEED, LOWER\n (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy,to SICU for\n recurrent LGIB\n .\n Plan:\n Neuro: alert and oriented x 3, stable for past 24 hours, Dilaudid prn\n pr primary team for abd pain.\n CVS: Hemodynamically stable, off pressors.\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal, on HD, held on due to active bleeding\n GI: protonix 4'', US guided paracentesis: 2.5L GI/hepatology\n consulted for EGD : severe esophagitis , protonix, carafate slurry ,\n Nystatin slush NPO. Melena x3\n ID: VRE on Daptomycin till , and Stenotrophamonas on bactrim till\n \n HEME: LGIB, HCT 21 -> received 2uPRBC & 1pack platelets-> HCT 23 ->\n received another 2PRBC. 26.9> 27.2\n ENDO: RISS for strict glycemic control\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Consults: Neurosurg\n Lines:\n Dialysis Catheter - 09:00 AM\n PICC Line - 09:12 AM\n Total time spent: 30 MINTS\n" }, { "category": "Social Work", "chartdate": "2164-12-05 00:00:00.000", "description": "Social Work Progress Note", "row_id": 710959, "text": "Social Work Progress Note, Transplant Service\n Clinical Data: Met with pt again briefly this afternoon. He presented\n reclined in bed, awake and alert, oriented x2. SW addressed pt\n refusal of any medical treatment, including IV meds and HD. Pt stated,\nI have a week. \n to prolong it. I want to see my\n daughter.\n SW informed pt that his wife and dtr are planning to arrive\n to see him around 7pm. SW spoke with pt\ns wife just prior to meeting\n with pt. SW updated her with info that pt continues to refuse\n interventions and is requesting visit from wife and dtr. SW also\n informed her that SICU team will meet with her to discuss code status\n when she arrives. She was agreeable to this plan.\n Clinical assessment/plan: Pt seemed more lucid this afternoon than this\n morning. He appears to have prepared himself for end of life and\n eagerly awaits visit with his immediate family. Pt\ns wife appears to be\n well-informed and coping with the many challenges surrounding pt\ns end\n of life issues. SW discussed with pt\ns RN and SICU resident pt\ns wife\n plan to visit this evening. They plan to f/u with her re:code status\n when they arrive. SW will continue to follow.\n \n Transplant Social Work\n #\n" }, { "category": "Nursing", "chartdate": "2164-11-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708086, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Admitted to SICU from F10 after having 4 large melanotic stools upon\n admission patient A&O times 3 following commands, no c/o abdominal pain\n and no signs of active bleeding. SBP 90\ns with HR 80\ns. 1^st unit PRBC\n up for a hct of 21.\n Action:\n Transfused with a total of 2 UPRBC\ns and 1 PLT. Continue to monitor\n closely for signs of bleeding, monitor SBP and HR closely.\n Response:\n Stable at present, no active bleeding since admission to unit. Will\n recheck Hct and plt count at 1300.\n Plan:\n If hct<26 plan to scope.\n .H/O ascites\n Assessment:\n Patient with taut, distended abd.\n Action:\n Ordered for therapeutic paracentesis\n Response:\n Awaiting radiology\n Plan:\n Paracentesis when radiology available.\n" }, { "category": "Nutrition", "chartdate": "2164-11-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 708083, "text": "Subjective: Did not speak with patient, MD in to see patient.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 185cm\n 98.2 kg\n 28.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 83.5kg\n 118%\n Pertinent medications: RISS, Calcium Acetate, NaCl tabs, Na Bicarb,\n Octreotide acetate, rifaximin, protonix, others noted\n Labs:\n Value\n Date\n Glucose Finger Stick\n 155\n 10:00 AM\n Current diet order / nutrition support: Tube Feeds: off\n Diet: NPO\n GI: + melanotic stool, bowel sounds present, +ascites\n Assessment of Nutritional Status\n 52 y.o. male readmitted to ICU from floor with hypotension and multiple\n episodes of bloody stool o/n. Patient has recently been started on HD,\n on hold for now due to hypotension. Patient has been receiving tube\n feeds via J-tube due to poor po intake; tube feeds are diluted to\n strength and are meeting 100% of estimated needs. Tube feeds are\n currently off due to GIB; work-up ongoing. Will follow up with GIB\n work-up. Recommend restarting tube feeds when able, and recommend\n changing to full strength to help with fluid status. Recommend full\n strength Novasource Renal @ 45mL/hr + 40g Beneprotein (2303kcals, 114g\n protein) to meet 100% of estimated needs. Following - #\n" }, { "category": "Nursing", "chartdate": "2164-11-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708085, "text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Admitted to SICU from F10 after having 4 large melanotic stools upon\n admission patient A&O times 3 following commands, no c/o abdominal pain\n and no signs of active bleeding. SBP 90\ns with HR 80\ns. 1^st unit PRBC\n up for a hct of 21.\n Action:\n Transfused with a total of 2 UPRBC\ns and 1 PLT. Continue to monitor\n closely for signs of bleeding, monitor SBP and HR closely.\n Response:\n Stable at present, no active bleeding since admission to unit. Will\n recheck Hct and plt count at 1300.\n Plan:\n If hct<26 plan to scope.\n .H/O ascites\n Assessment:\n Patient with taut, distended abd.\n Action:\n Ordered for therapeutic paracentesis\n Response:\n Awaiting radiology\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708169, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Several melena stools, hct >26.8-27.2 trending up, c/o abdominal pain,\n asites, hypoactive bs\n Action:\n J tubes clamped one for draining and one for feeding, pt does tolerate\n po food , Npo pt only able to drink sucralfate,\n Response:\n Hemodynamically stable,\n Plan:\n Serial hcts, monitor labs\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Very little urine output, bun 96, k 4.1\n Action:\n Pt has hemodialysis today most likely in the afternoon\n Response:\n No changes\n Plan:\n Fluid restriction 1liter per day, monitor labs, assess for fluid\n overload\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708149, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Melena stool x 1, hct >26.8 trending up, po c/o abdominal care, asites,\n hypoactive bs\n Action:\n J tubes clamped one for draining and one for feeding pt does tolerate\n po food also, Npo pt only able to drink sucralfate\n Response:\n Hemodynamically stable,\n Plan:\n Serial hcts\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Very little urine output\n Action:\n Pt has hemodialysis today most likely in the afternoon\n Response:\n No changes\n Plan:\n Fluid restriction 1liter per day, monitor labs, assess for fluid\n overload\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708158, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Several melena stool, hct >26.8-27.2 trending up, c/o abdominal pain,\n asites, hypoactive bs\n Action:\n J tubes clamped one for draining and one for feeding, pt does tolerate\n po food , Npo pt only able to drink sucralfate,\n Response:\n Hemodynamically stable,\n Plan:\n Serial hcts, monitor labs\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Very little urine output, bun 96, k 4.1\n Action:\n Pt has hemodialysis today most likely in the afternoon\n Response:\n No changes\n Plan:\n Fluid restriction 1liter per day, monitor labs, assess for fluid\n overload\n" }, { "category": "Physician ", "chartdate": "2164-11-23 00:00:00.000", "description": "Intensivist Note", "row_id": 708167, "text": "SICU\n HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. Readmitted to SICU with re-ocurance of GIB.\n Chief complaint:\n Melena\n Oesophagitis\n PMHx:\n ETOH cirrhosis c/b portal HTN esophageal & rectal varices last\n paracentesis , duodenal ulcer, internal hemorrhoids, s/p\n bilateral knee replacements\n .\n : ursodeoxycholic acid 200\"', protonix 40\", lactulose 30\", lasix\n 40', spironolactone 50', nadolol 20'\n ALLERGIES: NKDA\n Current medications:\n Active Medications , W\n 1. 2. 3. Albumin 25% (12.5g / 50mL) 4. Artificial Tear Ointment 5.\n Calcium Acetate 6. Cepacol (Menthol)\n 7. Daptomycin 8. Fentanyl Citrate 9. HYDROmorphone (Dilaudid) 10.\n Heparin Flush (10 units/ml) 11. Heparin Flush (10 units/ml)\n 12. 13. Insulin 14. Miconazole Powder 2% 15. Midodrine 16. Midazolam\n 17. Nystatin Oral Suspension\n 18. Octreotide Acetate 19. Ondansetron 20. Pantoprazole 21. Rifaximin\n 22. Simethicone 23. Sodium Chloride 0.9% Flush\n 24. Sodium Bicarbonate 25. Sodium Chloride 26. Sodium Chloride 0.9%\n Flush 27. Sulfameth/Trimethoprim\n 28. Sucralfate\n 24 Hour Events:\n DIALYSIS CATHETER - START 09:00 AM\n PICC LINE - START 09:12 AM\n PARACENTESIS - At 03:30 PM\n readmitted to SICU for LGIB, on HD x 2 courses so far for renal\n failure. Transfused 2UPRBC.\n PARACENTESIS\n EGD\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36\nC (96.8\n HR: 78 (78 - 91) bpm\n BP: 106/68(78) {85/43(56) - 106/69(78)} mmHg\n RR: 14 (14 - 24) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,957 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 1,176 mL\n Total out:\n 2,527 mL\n 0 mL\n Urine:\n 27 mL\n NG:\n Stool:\n Drains:\n 2,500 mL\n Balance:\n -570 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 51 K/uL\n 9.6 g/dL\n 78 mg/dL\n 5.1 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 96 mg/dL\n 92 mEq/L\n 135 mEq/L\n 27.2 %\n 11.4 K/uL\n [image002.jpg]\n 12:43 PM\n 07:48 PM\n 01:37 AM\n WBC\n 12.1\n 11.4\n Hct\n 23.9\n 26.8\n 27.2\n Plt\n 72\n 51\n Creatinine\n 5.1\n Glucose\n 78\n Other labs: PT / PTT / INR:21.3/43.4/2.0, ALT / AST:64/294, Alk-Phos /\n T bili:105/23.3, Ca:9.5 mg/dL, Mg:1.9 mg/dL, PO4:7.0 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE), .H/O ASCITES, .H/O GASTROINTESTINAL BLEED, LOWER\n (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n Assessment and Plan: Assessment: 52M with ETOH cirrhosis c/b esophageal\n and rectal varices with prior episodes of bleeding admitted with\n painless BRBPR and hypotension, s/p ex lap, gastrotomy, duodenotomy\n with suturing of bleeding vessel, draining jejunostomy,to SICU for\n recurrent LGIB\n .\n Plan:\n Neuro: alert and oriented x 3, stable for past 24 hours, Dilaudid prn\n pr primary team for abd pain.\n CVS: Hemodynamically stable, off pressors.\n PULM: Sats good on RA\n RENAL: /CRF/hepatorenal, on HD, held on due to active bleeding\n GI: protonix 4'', US guided paracentesis: 2.5L GI/hepatology\n consulted for EGD : severe esophagitis , protonix, carafate slurry ,\n Nystatin slush NPO. Melena x3\n ID: VRE on Daptomycin till , and Stenotrophamonas on bactrim till\n \n HEME: LGIB, HCT 21 -> received 2uPRBC & 1pack platelets-> HCT 23 ->\n received another 2PRBC. 26.9> 27.2\n ENDO: RISS for strict glycemic control\n PPX: PPI , pneumoboots\n ACCESS: PICC placed foley, PIV x1, JP x2, J-tube x2\n CODE: Full code\n CONTACT: , wife, \n DISPO: SICU\n Consults:\n Billing Diagnosis:\n Lines:\n Dialysis Catheter - 09:00 AM\n PICC Line - 09:12 AM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2164-11-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708147, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Melena stool x 1, hct >26.8 trending up, po c/o abdominal care, asites,\n hypoactive bs\n Action:\n J tubes clamped one for draining and one for feeding pt does tolerate\n po food also, Npo pt only able to drink sucralfate\n Response:\n Hemodynamically stable,\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 708148, "text": "52 y.o male with alcoholic cirrhosis c/b esophageal and rectal\n varices with upper and lower GI bleeding admitted on with\n UGI bleed and now with course complicated by yeast peritonitis\n and likely candidemia.\n He was initially admitted with UGI bleed from OSH. An EGD on\n did not show a clear source of bleeding. On the same day a\n bleeding study showed evidence of bleeding from the first portion\n of the duodenum. He was taken to the OR on emergently for an\n ex-lap with gastrotomy, duodenotomy with suturing of bleeding\n vessel and draining jejunostomy. Because of swelling his abdomen\n was left open until when he was taken back for abdominal\n closure. He has been on broad spectrum antimicrobials including\n Vancomycin, Zosyn, Flagyl and Fluconazole.\n PAST MEDICAL HISTORY:\n ETOH cirrhosis\n Alcoholic hepatitis s/p steroids\n s/p bilateral knee replacements OA\n Chronic GIB internal hemorrhoids\n Leg fracture 25years ago\n Grade 1 esophageal varices seen in (grade on EGD\n )\n UGI bleed , \n heptorenal syndrome\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Melena stool x 1, hct >26.8 trending up, po c/o abdominal care, asites,\n hypoactive bs\n Action:\n J tubes clamped one for draining and one for feeding pt does tolerate\n po food also, Npo pt only able to drink sucralfate\n Response:\n Hemodynamically stable,\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Very little urine output\n Action:\n Pt has hemodialysis today most likely in the afternoon\n Response:\n No changes\n Plan:\n Fluid restriction 1liter per day, monitor labs, assess for fluid\n overload\n" }, { "category": "Nursing", "chartdate": "2164-11-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 708300, "text": "HPI:\n 52M w/ETOH cirrhosis c/b esophageal and rectal varices w/prior episodes\n of bleeding admit w/painless BRBPR and hypotension.\n it. S/P transfusion of multiple 30+ units pRBC, FFP in MICU. To OR for\n ex-lap for duodenal arterial bleed, EBL 8L, 12U pRBC, 12U FFP, 3\n 6-packs of platelets, neo vasopressin intraop. Since admission grew\n C.glabra in ascities and completed course of micafungin, then grew\n Stenothrophamonas currently on bactrim and VRE currently on\n daptomycin. Readmitted to SICU with re-ocurance of GIB.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Admit to sicu from floor with lower gi bleed, tx with 3 u pc\n 1 bag platelets in icu, endoscopy done in icu, no active bleeding\n noted, esophagitis found, pt started on carafate slurry QID, also on iv\n protonix & sc octreotide TID, pt with stable VS since admission, HD\n done today x 3 hrs with no drop in sbp, 0.5 liters fluid removed, pt\n npo, g-tube & j-tube clamped, no maintenance ivf\n Action:\n HCT q 8 hrs today, po midodrine given as ordered, protonix, octreotide,\n carafate given as ordered, cl lix diet started this pm\n Response:\n 1500 hct stable @ 28.5, BM x 1 this pm, guiac +, mod amt liquid\n green/black stool, no BRB noted, no N/V, c/o mild abdominal pain,\n states does not need pain med, tolerating cl lix well\n Plan:\n Tx to floor on , advance to regular diet, resume tube feed,\n continue to monitor for GI bleed\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Height:\n Admission weight:\n 98.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH, GI Bleed\n CV-PMH:\n Additional history: s/p Bilateral knee replacements OA, Chronic GIB\n internal hemorrhoids, grade 1 esophageal varices seen in ,\n bleeding duodenal ulcer\n Surgery / Procedure and date: - Embolization in IR\n - Ex. Lap for duodenal ulcer repair\n S/P abdominal closure, placement of feeding J tube (draining\n jtube in place already)\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:70\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,360 mL\n 24h total out:\n 70 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 01:37 AM\n Potassium:\n 4.1 mEq/L\n 01:37 AM\n Chloride:\n 92 mEq/L\n 01:37 AM\n CO2:\n 25 mEq/L\n 01:37 AM\n BUN:\n 96 mg/dL\n 01:37 AM\n Creatinine:\n 5.1 mg/dL\n 01:37 AM\n Glucose:\n 78 mg/dL\n 01:37 AM\n Hematocrit:\n 28.5 %\n 02:46 PM\n Finger Stick Glucose:\n 221\n 04:00 PM\n Valuables / Signature\n Patient valuables: duffle bag with only clothing\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: 1020\n Date & time of Transfer: \n" }, { "category": "ECG", "chartdate": "2164-12-03 00:00:00.000", "description": "Report", "row_id": 232605, "text": "Normal sinus rhythm, rate 97. Possible left atrial abnormality. Late\ntransition. Compared to the previous tracing of no diagnostic\ninterval change.\n\n" }, { "category": "ECG", "chartdate": "2164-10-16 00:00:00.000", "description": "Report", "row_id": 232606, "text": "Baseline artifact. Sinus rhythm. Low limb lead voltage. Since the previous\ntracing of the rate is faster and the voltage is lower in the\nprecordial leads.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1102633, "text": " 8:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess tube location, cvl location, and for pneumothorax\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M s/p ex lap\n REASON FOR THIS EXAMINATION:\n assess tube location, cvl location, and for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment for tube location, assessment for pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 6 cm above the carina.\n The course and position of the nasogastric tube is unremarkable. Unchanged\n course and position of the left central venous access line. The lung volumes\n have slightly decreased. At both the bases of the left and the right lung,\n areas of atelectasis with air bronchograms are seen. There is no evidence of\n pulmonary edema, no evidence of focal parenchymal opacity suggesting\n pneumonia. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102902, "text": " 8:40 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with GI bleed\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: 52-year-old man with GI bleed.\n\n FINDINGS:\n\n In comparison to the previous chest radiograph, the pulmonary edema has\n improved and the bilateral pleural effusions which are small-to-moderate on\n the right side and small on the left side remain stable with unchanged left\n lower lobe retrocardiac atelectasis. No new consolidation or pneumothorax.\n\n A left IJ line, NG tube and ET tube are unchanged in position.\n\n IMPRESSION:\n\n Improved pulmonary edema with unchanged bilateral pleural effusions and left\n lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102645, "text": " 11:38 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change - please do at midnight\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with ? mediastinal widening\n REASON FOR THIS EXAMINATION:\n interval change - please do at midnight\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval changes.\n\n COMPARISON: , 8:27 p.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The mediastinal dimensions are constant. Unchanged position and\n course of the monitoring and support devices. Unchanged lung volumes,\n unchanged size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1102459, "text": " 7:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Is the line appropriately placed? Any pneumo?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/p left IJ CVL placement.\n REASON FOR THIS EXAMINATION:\n Is the line appropriately placed? Any pneumo?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left IJ central line placement.\n\n FINDINGS: Left central catheter extends to the mid portion of the SVC. No\n evidence of pneumothorax. No acute cardiopulmonary disease.\n\n Continued elevation of the right hemidiaphragmatic contour, as on the study of\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-17 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 1102473, "text": "GI BLEEDING STUDY Clip # \n Reason: ETOH CIRRHOSIS, ESOPHAGEAL VARICES, MASSIVE UGIB EVALUATE FOR SOURCE OF BLEEDING\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 15.7 mCi Tc-m RBC ();\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-99m, blood flow and dynamic images of the abdomen for 90 minutes\n were obtained. A left lateral view of the pelvis was also obtained.\n\n Blood flow images show normal flow through the aorta, perfusion of bowel, and\n flow into the IVC and portal vein.\n\n Dynamic blood pool images show evidence of bleeding, first noticed at 33\n minutes, extending from the first portion of the duodenum, and flowing into\n loops of small bowel. Note is also made of decreased uptake in the liver,\n consistent with the history of cirrhosis, as well as separation of the liver\n margin from the lateral abdominal wall, consistent with ascites. Increased\n uptake in the portal vein is consistent with portal hypertension.\n\n IMPRESSION: 1. Evidence of bleeding from the first portion of the duodenum,\n first seen at 33 minutes. 2. Evidence of cirrhosis, portal hypertension and\n ascites.\n\n Findings discussed over the phone with Dr. at 4:25 am.\n\n\n , M.D.\n , M.D. Approved: WED 3:41 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": "2164-10-16 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 1102448, "text": " 6:28 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: eval for dilated duct\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with BRBPR, evidence of possible ampullary bleed on EGD\n REASON FOR THIS EXAMINATION:\n eval for dilated duct\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa TUE 11:12 PM\n PFI:\n 1. Partially occluded portal vein thrombosis which is new when compared to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER QUADRANT ULTRASOUND\n\n COMPARISON: .\n\n HISTORY: Possible ampullary bleed, evaluate for biliary dilatation.\n\n FINDINGS: The liver demonstrates a nodular and shrunken appearance consistent\n with cirrhosis. There are no focal liver lesions identified. There is a\n patent umbilical vein. There is no intrahepatic or extrahepatic biliary\n dilatation. The gallbladder wall is mildly thickened measuring 6 mm likely\n due to chronic liver disease. There is no pericholecystic fluid or gallstones\n identified. The spleen is enlarged and measures 17.9 cm. The common bile\n duct measures 5 mm. The portal vein proximally demonstrates partially\n occlusive thrombus with minimal flow. More distally, there is very slow flow\n measuring approximately 7 cm/sec. These findings are new when compared to\n prior exam. There is a small amount of free fluid consistent with ascites\n again identified. The main hepatic artery demonstrates normal color flow and\n waveforms.\n\n IMPRESSION:\n 1. Partially occluded portal vein thrombosis which is new when compared to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites, recanalized umbilical vein,\n splenomegaly.\n 3. Gallbladder sludge and wall thickening, the latter is likely due to\n chronic liver disease. No evidence of acute cholecystitis.\n 4. No intrahepatic or extrahepatic biliary dilatation.\n\n Findings were discussed with Dr. via telephone at the time of\n review.\n DFDdp\n (Over)\n\n 6:28 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: eval for dilated duct\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-10-16 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 1102449, "text": ", D. MED MICU-7 6:28 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: eval for dilated duct\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with BRBPR, evidence of possible ampullary bleed on EGD\n REASON FOR THIS EXAMINATION:\n eval for dilated duct\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Partially occluded portal vein thrombosis which is new when compared to\n prior exam.\n 2. Cirrhotic-appearing liver with ascites.\n 3. Patent umbilical vein.\n 4. Splenomegaly.\n 5. Gallbladder sludge and wall thickening likely due to chronic liver\n disease. No evidence of acute cholecystitis.\n 6. No intrahepatic or extrahepatic biliary dilatation.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2164-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102677, "text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess lung fields\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n pls assess lung fields\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with respiratory failure, intubated. Assessment\n for interval changes.\n\n TECHNIQUE: Single portable chest radiograph.\n\n COMPARISON: Portable chest radiograph dated .\n\n FINDINGS: Low lung volumes and crowding of vascular structures are unchanged\n from prior. There is bibasilar and retrocardiac atelectasis, also unchanged.\n Widening of the mediastinum is stable. There is a left IJ terminating within\n the upper SVC. NG and ET tubes are in standard positions and unchanged.\n There is no pneumothorax.\n\n IMPRESSION: Stable radiograph; low lung volumes, bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-17 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1102510, "text": " 8:43 AM\n MESSENERTIC Clip # \n Reason: angiography for evaluation/treatment of bleeding\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 270\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE NON-TUNNELED *\n * F/U STATUS INFUSION/EMBO VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * TRANCATHETER EMBOLIZATION FLUORO GUID PLCT/REPLCT/REMOVE *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with ETOH cirrhosis, massive UGIB from duodenal source on RBC\n scan\n REASON FOR THIS EXAMINATION:\n angiography for evaluation/treatment of bleeding\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JVg FRI 8:52 AM\n PFI:\n Approximately 1-cm pseudoaneurysm seen off of gastroduodenal artery with no\n active bleeding at the time of injection. This lesion corresponded to\n location of blood/bleeding seen on both endoscopy and tagged red blood cell\n scan. Multiple coils were placed proximal and distal to this lesion along\n with Gelfoam. Successful postembolization arteriograms demonstrating no flow\n to pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with alcoholic cirrhosis, massive upper GI bleed\n from duodenal source on red blood cell scan.\n\n OPERATORS: Drs. , , and were present and\n supervising the procedure.\n\n Moderate sedation was provided by administering divided doses of 150 mcg of\n Fentanyl and 2 mg of Versed throughout the intra-service time of 4 hours\n during which the patient's hemodynamic parameters were continnously monitored.\n\n PROCEDURE: After the risks and benefits of the procedure were explained to\n the patient, written informed consent was obtained. The patient was brought\n to the angiography suite and placed supine on the table. His right and left\n groins were prepped and draped in standard sterile fashion. A preprocedure\n (Over)\n\n 8:43 AM\n MESSENERTIC Clip # \n Reason: angiography for evaluation/treatment of bleeding\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 270\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n timeout and huddle were performed per protocol.\n\n Initial scout views of the upper and lower abdomen revealed nonspecific bowel\n gas pattern. Under fluoroscopic and palpatory guidance, the right common\n femoral artery was cannulated with a 19-gauge single wall needle, through\n which wire was advanced into the lower aorta. The needle was\n exchanged for a 5 French sheath. The side arm was connected to continuous\n dilute heparinized saline flush. Initially, a 5-French soft Omni catheter was\n used to gain access into the superior mesenteric artery. However, given lack\n of stability this was exchanged for a 5-French C2 Cobra glide catheter. This\n maintained stable purchase within the entrance allowing for an angiogram to be\n performed. This angiogram demonstrated conventional anatomy with filling of\n the gastroduodenal artery via tertiary branches off of the proximal SMA, in\n part from the inferior pancreaticoduodenal artery. A 6-mm outpouching was\n demonstrated in the gastroepiploic artery approximately 4 cm distal to the\n most inferior aspect of the gastroduodenal artery. There was no active\n extravasation seen at this site or elsewhere within the superior mesenteric\n artery distribution. Next, using angled Glidewire and the C2 Cobra glide\n catheter, the celiac artery was cannulated and celiac angiogram was performed\n again demonstrating outpouching off of the gastroepiploic artery a few\n centimeters distal to the inferior aspect of the GDA. This finding was most\n consistent with a pseudoaneurysm and measured 6 mm in diameter. There was no\n active extravasation seen from this lesion. The angled Glidewire was advanced\n to the gastroduodenal artery and a selective gastroduodenal arteriogram was\n performed better characterizing this pseudoaneurysm. Again no active bleeding\n was demonstrated.\n\n Given these findings, which corroborate with the findings of both tagged red\n blood cell scan and endoscopy for the site of active bleeding, it was decided\n to embolize this area. Using a Renegade STC microcatheter, 0.018-tip\n guidewire as well as an Excelsior microcatheter and Synchro microwire, super-\n selective access of the gastroepiploic artery was attempted.\n\n During this time, the patient had approximately 600 cc of bright red blood\n aspirated through the orogastric tube along with a drop in blood pressure. It\n decided to have the patient intubated by anesthesia and also place a central\n venous line within his left groin (see below).\n\n Nearly an hour was spend attempting to get distal to the pseudoaneurysm using\n multiple microcatheters and wires. Apparent access was achieved beyond the\n pseudoaneurysm and two 1 cm x 2 mm coils were placed. However after the\n microcatheter was pulled back several centimeters for proximal embolization,\n it became apparent that the gastroepiploic pseudoaneurysm was not crossed. It\n was rather an adjacent arterial branch that had been coiled which was located\n in similar position to the initially seen gastroepiploic artery at the\n (Over)\n\n 8:43 AM\n MESSENERTIC Clip # \n Reason: angiography for evaluation/treatment of bleeding\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 270\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n beginning of the case, however shifted from initial anatomic position due to\n distention of the adjacent stomach.\n\n Again after access distal to the psuedoaneurysm was attemped, but\n unsuccessful. Given the emergent nature of this case it was decided to\n embolize proximal to the pseudoaneurysm. 3 cc of Gelfoam slurry were injected\n at the junction of the gastroduodenal and gastroepiploic arteries with\n satisfactory occlusion of the gastroepiploic artery pseudoaneurysm. Following\n this, the gastroduodenal artery was coiled with two 2 cm x 3 mm coils, two 2\n cm x 4 mm 0.035 coils, and four 3 cm x 4 mm 0.035 coils.\n\n The C2 cobra and microcatheter and wire were removed and and SOS\n Omni catheter placed into the aorta. A post- embolization arteriogram at the\n origin of the celiac artery demonstrated no filling of these previously seen\n pseudoaneurysm and no evidence of active extravasation. This was followed by\n an arteriogram of the SMA similarly demonstrating no filling of the\n pseudoaneurysm, gastroduodenal artery and proximal gastroepiploic artery.\n These findings were consistent with technically successful embolization o fthe\n psuedoaneurysm. The Sos Omni catheter was removed from the 5 French sheath.\n Through the sidearm, a common femoral arteriogram was performed demonstrating\n the bifurcation to be below the puncture site. The sheath was kept in place\n to pressure tranducer continous flush due to an elevated INR. There were no\n immediate complications.\n\n LEFT FEMORAL VEIN CENTRAL VENOUS LINE PLACEMENT: Given the emergent need for\n volume repletion, it was decided to place a left groin central venous line.\n Under son and guidance, the left common femoral vein was\n cannulated with a 19-gauge single wall needle, through which wire\n was advanced. The needle was exchanged for a 12 French dilator followed by\n placement of a 14 French triple-lumen central venous trauma catheter. The\n wire was removed as well as the inner dilator. The catheter was aspirated,\n flushed, capped, and secured to the skin. Volume repletion was immediately\n started through all three lines. There were no immediate complications.\n\n IMPRESSION:\n\n 1. Celiac and sub-selective gastroduodenal arteriograms performed\n demonstrating 6mm gastroepiploic pseudoaneurysm 4-5 cm distal to the inferior\n distal aspect of the gastroduodenal artery.\n\n 2. Superior mesenteric arteriogram demonstrating patent portal vein with\n hepatopetal flow and filling of the above pseudoaneurysm via tertiary branches\n off of the likely inferior pancreaticoduodenal artery.\n\n 3. Coil embolization proximal to the gastroepiploic pseudoaneurysm with\n (Over)\n\n 8:43 AM\n MESSENERTIC Clip # \n Reason: angiography for evaluation/treatment of bleeding\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 270\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Gelfoam embolization and with coiling throughout the gastroduodenal artery.\n All yielding successful technical results with non-filling of the\n pseudoaneurysm. Distal embolization could not be achieved due to difficulties\n with superselecting this artery and the emergent nature of this procedure.\n\n 4. No evidence of active extravasation through the gastroepiploic\n pseudoaneurysm or elsewhere before and after embolization.\n\n 5. Left common femoral central venous trauma line placement.\n\n 6. 5 French right common femoral artery sheath left in place due to elevated\n INR. This catheter was subsequently pulled on with hemostasis\n acheived by a 6 French Angioseal closure device and manual compression.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103444, "text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man intubated, ex lap, gastrotomy, duodenotomy\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Interval change following surgery.\n\n FINDINGS: Endotracheal tube tip terminates 6.5 cm above the carina, and could\n be advanced slightly for standard positioning. Other indwelling devices\n remain in standard position. Increased width of mediastinal vascular pedicle,\n accompanied by engorgement of pulmonary vasculature is suggestive of increased\n volume status of the patient. Slight increase in layering bilateral pleural\n effusions with adjacent areas of basilar atelectasis, left greater than right.\n Probable ascites and anasarca.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103171, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung volumes\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with GI bleed, intubated\n REASON FOR THIS EXAMINATION:\n lung volumes\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: GI bleed and intubated.\n\n Comparison is made with a prior study performed a day earlier.\n\n Mild vascular congestion has improved. Bibasilar opacities consistent with\n atelectasis are greater on the right. ET tube tip is 6.6 cm above the carina.\n NG tube tip is in the stomach. Left IJ catheter remains in place.\n Cardiomediastinal contours are unchanged. There are low lung volumes. The\n skin staples in the upper abdomen and drains in the right upper quadrant are\n in place.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-17 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1102511, "text": ", D. MED MICU-7 8:43 AM\n MESSENERTIC Clip # \n Reason: angiography for evaluation/treatment of bleeding\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 270\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with ETOH cirrhosis, massive UGIB from duodenal source on RBC\n scan\n REASON FOR THIS EXAMINATION:\n angiography for evaluation/treatment of bleeding\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n Approximately 1-cm pseudoaneurysm seen off of gastroduodenal artery with no\n active bleeding at the time of injection. This lesion corresponded to\n location of blood/bleeding seen on both endoscopy and tagged red blood cell\n scan. Multiple coils were placed proximal and distal to this lesion along\n with Gelfoam. Successful postembolization arteriograms demonstrating no flow\n to pseudoaneurysm.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103628, "text": " 3:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man intubated, ex lap, gastrotomy, duodenotomy\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of the patient after exploratory\n laparotomy, gastrostomy and duodenostomy.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The ET tube tip is 6.5 cm above the carina. The NG tube tip is in the\n stomach. The left internal jugular line tip is at the level of mid SVC.\n\n Cardiomediastinal silhouette is stable. There is overall improvement in lung\n herniation except for left basal consolidation, which is persistent and may\n represent atelectasis versus infectious process and should be closely\n monitored. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103130, "text": " 5:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ET tube location\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M s/p ex lap\n REASON FOR THIS EXAMINATION:\n assess ET tube location\n ______________________________________________________________________________\n WET READ: IPf SAT 6:18 PM\n Tip of ETT tube 6 cm above carina.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess ET tube.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube is 6 cm above the carina. Left IJ catheter tip is in the SVC. NG\n tube tip is in the stomach. There are tubes in the right upper quadrant.\n Bibasilar opacities, right greater than left, are consistent with atelectasis.\n If any, there are small bilateral pleural effusions. Cardiomediastinal\n contours are stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103256, "text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with intubated, poor O2 saturation\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation, poor oxygen saturation, evaluation for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Unchanged size of the cardiac silhouette.\n The lung volumes are smaller than at the previous examination. The extent of\n the pre-existing right-sided pleural effusion could have slightly increased.\n The appearance of the left hemithorax is unchanged. Unchanged size of the\n cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-20 00:00:00.000", "description": "O ABDOMEN, SINGLE VIEW IN O.R.", "row_id": 1103126, "text": " 4:24 PM\n ABDOMEN, SINGLE VIEW IN O.R. Clip # \n Reason: R/O LAP, SPONGES\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE ABDOMEN, PERFORMED IN THE OR\n\n REASON FOR EXAM: Assess for retained sponges.\n\n Although there is no abnormal counting of the surgical material, the team\n wanted to make sure that there are no intraabdominal foreign bodies.\n\n NG tube tip is in the stomach.\n\n Metallic bodies in the right upper quadrant are consistent with coils. Several\n drains are in the right hemi-abdomen. There is paucity of the gas\n pattern.\n\n There are no other radiopaque foreign bodies in the abdomen.\n\n Findings were discussed with fellow in charge of the patient.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-01 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1105104, "text": " 12:47 PM\n PORTABLE ABDOMEN Clip # \n Reason: evidence of obstruction?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with hx multiple abdominal drains s/p ex lap now with worsened\n abd pain\n REASON FOR THIS EXAMINATION:\n evidence of obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old man status post ex lap with worsened abdominal pain.\n\n COMPARISON: .\n\n ABDOMEN, SINGLE VIEW: General paucity of bowel gas limits assessment. Air is\n seen in a nondistended stomach. Evaluation for free air is precluded due to\n lack of upright view. There has been interval removal of a nasogastric tube\n since . Interval surgery is evidenced by a long transverse\n run of soft tissue staples across the abdomen. Several metal coils and a\n surgical clip overlie the right upper abdomen. Multiple surgical drains\n overlie the central abdomen. Osseous structures are grossly intact.\n\n IMPRESSION: No definite evidence of bowel obstruction, given limited\n assessment due to paucity of bowel gas.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-09 00:00:00.000", "description": "DRAINAGE HEMATOMA/FLUID", "row_id": 1106459, "text": " 3:06 PM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: 14 cm subhepatic mixed air and fluid collection in the lesse\n Admitting Diagnosis: UPPER GI BLEED\n ********************************* CPT Codes ********************************\n * DRAINAGE HEMATOMA/FLUID CT GUIDED NEEDLE PLACTMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M with ETOH cirrhosis c/b esophageal and rectal varices with prior episodes\n of bleeding admitted with painless BRBPR and hypotension, s/p ex lap,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining jejunostomy,\n now with fungemia and\n REASON FOR THIS EXAMINATION:\n 14 cm subhepatic mixed air and fluid collection in the lesser sac, need IR\n drainage. please place large drain, w/ po contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of alcoholic cirrhosis with recent exploratory\n laparotomy, gastrotomy and duodenotomy and ligation of bleeding vessel. Large\n gas containing lesser sac fluid collection.\n\n PHYSICIANS: Dr. , the attending physician was present and\n supervising throughout the procedure, Dr. , fellow.\n\n PROCEDURE NOTE: Following a discussion of the risks, benefits and\n alternatives of the procedure, informed written consent was obtained. The\n patient was placed on the CT table in the supine position and limited non-\n contrast CT of the upper abdomen was performed for localization purposes. A\n timeout procedure was performed utilizing three patient identifiers. An\n appropriate skin site in the midline anterior abdominal wall was chosen and\n the skin was prepped and draped in sterile fashion. 1% lidocaine was used for\n local anesthesia. A 20-gauge needle was advanced into the collection and\n positioning was confirmed with aspiration of purulent fluid. An 8 French\n catheter was advanced into the collection and positioning was again\n confirmed with aspiration of fluid. The catheter was advanced and positioning\n was confirmed under CT fluoroscopy. The pigtail was formed, the catheter was\n connected to gravity drainage, and approximately 400 cc of purulent fluid was\n then aspirated. The catheter was secured to the skin with a StatLock. The\n patient tolerated the procedure well, with no immediate complications.\n\n Dr. was present for the entire procedure.\n\n FINDINGS:\n Limited non-contrast CT through the upper abdomen again demonstrates a large\n gas containing fluid collection within the lesser sac. There is diffuse\n mesenteric stranding and a small amount of ascites. Dense fluid and\n gallstones are noted within the gallbladder. There are midline surgical\n staples.\n\n Post-procedural images demonstrate interval decrease in size of the fluid\n collection.\n (Over)\n\n 3:06 PM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: 14 cm subhepatic mixed air and fluid collection in the lesse\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Status post placement of 8F drainage catheter into the lesser sac\n fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1106488, "text": " 6:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 52cm left picc. tip?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with new picc.\n REASON FOR THIS EXAMINATION:\n 52cm left picc. tip?\n ______________________________________________________________________________\n WET READ: JXRl FRI 7:07 PM\n Left PICC termiantes in upper SVC. Right IJ line in SVC. No pneumothorax.\n Low lung volumes, bibasilar subsegmental atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a new PICC line has been\n inserted over the left upper extremity. The lung has normal course, the tip\n of the line projects over the upper SVC. There is no evidence of\n complications, notably no pneumothorax. Otherwise, the radiograph is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1104035, "text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man intubated\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Intubated.\n\n FINDINGS: The right middle lobe atelectasis has improved, otherwise there is\n no change with stable left lower lobe atelectasis. No new consolidation or\n pneumothorax.\n NG tube in stomach and out of view, the left central venous catheter tip in\n the mid SVC and ET tube is 5.6 cm above the carina.\n\n IMPRESSION:\n\n Improving right middle lobe atelectasis otherwise unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102861, "text": " 12:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with decreasing PaO2\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male with decreasing O2 saturation. Evaluation for\n interval changes.\n\n TECHNIQUE: Single portable chest radiograph.\n\n COMPARISON: Portable chest radiograph dated .\n\n FINDINGS: Overall there is little change from prior examination. There has\n been minimal increase in retrocardiac atelectasis. There is no pneumothorax\n or new opacity to suggest infection. Low lung volumes and right base\n atelectasis are unchanged. A left IJ ends in the lower SVC. Endotracheal and\n NG tubes are in standard position. The cardiomediastinal silhouette is\n unchanged.\n\n IMPRESSION: No pneumonia; overall unchanged examination with minimal increase\n in retrocardiac atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1104234, "text": " 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man intubated\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient, intubated for interval change.\n\n Portable AP chest radiograph was reviewed.\n\n The ET tube tip is at the level of clavicular heads, approximately 7.5 cm\n above the carina and potentially may be advanced for another 1.5 cm.\n\n The NG tube tip passes below the diaphragm with its tip not included in the\n field of view. The left internal jugular line tip is at the level of mid SVC.\n The right subclavian line tip is at the mid subclavian vein area. The\n cardiomediastinal silhouette is unchanged. The lung volumes remain low. The\n left retrocardiac opacity is unchanged and may represent atelectasis versus\n pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103320, "text": " 11:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with rigors\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Unchanged abdominal clips and abdominal\n drains. Unchanged size of the cardiac silhouette. The extent of the\n bilateral effusions appear slightly decreased. The lung parenchyma is\n unchanged, no evidence of interval appearance of new focal parenchymal\n opacities suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103189, "text": " 8:37 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for re-expansion\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with R collapse, s/p bronch\n REASON FOR THIS EXAMINATION:\n eval for re-expansion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Right collapse SP bronchoscopy.\n\n Comparison is made with prior study performed one hour before.\n\n Right upper lobe collapse has resolved. Right lower lobe collapse has\n improved. Left lower lobe opacity, almost complete collapse of the left lower\n lobe is increased. There is no pneumothorax. ET tube tip is slightly high,\n 8.2 cm above the carina. There is mild vascular congestion. Small bilateral\n pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106115, "text": " 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with 11/4 POD 21 / 18 s/p ex lap, gastrotomy, duodenotomy\n w/suturing of bleeding vessel, draining jejunostomy\n REASON FOR THIS EXAMINATION:\n pulm edema\n ______________________________________________________________________________\n WET READ: JXRl WED 8:15 PM\n low lung volumes. no evidence of pulmonary edema or infection. bibasilar\n subsegmental atelectasis. unchanged right IJ line.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Gastrostomy, duodenotomy. Pulmonary status.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. The tip is now seen projecting over the abdomen. Unchanged mild\n cardiomegaly without evidence of pulmonary edema. Subtle retrocardiac\n atelectasis. No overhydration, no recent parenchymal opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1104554, "text": " 12:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ?line placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man s/p R IJ placement\n REASON FOR THIS EXAMINATION:\n ?line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n Comparison study of .\n\n INDICATION: Line placement.\n\n FINDINGS:\n\n New right internal jugular vascular catheter terminates in the mid superior\n vena cava, with no evidence of pneumothorax. Appearance of the chest is\n otherwise similar to the recent study except for improving left retrocardiac\n opacity, which is nearly resolved.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103837, "text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man intubated, ex lap, gastrotomy, duodenotomy\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male intubated status post exploratory laparotomy.\n Evaluation for interval changes.\n\n TECHNIQUE: Single portable chest radiograph.\n\n COMPARISON: Portable chest radiograph dated .\n\n FINDINGS: Low lung volumes are unchanged. There is persistent atelectasis at\n the bilateral bases. There is no significant pleural effusion or\n pneumothorax. The cardiomediastinal silhouette is normal. An endotracheal\n tube is in place with tip approximately 6 cm above the carina. A left IJ is\n unchanged with tip in mid SVC. An NG tube courses inferiorly and out of view\n of the radiograph.\n\n IMPRESSION: Unchanged retrocardiac and right basilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2164-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103183, "text": " 7:38 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? PTX\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with desats\n REASON FOR THIS EXAMINATION:\n ? PTX\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Desaturation.\n\n Comparison is made with prior study performed two hours earlier.\n\n There is new collapse of the right upper lobe and a new collapse of the right\n lower lobe. only a small area in the right mid lung is aerated. Left lower\n lobe atelectasis minimally improved. ET tube tip is 8.3 cm above the carina.\n No pneumothorax. Mild vascular congestion is stable.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-22 00:00:00.000", "description": "PARACENTESIS DIAG. OR THERAPEUTIC", "row_id": 1108443, "text": " 3:14 PM\n PARACENTESIS DIAG. OR THERAPEUTIC Clip # \n Reason: Please provide with therapeutic paracentesis\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Childs C cirrhosis\n REASON FOR THIS EXAMINATION:\n Please provide with therapeutic paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 52-year-old man with Child's C cirrhosis. Please provide\n therapeutic paracentesis.\n\n PROCEDURE:\n\n The general ICU consent was used for the procedure. The patient's INR and\n platelet count were reviewed and deemed appropriate for the procedure. A\n preprocedure timeout was performed using three patient identifiers.\n\n Using ultrasound guidance, an appropriate site in the right lower quadrant was\n marked. Skin was cleaned and draped in sterile fashion. Local anesthesia was\n obtained using a 9:1 mixture of 1% lidocaine and 8.4% sodium bicarbonate. A 5\n French catheter was inserted, and 2.2 liters of fluid was drained. There\n were no immediate complications.Samples were sent to the lab as requested.\n\n The attending, Dr. , was present for the procedure.\n\n CONCLUSION: Successful ultrasound-guided therapeutic and diagnostic\n paracentesis, with no immediate complications.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-30 00:00:00.000", "description": "PARACENTESIS DIAG. OR THERAPEUTIC", "row_id": 1109488, "text": " 1:32 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please perform therapeutic para and send fluid to lab for cu\n Admitting Diagnosis: UPPER GI BLEED\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG. OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with end stage liver disease.\n REASON FOR THIS EXAMINATION:\n Please perform therapeutic para and send fluid to lab for culture and cell\n counts. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 52-year-old man with end-stage liver disease. Perform\n therapeutic paracentesis.\n\n FINDINGS: A limited ultrasound scan prior to procedure showed a moderate\n amount of ascites in the lower abdomen.\n\n TECHNIQUE: Written consent was obtained from patient prior to procedure\n confirming risks and benefits. Explanation of risks included hemorrhage,\n infection, and damage to adjacent vessels and structures requiring surgical\n repair.\n\n A timeout was performed prior to the procedure, confirming procedure to be\n performed and patient identity by three parameters.\n\n A site suitable for percutaneous aspiration of ascites was marked in the right\n lower anterolateral abdominal wall with patient in supine position. The\n patient was prepped and draped in sterile manner. The superficial tissues\n were infiltrated with 14 mL 1% lidocaine. Drainage was performed through a 5\n French catheter. No significant complications occurred during the\n procedure. Three liters of clear, dark yellow fluid were aspirated.\n\n Dr. was present and supervising during the procedure.\n\n IMPRESSION: Technically successful aspiration of 3 liters of ascites.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-21 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 1108264, "text": "GI BLEEDING STUDY Clip # \n Reason: 52 YR OLD MAN WITH KNOWN DUODENAL BLEED S/P EXLAP AND GDA LIGATION AND CONTROL OF BLEEDING\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 16.5 mCi Tc-m RBC ();\n HISTORY:52 YR OLD MAN WITH KNOWN DUODENAL BLEED S/P EXLAP AND GDA LIGATION AND\n CONTROL OF BLEEDING, NOW WITH DECREASING HEMATOCRIT. CLINICAL CONCERN FOR\n CONTINUED BLEEDING.\n\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for 113\n minutes were obtained. A left lateral view of the pelvis was also obtained.\n\n Blood flow images show normal flow through the aorta, and many collateral\n vessels. The liver is not well perfused.\n Dynamic blood pool images show no evidence of bleeding until 113 minutes.\n Again, note is made of decreased liver uptake, comatible with known history of\n cirrhosis, subcutaneous varices, likely sequale of portal hypertension, as well\n as medialization of the bowel loops compatible with ascites.\n\n IMPRESSION: 1. No evidence of bleeding up to 113 minutes after injection. 2.\n Evidence of cirrhosis, varices (likely sequale of portal hypertension), and\n ascites.\n\n\n , M.D.\n , M.D. Approved: FRI 3:10 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": "2164-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109840, "text": " 4:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA/infiltrate\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with fevers\n REASON FOR THIS EXAMINATION:\n eval for PNA/infiltrate\n ______________________________________________________________________________\n WET READ: IPf SUN 10:50 PM\n Low lung volumes. Suboptimal radiograph; however no significant inetrval\n change. If clinical concern, PA and Lat chest radiograph recommended.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Fever.\n\n COMPARISON: Multiple chest radiographs with the most recent from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: There has been interval placement of a\n double-barrel intravenous catheter with the tip at the cavoatrial\n junction.Left-sided PICC line can be tracked as far as the brachiocephalic\n vein but tip not well visualized likely secondary to motion. Low lung\n volumes and motion limit evaluation. Interval improvement of left lower lobe\n atelectasis and/or pneumonia and probable worsening of right lower lobe\n atelectasis are noted. Heart and mediastinum are grossly stable.\n\n IMPRESSION:\n 1. Severely limited study due to motion artifact and low lung volumes.\n 2. Interval improvement of left lower lobe atelectasis and/or pneumonia and\n probable worsening of right lower lobe atelectasis .\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-07 00:00:00.000", "description": "PL UNILAT LOWER EXT VEINS PORT LEFT", "row_id": 1106102, "text": " 5:49 PM\n UNILAT LOWER EXT VEINS PORT LEFT Clip # \n Reason: CELLULITIS IN LT THIGH\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with 52M w/ Child's C EtOH Cirrhosis s/p Exlap, doudenotomy and\n drainage for massive UGIB , cellulitis L thigh\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n WET READ: SPfc WED 7:52 PM\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cellulitis of the left thigh and question of deep venous\n thrombosis.\n\n COMPARISON: None available.\n\n FINDINGS: Waveforms of the common femoral veins are symmetric bilaterally\n with appropriate response to Valsalva maneuvers. In the left lower extremity,\n the common femoral, proximal greater saphenous, superficial femoral and\n popliteal veins are normal with appropriate response to waveform augmentation,\n compression and wall-to-wall flow seen on color analysis. Wall-to-wall flow\n is also visualized in the posterior tibial and peroneal veins in the calf. A\n spot son image at the area of pain on the thigh reveals no underlying\n abscess.\n\n IMPRESSION: No deep venous thrombosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1107550, "text": " 3:58 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumonia\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with etoh cirrhosis s/p ex lap duodenotomy and drainage for\n massive ugib now with increased wbc on antibiotics\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 5:03 PM\n PFI: Left lower lobe consolidation, new, worrisome for infectious process.\n Atelectasis is less likely.\n ______________________________________________________________________________\n FINAL REPORT\n `REASON FOR EXAMINATION: Followup of the patient with ethanol cirrhosis after\n exploratory duodenotomy and drainage for massive upper GI bleeding, currently\n with increased white blood cell count.\n\n Portable AP and lateral chest radiographs were reviewed in comparison to\n .\n\n There is new consolidation in the left retrocardiac area, increased since the\n prior study that might represent pneumonia versus atelectasis. Close followup\n is recommended. Small amount of pleural effusion is noted.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107736, "text": " 8:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for evidence of worsening infiltrate\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with question PNA\n REASON FOR THIS EXAMINATION:\n please evaluate for evidence of worsening infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 52-year-old man with possible pneumonia.\n\n FINDINGS: Comparison is made to prior study from .\n\n There are low lung volumes due to poor inspiratory effort. There are hazy\n densities at the lung bases, most compatible with subsegmental atelectasis;\n however, early infiltrate cannot be entirely excluded. There is a small left-\n sided pleural effusion.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1107551, "text": ", J. FA10 3:58 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumonia\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with etoh cirrhosis s/p ex lap duodenotomy and drainage for\n massive ugib now with increased wbc on antibiotics\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left lower lobe consolidation, new, worrisome for infectious process.\n Atelectasis is less likely.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105213, "text": " 7:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusions\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with volume overload\n REASON FOR THIS EXAMINATION:\n eval for effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Volume overload.\n\n FINDINGS: In comparison with study of , there are lower lung volumes but\n otherwise little change except for removal of the nasogastric tube.\n Persistent mild elevation of the right hemidiaphragmatic contour with mild\n atelectatic changes at the left base in the retrocardiac region.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1104837, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man extubated, fluid overload\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Extubation with fluid overload, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the lung volumes have\n improved. Left IJ catheter has been removed. The right IJ catheter and\n nasogastric tube remain in place. Little overall change in the appearance of\n the heart and lungs with persistent elevation of the right hemidiaphragm.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-19 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1107882, "text": " 11:47 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Place temporary hemodialysis line with VIP port. PLease leav\n Admitting Diagnosis: UPPER GI BLEED\n ********************************* CPT Codes ********************************\n * NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with renal insufficiency in need of HD today, please place line\n REASON FOR THIS EXAMINATION:\n Place temporary hemodialysis line with VIP port. PLease leave PICC in place\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BTCa MON 1:39 PM\n PFI: Successful placement of temporary hemodialysis catheter with VIP port\n via the right internal jugular vein with the tip terminating in the right\n atrium. The catheter is ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL INFORMATION: 52-year-old male with cirrhosis and renal insufficiency\n requiring hemodialysis. Request to place temporary hemodialysis line with VIP\n port.\n\n OPERATORS: The procedure was performed by Dr. . Dr. \n , the attending radiologist, supervised the procedure.\n\n ANESTHESIA: 1% lidocaine was administered locally.\n\n PROCEDURE AND FINDINGS: After the risks, benefits and alternatives of the\n procedure were explained to the patient, written informed consent was\n obtained. The patient requested to be DNR/DNI for the duration of the\n procedure. The patient was brought to the angiography suite and placed supine\n on the imaging table. The right neck was prepped and draped in usual sterile\n fashion. A preprocedure timeout was performed. A scout view of the chest was\n obtained demonstrating a left PICC with its tip in the SVC. Next, a\n micropuncture kit was used to gain access into the right internal jugular vein\n under ultrasound guidance with hard copy images on file. 0.018 wire was\n placed through the needle into the SVC using fluoroscopic guidance. A small\n incision was made over the needle and the needle was removed and replaced with\n a 4.5 French micropuncture sheath. The wire and inner 3 French sheath were\n removed and replaced with a 0.035 wire with the tip of the wire\n terminating in the IVC. A 4.5 French sheath was then removed over the wire\n and a 12 French dilator was placed over the wire to dilate the soft tissue\n tract into the right IJ. The dilator was removed. A 12 French triple-lumen\n 15 cm temporary hemodialysis catheter with a VIP port was then placed over the\n wire into the right IJ with the tip terminating in the right atrium. All\n three ports of the catheter aspirated and flushed easily. The ports were\n capped and the catheter was sutured to the skin with 0 silk and a sterile\n dressing was applied. The patient tolerated the procedure well and there were\n no immediate complications.\n\n (Over)\n\n 11:47 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Place temporary hemodialysis line with VIP port. PLease leav\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Uncomplicated placement of a non-tunneled hemodialysis catheter\n with a VIP port via the right IJ access with the tip of the catheter in the\n right atrium. The catheter is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-19 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1107883, "text": ", J. FA10 11:47 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Place temporary hemodialysis line with VIP port. PLease leav\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with renal insufficiency in need of HD today, please place line\n REASON FOR THIS EXAMINATION:\n Place temporary hemodialysis line with VIP port. PLease leave PICC in place\n ______________________________________________________________________________\n PFI REPORT\n PFI: Successful placement of temporary hemodialysis catheter with VIP port\n via the right internal jugular vein with the tip terminating in the right\n atrium. The catheter is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105619, "text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o free air, interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with persistent secretions, increased abdominal distension\n REASON FOR THIS EXAMINATION:\n r/o free air, interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: .\n\n INDICATION: Abdominal distention and secretions.\n\n FINDINGS: Lung volumes remain low. Cardiomediastinal contours are unchanged.\n Slight worsening of patchy opacity at the left base which may be due to\n atelectasis or developing pneumonia. Persistent moderate elevation of right\n hemidiaphragm with adjacent linear atelectasis. Small pleural effusions\n unchanged. Probable ascites.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106470, "text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval intervalk change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M with ETOH cirrhosis c/b esophageal and rectal varices with prior episodes\n of bleeding admitted with painless BRBPR and hypotension, s/p ex lap,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining jejunostomy,\n now with fungemia\n REASON FOR THIS EXAMINATION:\n Eval intervalk change\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: \n\n INDICATION: Fungemia.\n\n FINDINGS: Persistent minor areas of atelectasis at the bases and elevation of\n right hemidiaphragm. Cardiomediastinal contours are within normal limits for\n technique and appear unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105031, "text": " 3:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with poor O2 sats\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest single supine portable AP view.\n\n CLINICAL INFORMATION: A 52-year-old male with history poor O2 saturations.\n\n COMPARISON: .\n\n FINDINGS: Nasogastric tube and right internal jugular central venous line are\n unchaged in position. There are low lung volumes, which accentuate the\n bronchovascular markings. There is persistent mild elevation of the right\n hemidiaphragm. Mild bibasilar atelectasis is noted.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-08 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1106232, "text": " 11:15 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: without IV but with oral contrast eval for collection/absces\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with hepatic failure now with markedly increase white count and\n left thigh cellulitis\n REASON FOR THIS EXAMINATION:\n without IV but with oral contrast eval for collection/abscess please include\n bilateral thighs to knee to evaluate for leg abcess\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 6:25 PM\n 14 cm subhepatic mixed air and fluid collection in the lesser sac, in the\n setting of recent perforated duodenal ulcer, concerning for infected\n collection. Wall thickening of ascending colon, a nonspecific finding.\n Diagnostic consideration include infection, ischemic, and inflammatory\n etiologies. Discussed with Dr. .\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with hepatic failure and increasing white cell\n count. Evaluate for abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the abdomen, pelvis, and thighs were\n obtained following the administration of oral contrast only via the\n jejunostomy tube.\n\n CT ABDOMEN WITHOUT CONTRAST: Bibasilar consolidations likely represent\n atelectasis with a small left pleural effusion suggested.\n Non-contrast evaluation of the liver is unremarkable without evidence for\n intra- or extra-hepatic biliary ductal dilatation. Hyperdense material in the\n gallbladder may represent vicarious excretion from recent intravenous\n administration. Small gallstones would be obscured. Splenomegaly is noted with\n the spleen measuring up to 12 cm. Non- contrast evaluation of the kidneys,\n adrenal glands, and pancreas are unremarkable. Diffuse mesenteric fluid\n stranding is noted in the setting of mild ascites and anasarca.\n\n A large subhepatic fluid collection in the lesser sac produces mass effect on\n a nondistended stomach, measuring approximately 14.4 x 11.2 x 8.1 cm and\n containing a mixture of hypodense fluid and air. Duodenal suture material and\n evidence of gastroduodenal artery ligation are apparent. Enteric contrast has\n passed through nondistended loops of small bowel into the distal colon without\n evidence for obstruction. A percutaneous jejunostomy is in place without\n evidence for complication. Wall thickening of the ascending colon extends into\n the proximal transverse colon. The abdominal aorta is of normal caliber.\n\n CT PELVIS WITHOUT CONTRAST: The rectum and sigmoid colon are unremarkable.\n The bladder contains a Foley and non-dependent air. A surgical drain\n (Over)\n\n 11:15 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: without IV but with oral contrast eval for collection/absces\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n terminates in the pelvis.\n\n Bone windows reveal no worrisome lytic or sclerotic osseous lesions. A distal\n right tibia screw is noted. Subcutaneous edema is noted in the thighs without\n evidence of focal fluid collection.\n\n IMPRESSION:\n 1. Large air and fluid collection in the lesser sac. In the setting of sepsis,\n concern is raised for an infected collection and percutaneous drainage should\n be considered.\n 2. Ascending colonic wall thickening extending into the transverse colon.\n This is a nonspecific finding for which diagnostic considerations include\n ischemic, infectious and inflammatory etiologies.\n 3. Anasarca with mild ascites and small left pleural effusion.\n 4. Splenomegaly.\n\n Findings discussed with Dr. on .\n\n" }, { "category": "Radiology", "chartdate": "2164-11-05 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1105732, "text": " 4:05 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for ileus\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with distended abdomen\n REASON FOR THIS EXAMINATION:\n please eval for ileus\n ______________________________________________________________________________\n WET READ: JXRl MON 8:40 PM\n limited study. air filled midline loop of bowel measuring 4.8cm in diameter,\n difficult to determine whether colon or small bowel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with distended abdomen. Please evaluate for\n ileus.\n\n TECHNIQUE: Portable single view AP radiograph of the abdomen.\n\n COMPARISON: Portable radiograph from .\n\n FINDINGS: Compared to , there is slightly increase of large\n bowel gas. There is a 5 cm measuring likely large bowel loop in the lower\n abdomen. The stomach is displaced laterally, likely secondary to ascites.\n Diffuse haziness overlying the abdomen secondary to ascites. Multiple drains\n are visualized in the abdomen.\n\n IMPRESSION: There is a moderately dilated large bowel loop in the inferior\n abdomen without evidence of obstruction. There is ascites.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1106852, "text": " 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: High wbc eval for pneumonia\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52M with ETOH cirrhosis c/b esophageal and rectal varices with prior episodes\n of bleeding admitted with painless BRBPR and hypotension, s/p ex lap,\n gastrotomy, duodenotomy with suturing of bleeding vessel, draining jejunostomy,\n now with fungemia, S/P IR drainage of fluid collection\n REASON FOR THIS EXAMINATION:\n High wbc eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 52-year-old man with alcoholic cirrhosis complicated by\n esophageal and rectal varices with prior episodes of bleeding, admitted with\n painless, bright red blood per rectum and hypotension, status post Ex-Lap,\n gastrotomy, duodenotomy with suturing of bleeding vessel draining\n\n COMPARISON: , ; .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: In the interval, a right internal\n jugular catheter has been removed. A left-sided PICC persists with tip\n projecting over the mid SVC. Mild cardiomegaly persists. Mediastinal and\n hilar contours are stable. There is no focal consolidation, large effusion or\n pneumothorax. There is persistent elevation of the right hemidiaphragm. Mild\n retrocardiac opacification and right basal suggests atelectasis.\n\n IMPRESSION: No pneumothorax. No large pleural effusion.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2114-04-11 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 758264, "text": " 2:20 PM\n LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: s/p fall from 80feet w/ thoracolumbar pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall from 80feet w/ thoracolumbar pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post 0 feet, question fracture.\n\n AP and lateral views of the lumbar spine demonstrate no evidence of fracture.\n There is slight straightening of the normal lordotic curvature of the lumbar\n spine. No spondylolysis or spondylolisthesis identified. No intervertebral\n disc space narrowing is seen.\n\n" }, { "category": "Radiology", "chartdate": "2114-04-11 00:00:00.000", "description": "T-SPINE", "row_id": 758265, "text": " 2:21 PM\n T-SPINE Clip # \n Reason: s/p fall from 80feet w/ thoracolumbar spine pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall from 80feet w/ thoracolumbar spine pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post 0 feet. Question fracture.\n\n AP and lateral views of the thoracic spine demonstrate no evidence of\n fractures or subluxations. There is normal alignment of the visualized\n vertebral bodies. No destructive osseous lesions are seen.\n\n" }, { "category": "Radiology", "chartdate": "2114-04-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 758187, "text": " 6:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p 80 ft fall off of a bridge into the . Evalu\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Additional information has been obtained from CareWeb Clinical Lookup since\n the approval of the original report. Reason for exam should also state\n hypothermia.\n\n\n 6:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p 80 ft fall off of a bridge into the . Evalu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman see above for details\n REASON FOR THIS EXAMINATION:\n s/p 80 ft fall off of a bridge into the . Evaluate for abd\n injuries.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 foot fall off bridge into .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage. The ventricles,\n cisterns and sulci are normal. There is no shift of normally midline\n structures. There is no evidence of mass effect.\n\n The soft tissues and osseous structures are unremarkable. There is moderate\n mucosal sinus thickening within the right maxillary sinus. The remainder of\n the visualized sinuses are within normal limits.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage, edema or mass\n effect. Moderate chronic mucosal sinus thickening within the right maxillary\n sinus.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-04-10 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 758188, "text": " 6:19 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: s/p 80' fall from bridge into river\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p 80' fall from bridge into river\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Fell from bridge into river.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases to the pubic symphysis after the administration of intravenous\n contrast.\n\n CONTRAST: 150 cc of Optiray was administered due to patient's history of\n trauma.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases demonstrate bilateral\n minimal dependent atelectasis. No pleural effusions or consolidations are\n identified. Within the posterior right lobe of the liver there is a 1.5 cm\n hypodensity consistent with a simple cyst. Within the anterior portion of the\n right lobe of the liver there is a rounded hypodensity measuring 1.3 cm\n consistent with a simple cyst. In the most anterior medial aspect of the\n right lobe of the liver there is an area of hypodensity which is too small to\n characterize. No other focal liver abnormalities are detected. The\n gallbladder contains two calcified gallstones. There is no evidence of\n gallbladder wall thickening or pericholecystic fluid. The spleen, bilateral\n adrenal glands, pancreas, bilateral kidneys, large and small bowel are normal.\n There is no free fluid or free air within the abdomen. There is no\n significant mesenteric or retroperitoneal lymphadenopathy.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: A Foley catheter is located\n within the bladder. The uterus and adnexa are unremarkable. The distal colon\n and visualized small bowel are normal. The distal ureters are normal. There\n is no pelvic free fluid. There is no free air within the pelvis. There is no\n significant inguinal or pelvic lymphadenopathy.\n\n Osseous structures are normal.\n\n IMPRESSION:\n 1. No evidence of an acute intra-abdominal injury.\n 2. Cholelithiasis without evidence of acute cholecystitis.\n 3. Two simple cysts within the liver.\n 4. There is an additional smaller area of hypodensity within the liver which\n is too small to characterize and may represent focal fat, cyst or\n hemangioma.\n (Over)\n\n 6:19 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: s/p 80' fall from bridge into river\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2114-04-10 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 758191, "text": " 7:03 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: eval for mediastinal widening, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p 80 ft fall off bridge into water.\n REASON FOR THIS EXAMINATION:\n eval for mediastinal widening, ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n CHEST AP: Comparison is made to the prior film that was obtained earlier\n today. The heart is at the upper limit of normal size. The right\n hemidiaphragm appears to be slightly elevated compared to the left\n hemidiaphragm. The hilar and mediastinal contours are unremarkable. There is\n no focal consolidation or pneumothorax. A small left pleural effusion is\n noted.\n\n Visualized osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1) There is a small left-sided pleural effusion.\n\n 2) Slightly elevated right hemidiaphragm.\n\n 3) No evidence of acute intrathoracic injury.\n\n" }, { "category": "Radiology", "chartdate": "2114-04-10 00:00:00.000", "description": "TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)", "row_id": 758185, "text": " 6:04 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: FALL\n ______________________________________________________________________________\n FINAL REPORT\n\n TRAUMA SERIES: The C-spine is visualized to the level of C7. There is normal\n alignment of the cervical spine, without evidence of fracture or dislocation.\n The visualized soft tissues are unremarkable. There is no loss of vertebral\n height.\n\n Chest radiograph demonstrates no evidence of fracture. Limited study because\n part of the lung apices is not included. The heart is at the upper limit of\n normal size. No evidence of focal consolidation or pneumothorax. There is no\n pleural effusion noted. A repeat chest radiograph was obtained for better\n visualization of the lung parenchyma.\n\n The pelvic image demonstrates no evidence of fracture or dislocation. The hip\n joints are unremarkable bilaterally. The soft tissues are within normal\n limits.\n\n IMPRESSION: No evidence of acute fracture or dislocation.\n\n Limited chest radiograph which has been repeated and dictated separately.\n\n\n\n" }, { "category": "ECG", "chartdate": "2114-04-11 00:00:00.000", "description": "Report", "row_id": 159771, "text": "Sinus rhythm\nLeft atrial abnormality\nInferior + anterior T wave change are nonspecific\nLow QRS voltage diffusely\nNo previous tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2114-04-11 00:00:00.000", "description": "Report", "row_id": 1268032, "text": "NSG TRANSFER NOTE\n~~~~~~~~~~~~~~~~~\nREFER TO ADMISSION NOTE FOR DETAILS OF INJURY.\n\nN: PT A/OX3, BRIGHT AFFECT. DENIES SI/HI. 1:1 SITTER FOR SAFETY. C/O LOW BACK PAIN AND NON SPECIFIC ABD PAIN. TLS PLAIN FILMS COMPLETED THIS AFTERNOON WITH RESULTS STILL PENDING.\nCV: STABLE. FEMORAL CL D/C'D. MG/K REPLETED.\nR: RA SATS >97%. LUNGS CLEAR BILAT.\nGI: NPO UNTIL FILMS READ. ABD SOFT/DISTENDED WITH PRESENT BS. NO N/V/D.\nGU: FOLEY D/C'D AND VOIDING IN GOOD AMTS CLEAR YELLOW.\nHEME: HCT/COAGS STABLE. HCT 28/INR 1.1\nID: TMAX 99.5\nSOC: BROTHER IN VISITING.\nPSYCH CONSULTED AND MET WITH PT. RECOMMENDATIONS IN CHART.\nA/P: STABLE FOR TRANSFER TO FLR. RESTART PSYCH MEDS. MONITOR ABD FOR S/S RETROPERITONEAL BLD. ?TRANSFER TO INPATIENT PSYCH AT .\n\n" }, { "category": "Nursing/other", "chartdate": "2114-04-11 00:00:00.000", "description": "Report", "row_id": 1268033, "text": "SOCIAL WORK NOTE:\nNew trauma pt on T-SICU. Pt is s/p 80' jump off a bridge as a suicide attempt. Pt is being transferred to the floor soon for further medical monitoring before transfer to psychiatric unit. Please see RN notes and psychiatry notes for further information. Pt is resting at this time and family is not present at this time. Social work can be involved as needed. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2114-04-11 00:00:00.000", "description": "Report", "row_id": 1268031, "text": "SICU NURSING NOTE 7P-7A\n PT ADM TO S/P JUMP FROM 80FT BRIDGE INTO RIVER AND RESCUED BY FIRE FIGTHERS. ? LOC AT SCENE BUT GCS 15 IN EW. ALL SCANS NEGATIVE. TLS CLEARED IN EW. HYPOTHERMIC ON ARRIVAL TO EW AND SENT TO SICU D/T HYPOTHERMIA.\n\nPMHX: DEPRESSION AND SEVERAL SUICIDE ATTEMPTS.\nMEDS: CLONAPIN, ZOLOFT, AND TRILAFON.\nALLE: NKDA\nSOCIAL: PT LIVES ALONE WITH BROTHER,, LIVING IN AREA. PTS SON LIVES IN WITH HIS WIFE. PT HAS BEEN SEEN BY DR. AT HOSPITAL FOR HER PSYCH ISSUES. PT DENIED THAT THIS WAS A SUICIDE ATTEMPT UNTIL THIS AM. +TOBACCO -ETOH.\n\nREVIEW OF SYSTEMS\n\nNEURO: PT 2-3 WITH FREQ. PERIODS ON LETHARGY NOTED. FOLLOWING ALL COMMANDS WITH ALL EXTREMETIES. PUPILS 3-4MM BSK BILAT. ZOLOFT AND ATIVAN HELD. C SPINE CLEARED BY TRAUMA TEAM THIS AM.\n\nCV: HR 90-100 SR-ST NO ECTOPY. SBP 130-150. +PP WITH SKIN WARM AND DRY. TRAUMA LINE R GROIN. 2 PIV IN R ARM. INITIALLY TEMP 93.9 ON ARRIVAL BEAR HUGGER APPLIED AND LEVEL ONE USED FOR FLUID WARMING WITH TEMP RISING TO 98 OVER FEW HOURS.\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. NEEDS A LOT OF ENCOURAGEMENT TO DEEP BREATHE. 2LNC WITH SATS 94-97%. DRY COUGH NOTED. NO RESP DISTRESS OR SOB NOTED.\n\nGI: ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. REMAINS NPO EXCEPT SIPS. INITIALLY C/O NAUSEA THAT SUBSIDED ON ITS OWN. NO STOOL OR FLATUS.\nAS SHIFT PROGRESSED C/O ABD AND LOWER BACK PAIN. ALL TEAMS AWARE.\n\nHEME: HCT STABLE 28. 4UFFP GIVNE FOR INR 7.4. VITAMIN K IV GIVEN. REPEAT INR NORMAL.\n\nENDO: NO ISSUES\n\nID: LOWGRADE 100.8. WBC IMPROVED FROM 17 TO 11.\n\nSKIN: SEVERAL SMALL ECCYMOTIC AREAS ON ARMS AND UPPER LEGS. NO BREAKDOWN NOTED.\n\nSOCIAL: BROTHER AND SON CALLED. BOTH STATED PT HAS BEEN HAVING TROUBLE WITH HER MEDS LATELY AND THAT THEY FELT STRONGLY THAT THIS WAS A SUICIDE ATTEMPT. SON STATED THAT MOTHER LEFT ANGRY AND IRRATE MESSAGE ON HIS MACHINE RIGHT BEFORE THE INCIDENT. PT INITIALLY DENIED THAT THIS EPISODE WAS A SUICIDE ATTEMPT BUT STATED LATER IN THE SHIFT \" I DID JUMP YOU KNOW\". SHE ALSO STATED THAT \"I JUST WANT TO TO DIE. LAST WEEK I TRIED TO TAKE OUT MY HEART WITH A SCREW DRIVER\". PYSCH UP TO SEE PT. 1:1 SITTER WITH PT.\n\nA: S/P SUICIDE ATTEMPT.\nP: CONT TO MONITOR HEMODYNAMICS, PYSCH STATUS, AND TRANSFER TO PYSCH UNIT WHEN MEDICALLY CLEARED.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2114-04-11 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 758208, "text": " 6:12 AM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: EVAL FOR FX\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Evaluate for fracture.\n\n Contiguous axial images obtained during an abdominal CT with multiplanar\n reformats.\n\n FINDINGS:\n\n There is no definite evidence of fracture or malalignment.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2177-10-13 00:00:00.000", "description": "Report", "row_id": 1576829, "text": "NSG NOTE\n\nCV: HR 80-90 NSR WITH FREQ PAC'S. SBP 106-149/ INCREASED FREQ IN PAC'S. HR INCREASED TO 104 AFTER FIRST UNIT OF BLOOD. PT BECAME SL SOB BUT SATS 99%. CRACKLES AT BASES. NOTED. DR NOTIFIED. LASIX 20 MG IV GIVEN AND FOLEY PLACED. ADEQUATE DIURESIS. PT BACK INTO NSR WITH LESS PAC'S. PT STATED SHE FELT MUCH BETTER. HR NOW 79. PT IS ON ATENOLOL QD.\n\nRESP: O2 @ 2L NP @ HS SATS 99%. RR-16 APPEARS COMFORTABLE. CRCAKLES AT BASES\n\nGI: ATE DINNER TOL WELL. NO STOOL THIS SHIFT. NOW NPO AFTER MN. HAD GAS AND BLOATING AFTER EATIMG MAALOX GIVEN WITH GOOD EFFECT. + BS\n\nGU: FOLEY PLACED FOR CATH LAB AND POST LASIX ADM. URINE CL YELLOW. SEE FLOW PLAESE\n\nSKIN; INATCT\n\nID: TEMP MAX 99.2\n\nNEURO: A/O X3 MAE. STEADY ON FT PT STANDS AND SITS IN CH. SHE HAD DIIFCULTY SLEEPING. STATES SHE NEVER SLEEPS AT NOC. GETS UP AND INTO CH AT HOME FOR COMFORT. SHE IS PLEASANT AND COOPERATIVE.\n\nSOCIAL: LIVES ALONE IN HER OWN HOME. SON LIVES NEARBY, DAUGHTER IN . NO INQUIERES OVERNOC.\n\nLABS: HCT 26 RECEIVED 2 U PRBC\n BUN 29 CREAT 1.3 RECEIVING MYCOMIST\n CK 11\n\nA/P: 83 YR OLD PMH CAD,HTN,RF,SEVERE PULM HTN, ADM FOR SOB,DOE, CATH ON 90% LAD,80% RCA. NPO AFTER MN FOR INTERVENTION. MONITOR LYTES. CON'T PER NSG JUDGEMENT.\n" }, { "category": "Radiology", "chartdate": "2177-10-14 00:00:00.000", "description": "B KNEE (2 VIEWS) BILAT", "row_id": 843116, "text": " 10:33 AM\n KNEE (2 VIEWS) BILAT Clip # \n Reason: evaluate soft tissue mass on lateral aspect of bilateral kne\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\STENT AND ANGIOPLASTY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with gout, CAD with long standing history of bilateral knee\n soft tissue masses now draining proteinaceous material.\n REASON FOR THIS EXAMINATION:\n evaluate soft tissue mass on lateral aspect of bilateral knees, evaluate for\n joint involvment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of gout and bilateral knee soft tissue masses.\n\n THREE VIEWS OF THE RIGHT KNEE: There is an ill-defined soft tissue density\n lateral to the knee. There are subchondral cysts. Evaluation of the joint\n spaces on these non-weight bearing views is somewhat limited. However, the\n joint spaces appear to be preserved. There is no effusion. There are small\n patellar spurs. No evidence of acute fracture.\n\n IMPRESSION: Sub-chondral cysts and an ill-defined soft tissue density lateral\n to the right knee that may be consistent with gout in an aypical location. The\n ill defined soft tissue density lateral to the right knee may also be\n consistent with an ayptical, loculated cyst.\n\n THREE VIEWS OF THE LEFT KNEE: There is a marginal erosion at the lateral\n tibial plateau. There also appears to be an area of subchondral lucency in the\n medial femoral condyle that may represent a subchondral cyst. There is an ill-\n defined opacity at the lateral aspect of the knee. There is no effusion. There\n is a small patellar spur at the attachment site of the quadriceps tendon on\n these non-weight bearing views. The joint spaces appear to be preserved.\n\n IMPRESSION: Marginal erosion, subchondral cyst, and soft tissue mass that\n may be consistent with gouty changes in an atypical location. The ill-defined\n soft tissue density may also be consistent with an atypically laterally\n located loculated cyst. Further MRI examination of both knees with\n contrast is recommended for further characterization of these findings.\n\n\n\n\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2177-10-14 00:00:00.000", "description": "Report", "row_id": 184960, "text": "Sinus rhythm at a normal rate. Compared to the previous tracing right\nbundle-branch block persists. However, there is now ST segment depression in\nleads V2-V3 with diphasic T waves in these leads. Question anteromedial\nischemia. Compared to the previous tracing of ST segment depressions\nwere previously present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-10-13 00:00:00.000", "description": "Report", "row_id": 184961, "text": "Sinus rhythm with tachycardia. Right bundle-branch block patterning.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2201-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784090, "text": " 11:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: increased secretions/assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with PEA arrest s/p line placement\n\n REASON FOR THIS EXAMINATION:\n increased secretions/assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n FINDINGS: Tip of the ET tube is 2.9 cm above the carina. There is a right\n central venous catheter with tip in the SVC and no pneumothorax. NG tube\n extends below the diaphragm. As noted previously, there is a right effusion.\n Pulmonary vascular markings are somewhat indistinct consistent with an element\n of fluid overload. Left hemidiaphragm is not well seen, and a possibility of\n infiltrate in that location remains.\n\n IMPRESSION:\n\n No pneumothorax and no significant interval change vs. prior--fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-14 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 784038, "text": " 6:07 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: r/o dvt\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with dm II, s/p pea arrest.\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out DVT in patient status post PEA arrest.\n\n There is no prior for comparison.\n\n FINDINGS: scale and Doppler color images of the right superficial\n femoral and popliteal veins were performed. The right common femoral vein\n could not be visualized due to overlying bandage. Similar images were\n obtained of the left common femoral vein, superficial vein and left popliteal\n veins. Normal waveforms, flow, compression and augmentation were identified\n throughout all of the aforementioned veins. No intraluminal thrombus was\n identified.\n\n IMPRESSION:\n\n Normal DVT study of the lower extremities bilaterally. Right common femoral\n vein not seen due to overlying bandage.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784121, "text": " 8:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for CHF exacerbation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with CHF, extubated today, now in resp distress\n REASON FOR THIS EXAMINATION:\n please eval for CHF exacerbation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, 19:54:\n\n INDICATION: CHF with recent extubation. Respiratory distress now.\n\n COMPARISON: at 11:37\n\n FINDINGS: Compared to prior the endotracheal tube has been removed. The\n right CVL remains in place and there is no pneumothorax. Pulmonary vascular\n markings are somewhat distended but unchanged from previous exam. There are\n no new consolidations visualized. Left hemidiaphragm is not well seen and the\n possibility of a left lower lobe air space process remains.\n\n IMPRESSION: Status post extubation otherwise no significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784198, "text": " 2:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval ngt placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with CHF\n REASON FOR THIS EXAMINATION:\n please eval ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check NG tube. CHF.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST: The NG tube extends below the diaphragm and is at least\n within the stomach. The tip is beyond the confines of the inferior aspect of\n the film. There is a right IJ central venous catheter with tip in the distal\n SVC. The heart is mildly enlarged. There is evidence of perivascular haziness\n with small bilateral pleural effusions with patchy bibasilar atelectasis. No\n pneumthorax.\n\n IMPRESSION:\n 1. NG tube at least within the stomach, tip not visualized on the film.\n 2. No significant change in the degree of CHF and small bilateral effusions.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 783954, "text": " 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: sob, eval for infiltrate or chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with above\n .\n REASON FOR THIS EXAMINATION:\n sob, eval for infiltrate or chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath. Evaluate for infiltrate or CHF.\n\n COMPARISONS: .\n\n FINDINGS: Right sided central venous line has been removed in the interval.\n There is stable cardiomegaly and mediastinal contour is unchanged. Pulmonary\n vasculature is indistinct. There are small bilateral pleural effusions. no\n pneumothorax. The bones are demineralized.\n\n IMPRESSION: CHF with increased bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784020, "text": " 1:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: code situation/r/o tension pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with above .\n REASON FOR THIS EXAMINATION:\n code situation/r/o tension pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON - 13:08.\n\n INDICATION: Status post code - assess for tension pneumothorax.\n\n FINDINGS: An endotracheal tube is in place with the tip 1.8 above the carina.\n This could be pulled back 2 cm. There is no pneumothorax. Right pleural\n effusion is seen and appears to be layering out more than that on the prior\n study - positioning differences could contribute. The left hemidiaphragm is\n not well delineated and atelectasis or pneumonia could be responsible.\n Pulmonary vessels remain distended. No definite new infiltrates.\n\n IMPRESSION:\n\n No pneumothorax. Persistent congestive features.\n\n ET tube with tip 1.8 cm above the carina.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-14 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 784037, "text": " 6:07 PM\n RENAL U.S. PORT Clip # \n Reason: assess for kidney size, r/o hydronephrosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with h/o diabetes, cad p/w acute on chronic renal\n insufficiency\n REASON FOR THIS EXAMINATION:\n assess for kidney size, r/o hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of diabetes, coronary artery disease, now with acute on\n chronic renal insufficiency. Assess kidney size and rule out hydronephrosis.\n\n RENAL ULTRASOUND: The right kidney is unremarkable without evidence for\n stones, hydronephrosis, or masses. The left kidney is poorly visualized\n though there is no evidence for hydronephrosis. The right kidney measures 8.8\n cm. The left kidney measures 10.4 cm.\n\n IMPRESSION: No evidence for hydronephrosis. Suboptimal evaluation of the\n left kidney.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784034, "text": " 5:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumo; line tip ?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with PEA arrest s/p line placement\n REASON FOR THIS EXAMINATION:\n ?pneumo; line tip ?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST - 17:39\n\n INDICATION: New line placement.\n\n Comparison: - 13:08\n\n FINDINGS: Compared to prior study, the endotracheal tube has been pulled back\n and the tip is now 3.7 cm above the carina. The right-sided central venous\n catheter has been placed and the tip is in the SVC - no pneumothorax.\n\n Right pleural effusion is again evident without significant change. There are\n no new infiltrates. Cardiomegaly persists.\n\n IMPRESSION: No pneumothorax following right central venous catheter\n placement. ET tube better positioned. No change in the appearance of the\n lungs.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-16 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 784194, "text": " 2:16 PM\n RENAL U.S. PORT Clip # \n Reason: please eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with h/o diabetes, cad p/w acute on chronic renal\n insufficiency\n REASON FOR THIS EXAMINATION:\n please eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of diabetes, coronary artery disease, now with acute on\n chronic renal insufficiency. Evaluate for obstruction.\n\n RENAL ULTRASOUND: The right kidney measures 9.2 cm. The left kidney measures\n 9.5 cm. There is a small, 2 mm stone in the mid-portion of the right kidney.\n No hydronephrosis is present. There is a Foley catheter within the bladder.\n\n IMPRESSION: Small right kidney stone. No hydronephrosis.\n\n" }, { "category": "Echo", "chartdate": "2201-02-16 00:00:00.000", "description": "Report", "row_id": 68403, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Mitral valve disease. Myocardial infarction.\nHeight: (in) 60\nWeight (lb): 146\nBSA (m2): 1.63 m2\nBP (mm Hg): 95/58\nStatus: Inpatient\nDate/Time: at 09:00\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated. The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. There is\nlipomatous hypertrophy of the interatrial septum.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis moderately depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic; basal\ninferolateral - hypokinetic; mid inferolateral - hypokinetic; septal apex -\nhypokinetic; inferior apex - hypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\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. There is\nmoderate mitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is elongated. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is moderately depressed\nwith mild globabl hypokinesis with more marked hypokinesis of the inferior,\ninferolateral and inferoseptal walls. Resting regional wall motion\nabnormalities include . Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared with the prior study of , there is no overall change in LV\nfunction or wall motion abnormalities seen. There is now mild mitral\nregurgitation present.\n\n\n" }, { "category": "ECG", "chartdate": "2201-02-15 00:00:00.000", "description": "Report", "row_id": 147433, "text": "Sinus rhythm\nFirst degree A-V block\nRight axis deviation\nConsider prior inferior infarct, age indeterminate - and/or left posterior\nfascicular block\nPoor R wave progression\nInferolateral ST-T wave abnormalities - cannot exclude ischemia - clinical\ncorrelation is suggested\nSince previous tracing of : tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2201-02-13 00:00:00.000", "description": "Report", "row_id": 147434, "text": "Sinus rhythm\nFirst degree A-V block\nLow R(V2-V4) probably due to right ventricular hypertrophy\nInferior/lateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2201-02-14 00:00:00.000", "description": "Report", "row_id": 147435, "text": "*** technically unsatisfactory tracing ***\nP waves difficult to visualize\nQRS complexes unchanged from previous\n\n" }, { "category": "Nursing/other", "chartdate": "2201-02-16 00:00:00.000", "description": "Report", "row_id": 1398364, "text": "P-MICU NPN 7p-7a\nSystems Review:\n\nCV: SBP 88-150/. HR has been basically been in the 80's SR with no noted ectopy. K+ 5.0, Ca 7.4, PO 9.3. Pt becoming tachycardic and diophoretic. Suctioned for scant amt of secretions. Given 80mg IVP lasix and 1mg IVP MSO4. Minimal urine response, but the MSO4 calmed pt and she settled out without further interventions..\n\nHeme: Hct up to 28.1. CVP ~28 after receiving unit and prior to going into CHF. Received 80 mg Lasix and CVP dropping to 13-15\n\nResp: Remains on Bipap, masked ventilation, with RR in the teens to low 20's. Suctioned times one for scant secretions, blood tinged. At times having difficulty with seal. Required frequent repositioning.\n\nID: Afebrile. WBC elevated 21.6.\n\nGI: Abdomen soft and distended. +BS, no stool this shift. Unable to receive po meds due to no NGT.\n\nGU: 24 hour urine in progress. Urine output has been tapering off..under 10cc/hr. BUN/Cr have worsened again 93/4.0\n\nNeuro: Following commands incosistently. Difficult to hold any conversation due to MS. Pt receiving MSO4 for CHF and dozing frequently throughout shift.\n\nSocial: No calls this shift. Brother due to arrive from this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2201-02-16 00:00:00.000", "description": "Report", "row_id": 1398365, "text": "P-MICU NPN 7p-7a\nPTT 62. No changes made to Hep gtt. Cont's to infuse at 800u/hr.\n" }, { "category": "Nursing/other", "chartdate": "2201-02-16 00:00:00.000", "description": "Report", "row_id": 1398366, "text": "Resp Care\npt received on mask ventilation. difficulty maintaining a comfortable and adequate seal . removed to 50% cool neb. pt maintaining rr low 20's, sat 100%. +bilat wheezing/wet sounding. admin albuterol/atrovent neb q4h. attempted nts however pt quite agitated. has raspy cough on command. occas able to sxn with yankauer. tolerating off mask vent. c/w nebs for wheezing q4-6h.\n" }, { "category": "Nursing/other", "chartdate": "2201-02-16 00:00:00.000", "description": "Report", "row_id": 1398367, "text": "micu A RN NOTE\nSTABLE DAY, ALTHOUGH BUSY...ECHO DONE (TECH REPORTS W/O CHANGE FROM ECHO 3 WEEKS AGO). RENAL US DONE. RENAL F/U. BLOOD AND URINE CLTS SENT ESSENTIALLY TODAY WAS ABOUT FAMILY/PT RE: PLAN OF CARE...DISPO. BROTHER IN FROM FLA AT 1600 AND RENAL AND MICU AND HIS COUSIN AND CASE WORKERS FROM GROUP HOME ALL INVOLVED IN DECISION TO MAKE PT DNR/DNI.\n\nPLEASE SEE THE MANY MED CHANGES. WILL SUPPORT BLOOD SUGARS AND OTHER CARE TOWARD COMFORT.\n\nA LOT OF FAMILY/PT EMOTIONAL SUPPORT THROUGHOUT DAY. NO FURTHER BIPAP. HEPARIN GTT D/C'D. 24 HOUR URINE STOPPED.\n\nPLEASE SEE CAREVUE FOR OTHER DETAILS\n" }, { "category": "Nursing/other", "chartdate": "2201-02-15 00:00:00.000", "description": "Report", "row_id": 1398360, "text": " 7a-7p\n\nPatient awake,following commands, smiling at times, purposeful movement as well as myoclonic movements of all extremities. Calcium7.7 treated with 2 grams of calcium gluconate(albumin3.0)\nPatient sucessfully completed RSBI (40) and was extubated at 4pm. Diffusely wheezy on expiration which is not new. Copious yellow sputum early in the shift cleared after vigorous pulmonary hygiene.T.100, with WBC16000, sputum spec sent for culture. OOB to chair for one hour. Patient able to stand and pivot with 2 assist, briefly postural when up in chair. Troponin 2.2,Heparin 800 units with PTT67 and 75 Hct 26 stoolx3 quiac negative, 1 unit PC infused slowly.Allowing BS to run 150 to 175, no insulin coverage this shift. D10 D/C,D AND D5 AT 50CC an hour. Worsening renal status with creat up to 3.6 and bun90, q1uo20 an hour and cvp12 to 14. Brother flying in from tomorrow and will meet with MD,s regardig plan of care. \n" }, { "category": "Nursing/other", "chartdate": "2201-02-14 00:00:00.000", "description": "Report", "row_id": 1398357, "text": "Resp. Care Note\nPt s/p PEA arrest on floors today, intubated with 7.5ETT secured now at 21cm lip. Initially placed on AC 500x 14 x100% peep 5 but later changed to PSV as dysynchronous with vent. Cuurent ettings PSV 20 peep 5 and 40%. ABG on 100% was 7.43/39/555/27/2. BS with exp wheezes, ordered for Albuterol MDI.\n" }, { "category": "Nursing/other", "chartdate": "2201-02-14 00:00:00.000", "description": "Report", "row_id": 1398358, "text": "admission note\npt admitted @ 1245 from floor s/p PEA arrest x 5 minutes, BS 52 prior to arrest, admission K to MICU = 5.6, pt unresponsive on admission with posturing to upper extremities, pupils 3 mm & non-reactive- HO aware, 2 amps atropine, 2 amps epi, 1 amp dextrose & 10 u reg insulin given during code, dopa gtt started on floor @ 3 mic/kg/min, gtt dc'd soon after admission to MICU for sbp > 95, admission fio2 100%, after abg sent fio2 decreased to 40%, HO unable to get a-line in, new R IJ TLC inserted, R fem TLC inserted during code to be dc'd after line placement cleared by cxr, chem stick on admission = 132, admission labs sent @ 1330 with BS only 18- HO aware, 2 amps dextrose given & D10W started @ 75 cc/hr, repeat BS's 71-73, 2 amps ca+ gluc given for I+ CA 0.8, renal ultrasound/doppler studies of lower extremities done, plan: continue with hemodynamic/ventilatory support, BS q 1hr until stable\n" }, { "category": "Nursing/other", "chartdate": "2201-02-15 00:00:00.000", "description": "Report", "row_id": 1398359, "text": "P-MICU NPN 7P-7A\nSystems Review:\n\nCV: K+ this am 5.1. Hr has been in the 80's- low 100's SR/ST. BP 90's-100's/. Heparin gtt initiated at 8:30pm at 800u/hr. PTT checked with am labs: 67.5, (No changes made to gtt per guideline orders).\n\nGU: BUN/Cr remain elevated. U/O averaging ~30cc's/hr. Epoetin 8000u administered SQ per biweekly schedule. Hct down to 26.0 this am (NG aspirates and stool are both OB-)\n\nNeuro: Pt has myoclonic twitching at baseline. No apparent seizure activity. Initially pt had eyes closed, but as shift progressed, she was opening eyes, following commands (inconsistantly), somewhat tracking. Pupils ~4mm. Right eye reacts sluggishly and left has a cataract. Received fentanyl 25mcg times 2.\n\nGI: Abdomen soft and distended. +BS, + OB- stool. OGT intact, placement checked. Minimal aspirates.\n\nID: Tmax 100.1 po, WBC down to 16.6 from 27.\n\nSocial: Mother is listed as next of , but pt lives in and no one has called this shift.\n\nLines: Right groin CL d/c'd after right IJ CL was confirmed by cxr.\n\nResp: LS coarse bilat with scattered exp wheezes. Suctioned for thick yellowish secretions. Copious amts of oral secretions.\n\nEndo: FS ranging from the 70's-120's. Cont's on D10 at 50cc/hr.\n" }, { "category": "Nursing/other", "chartdate": "2201-02-15 00:00:00.000", "description": "Report", "row_id": 1398361, "text": "Resp. Care Note\nPt received intubated and vented on PSV 20 peep 5 and 40%. Pt awake, interactive. RSBI done and was 40 so Pt placed on SBT of PSV 5 peep0 and 40%. Did well on this for most of shift, so decision made about 4:00p to extubated Pt. + cuff leak, Pt extub. to cool aerosol. Pt quite wheezy post extub. diffuse exp wheezes. Pt rx'd with Albuterol nebulizer with little improvement in wheezing. Pt stated breathing was okay, would cough to command but did require some oral/nasal sxn to help clear secretions. At 5:30pm. Pt with ^^ WOB, figety, tachy and diaphoretic. Rx'd again with albuterol neb., NTS for thin blood tinged secretions and full mask ventilation initiated with settings PSV 10 peep 5and 50%. Pt given some MSO4 to relax and is currently tolerating mask vent well, RR 15-20 TV 400's sat 1005 and HR down to 90. cont to follow closely\n" }, { "category": "Nursing/other", "chartdate": "2201-02-15 00:00:00.000", "description": "Report", "row_id": 1398362, "text": " addendum 6PM . Patient became increasingly wheezy, tachypneic, tachycardic at 108,and sat,s down to 92% Suctioned for scant clear sputum witout resolution and no improvement from neb rx. MD called and MS 2mg followed by lasix 40mg for failure given. Patient placed on bypap also () WITH DRAMATIC IMPROVEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2201-02-15 00:00:00.000", "description": "Report", "row_id": 1398363, "text": " 7PN ADDENDUM Will r/o MI as there are q,s in 1and avl.\n \n" } ]

[ { "category": "Nursing/other", "chartdate": "2173-06-18 00:00:00.000", "description": "Report", "row_id": 1707697, "text": "2300-0730 PCA PRogress Note\n\n\nRESP:\nO: Infant remains in RA, RR 30-70s, SATing above 95%. BS are\nclear and equal, mild subcostal retractions noted. No\nepisodes of apnea, bradycardia or desaturation as of this\nwriting. A: Stable in RA. P: Continue to monitor.\n\nFEN:\nO: CW 2.215kg (no change). Infant ad lib on min 60cc/kg/day\nBM/Sim20 =24cc Q4 hours. Infant has bottled 20-23cc Q2.5\nhours thus far. Abdomen is soft and round with no loops and\n+BS. No spits noted thus far. Infant voiding, passing heme\nnegative stool this shift. A: Tolerating current feeding\nplan. P: Contnue to support nutritional needs.\n\nDEV:\nO: Infant remains in OAC maintaining stable temps. Font\nsoft/flat, MAE. Infant wakes for all cares, alert and active\nthroughout. Sleeps well between cares with pacifier. Brings\nhands to face. Infant passed carseat test this shift. A:\nAGA. P: Continue to support developmental needs.\n\nSOCIAL:\nNo contact from this shift. Plan to return in am.\nMom will be discharged today and plans to stay in parent\nroom overnight. P: Continue to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-18 00:00:00.000", "description": "Report", "row_id": 1707698, "text": "AGREE WITH ABOVE.\n" }, { "category": "Nursing/other", "chartdate": "2173-06-18 00:00:00.000", "description": "Report", "row_id": 1707699, "text": "Attending Note\nDay of life 4 PMA 35 \nin room air sat above 94%\nRR 30-70 no spells\nHR 120-150 BP 70/49 mean 56\nweight 2215 no change on min 60 cc/kg/day and fed every two hour and breast fed well\nno spits\nvoiding and stooling\nD stick 68\non phototherapy for bili 12.4/0.3\npassed car seat test\npassed hearing screen\n\n\nImp-stable making progress\nwill plan to continue phototherapy\nwill consider transfer to NBN\n" }, { "category": "Nursing/other", "chartdate": "2173-06-18 00:00:00.000", "description": "Report", "row_id": 1707700, "text": "NICU NSG NOTE\n\n35 week male, now dol#4, ready for transfer to NN.\nInfant is in RA sating >95%. LS clear and equal. RR 50-60's. Intermittant mild SubC retractions. Pectis noted. No murmur. HR 120-150's. Pink--slightly jaundiced. Ad lib demand feedings BM20. Waking q3h and taking 30-35cc po qfeed with yellow nipple. Abd exam benign. Voiding and stooling. Awake and active. Temps stable in off isolette (for phototherapy). Remains on single phototherapy with eye in place. Plan for repeat bili in am. aware of transfer. Infant is ready for transfer to NN.\n" }, { "category": "Nursing/other", "chartdate": "2173-06-16 00:00:00.000", "description": "Report", "row_id": 1707693, "text": "NP NOTE\nPE: well developed moderalty premature inffant pink well perfused in AR. Lying in mothers arms. Active and responsive, consoles easily.\nAFOF sutures approximated, eyes clear, MMMP\nChest is clear, equal bs, pectus excavatum. Mils SCR.\nCV: RRR, nl S1, splitS2, no murmur, pulses+2=\nAbd: soft, full active bs, cord dry\nGU: testes in scrotum,spine is smooth\nEXT: lean, PIV in place, MAE\nNeuro: active with symmetric tone and relfexes.\n\nUpdated mother at bedside. Will plan for family meeting later in week.\n" }, { "category": "Nursing/other", "chartdate": "2173-06-17 00:00:00.000", "description": "Report", "row_id": 1707694, "text": "Nursing Progress Note 1900-0700\n\n\nResp O/A: In RA. Lungs c/=. Mild ic/sc retractions. No\nA/B/D's. Requires help pacing at start of bottles to\nmaintain HR. P: Continue to monitor.\n\nFEN O/A: BW 2360g. Current weight 2215g, down 50g. Ad lib\nfeeds, with PIV in R hand at 30cc/k/d D10 with 2Na. So far\nthis shift, bottled 14-16cc Similac 20. Abdomen pink, flat,\nsoft, no loops. Active bowel sounds. Girth 23cm. No spits.\nVoiding 1.1cc/k/h over past 8 hours. Mec stool x1. P:\nContinue to encourage PO skills.\n\nBili O/A: Infant slightly jaundiced, not under phototherapy\nat this time. Bili this shift 9.7/0.3.\n\nG&D O/A: Temps stable, swaddled in OAC. Waking for feeds.\nActive/alert with cares. AGA. MAE. Font s/f. Sucks pacifier.\nLearning to bottlefeed. P: Continue to monitor and support\nnormal infant development.\n\n O/A: Mom and dad at bedside this shift for end of\n1st feed. Updated by this RN. Invested and appropriate. Held\ninfant x several hours. Remain in house, will prob return\n~0800. P: Continue to update, educate, and support NICU\nfamily.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-17 00:00:00.000", "description": "Report", "row_id": 1707695, "text": "Neonatology Attending\nDOL 3 / PMA 36 weeks\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 72/48 (56).\n\nWt 2215 (-50) on ad lib BM20/S20 with intake 40 cc/kg/day in addition to PIV at 20 cc/kg/day. Voiding 1.1 cc/kg/hr. Stooling normally. D-stick 57.\n\nBilirubin 9.7/0.3.\n\nTemp stable in open crib.\n\nA&P\n35 week GA infant with feeding immaturity, resolved TTN\n-Will discontinue IV and continue with minimum TFI 60 cc/kg/day; gavage feeds if indicated\n-Continue to monitor fluid status closely\n-Repeat bilirubin in 24 hours\n" }, { "category": "Nursing/other", "chartdate": "2173-06-17 00:00:00.000", "description": "Report", "row_id": 1707696, "text": "Nursing Progress Note\n\n\n#1-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. P- Cont to assess for Resp needs.\n#2-O/A- TFmin of 60cc/kg/d of BM/SIM20. Infant meeting min\nfluid req by bottle since IVF d/c'd. Abd exam benign.\nVoiding and stooling. Tol feeds. P- Cont to assess for\nFEN needs.\n#3-O/A- Baby boy cont to be awake and active with\ncluster cares q4hrs. Sleeps well between cares. Temp\nstable in open crib. P- Cont to assess for G&D needs.\n#4-O/A- in to visit with updates given. \nheld and fed infant. Teaching done with regarding\nbottling, diaper changed and temp taking. P- Cont to enc\nparental calls and visits.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-15 00:00:00.000", "description": "Report", "row_id": 1707688, "text": "Neonatology Attending\nDOL 1\n\nInfant remains in NC 25-40 cc/min of 100% FIO2. Occasional desaturations but no bradycardias. BG 7.32/42\n\nNo murmur. BP 57/28 (37).\n\nWt 2360 (BW). On TFI 60 cc/kg/day D10W. Remains NPO. Voiding 1.3 cc/kg/hr; no stools yet.\n\nA&P\n35-4/7 week GA infant with probable TTN\n-Continue to wean oxygen as tolerated\n-Given the mild RLL focal opacification, we will begin empirical antibiotic coverage for anticipated duration of 48 hours pending clinical course and culture result\n-We will start breastfeeds provided no significant distress is noted\n" }, { "category": "Nursing/other", "chartdate": "2173-06-15 00:00:00.000", "description": "Report", "row_id": 1707689, "text": "Nursing Progress Note\n\n5 Bili\n6 Sepsis\n\n1. Resp O/A Rec'd inf in NC. Inf remains in NC 100%\n25cc. IC/SCR noted. Pcont to assess resp needs.\n2. FEN O/A TF=60cc/kg/day D10 w 2/NaAcetate running at\n5.9cc/hr via PIV. Belly soft, no loops. Voiding 4.5c/kg/hr\nfor this 12 hr shift. Trace amt mec stool. D/S 65, 75. P\ncont to assess FEN needs.\n3. DEV O/A Baby is swaddled on open warmer with\nstable temp. A/A with cares. Sleeping well between cares.\nSucks pacifier. P cont to assess dev needs.\n4. O/A Mom and Dad in for visit and cares.\nUpdates given. Mom held infant. P support, educate.\n\nBili 24 hr bili 5.1, 0.2\nID CXR done, retained fetal fluid. ABX started, Ampi and\nGent.\n\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 5 Bili; added\n Start date: \n 6 Sepsis; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-16 00:00:00.000", "description": "Report", "row_id": 1707690, "text": "NICU nursing note 7p-7a\n\n\n1.Resp= O/Remains on NCO2 100%, 15-40cc flow. BSC/=, mild\nIC/SC retractions. Tacypnic at times with RR in 90s. Occas\ndrifts in O2sats at start of shift. No bradys or desats.\nA/Stable on NCO2. P/Cont to wean O2 as tolerated, Cont to\nmonitor for distress.\n\n2. FEN= O/Wgt= 2265g (-95). NPO. Cont on TF= 60cc/kg/d of\nD10 2mEq Na via Rhand PIV. Abd soft, +bowel sounds. AG\nstable. voiding(2.9cc/kg/h x12h), stooling heme(-).\nD-stick= 77. A/Stable. P/Cont to monitor FEN status.\n\n3. G&D= O/Temp stable swaddled in OAC. Alert and active,\njitteriness noted with last cares. NNP aware. Ca+ sent.\nMAEW. AFOF. Likes paci. A/AGA. P/Cont to support G&D needs.\n\n4. = No contact from this shift.\n\n5. Bili= baby slightly jaundice, No phototherapy on for last\nbili of 5.1/0.2.\n\n6. ID= Cont on Ampi/Gent. P/Please cont to monitor for s/sx\nof sepsis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-16 00:00:00.000", "description": "Report", "row_id": 1707691, "text": "Neonatology Attending\nDOL 2 / PMA 35-6/7 weeks\n\nInfant transitioned from NC to room air and is currently well-saturated and in no distress.\n\nNo murmur. BP 65/45 (51).\n\nOn amp/gent with negative culture and normal WBC\n\nRemains NPO for tachypnea. Wt 2265 (-95) on TFI 60 cc/kg/day. Breastfeeding without distress. D-stick 77. Abd benign. Voiding 2.9 cc/kg/hr overnight and stooling normally.\n\nTemp stable in open crib.\n\nBilirubin 5.1/0.2 at 24 hours.\n\nSerum calcium 9.1 for jitteriness overnight (no longer showing this symptom)\n\nA&P\n35-4/7 week GA infant with resolving TTN\n-Discontinue antibiotics once culture is negative at 48 hours\n-Continue to monitor to ensure adequate respiratory and feeding maturity\n-Continue with ad lib breastfeeding and wean IV as tolerated\n- updated at bedside\n" }, { "category": "Nursing/other", "chartdate": "2173-06-16 00:00:00.000", "description": "Report", "row_id": 1707692, "text": "NPN 0700-1900\n\n\nResp: Rec'd infant on NC 100%, 15cc flow. Flowrate noted to\nbe off at 0800 checks, infant trialed off NC at 0800 and has\nremained off NC thus far this shift, doing very well in room\nair. O2 sats>96%. RR~30-60's. Mild ic/sc retrx. Cont w/\npectis. LS clear/=. Pink. Breathing comfortably. No A's/B's\nthus far this shift. P: Continue to assess resp status.\n\nF/N: Rec'd infant NPO for resolving resp status. pt.\non TF 60cc/kg/day of D10W w/2 Na+ infusing well via PIV (R)\nhand at 5.9cc/hr. Infant ordered to breastfeed ad lib and\ncut IVF in half w/ successful BF. Thus, D10W presently at\n30cc/kg/day= 3cc/hr via PIV infusing well. D/S=59. Abdomen\nexam is benign. +BS. Ag 23cm. Voiding 1.6cc/kg/hr this\nshift, w/void in bedspace also. Passing lg mec.stool. P:\nContinue to monitor and support FEN status. To recheck bili\nin AM w/ routine state screen. Monitor Dstick's closely.\n\nG&D: Remains swaddled w/hat in open crib. Temp stable. A&A\nwith his cares; sleeps well bwtn . Brings hands to face to\ncomfort self and loves to suck on his pacifier. NNP spoke\nwith mother re: Hep B vaccine and state screen consents.\nAFSF. MAEW. AGA. CGA=35 wkr. P: COntinue to support.\n\nSocial: in throughout day. Mom in for all care\ntimes, semi-independent w/ temp/diaper, became increasingly\ncomfortable w/handling of pt throughout the day. Mom/Dad\nupdated at bedside by this RN and also by NNP P.. Mom\nattended 10am LC mtg on w/, RN and then\n in to help mom w/BF at 1600 and nipple shield utilized\nw/ good effect, +latch for first time. Mom held sleeping\ninfant bwtn cares throughout the day and stated that she has\nnever been this happy. left for dinner and will\nreturn for 8pm cares. P: Continue to update and support.\n\nID: CBC benign. BC NTD at 48hrs MD. NO s/s of sepsis.\nAntibiotics DC'd this am MD/NNP. Continue to monitor pt.\nclinically for any s/s of sepsis.\n\nBili: To obtain repeat bili w/PKU in am. 24hr bili= 5.1/0.2.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-14 00:00:00.000", "description": "Report", "row_id": 1707681, "text": "Admission Note\nNeonatology Attending\n\nHistory reviewed, patient examined. Agree with note as outlined by Dr. above.\n\nBriefly, Baby is a newborn approximately 35 wk gestational infant admitted to the NICU with prematurity and respiratory distress. He was born this afternoon to a 37 y.o. G1 P0-1 mother by c-section with of or , per parents; prenatal records not available as parents moved to from yesterday. Maternal blood type is O-/Ab-; other labs pending. Pregnancy was uncomplicated until this morning, when mother presented with severe abdominal pain. Ovarian torsion was suspected, and laporatomy with c-section was planned; diagnosis of right ovarian torsion was confirmed at laporatomy. Mother received multiple doses of narcotics for pain control prior to c-section. Membranes were intact at delivery, there was no preterm labor, and mother did not receive intrapartum antibiotics. Infant emerged vigorous with Apgars , and was brought to NICU for prematurity.\n\nIn NICU, infant was found to be mildly hypotonic with decreased activity. Initial VS were stable, but oxygen saturations subsequently drifted into high 80s, and infant was started on nasal cannula.\n\nExam:\nTemp stable, RR 70s, HR 150s, MAPs 32-33. O2sat 94-95% on 25 cc oxygen.\nWD premature infant, appears c/w EGA 34-35 weeks.\nSkin warm and dry.\nFontanelles soft and flat.\nChest coarse, moderately aerated, mildly tachypnic, mild retractions and intermittent grunting.\nCardiac RRR, no m.\nAbdomen soft, no HSM, no mass, quiet BS.\nGU normal male, testes palpable, anus patent.\nFemoral pulses 2+.\nBack and hips stable.\nTone mildly reduced, activity mildly reduced, but reactive with exam. Weak suck, intact Moro.\n\nIMP: 35 (estimated) wk premature infant with mild respiratory distress, likely secondary to TTN, although component of HMD or infection are also possible. Mild hypoventilation due to antepartum narcotic exposure should also be considered.\n\nInfant is overall well-appearing.\n\nPLANS:\n- Admit NICU.\n- Nasal cannula, adjust as needed.\n- Blood gas.\n- CXR if oxygen requirement or resp distress increase.\n- NPO for now.\n- Maintenance IVF.\n- CBC with diff, blood cx.\n- Consider empiric abx if CBC abnl or respiratory distress persists.\n- Monitor neurologic exam.\n\nUpdated parents at bedside.\nPMD not identified (parents new to area).\n" }, { "category": "Nursing/other", "chartdate": "2173-06-14 00:00:00.000", "description": "Report", "row_id": 1707682, "text": "Admission Note\nNeonatology Attending\n\nHistory reviewed, patient examined. Agree with note as outlined by Dr. above.\n\nBriefly, Baby is a newborn approximately 35 wk gestational infant admitted to the NICU with prematurity and respiratory distress. He was born this afternoon to a 37 y.o. G1 P0-1 mother by c-section with of or , per parents; prenatal records not available as parents moved to from yesterday. Maternal blood type is O-/Ab-; other labs pending. Pregnancy was uncomplicated until this morning, when mother presented with severe abdominal pain. Ovarian torsion was suspected, and laporatomy with c-section was planned; diagnosis of right ovarian torsion was confirmed at laporatomy. Mother received multiple doses of narcotics for pain control prior to c-section. Membranes were intact at delivery, there was no preterm labor, and mother did not receive intrapartum antibiotics. Infant emerged vigorous with Apgars , and was brought to NICU for prematurity.\n\nIn NICU, infant was found to be mildly hypotonic with decreased activity. Initial VS were stable, but oxygen saturations subsequently drifted into high 80s, and infant was started on nasal cannula.\n\nExam:\nTemp stable, RR 70s, HR 150s, MAPs 32-33. O2sat 94-95% on 25 cc oxygen.\nWD premature infant, appears c/w EGA 34-35 weeks.\nSkin warm and dry.\nFontanelles soft and flat.\nChest coarse, moderately aerated, mildly tachypnic, mild retractions and intermittent grunting.\nCardiac RRR, no m.\nAbdomen soft, no HSM, no mass, quiet BS.\nGU normal male, testes palpable, anus patent.\nFemoral pulses 2+.\nBack and hips stable.\nTone mildly reduced, activity mildly reduced, but reactive with exam. Weak suck, intact Moro.\n\nIMP: 35 (estimated) wk premature infant with mild respiratory distress, likely secondary to TTN, although component of HMD or infection are also possible. Mild hypoventilation due to antepartum narcotic exposure should also be considered.\n\nInfant is overall well-appearing.\n\nPLANS:\n- Admit NICU.\n- Nasal cannula, adjust as needed.\n- Blood gas.\n- CXR if oxygen requirement or resp distress increase.\n- NPO for now.\n- Maintenance IVF.\n- CBC with diff, blood cx.\n- Consider empiric abx if CBC abnl or respiratory distress persists.\n- Monitor neurologic exam.\n\nUpdated parents at bedside.\nPMD not identified (parents new to area).\n" }, { "category": "Nursing/other", "chartdate": "2173-06-14 00:00:00.000", "description": "Report", "row_id": 1707683, "text": "Admission Note\nNeonatology Fellow Note:\nInfant is a 2360 grams, 35 weeks male who is admitted to the NICU for management of prematurity.\n\nInfant was born to a 37 years old female G1 P0. Prenatal screens O-, antibody negtaive. All of the remaining labs are pending at the present moment.\n\nShe has an unremarkable past medical and surgical history. She presented to the ED with the c/o abdominal pain and she was found to have right ovarian mass with possible torsion and normal fetal survey. She was started on Morphine and a decision for a stat C-section was made and the rupture of membranes was intrapartum and no maternal fever and any other risk factors. Maternal anesthesia by epidural. Baby born with APGAR scores of 9 and 9 at one and five minutes respectively. Baby recieved routine neonatal resuscitation in the delivery room and was then transferred to NICU for the management of prematurity.\n\nPhysical exam:\nVS per care view\nGrowth: Wt 2360 gms = 50-75%, L 45 cm = 25-50% and HC 32 cm = 50%\nGeneral: Pink preterm infant with mild floppiness. Non dysmorphic, AFOF. RR x 2. Ears normal set, palate intact. Neck supple with intact clavicles. Lungs clear and good aeration, + GFR. CVS: RRR, no murmur , 2+ FP. Abdomen: Soft, no masses and +BS. GU: Normal preterm male and testes descended B/L. Patent anus. No sacral anomalies. Hips stable. Extrem: Warm, pink and well perfused. MAEW. Neuro: Mild lethargic and normal tone.\n\nImpression:\n1. Preterm male\n2. Mild lethargic possibly due to maternal Morphine administration\n\nPlan:\nResp: Routine care\nCV: Routine care and cardiac monitoring\nFEN: NPO for now. Maintenace IVFs. Close monitoring of fluid and electrolyte status. Monitor glucose per hypoglycemia protocol.\nID: No issues and no risk factors.\nSocial: Will keep family updated.\nNeuro: Continuous evaluation for lethargy.\nOthers: Hepatitis B vaccine given the unknown Hepatitis B status of the mother at this time and follow up maternal status to determine the need for HBIG.\n\nOB: Croupunick\n" }, { "category": "Nursing/other", "chartdate": "2173-06-14 00:00:00.000", "description": "Report", "row_id": 1707684, "text": "Admission Note\nBaby rec'd from L+D. Breathing spontaneously without intervention.\n\nBaby meds given, infant settled with stable VS. After a few hours around 1730 infant was placed on low flow o2. NC 100% 25cc flowrate for cont'd drifts to 80%'s. Mild retractions noted but infant appears comfortable.\n\nMom rec'd morphine and diloudid prior to birth and infant appears groggy from this. Spontaneous cry with intervention; reacts appropriately.\n\nMom down to visit infant for a few minutes from L+D. Educated on NICU and infants status. Mom plans to breastfeed.\n\nStarted D10 ivf at 60cc/kg r/t infants inability to bottle in sleepy state. NPO at this time until infant becomes more active. Dsticks 54, 51.\n\nTemp stable nested on a servo warmer.\n\nWill cont to follow infant. To draw bld cx and CBC and gas to check for resp distress. If o2 needs increase will obtain CXR.\n\nSee flowsheet.\n" }, { "category": "Nursing/other", "chartdate": "2173-06-15 00:00:00.000", "description": "Report", "row_id": 1707685, "text": "NICU nursing 7p-7a\n\n1 Respiratory\n2 FEN\n3 G&D\n4 Social\n\n1.Resp= O/Baby remains in NCO2 25cc flow at 100% FiO2. RR=\n30-70, occas tacypnic with RR in 100's. BSC/= with good\naeration. Moderate IC/SC retractions. No bradys or desats,\noccas drifts in O2sats to mid 80's, self-resolving. ABG=\n7.32, 42,51,23,-4. A/Mildly increase , MD aware. P/Cont\nto monitor for resp distress.\n\n\n2. FEN= O/Birth wgt= 2360g. NPO, TF= 60cc/kg/d of D10 via\nRhand PIV. Infusing well, without difficulty. Abd soft,\nbenign. +bowel sounds. no spits. AG=23-23.5cm. voiding,\nno stools. D-stick= 79. A/As above. P/Cont to monitor FEN\nstatus.\n\n3.G&D= O/Temp stable nested under open warmer. Sleeping\nwell, active and alert during cares. MAEW. AFOF. Hep B\nvaccine given r/t unknown maternal status. A/AGA. P/Cont to\nsupport G&D needs.\n\n4. = No contact from this shift.\n\nREVISIONS TO PATHWAY:\n\n 1 Respiratory; added\n Start date: \n 2 FEN; added\n Start date: \n 3 G&D; added\n Start date: \n 4 Social; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2173-06-15 00:00:00.000", "description": "Report", "row_id": 1707686, "text": "Case Management Note\nChart has been reviewed and events noted. EIP & VNA option placed in record. I will provide clinical updates to Healthcare insurance and will follow for any d'c planning needs along w/team & family\n" }, { "category": "Nursing/other", "chartdate": "2173-06-15 00:00:00.000", "description": "Report", "row_id": 1707687, "text": "Social Work\n\n\nMet with at the bedside today, doing well and delighted with infant's rapid recovery.\nCouple have just moved to the area, mother with stat c-section due to abdominal pain and ovarian tortion. Couple visiting, mother state she is recovering well, very loving and invested. Coping well and adapting to events of the passed day.\n" }, { "category": "Radiology", "chartdate": "2173-06-15 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 919566, "text": " 12:03 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: preterm infant with persistent O2 requirement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity/O2 requirement\n REASON FOR THIS EXAMINATION:\n preterm infant with persistent O2 requirement\n ______________________________________________________________________________\n FINAL REPORT\n This is our initial radiograph on this child with prematurity. There is\n bilateral lower lobe parenchymal disease of the lungs. These findings are\n most consistent with hyaline membrane disease. Pneumonia would be less\n likely. No other abnormalities are apparent.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2177-12-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 987698, "text": " 8:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for bleed or acute change\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with delirium, liver disease, and renal disease presenting\n with persistent confusion in the setting of a recent fall.\n REASON FOR THIS EXAMINATION:\n please evaluate for bleed or acute change\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old female with delirium, liver disease and renal disease,\n now with persistent confusion in the setting of a recent fall.\n\n COMPARISON: Head CT .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, shift of normally\n midline structures, mass effect, hydrocephalus or acute major vascular\n territorial infarction. As before, there is hypodensity of the\n periventricular white matter consistent with chronic microvascular infarction.\n There are atherosclerotic calcifications of the internal carotid and vertebral\n arteries. The regional soft tissues and osseous structures are unremarkable.\n No fracture is identified. The mastoid air cells and visualized paranasal\n sinuses are clear.\n\n IMPRESSION: No acute intracranial pathology identified.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986941, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p fluid resuscitation\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after fluid resuscitation.\n\n Portable AP chest radiograph compared to .\n\n Overall decrease in bilateral perihilar congestion is demonstrated suggesting\n improvement of pulmonary edema. Still present right moderate pleural effusion\n and bibasilar atelectasis are noted. The right internal jugular line tip is\n in mid SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-24 00:00:00.000", "description": "L TIB/FIB (AP & LAT) LEFT", "row_id": 987650, "text": " 12:14 PM\n TIB/FIB (AP & LAT) LEFT Clip # \n Reason: check alignment\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with proximal tib-fib fx set in ED, now in brace.\n REASON FOR THIS EXAMINATION:\n check alignment\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left tib/fib 2 views .\n\n HISTORY: Status post ORIF. Check alignment.\n\n There is a brace overlying the left knee which limits fine bony detail. There\n is again seen a fracture plate with multiple associated cortical screws\n fixating a fracture of the distal left femoral diametaphysis. There is also a\n non-fixated fracture involving the left proximal tibial metaphysis. Overall,\n the findings are similar. There is disuse osteopenia. There is also\n persistent soft tissue swelling and edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-26 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 987863, "text": " 8:22 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: Concern for worsened encephalopathy. Please evaluate with do\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with cirrhosis, found to be transiently unresponsive despite\n taking lactulose/rifaximin.\n REASON FOR THIS EXAMINATION:\n Concern for worsened encephalopathy. Please evaluate with doppler for hepatic\n vessel patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 71-year-old female with cirrhosis and worsening encephalopathy.\n\n COMPARISON: Abdominal ultrasound, .\n\n FINDINGS: Note is made that this is a difficult study due to the patient's\n body habitus. The liver has a coarse echotexture appearance, but there are no\n lesions identified. There is no biliary dilatation and the common duct\n measures 0.5 cm. There is a partially shadowing echogenic structure within\n the gallbladder, which appears to be sludge with developing gallstone. There\n is no ascites identified. The spleen was not identified on this exam.\n\n DOPPLER EXAMINATION: No flow is identified in the portal veins, which is\n consistent with the prior finding of thrombosed portal veins. There is\n appropriate flow identified in the hepatic veins and the IVC. Arterial\n waveforms in the main hepatic artery demonstrates good upstrokes with an RI of\n 0.8.\n\n IMPRESSION: Thrombosed portal veins consistent with the prior finding.\n Appropriate flow in the hepatic veins and main hepatic artery. Sludge with\n gallstone. Coarse liver texture with no lesions identified.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986803, "text": " 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval interval change\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with mod R pulm effusion, hypotension\n REASON FOR THIS EXAMINATION:\n pls eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right pleural effusion, to assess for interval change.\n\n FINDINGS: In comparison with the study of , there is little change in\n the opacification at the right base consistent with pleural effusion and\n probable underlying atelectasis. The pulmonary vascularity is somewhat\n engorged, consistent with overhydration. Some increased opacification at the\n left base is consistent with atelectatic change or possibly acute pneumonia.\n Right jugular catheter is again seen.\n\n IMPRESSION: No change in the right pleural effusion. Increasing\n opacification at the left base consistent with atelectasis or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-16 00:00:00.000", "description": "L TIB/FIB (AP & LAT) LEFT", "row_id": 986596, "text": " 10:10 PM\n TIB/FIB (AP & LAT) LEFT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p reduction\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with tibia fx, please perform in ED\n REASON FOR THIS EXAMINATION:\n s/p reduction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Reduction of tibial fracture.\n\n FINDINGS: Two views show reduction of a comminuted fracture of the proximal\n tibia, somewhat obscured by overlying cast. Metallic fixation device is seen\n about a previous fracture of the distal femur.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987093, "text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with cirrhosis with R pleural effusion\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST \n\n INDICATION: 71-year-old female with cirrhosis and pleural effusion.\n\n Single portable upright radiograph of chest performed and compared to\n .\n\n Patient is rotated towards the left. The right jugular catheter is unchanged\n at the superior vena cava. The heart size is not well assessed. There is\n unchanged right lower lobe atelectasis/infiltrate and moderate right pleural\n effusion. A small left pleural effusion is again seen. There is no\n pneumothorax. There is mild prominence of the pulmonary vasculature.\n\n IMPRESSION: No significant change. Persistent moderate right effusion and\n right basilar consolidation/atelectasis. Follow up to resolution.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 986688, "text": " 12:24 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new R IJ, please check placement\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n new R IJ, please check placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ _____ placement.\n\n FINDINGS: In comparison with earlier study of this date, the malpositioned\n PICC line has been removed. Right IJ catheter now extends to the mid portion\n of the SVC at the level of the carina. No change in the appearance of the\n heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 986578, "text": " 6:08 PM\n CHEST (PA & LAT) Clip # \n Reason: eval lung fields\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ? femur fx\n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 71-year-old female with question of femur fracture.\n Evaluate lung fields.\n\n COMPARISON: .\n\n FINDINGS: Single AP chest radiograph. The lungs demonstrate persistent right\n pleural effusion. Hazy opacity within the right lower lobe which may reflect\n atelectasis/effusion. However, consolidation cannot be entirely excluded.\n Cardiomediastinal contour is unchanged. No pneumothorax.\n\n IMPRESSION: Stable right pleural effusion and a lower lobe opacity which may\n reflect effusion/atelectasis, although underlying pneumonia cannot be entirely\n excluded.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-16 00:00:00.000", "description": "L ANKLE (AP, MORTISE & LAT) LEFT", "row_id": 986580, "text": " 7:13 PM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: pain after fall assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p fall, L foot/ankle pain\n REASON FOR THIS EXAMINATION:\n pain after fall assess for fx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 71-year-old female status post fall, left foot and ankle\n pain. Evaluate for fracture.\n\n COMPARISON: None.\n\n FINDINGS: AP, lateral and oblique views of the left ankle. No fracture or\n dislocation is identified. Ankle mortise is congruent and the talar dome is\n intact. Degenerative changes are noted at the tibiotalar joint. Large\n calcaneal spur and enthesophyte at the achilles tendon insertion site is\n noted.\n\n IMPRESSION: No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-17 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 986730, "text": " 5:05 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: please eval for ascites\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with cirrhosis, encephalopathy, hypotension\n REASON FOR THIS EXAMINATION:\n please eval for ascites\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 71-year-old female with cirrhosis, encephalopathy. Evaluate\n for ascites.\n\n ABDOMINAL ULTRASOUND: Limited ultrasound of the abdomen performed for\n localization of ascites show no fluid within the abdomen. Right pleural\n effusion is identified. Evaluation of solid organs is limited due to poor\n penetration.\n\n IMPRESSION:\n\n 1. Limited study demonstrating no evidence of ascites.\n\n 2. Right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-16 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 986577, "text": " 5:30 PM\n PELVIS (AP ONLY); HIP UNILAT MIN 2 VIEWS LEFT Clip # \n KNEE (AP, LAT & OBLIQUE) LEFT; TIB/FIB (AP & LAT) LEFT\n Reason: eval for pelvic fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 y/o F mult med issues s/p fixation of a distal femur fx ' p/w fall and L\n hip pain, ? femur fx\n REASON FOR THIS EXAMINATION:\n eval for pelvic fx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 71-year-old female with multiple medical issues status post\n fixation of distal femur fracture in presenting with fall and left hip\n pain. Evaluate for femur fracture.\n\n COMPARISON: None.\n\n AP PELVIS; AP LATERAL VIEWS OF LEFT FEMUR; AP AND LATERAL VIEWS OF\n TIBIA/FIBULA: Displaced fracture is identified involving the proximal tibial\n and fibular metaphysis with approximately 6 mm medial displacement of the\n distal fracture fragments. Patient is status post plate and screw fixation of\n the distal femur metadiaphyseal fracture. There is no evidence of hardware\n loosening. Fracture line remains visible. Degenerative changes are seen\n involving bilateral hips and lower lumbar spine.\n\n IMPRESSION: Acute fracture involving the proximal tibia and fibula metaphysis\n with approximately 6 mm medial displacement of the distal fracture fragment.\n\n" }, { "category": "Radiology", "chartdate": "2177-12-23 00:00:00.000", "description": "PICC W/O PORT", "row_id": 987490, "text": " 11:31 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ESRD, ESLD, urosepsis, needs PICC for long term\n antibiotics\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Urosepsis with need for antibiotics.\n\n RADIOLOGISTS: Dr. performed the procedure. Dr. , the\n Attending Radiologist, was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: The risks and benefits were explained to the patient.\n A preprocedural timeout was performed. The patient was placed supine on the\n angiographic table and the right arm was prepped and draped in usual sterile\n fashion. A micropuncture set was used to access the right brachial vein under\n direct ultrasound guidance. Hard copy ultrasound images were obtained before\n and after intravenous access. A 0.018-inch guidewire was then inserted into\n the brachial vein. The needle was exchanged for a 4.5 French peel-away\n sheath. Given resistance to advancing the wire, 4 cc of contrast was injected\n demonstrating normal opacification of the brachial and axillary vein with\n normal-appearing side branches. The wire was removed and catheter\n was inserted through the peel-away sheath and positioned with the tip in the\n lower SVC under fluoroscopic guidance. The wire was removed and the catheter\n was trimmed at 35 cm. The securing adapter was slipped over the\n catheter tip and snapped into place. The catheter was secured to the skin\n with two StatLock devices. Pressure was applied to the puncture site about the\n catheter for 20 minutes until hemostasis was achieved given elevated INR and\n thrombocytopenia. After hemostasis was achieved, sterile Tegaderm was applied.\n The patient tolerated the procedure well without additional complications.\n\n IMPRESSION: Successful placement of 35-cm right brachial catheter\n with tip positioned in the SVC. The line is ready for use. No heparin is\n required for this catheter.\n\n\n\n\n\n\n (Over)\n\n 11:31 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2177-12-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 986659, "text": " 9:30 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PIC placed on the R at 45cm, please check placement\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with\n REASON FOR THIS EXAMINATION:\n PIC placed on the R at 45cm, please check placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with the study of , the cardiac silhouette is\n somewhat less prominent, though there is still evidence of increased pulmonary\n venous pressure and a large right effusion.\n\n The right PICC line extends well into the neck. This information was\n telephoned to the venous access nurse.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-12-17 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 986751, "text": " 9:11 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please rule out PE. Also, please scan abdomen as well to rul\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Field of view: 50 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with cirrhosis, ESRD on HD, s/p mechanical fall and tibia\n fracture now with hypotension requiring pressors and 3 point HCT drop\n REASON FOR THIS EXAMINATION:\n please rule out PE. Also, please scan abdomen as well to rule out RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypertension, decreased hematocrit in 71-year-old female with end-\n stage renal disease on hemodialysis and on cirrhosis. Evaluate for pulmonary\n embolism or retroperitoneal bleed.\n\n Comparison is made to prior CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT acquired axial images were obtained through the chest,\n abdomen, and pelvis without oral contrast and without and with intravenous\n contrast. Coronal, sagittal, and oblique reformations were evaluated.\n\n Please note this entire examination is markedly suboptimal due to patient body\n habitus, respiratory variation, poor contrast bolus, and marked beam hardening\n artifact due to upper extremities position.\n\n CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is no evidence\n of central or proximal segmental pulmonary emboli involving the right upper,\n right lower, right middle, and left upper lobes. The majority of the lingular\n and left lower lobe branches are incompletely opacified and markedly affected\n by beam hardening artifact causing inability to evaluate for pulmonary emboli.\n There is no evidence of aortic dissection. The lungs display scattered areas\n of peripheral interstitial septal thickening and ground-glass opacities within\n the right upper and left upper/lingular lobes with no discrete pneumonia\n identified. There is a moderate size simple right pleural effusion with a\n fissural component and adjacent compression atelectasis of the right lower\n lobe. A few small pockets of anterior extrapleural air are noted (3:36, 31).\n The airways are grossly patent. There is extensive mediastinal lipomatosis,\n cardiomegaly, and atherosclerotic disease involving the intrathoracic aorta\n and coronary circulation. A moderate amount of mitral annulus calcification\n and aortic valvular calcification is noted. No pathologically enlarged\n axillary or central lymph nodes are identified. Multiple prominent\n mediastinal nodes are likely reactive measuring up to 10 mm in the precarinal\n station. Central venous catheter terminates within the mid SVC. Moderate\n amount of subcutaneous emphysema is noted along the anterior mid right\n clavicle (3:2). There is a irregular hypoattenuating lesion noted within the\n right thyroid likely consistent with a benign nodule.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Sequelae of patient's\n underlying cirrhosis are again identified with a shrunken, nodular-appearing\n (Over)\n\n 9:11 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please rule out PE. Also, please scan abdomen as well to rul\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Field of view: 50 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n liver, mild splenomegaly, and diffuse vascular collateral vessels which are\n difficult to evaluate on this non-contrast examination. There is unchanged\n cholelithiasis without evidence of acute cholecystitis and a trace amount of\n ascites surrounding the liver. Remaining evaluation of the intra-abdominal\n organs including the pancreas, stomach, small bowel, adrenal glands, and\n atrophic kidneys appears unremarkable. There is unchanged 1-2 mm right\n interpolar calculi. No free air or pathologically enlarged lymph nodes are\n identified within the abdominal cavity.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: There is a small fat-\n containing periumbilical hernia with remaining intrapelvic bowel, and urinary\n bladder appearing unremarkable. There is no evidence of retroperitoneal\n hemorrhage. Significant free fluid is noted within the pelvic cavity and no\n pathologically enlarged lymph nodes are identified.\n\n BONE WINDOWS: No malignant-appearing osseous lesions are identified. Marked\n degenerative changes involving the thoracolumbar spine and hips are again\n identified.\n\n IMPRESSION:\n 1. No evidence of aortic dissection or central/proximal segmental pulmonary\n emboli. The subsegmental branches and majority of the lingular/left lower\n lobe branches are incompletely evaluated due to poor contrast opacification\n and marked beam hardening artifact.\n\n 2. Moderate right pleural effusion with additional areas of peripheral\n interstitial septal thickening and ground-glass opacities likely related to\n mild-to-moderate pulmonary edema. Minimal right pneumothorax.\n\n 3. No evidence of retroperitoneal hemorrhage. Unchanged cholelithiasis\n without evidence of acute cholecystitis and sequelae of known cirrhosis.\n\n 4. Stable nonobstructing right renal calculi.\n\n 5. Diffuse anasarca.\n\n 6. Subcutaneous emphysema adjacent to the mid right clavicle likely related\n to attempted line placement.\n\n 7. Atherosclerotic disease involving the intrathoracic aorta, coronary\n circulation, and a mitral annulus.\n\n Findings discussed with Dr. on at approximately 10 a.m.\n (Over)\n\n 9:11 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please rule out PE. Also, please scan abdomen as well to rul\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n Field of view: 50 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2177-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 988410, "text": " 1:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess PICC placement\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman on IV abx\n REASON FOR THIS EXAMINATION:\n please assess PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old female on IV antibiotics status post PICC placement by\n IR on , now with PICC retracted.\n\n COMPARISON: Chest radiograph of .\n\n PORTABLE UPRIGHT CHEST X-RAY: There has been removal of right IJ central\n venous catheter. A right PICC is seen with its tip terminating in the mid\n subclavian vein. There is interval resolution of pulmonary congestion and\n improvement in right pleural effusion which is now small-to-moderate. Right\n lower lung opacities persist likely representing atelectasis. Streaky\n atelectasis persists in the left mid and lower lung. Otherwise no new\n pulmonary infiltrates are identified. The heart size remains enlarged. No\n pneumothorax is identified.\n\n IMPRESSION:\n 1. Right PICC tip seen in the mid subclavian vein. This finding was\n discussed with the IV nurse at the time of this study.\n 2. Interval resolution of pulmonary congestion.\n 3. Interval improvement in right pleural effusion, although small-to-moderate\n pleural effusion persists with associated atelectasis.\n\n\n jr\n\n" }, { "category": "Radiology", "chartdate": "2177-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987058, "text": " 5:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls assess lung volumes, PTX, thx\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p right diagnostic \n REASON FOR THIS EXAMINATION:\n pls assess lung volumes, PTX, thx\n ______________________________________________________________________________\n WET READ: JWK FRI 6:13 PM\n No pneumothorax. No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n CLINICAL INDICATION: 71-year-old woman status post right diagnostic\n thoracentesis. Please assess lung volumes and for a pneumothorax.\n\n FINDINGS: A single portable image of the chest is compared to the prior\n examination the same day, at 4:39 a.m. The lateral aspect of the\n right hemithorax is not included in its entirety nor is the right costophrenic\n angle visualized. No pneumothorax is visualized. Low lung volumes are\n present. There is a hazy opacity noted at the right base with an appearance\n most consistent with an underlying effusion. The left hemithorax is clear.\n The cardiomediastinal silhouette is within normal limits. The right internal\n jugular line tip is in the mid SVC.\n\n\n" }, { "category": "Echo", "chartdate": "2177-12-18 00:00:00.000", "description": "Report", "row_id": 71996, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 229\nBSA (m2): 2.10 m2\nBP (mm Hg): 90/47\nHR (bpm): 64\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\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (AoVA 1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild functional MS due to MAC. Mild to moderate (+) MR. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). The right ventricular cavity is mildly dilated.\nThere is mild global right ventricular free wall hypokinesis. The aortic valve\nleaflets (3) are moderately thickened. There is mild aortic valve stenosis\n(area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is minimal functional mitral stenosis\n(mean gradient 4 mmHg) due to mitral annular calcification. Mild to moderate\n(+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity\nof mitral regurgitation may be significantly UNDERestimated.] The tricuspid\nvalve leaflets are mildly thickened. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Symmetric left ventricular hypertrophy with preserved global and\nregional systolic function. Mildly dilated right ventricle with mild systolic\ndysfunction. Mild calcific aortic stenosis. At least mild-to-moderate mitral\nregurgitation. Moderate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , right ventricle\nis now dilated and its systolic function has declined. The other findings are\nsimilar.\n\n\n" }, { "category": "ECG", "chartdate": "2177-12-16 00:00:00.000", "description": "Report", "row_id": 162107, "text": "Baseline artifact\nProbable sinus bradycardia\nNonspecific intraventricular conduction delay\nLow precordial lead QRS voltages\nDiffuse ST-T wave changes with prolonged Q-Tc interval\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/electrolyte/metabolic effect\nSince previous tracing of , may be no significant change but baseline\nartifact makes comparison difficult\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-18 00:00:00.000", "description": "Report", "row_id": 1282391, "text": "See and Carevue for detailed documentation\n\nNeuro: Patient sleepy, arouses easily, oriented x2. Sometimes confused when awakened. c/o LLE pain treated with IV hydromorphone this am with good result. Patient with c/o pain with turning/ cares but falls quickly to sleep without stim. Changed to po hydromorphone. Patient rating pain scale 3-6 thru shift.\n\nResp: BS clear with good aeration, scattered crackles. Weaned to RA with SAT >95%.\n\nCV: In NSR rate 60's. BP 100-110, MAP maintained >65 with dopamine. Attempt to wean with drop in BP. Rec'd 1L fluid boluses without improvement. CVP now 14 but continues to require dopamine. Cortisol stim test with cortisol given without improvement. Hct Stable at 26.\n\nGI/Endo: Refusing po's most of day. Cooperative with meds. Took small amount this evening, tol well. Patient with intermittent c/o nausea, no emesis. Zofran x1 without change. Indivual sliding scale insulin coverage.\n\nGU: Foley out, no urine output. Renal holding HD for now.\n\nSkin: LLE in splint. Doppler pulses. LE cool, pale. R lower arm with blister, weeping s/s fluid.\n\nSocial: Daughter in, discussed plan of care with medical team.\n\nPlan: Continue cardiopulmonary monitoring. Maintain dopamine for MAP >65. Renal to follow. Pain managed with po hydromorphone.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-19 00:00:00.000", "description": "Report", "row_id": 1282392, "text": "MICU 7 RN REPORT 1900-0700\n\nNEURO: Pt is lethargic dozing on and off confused about place and date. Refuses personal care but accepts when explained. Follow commands. PERL. Lt leg supported on splint. Shouts in pain with activities but calm down immediately without intervention.Received 0.5mg dilaudid for pain after personal care.\n\nCV: HR 60-70 NSR, No ectopy. Dopamine 5mic/kg/min . SBP 90-110. Rt radial A line sharp. CVP 8-10. No chest pain. Hydrocortisone started and received 1st dose.\n\nRESP: LS crackles @ bases. SPO2 > 92% on room air. No SOB. No cough.\n\nGI/GU: Abd soft. BS x4. BM x1. Takes medications orally. Refuse food. Appetite poor. Anuric. Possible HD today.\n\nORTHO: Lt leg # supported in splint. PP . Leg is cool to touch and pale. Splint got soaked in stools. Cleaned and informed to ortho team. Possibly they will change the splint in AM.\n\nSKIN: Multiple bruises from fall. Rt upper arm weeping blister dressing intact.\n\nID: T max 98.1. Abx zosyn and daptomycin\n\nSOCIAL: Full code. No contact from family in this shift.\n\nENDO: BS q6. insuin as per sliding scale.\n\nPLAN: HD\n Wean dopamine if BP stabilizes.\n Change splint.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-17 00:00:00.000", "description": "Report", "row_id": 1282388, "text": "NPN\n\nNeuro: Pt is lethargic but able to follow commands, ususally oriented x3. She has not received narcotics from me but her pupils are small at 2 mm.\n\nCV: Her SBP was low 70s-80s, MAPs 40s for much of the morning, a CL was placed and her CVP was 16-17, she was given a liter of IVF on my time, dopa was started to increase her HR (she had been in the 50s) as well as to increase her BP. An aline was placed and his aline BP was 20-25 points higher than his NBP pressure, her aline BP on 4 mcg/kg of dopa is 100s/48 - MAP 65, and a NBP pressure of 76/36, MAP 44, HR 70s.\n\nResp: LS with rales in the bases, 02 SAT has been 98-100% on RA.\n\nGI: Poor appitite and her somulence does not support feeding. She has been given lactulose, no stool thus far.\n\nGU: Almost no urine - she states that she urinates about once a week at home. She says that she is dialysed qMWF, renal came by but she will not be dialysed today.\n\nOrtho: She was seen by ortho, no plans for surgery, they said that her fx is in a good position, they will check an xray in a week. She is now in a splint, she needs to keep her leg straight and no weight bearing. Her HCT dropped 23 - a repeat was 26, she does not appear to be bleeding into her leg, ortho states that this is very unlikely, to have HCT checked this evening.\n\nHeme: heme is following for her past HIT positive, further blood was sent for HIT antibodies.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-17 00:00:00.000", "description": "Report", "row_id": 1282389, "text": "NPN Addendum\n\nHer heparin was shut off to see if she was able to maintain her BP, she dropped to the 60s and her dopa was turned back on, now at 7 mcg/kg up from 5 mcg/kg prior to the gtt being shut off. Pt was given a 5oocc NS bolus, to have an US of her abd as well as a CT to look for a PE and bleeding. Pt was pan cultured, to receive abx as well as a unit of blood when it is ready - she has antibodies and it is not ready in the blood bank.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-18 00:00:00.000", "description": "Report", "row_id": 1282390, "text": "MICU 7 RN REPORT 1900-0700\n\nEVENTS: CAT SCAN ABDOMEN AND CHEST, DILAUDID FOR PAIN, BLOOD TRANSFUSION.\n\nNEURO: Pt is alert dozing. Follow commands consistently. Received dilaudid 0.125mg IVP for leg pain w/ effect. Moves all four extremities. Pupil 2mm brisk.\n\nCV: HR 60-80 NSR. No ectopy. Recived 1 unit PRBC's. Dopamine titrated to 6 mic/kg/min. SBP 100-120. Hypotensive to 70's while changing dopamine bag. Rt A line sharp. AM labs pending.\n\nRESP: LS clear and crackles @ bases. Desated to mid 80's and O@ 3lit NC started. No SOB. chest and abd cat scan done. Result pending.\n\nGI: Abd soft, BS x4. Received lactulose and vomited after that x2. BM x1 small guiac neg.\n\nGU: Foley cath in place. No urine output in this shift.\n\nOrtho: # lt leg on splint. No surgical plan @ this point. C/O severe pain and received dilaudid 0.125mg @ 0100 w/ effect. pulses . Leg is cold to touch and normal in color.\n\nSKIN: Multiple bruises from fall.\n\nID: T max 97.3. Abx zosyn and daptomycin.\n\nPLAN: Wean off dopamine MAP goal > 65.\n HD today.\n Pain management.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-25 00:00:00.000", "description": "Report", "row_id": 1282399, "text": "pt is called out to floor,awaiting for bed placement.\n\nPt is alert and oriented X 3,MS status improved after admission to MICU.follows all commands,moves all extrimities,denies any pain.Repositioned as needed.\n\nLS are clear to dim at bases,O2 sats are maintained upto 97% on room air,shallow breathing noted short periods of apnea which resolves on stimulation.No SOB or related symptoms.\n\nHR 60-70 NSR no ectopy,NBP 110-120/50-60 pedal pulses are doppled extrimities are edematous,elevated on pillows.RIJ d/cd pressure dressing applied no bleeding.Has single lumen PICC line on rt hand,multiple dressing changes due to oozing.\n\nAbdomen soft positive bowel sounds,poor intake no bowel movement till this time,on lactulose Q6H.\n\nfor HD tommorrow,remains anuric.AV fistula intact on lt hand.\n\nSKIN;Has several areas of skin break down on lt hand and oozing transparent dressing on.\n\nID;Afebrile,on Meropenem.\n\nNo contact from family at this shift.\n\nPt is called out to floor when bed is available\nMonitor respitory status and alteration in MS\nContinue present meds,Blood sugar Q6h\nUpdate pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-25 00:00:00.000", "description": "Report", "row_id": 1282400, "text": "addendem...\n\npt's daughter called and updated,and informed that her other sister passed away on and pt's is unaware about this,so please involve social worker and the daughter to inform this sad event to pt.Pt is called to floor cc723,endorsed to RN regarding these issues.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-17 00:00:00.000", "description": "Report", "row_id": 1282387, "text": "MICU Nursing Admission Note 1900-0700\n\nCode: Full\nAllergies: heparin, morphine, ASA, tylenol\n\nPt is 71 year old female with history of DM, cirrhosis NASH and tylnol toxicity, hx GAVE, ESRD on HD qMWF, dCHF, HIT +, seizures disorder who presented to ED with mechanical fall. According to pt, she fell twice this AM, once as she tripped over walker then fell backwards walking down stairs. Daughter witnessed fall, no LOC, CP, dizziness, palpitations. In pt had elevated slightly elevated troponin from pt's baseline, films revealed acute fracture involving proximal tibia and fibula metaphysis, splint placed by ortho in ED. Ruled out by cards for ACS. Transferred to MICU for pain control and hypotension, pt hypotensive at baseline SBP 90-100.\n\nNeuro: Pt A&O x 3 at times somewhat lethargic, following commands consistently, pupils equal and sluggish. Complained of pain to left heel, received PRN oxycodone x 1 with good effect.\n\nCV: HR 50s SR/SB with no ectopy noted, pt dropped to mid 40's once, atropine at bedside. NBP 70-90/20-40, received 500cc bolus x 2 with some effect. Baseline SBP 90-100s. Pedal pulses dopplerable. Feet cool bilaterally with capillary refill <3 seconds. Access includes #22 to right upper arm. MDs hesitant to insert central line at this time given pt's increased coags and liver function. Clot sent for type and screen. Ordered for PICC eval this AM, will likely need IR. Pt on HD MWF, due to be dialyzed today, pt with functioning AV fistula to left arm, + bruit/thrill.\n\nResp: RR teens with sats >96% on RA, lung sounds clear in all fields, pt's cough and gag intact.\n\nGI: BS x 4, no stool this shift, guiac negative MD's rectal exam. Pt remains NPO except for meds. Taking pills well with water.\n\nGU: Foley patent and draining small amounts urine. Pt mostly anuric, UO <20cc since admission to MICU. MD aware. HD today.\n\nSkin: Cast to left leg placed by ortho. Multiple bruises to right lower arm from IV attempts, lab draws.\n\nEndo: BS WNL, no coverage needed this shift.\n\nID: No ABX at this time, will send BC and urine when available.\n\nSocial: Daughter updated by RN and MD overnight. Will call this AM.\n\nPlan:\nIV access, PICC placement?\nmonitor BP\nUA and BC\npain management\ndialysis today\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2177-12-21 00:00:00.000", "description": "Report", "row_id": 1282397, "text": "NEURO;Alert and oriented X 3 follows all commands,moves upper extrimities off the bed and lower extrimities on bed.C/O of pain on lt lower limb medicated once with Dilaudid with good effect,and repositined as needed.\n\nRESP;LS are clear to dim at bases,O2 sats are mainatained 96-100% on room air,denies SOB.Breathing efforts are normal RR 12-16.\n\nCVS;HR 60-70 NSR no ectopy,off inotropes since yesterday 530 pm ABP's are well mainatained 100-130/45-60 MAP >60.Pedal pulses are doppled.\n\nfor access RIJ and rt radial A-Line are patent A-Line ,site has oozing dressing changed.\n\nGI;Abdomen soft positive bowel sounds,tolerating diet well,for calorie count till monday.Mushroom catheter in for brown liquid stool,on bowel regimen.Stool [positive for guiac]\n\nGU;Dialysed via lt AV fistula today with 2 kg wt reduction,tolerated\n well.\n\nSKIN;HAs multiple areas of bruises and weeping from rt hand,transparent dressing intact.Skin on lt lower limb has bruises and blisters on two spots due to splint.Splint has been changed today by ortho services.pedal pulses are positive.\nSocial;Daughter called and updated with RN.\nID; Antibiotc changed to meropenem today,remains afebrile.\nPLAN;Maintain ABP,MAP >60\nObserve MS reorientation as needed\nContinue calorie count till monday/encourage oral intake\nPain management\nupdate with pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-25 00:00:00.000", "description": "Report", "row_id": 1282398, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS ALLERGIES TO MORPHINE, TYLENOL, ASA, AND HEPARIN.\n\nPT. IS ON CONTACT PRECAUTIONS FOR MRSA, AND CDIFF.\n\nPT. REMAINS A/A/O, WHICH IS MUCH IMORIVED FROM BARELY AROUSABLE ON FLOOR. PT. WAS TRANSFERRED TO ICU AFTER PT. RECEIVED DILAUDID ON THE FLOOR, AND RESP RATE DROPPED TO 8 RR/MIN, AND PT. WAS HARD TO AROUSE. PT. WAS DIALYZED AND THESE ISSUES LESSENED, AND IMPROVED. PT. HAS REMAINED AFEBILE THROUGHOUT THIS SHIFT.\n\nPT. HAS BEEN NSB/SR 54-68 WITH NO ECTOPY. B/P HAS REMAINED NORMAL 112-130'S/40-60'S. PULSES ARE WEAK BUT PALPABLE. TRACE EDEMA NOTED IN BOTRH LOWER EXTREMITIES. LEFT LEG IS SPLINTED AND CIRCULATION TO THIS LEG IS WNL'S.\n\nPT'S LUNG'S EXHIBIT CRACKLES THROUGHOUT. RESP RATE IS CONTROLLED WITH SATS >98% PT. EVEN WHEN RESP RATE WAS WERE 99-100%.\n\nPT. BLOOD SUGARS REMAIN SLIGHTLY ELEVATED WITH SMALL AMT'S OF COVERAGE. ABD. IS BENIGN IN ASSESSMENT, B.S. ARE EASILY AUDIBLE AND NO STOOL NOTED THIS SHIFT. PT. IS ANURIC, AND RECEIVES ON M/W/F AND RECEIVED YESTERDAY, PT. HAS A LEFT AV FISTULA.\n\nSKIN REMAINS INTACT, WITH SPLINT ON LEFT LEG. OTHERWISE, NEW RIGHT PICC LINE REMAINS INTACT, BUT CONTINUES TO OOZE DUE TO LOW PLATELETS. PT. ALSO HAS RIGHT IJ TLC WHICH NEEDS TO BE D/C'D ONCE PLT'S ARE UP.\n\nPLAN IS TO MONITOR BLOOD AND ELECTROLYTES, WHILE MONITORING CLOSELY HER MENTAL STATUS WHICH CONTINUED TO IMPROVE THROUGHOUT THIS SHIFT.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-20 00:00:00.000", "description": "Report", "row_id": 1282395, "text": "71 y/o female with Cirrhosis,ESRD,L leg fracture due to fall at home now in hypotension currently on Dopamine gtt 2 mcg/kg/mt attempted to wean and d/c but drpopped to SBP 60-80 with MAP < 40.\n\nEvents;crit stable today but low to 23,transfused 1 unit PRBC without any adverse reactions.\n\nCVS;HR 73-80 NSR no ectopy,ABP 94-126/40-60 on Dopamine gtt unable to wean off.CVP 10-12.Post transfusion crit send please see carevue for lab results.Pedal pulses are doppled.\n\nAccess;RIJ and Rt R A-Line remains patent.lt AV fistula positive for bruit and thrill.\n\nNEURO;Looks more alert today answers all question appropriately but remains confused at times and trying to pull out invasive lines ,rt hand restrained for few hrs and released with reorientation.Lt leg spilnted and able to move lower extrimities on bed and upper extrimites are able to move off the bed,no tremors or flaps noted today.\n\nRESP;LS are clear to dim at bases O2 sats are maintained 100% on room air,breathing efforts are normal.\n\nGI;Abdomen soft,positive bowel sounds tolerating diet,no N/V pantoprasole increased to BD,GI followed up not planning for any invasive procedures at this time. Draining brown colored liquid stool via mushroom catheter which is positive for guaic.On bowel regimen.\n\nGU;Not dialysed since 5 days due to hypotension.Please see carevue for lab values.\n\nSKIN;Multiple areas of bruises all over teh body due to fall rt upper extrimities has weeping areas and bleeding.Lt leg is spilnted.Positioned as needed for comfort.\n\nID;Afebrile,WBC 7.5 on Zosyn and Daptomycin(recieved only one dose/on HD days)On contact precautions for MRSA/VRE.\n\nENDO;Blood sugar > 200 sliding scale renewed and started on fixed dopse today.\n\nSocial;Daughter called and updated and will be coming later to visit her.\n\nPLAN;Follow crit BD,transfuse prn\nMaintain MAP>60\nReorientation and restraints as needed\nFS Q6H,calorie count till monday.\n PT for left leg.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-21 00:00:00.000", "description": "Report", "row_id": 1282396, "text": "nursing note 7p-7a\nreview of systems\n\nneuro: aox3 with rare occasion of disorientation that resolves easily. moving all extremeties and following commands. c/o pain in left leg. medicated with prn dilaudid with effect.\n\ncv: hr 50-70sb-sr with occ pvc. sbp 90-120 with map>60. aline positional and leaking at site. dsg changed multiple times. r ij triple lumen intact with cvp 9-22. dopplerable pedal pulses. + generalized edema noted.\n\nresp: l/s clear and diminished at bases. sats 96-100% on ra. no sob or resp distress noted.\n\ngi: abd obese with +bs. tol pos well. large amts of dark brown stool. mushroom catheter leaking multiple times. nystatin powder to .\n\ngu: no urine. creatinine 6.5 with k 4.3.\n\nheme: 1uprbc hung over 4hrs for hct 23. repeat hct is 25.4. coags wnl.\n\nendo: conts on nph and humalog ss.\n\nid: zosyn conts q12hr.\n\nskin: 2 skin tears to r arm with tegaderm intact. left lower leg eccymotic and swollen. splint intact to left leg.\n\nsocial: no contact from family this shift.\n\nplan: hemodynamic monitoring, ? dialysis in next few days, ortho to replace cast, pain medication as needed, to transfuse to keep hct>25, and support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2177-12-19 00:00:00.000", "description": "Report", "row_id": 1282393, "text": "Events;Fluid bolus for hypotension,Diagnostic thoracentesis,FFP and PRBC transfusion for INR 2.2 and crit 22.4 recieved Albumin and Desmopressin acetate.\n\nCVS;HR 70-88 NSR no ectopy, Recieved on Dopamine gtt,team wanted to wean off gtt and ABP low to 60/31 NBP correlates with ABP initially tried with fluid bolus NS 500 ml still BP was low and Dopamine restarted at 5 mcg/kg/mt and then weaned off to 3 mcg now.ABP 110-120/50-70 with MAP >60.Pedal pulses are doppled.CVP 9-12\n\nFor access RIJ/Rt R A-Line are patent,A-Line has oozing dressing changed.AV fistula in lt hand.\n\nRESP;LS are clear to dim at bases,shallow breathing RR 11-13 O2 sats are maintained 96-98% on room air.\n\nNEURO;Alert and oriented X 3,lethargic and sleepy but wakes up easily,confused at times and trying to pull line at early afternoon rt hand restrained for one hr and reoriented her,released then onwards.moves upper extrimities off the bed and lower extrimiteis moves on bed.lt leg is splinted and rt has pneumoboots on.\n\nGI;Abdomen soft,positive bowel sounds refuses to take diet and meds,team notified and planning for dobhoff tube.Rectal bag in place draining small mats of stool now.\n\nGU;NOt for HD today.\n\nSKIN;Anasarca,multiple areas of bruises on rt hand and lt lower extrimities.Bleeding spots on rt hand.Positioned as needed has pain on lt hand but get settled after reposition.\n\nID;Afebrile on Zosyn.Diagnostic thoracentesis done and samples are send.\n\nSocial;Daughter called and updated,concerned about not getting HD for 3 days,answered all questions appropriate,MD also updated with her.\n\nPLAN; Mnitor vital signs MAP > 60 titrate Dopamine gtt\npain management,nutrtion management,calorie count X 3 days starts from tommorow.\nFollow up crit and tranfuse as needed\nguaic all stool.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-12-20 00:00:00.000", "description": "Report", "row_id": 1282394, "text": "MICU 7 RN REPORT 1900-0700\n\nNEURO: Pt is alert and oriented x3.In times she is confused and try to pull the RIJ. So UE restrained w/ soft restraints to secure the lines. Follows commands. MAE. Received dilaudid 0.125mg IVP @ 0200 for leg pain w/ good effect. Received routine keppra.\n\nCV: HR 60-90 NSR, SBP 90-120. S/P transfusion Hct @ 23.5. Tappering of dopamine resulted in hypotension so on 3mics/kg/min. Rt radial A line sharp. CVP 9-11.\n\nRESP: LS clear diminished. SPO2 > 95% on room air. No SOB. Noted to have cough for approximately 10 min after drinking juice which resolved on its own. MD aware.\n\nGI/GU: Abd soft BS x4. BM x2 loose brown color. Mushroom cath placed and draining liq stool. Appetite poor refuses food but likes to drink juices. Anuric no UO in this shift.\n\nORTHO: Lt leg # secured on splint. Splint got soiled w/ stool ortho team informed and changed w/ temporary splint. As per ortho resident Splint w/ lock in system will arrive on monday. PT consult done. Pedal pulses leg looks pale.\n\nSKIN: Multiple bruises from fall. Rt arm weeping blister covered w/ tranparent dressing.\n\nID: T max 98. Abx Zosyn, and daptomycin.\n\nSOCIAL: Full code. Family visited and updated by MD.\n\nPLAN: dopamine Goal MAP > 65.\n Calorie count.\n PT to lt leg.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2159-02-25 00:00:00.000", "description": "Report", "row_id": 1575750, "text": "MICU NPN 2300-0700\nPt is 63y/o male with PMH Hep C cirrhosis, s/p liver transplant , DM, GERD, MR, Afib - s/p ablation, CHF-home O2 2-4L, CRI, and stage IV small cell lung ca with mets to liver and bone. Pt was tx with chemo unsuccessfully and was recently told that there is no further treatment. Pt into EW today with hypotension and 3 day history of increased weakness. In EW, pt intubated for poor ABG's. He was started on the MUST protocol and transferred to MICU.\n\nNeuro: Pt arrived on small amount of propofol, awake and alert. Propfol changed to fentanyl. Pt remains awake and alert, follows all commands. He is primarily italian speaking but understands most english. Pt appears to be in pain, bolused x2 with 50mcg fentanyl with good effect.\n\nCV: HR 80's-90's, Afib, no ectopy noted. BP on arrival in the 60's. On levofed gtt which has been titrated to keep MAP >60, presently on .06 mcg/kg/min. Presep catheter in place with CVP ranging . SVO2 ranging 50's-70's on monitor. HCT in EW 25, being transfused with 2units PRBC's, 2nd unit up at 0500. Maintenance fluid 500cc/hour for 3L, stopped for blood tx, but restarted for low u/o and rising lactate. Lacate had been trending down, but last 2 levels rising, most recently 4.6. 3+ pitting edema to BLE which SO has reported has been getting worse over past 3 weeks. K+ and Mag low this am, will replete.\n\nResp: LS's coarse througout. Vented on AC 600x16, PEEP 5, FiO2 70%. Not requiring suctioning. O2 sat 100%. HO will get ABG in am.\n\nGI: Abd firm, absent BS's. OGT placed and confirmed by auscultation and x-ray. Abd very tender to touch. Upright abd x-ray done, no report as of yet.\n\nGU: Foley draining 20-50cc/hour clear yellow urine.\n\nEndo: BS on arrival 222, insulin gtt started and titrated for BS 80-120.\n\nID: Hypothermic on arrival, warming to tmax 98.8. WBC 3 this am. On flagyl and cefepime. He rec'd levaquin and ceftriaxone in the EW. Bld cx X2 sent, urine sent in EW.\n\nAccess: Left SC presep cathter and PIV x2 to left FA, flushed and patent.\n\nSkin: No breakdown noted to backside, turned and repositioned as tolerated. Pt appears to have a lot of discomfort with movement.\n\nSoc: Pt's and another relative in with pt on admission. is health care proxy, consents signed. She was updated on the plan of care, rec'd phone number to the unit and went home.\n\nPlan: Cont to monitor VS's, I&O, labs, resp status, mental status and pain control. ?extubate today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-02-25 00:00:00.000", "description": "Report", "row_id": 1575751, "text": "Resp Care,\nPt. admitted to MICU from ER intubated. Currently on A/C 600 RR 16 70% 5peep. Started on Albuterol MDI. Wean Fio2 as tol. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-25 00:00:00.000", "description": "Report", "row_id": 1575752, "text": "NPN\n\nNeuro: Pt dozing on and off, conts on fent at 25mcg/hr, easily arousible, denies pain. He is able understand some english nad is also able to gester some of his needs.\n\nCV: Pt remains on levo, able to decreased the dose from .065 to .02, occationally he drops his BP to the 70s but has maintained his MAP >60. His HR has been steadily increasing through the day, he was in the 80s this morning and it has increased to the 120s-130s this afternoon. His CVP has been ~ 16, U/O has been decreasing now at ~ 10cc/hr. He was given a 250cc NS bolus. An echo has been ordered for tomorrow. He has 4 + pitting edema of his lower extremities - he has been ordered for LE US tomorrow. He is to be started on steroid due to a low response from the cortstim test. CPK were 202 with MBs of 3.\n\nResp: Remains intubated, he is now on /.5 and feels ok on these settings. 02 SAT mid 90s, sv02 has been ~70. Sx for mod amounts of thick yellow secreations - sent for clx. He may be extubated tomorrow.\n\nGI: ABD firm, pos BS, presently NPO for possible extubation tomorrow. No plan for CT at present.\n\nGU: His u/o initially was ~ 100cc/hr this was while he was receiving his NS boluses, his u/o has since decreased to ~ 8-10cc/hr, he was given a 250cc bolus with no effect. Last creat was 2.6 with a BUN of 79.\n\nID: He has been afebrile, his lactate was 2.1, vanco was added. SV02~ 70.\n\nHeme: His HCT was 29.6 after the 2 units of PRBC he received earlier this morning.\n\nEndo: His blood sugars have been 70-120 - he has been off of the insulin gtt since before 7am.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-02-26 00:00:00.000", "description": "Report", "row_id": 1575753, "text": "Resp Care: Pt continues intubated and on ventilatory support, abg drawn from lRA >> resp acidosis with poor oxygenation >> changed to a/c; bs coarse, sxn thick yell secretions, rx with mdi albuterol except when hr elevated, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-26 00:00:00.000", "description": "Report", "row_id": 1575754, "text": "D neuro: pt alert responds to commands and question communicates well with gestures and mouthing words, pt primary language is italian but he is able to understand basic english. MAE. PERL.\n\nCV: AF 110-140's. pt is in chronic AF throughout night HR has been high pt is usually on betablockers but currently unable to give do to low BP. pt on levophed at start of shift. attempted to wean levophed in hopes of reducing HR but pt BP too unstable . placed on vasopressin .04units and reduced then stopped levophed for a few hours but HR continue to be high . At 0100 pt B/p started to drop to 70's; Hr 130-140; no urine output. pt on vasopressin restarteed levophed and discussed with Dr . fluid NS boluses and pressures to be used to maintain MAP > 60. after 1 liter pt started to put out some urine CVP 18 then 16 then 15 currently 14-19. after 2 liters of NS levophed is off and vasopressin is on. HCT 24.3, K 3.5 CR 2.8 discussed with Dr . repleat lytes with caution due to high CRE and BUN . lactate still high. SVO2 60-70 most of night droped to 55-57 when pressure was low and pt was turned. LSC 3 lumen presep cath. R aline placed and R PIV patent. Drips fentanyl at 40mcg. vasopressin at .04 levophed off. NS kvo. insulin.\n\nLungs; pt on 50/ 5 PS 5 peep and appeared comfortable with SAT > 95 then about 0100. SAT down to 93 SVO2 556-62. ABG sent PO2 55 PCO2 56 PH 7.22 pt placed on AC and fentanyl increased from 30 to 40mcg. lungs upper clear to coarse bases coase to diminished. SVO2 dropped when turning pt . space activity. suction for scant amt of thick clear to light tan sputum.\n\nGI: ABD distended slight soft. NG in place checked by ascultation. TF promote with fiber started at 10cc no advnced for residual of 50cc and pt hemodynamic instability. BS present to hypoactive.\n\nGU: urine clear to cloudy and yellow initially 8-10cc an hour . after 2 liter of fluid 40cc an hour.\n\nSkin intact. no redness or breakdown old scaring in buttock area.\n\nA unstable\np possible transfusion of PRBC, possible lyte repleation. maintain MAP > 60 with pressors and fluids as needed. FS hourly titrate regular insulin as indicated. promote pt comfort elevate scrotum . continue fentanyl drip.\n" }, { "category": "Nursing/other", "chartdate": "2159-03-01 00:00:00.000", "description": "Report", "row_id": 1575765, "text": " 4 ICU NPN 0700-1900\nUnresponsive on MS04 3mg hr. Family members in & out throughout the day. Expired at 12:35Pm. Catholic priest & social worker supporting family. Autopsy declined by family.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-28 00:00:00.000", "description": "Report", "row_id": 1575761, "text": "Smicu nsg progress note\nNeuro- Initially quite agitated moving about in bed pulling sheets on and off. Pt oriented and answering questions appropiately. Asking for something to help him sleep. Given .5mg ativan followed by additional 1mg without change. Pt then becoming confused attemping to get oob pulling at tubes. Restraints on for safety. Ho notified and pt given 1mg haldolx2 followed by 4mg with improvement of agitation although pt still unable to sleep. Pt requiring frequent reorientation to room and reason he was admitted.\n\nResp- Remains intub/vented on ac 500x22 breathing above vent. Suctioned for minimal secretions. On 50% 5peep with sats 96-98%.\n\nCardiac- Bp remains stable. Cont in af with hr low 98 to high 140 dependent on state of agitiation. No futher fluid boluses. Cont with total body anascara and minimal uo. ?need to diuresis before attempting to wean.\n\nGi- On goal tube feeds at 30/hr with minimal aspirates. Abdomen firm with bs. C/o intermittent nausea. Given compazine with some improvement. Passing sm amt loose stool. Cont on insulin gtt adjusted according to fs (see flow sheet)\n\nId- Remains afebrile on current antibiotics.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-28 00:00:00.000", "description": "Report", "row_id": 1575762, "text": "Nsg addendem\nAt 6am pt found self extubated. Hands in soft restraints at time. 100% nr on. Although pt denies sob appears sob with rr 26 rales anteriorly. Given 40mg lasix. Hr now 130's with bp 140/80. Awaiting abg for possible re-intubation. Pt's called and she is on her way to hospital.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-28 00:00:00.000", "description": "Report", "row_id": 1575763, "text": " 4 ICU NPN 0700-1900\n\nSelf-extubated for second time in five hrs despite being on fentanyl gtt after the first extubation. Per family he did not know why he pulled the tube out but just wanted to go home. Placed on supportive mask ventilation until brother arrived this afternoon. When all family present decision was to make pt . Currently on morphine sulfate gtt at 3 mg/hr. Presently unresponsive when name called. RR 20's. Does not appear be be in pain.\n\nUnable to determine if pt oriented this morning. Unable to effective communicate with pt when intubated & with mask ventilation. ABG 92/61/7.15-7.26/21/-7. BS coarse.\n\nOliguric.\n\nFentanyl gtt stopped when pt extubated self. arrived shortly after extubation Documents signed by pt with an X. Signing not witnessed by this nurse or any medical staff. When questioned about the documents this nurse & visiters that pt's mental status was in question this morning & pt's blood PH was very acidotic as well.\n provided one document which was copied & returned to \nSecond document was placed in folder.\n\nA/P:\n goal for pt care. Titrate morphine sulfate to comfort.\n? competency of pt's mentals status throughout tha day.\nSupport to family.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-03-01 00:00:00.000", "description": "Report", "row_id": 1575764, "text": "Smicu nsg progress note\ns/o- Pt unresponsive on 3mg/hr morphine. Agonal breathing with rr 8-10 with minimal bp thoughout night. Family in and out at bedside.\nA- without pain on morphine gtt. Family grieving appropriately\nP- Cont with comfort measures. Support family.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-26 00:00:00.000", "description": "Report", "row_id": 1575755, "text": "MSICU NPN 0700-1900\n\n\nsee flowsheet for further details....\n\n\nAlert. Follows commands. Makes needs known. Denies pain except when moved he has hip pain (chronic per S.O.).\n\nFent gtt dc'd as he failed PSV trial (see abg) although at the time his MV was 6L. He denied SOB and appeared very comfortable. ?central in etiology. Plan for possible head ct in am. O2sats had been good but currently unable to get them. FiO2 increased to 60%. Currently on a/c. Occ over breathes 1-2 breaths. MIn secretions. SVO2 67-72.\n\n800cc readi cat given for chest and abd ct. Vomited x3 in ct. No noted aspiration. Residual barium (400cc) aspirated out and discarded. In am he had >100cc residual and TFs were dc'd. Plan to start Reglan and resume Nepro at 10cc/hr. No stool. + bowel sds.\n\nGiven 2uPRBCs with repeat Hct ~34.\n\nCentral line fell out of phalange in ct scan. Currently has 3 PIVs. Stable BP off Vassopressin. Remains in A-Fib. Cardiac echo done.\n\nK+, Mg++ and Calcium replaced.\n\nAfebrile all day.\n\n in all day and updated by pulm fellow.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-26 00:00:00.000", "description": "Report", "row_id": 1575756, "text": "Respiratory Care\nPt. placed back on A/C after failed wean from with abg resulting in 723/56/53/25/-4/ , even with a RSBI of 13, rr 14 mv only 4.0. Will stoop fentyl and wean in am.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-26 00:00:00.000", "description": "Report", "row_id": 1575757, "text": "Respiratory Care\nPt to cat-scan without respiratory complications.\n" }, { "category": "Nursing/other", "chartdate": "2159-02-27 00:00:00.000", "description": "Report", "row_id": 1575758, "text": "npn 7p-7a (see carevue flownotes for objective data)\n\ndx: s/p liver transplant ; since transplant developed lung CA, now with liver mets and possible pelvic mets;\n\nneuro/c-v:\nreceived pt off fentanyl; some gtts dc'd abruptly yesterday afternoon d/t cvl came out at procedure (CT) during transfer;\n pt stable, restarted fentanyl at low dose d/t pt w hx pelvic pain, and goal to avoid w/drawal syndrome;\n urine output low, v-response increased to 130's up to 150 at times; received 500 cc IVF boluses over the night x2; did also receive IV lopressor 5 mg x2, 2nd dose after 2nd 500 bolus infused--to avoid hypotension; hrt rate did decrease to low 100's/low 110's;\n urine output remained low overnight despite fluid boluses; BUN/creatinine w/out much change from previous;\n\nresp:\npt s/p PS trial yesterday;\n received pt on a/c rate 16 decreased to 10 last eve, TV 500/.60/peep 8; ABG showed good toleration of settings; at 06:00 changed to PS, immediately hrt rhythm became rapid a-fib in 140's, sbp increased from 99/102 to 140's, resp rate increased; peep 8 added; pt's vs returned to current baseline with PS 15/Peep 8, FIO2 .60--pt's resp rate approx 22 without distress;\n\ng-i:\nstarted on Nepro, tolerated increase w/ scant resids overnight, currently at 30 cc/hr, which is current goal for this formula; whith continued toleration, nurition c/s suggests switching to Nepro to promode 55 g daily, with goal 45 cc/hr;\n no stool this night;\n\nendo:\ninsulin gtt off late last eve, has stayed off overnight, with FS's 99-104;\n\nskin:\npt with taught skin in peri-area d/t generalized anascara d/t liver failure; smaller than dime size decube rt hip; coccyx slightly reddned, though w/out breakdown;\n\naccess:\nleft a.c. IV site found infiltrated at beginning of shift, new #20 started in rt hand; managing this pt with delicate hemodynamic situation may be tenuous with only periph IV's; may want to consider another cvl or PICC;\n\nsocial:\npt's present last eve, as well as other visitors;\n\ni.d./spesis:\ncontinues to receive IV Abx; WBC 2.0 this a.m.; afebrile overnight;\n\nPLAN:\nsee how long pt tolerates PS/PEEP; rest back on A/C if resp distress occurs; ? extubation if very good toleration with continued wean;\n keep narcotics low dose re liver mets;\n meticulous skin care;\n consider access situation re medical/physical status;\n" }, { "category": "Nursing/other", "chartdate": "2159-02-27 00:00:00.000", "description": "Report", "row_id": 1575759, "text": "Resp Care\n\nAttempted pt on psv 5/5 this am. Follow up abg 7.18/58/60/23. Pt placed on A/C with a corresponding improved abg. BS coarse. Receiving Alb mdi's\n" }, { "category": "Nursing/other", "chartdate": "2159-02-27 00:00:00.000", "description": "Report", "row_id": 1575760, "text": "NPN\n\nNeuro: Pt alert and oriented, able to understand a fair amount of english, able to participate some in his care.\n\nCV: Pt was started on lopressor 25mg per OGT, this lowered his HR from the 120s-150s to the 90s-100s, SBP also decreased from the 120s-130s to the 90s.\n\nResp: Remains vented, he was tried on PS of and his ABG was 7.18/58/60, he was placed back on A/C 16/500/5/.5 and his ABG was 7.27/45/100 - his rate was increaed to 22. Sx for a mod amount of yellow secreations.\n\nGI: He remains on nepro at 30cc/hr - his goal rate. He has been intermitantly c/o feeling nauseated for short periods of time. He has been ordered for compazine. His abd remains firm, hypoactive BS, he did have a lg BM today.\n\nGU: Poor u/o ~ 2-10cc/hr, there was some discussion on rounds about starting lasix but it has not been ordered.\n\nEndo: He is now back on an insulin gtt to maintain a BS 80-120.\n\nSoc: There was a family meeting today to discuss end of life choices. The attending, intern, myself, an italian interpreter, and his family were there. We talked to him about taking him off of the vent and keeping him comfortable on morphine gtt vs taking him off of the vent with the option of putting him back on the vent if he didn't tolerate being extubated. He talked to his family after the meeting and per his SO he would want to go back on the vent if he needed to. We will have another discussion with him tomorrow with the interpreter.\n\n" }, { "category": "Echo", "chartdate": "2159-02-26 00:00:00.000", "description": "Report", "row_id": 62648, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 150\nBSA (m2): 1.79 m2\nBP (mm Hg): 107/67\nHR (bpm): 100\nStatus: Outpatient\nDate/Time: at 11:03\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Depressed\nLVEF. [Intrinsic LV systolic function depressed given the severity of valvular\nregurgitation.]\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed. [Intrinsic RV\nsystolic function more depressed given the severity of TR].\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Moderate (2+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade. Echocardiographic signs of tamponade may be absent in the presence\nof elevated right sided pressures.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. LV systolic function\nappears moderately depressed with global hypokinesis. [Intrinsic left\nventricular systolic function may be more depressed given the severity of\nvalvular regurgitation.] The right ventricular cavity is dilated. Right\nventricular systolic function appears depressed. [Intrinsic right ventricular\nsystolic function may be more depressed given the severity of tricuspid\nregurgitation.] The ascending aorta is mildly dilated. The aortic valve\nleaflets are mildly thickened. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate (2+) mitral regurgitation is seen. The mitral regurgitation jet is\neccentric. The tricuspid valve leaflets are mildly thickened. Severe [4+]\ntricuspid regurgitation is seen. There is a small pericardial effusion. There\nare no echocardiographic signs of tamponade. Echocardiographic signs of\ntamponade may be absent in the presence of elevated right sided pressures.\n\nNo vegetations seen (cannot exclude).\n\nCompared with the report of the prior study (tape unavailable for review) of\n, biventricular abnormalities are new and mitral regurgitation and\ntricuspid regurgitation are now significantly worse.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 854731, "text": " 6:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 63 year old man with cough and hypotension eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cough and hypotension eval for PNA\n\n REASON FOR THIS EXAMINATION:\n 63 year old man with cough and hypotension eval for PNA\n\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung cancer, cough and hypotension.\n\n COMPARISON: and .\n\n AP UPRIGHT VIEW OF THE CHEST: There is stable cardiac enlargement.\n Mediastinal contours remain unchanged. Again demonstrated is a large left\n upper lobe mass. There has been interval development of a patchy opacity\n within the left lung base and interval worsening of the patchy opacity present\n within the right lung base. There has been interval increase in the pleural\n fluid along the right inferolateral chest wall as well as continued fluid\n within the right minor fissure. Mild blunting at the left costophrenic angle\n persists. No pneumothorax is demonstrated. Again seen are several calcified\n pleural plaques within the left lung apex and right base. Soft tissues and\n osseous structures are unchanged.\n\n IMPRESSION:\n\n 1. Interval development of left basilar opacity and worsening of right\n basilar patchy opacity, findings most suggestive of multifocal pneumonia.\n Asymmetric pulmonary edema and lymphangitic spread of cancer are also\n considerations.\n\n 2. Stable appearance of left upper lobe mass.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2159-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 854735, "text": " 7:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p intub, eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cough and hypotension eval for PNA\n\n REASON FOR THIS EXAMINATION:\n s/p intub, eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Often hypertension, lung cancer, status post intubation.\n\n SUPINE AP VIEW: Comparison is made to a prior radiograph from approximately\n one hour earlier the same day. The patient has undergone interval intubation\n with endotracheal tube tip lying approximately 7.6 cm above the carina, in\n satisfactory position. Appearance of the lungs again remains unchanged with\n the large left upper lobe mass and air space opacities in both bases. Cardiac\n and mediastinal contours remain unchanged. No pneumothorax is demonstrated.\n\n IMPRESSION:\n\n Satisfactory endotracheal tube placement. Stable appearance of the chest from\n one hour earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-02-26 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 854879, "text": " 9:13 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BILAT LEG SWELLING, MET NSCLC, HYPOXIA, ? DVT'S\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with h/o met NSCLC p/w hypoxia, has asymmetrically enlarged\n RLE but B large LE's.\n REASON FOR THIS EXAMINATION:\n DVT's?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral leg swelling. Nonsmall cell lung cancer. Hypoxia.\n\n COMPARISON: , prior study failed to demonstrate DVT in the right\n lower extremity.\n\n The right and left common femoral, femoral, and popliteal veins are well\n visualized. They are easily compressible. They also demonstrate normal flow\n and augmentation.\n\n IMPRESSION:\n\n No evidence of DVT in the visualized venous structures bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-02-26 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 854924, "text": " 1:50 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: abscess? bleed? new pleural effusion? characterize lung mass\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with lung mets and new fever.also falling Hct after left SC\n placed\n REASON FOR THIS EXAMINATION:\n abscess? bleed? new pleural effusion? characterize lung mass\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic lung cancer, new fever, falling hematocrit. Evaluate\n for abscess, hemorrhage, or new pleural effusion.\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the femoral heads without intravenous contrast.\n\n COMPARISON: CT of the chest from and a CT of the abdomen and\n pelvis from .\n\n CT chest without IV contrast: There is a very large mass in the left upper\n lobe, which has significantly increased in size from . At the level\n of the aortic arch, this mass spans the entire A-P diameter of the chest.\n There is increased atelectasis of the left lower lobe, presumably related to\n compression from the large left upper lobe mass. There are small bilateral\n pleural effusions. The heart is enlarged. There is diffuse septal\n thickening, which may relate to congestive heart failure. However,\n lymphangitic spread of cancer cannot be excluded. The endotracheal tube\n extends to just above the carina.\n\n Abdomen without IV contrast: There are numerous large low attenuation masses\n throughout the liver, significantly increased in size and number from\n . These findings are consistent with diffuse metastatic disease.\n The splenic metastasis is also increased in size, currently measuring 5.3 x\n 5.4 cm. The pancreas is unremarkable on unenhanced scan. The adrenal glands\n and kidneys appear normal. There is extensive ascites throughout the abdomen\n and pelvis, significantly increased in extent from the prior study. The\n opacified loops of bowel are unremarkable. The IVC is prominent, which may\n relate to congestive heart failure. This appearance is not significantly\n changed in the interval. However, thrombosis in this region cannot be\n excluded on this unenhanced scan.\n\n CT pelvis without IV contrast: A Foley catheter is in place. There is\n extensive ascites throughout the pelvis. Diffuse vascular calcifications are\n also noted.\n\n Bone windows demonstrate a mottled appearance of the iliac bones bilaterally,\n adjacent to the sacroiliac joints. These findings raise concern for\n (Over)\n\n 1:50 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: abscess? bleed? new pleural effusion? characterize lung mass\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n metastatic disease. There is also a suggestion of a lytic lesion within the\n L4 vertebral body on the right. This may represent a metastasis.\n\n IMPRESSION:\n 1. Significant interval increase in the size of the large left upper lobe\n mass as well as interval worsening of the liver and splenic metastases.\n 2. Diffuse septal thickening, which may relate to congestive heart failure.\n Lymphangitic spread of tumor cannot be excluded.\n 3. Mottled appearance of the iliac bones, which may relate to metastatic\n lesions.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 854753, "text": " 12:25 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess OG tube placement and eval for SBO\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with abdominal pain, recent intubation and OG tube placement.\n REASON FOR THIS EXAMINATION:\n please assess OG tube placement and eval for SBO\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain, recent intubation and OG tube placed. Check\n position for abdomen.\n\n The film is underpenetrated and the exact position of the orogastric tube is\n difficult to determine. A portion of it is definitely below the diaphragm\n within the anteral region.\n\n Lung infiltrates are noted.\n\n IMPRESSION: A gastric in stomach, theexact end-point could not be determined.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 855150, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess ETT placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with pna. sepsis self-extubated, now reintubated.\n\n REASON FOR THIS EXAMINATION:\n please assess ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and sepsis. EETT placement. COMPARISON: .\n\n AP bedside chest: The endotracheal tube is unchanged in position. The tip of\n the nasogastric tube is seen well below the left diaphragm in the expected\n stomach. The left subclavian central venous catheter has been removed. No\n pneumothorax. A large left upper lobe opacity/mass is unchanged. There is\n lucency of the right upper lobe which may represent a bulla. Right and left\n pleural effusions are present, layering posteriorly. The right pleural\n effusion is seen in the 'open' portion of the right major fissure laterally.\n No pneumothorax. The cardiovascular status of the patient is difficult to\n assess on this bedside exam. There is borderline cardiomegaly with prominent\n pulmonary vasculature, without overt failure.\n\n IMPRESSION: No significant interval change except for removal of left\n subclavian central venous catheter. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 854740, "text": " 8:40 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval L sc central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with pna. sepsis\n REASON FOR THIS EXAMINATION:\n eval L sc central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and sepsis. Status post central line placement.\n\n COMPARISON: , at 19:40 and 18:27.\n\n SUPINE AP VIEW OF THE CHEST: There has been interval placement of a left\n subclavian central venous catheter with the tip at the\n brachiocephalic/proximal superior vena cava junction. There is no\n pneumothorax. Endotracheal tube remains in stable position. The appearance\n of the chest remains unchanged. No pneumothorax.\n\n IMPRESSION:\n\n Left subclavian central venous catheter with tip at the brachiocephalic/SVC\n junction. No pneumothorax.\n DFDdp\n\n" }, { "category": "ECG", "chartdate": "2159-02-24 00:00:00.000", "description": "Report", "row_id": 117453, "text": "Atrial fibrillation. Low voltage in the limb leads. Compared to the previous\ntracing no significant change.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2170-02-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 729983, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 12:16 PM\n MRSA\n She had a CXR y/d morning which showed increased calcification of the\n ascending aorta raising a concern by radiology for dissection. They\n rrequested a repeat CXR which did not show any widening of the\n mediastinum or any other findings to suggest dissection.\n They did not that there had been an interval decrease in the extent of\n pulmonary edema, and an increase in ventilation of the basal lungs\n bilaterally as well as decrease in the left pleural effusion.\n She received 20mg p.o lasix with UOP 850cc.\n Her metoprolol was changed to 50mg TID from 25mg TID\n - I/O: -850mL at midnight\n - Metoprolol changed to 50 TID\n - D/c'ed prozac at pt refused it\n - Gave ambien for sleep\n - Emailed ; she recommended talking to Dr. about\n having pt see Dr. \n - PT Recs _________________________\n - complained of some pain in her hip/thigh on the L; she was concerned\n it could be related to her recent fall; i gave her some trazodone for\n sleep (had recently gotten tylenol) and ordered a heat pack for her\n hip; we can consider imaging in the AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 78 (67 - 89) bpm\n BP: 107/46(61) {99/42(57) - 144/69(84)} mmHg\n RR: 20 (16 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 520 mL\n PO:\n 520 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,340 mL\n 320 mL\n Urine:\n 1,340 mL\n 320 mL\n NG:\n Stool:\n lOS-ve\n 1.140L\n Balance:\n -820 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General: elderly woman, generally anxious-appearing, lying comfortably\n in bed, speaking in complete sentences without pauses, no accessory\n muscle use or labored breathing\n HEENT: NC/AT, PERRLA, EOMI\n Neck: supple, no appreciable JVD\n Chest: RRR, normal s1/s2, systolic murmur loudest along left sternal\n border, radiating toward apex although not audible in axilla\n Lungs:clear anteriorly\n Abdomen: soft, non-tender, normal bowel sounds\n Extremities: trace pitting edema to ankles L>R bilaterally; feet warm\n and well-perfused\n Neurological: AAOx3,\n NO ttp LEFT HIP, pain worse on adduction,. , pt unable to raise on\n own\n Labs / Radiology\n 396 K/uL\n 9.2 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 108 mEq/L\n 141 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 04:20 AM\n WBC\n 11.2\n Hct\n 27.1\n Plt\n 396\n Cr\n 0.7\n Glucose\n 117\n Other labs: PT / PTT / INR:13.8/37.1/1.2, Ca++:8.5 mg/dL, Mg++:1.8\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n .H/O CHEST PAIN\n This 82 year old woman discharged yesterday following stent placement\n of the LAD and newly diagnosed CHF with ischemic MR \n, hypoxemia, and tachycardia after arrival at the\n Rehabilitation Center. She developed\nflash\n pulmonary edema that\n responded to diuresis and oygen. We will optimize her medicatlons\n including her lisinopril, furosemide, and metoprolol. We will\n coordinate with our CHF nursing unit for discharge planning.\n ..\n .H/O CHEST PAIN\n ASSESSMENT AND PLAN: 82 yo woman with history of type II diabetes,\n peripheral vascular disease, hypertension, and hyperlipid recently\n admitted to CCU for respiratory distress in the setting of\n decompensated heart failure and NSTEMI, now presenting for acute\n worsening of shortness of breath.\n .\n # Hypoxia. Ddx flash pulmonary edema in setting of hypertension,\n worsening heart failure, pneumonia, aspiration event, arrhythmia,\n pulmonary embolism. CXR consistent with worsening pulmonary edema.\n Patient had been treated previously with 20 mg IV Lasix (received on\n and ), now s/p 40 mg IV Lasix in the ED with urine output of\n 400 cc and overall improvement in symptoms. Blood pressure currently\n well-controlled.\n - continue recent discharge regimen lisinopril 20 mg qday\n - will increase metoprolol from 50 XL to 25 mg metoprolol tartrate tid\n - will add Lasix at dose 20 mg PO qday, goal I/O 500-1L negative\n - monitor on telemetry\n .\n # Leukocytosis. No bandemia. No fevers. No localizing signs for\n infection. UA negative. CXR could not definitively exclude pneumonia\n although pulmonary edema seems much more likely to account for\n symptoms. Patient is s/p 1 dose of levofloxacin in ED.\n - continue to trend white cell count\n - hold off antibiotics for now\n - team can consider repeating lactate if concern of infection\n .\n # ?Anxiety / history of depression. Patient previously had been treated\n with Prozac 20 mg daily and it is not clear why this medicine was\n stopped. I have added this back. Additionally, I would like to address\n with team getting a social work consult versus starting an anxiolytic,\n as it seems possible that anxiety may be contributing to her\n tachycardia and symptoms.\n .\n # Coronary artery disease. No new ischemic changes on EKG. First set of\n cardiac enzymes with normal CK, downtrending troponin.\n - continue Plavix and aspirin\n - continue simvastatin at 80 mg qday\n .\n # Pump. As above, her current presentation likely represents\n decompensation of known systolic CHF. Patient with good diuresis after\n 40 mg IV Lasix in ED. Will start on 20 mg PO Lasix daily and monitor\n Is/Os, aiming for 500-1L negative. Apical akinesis currently being\n treated with six months of anticoagulation.\n - continue Lovenox and coumadin\n - daily INR/PTT\n .\n # Rhythm. Currently in normal sinus rhythm. No active issues.\n .\n # S/p left hip replacement. She had a left hip replacement at \n prior to her previous admission. Communication with performing\n surgeon related that she was full weight bearing and she was evaluated\n by PT with a recommendation for rehab. She is on lovenox bridge to\n coumadin currently and she has follow-up with her orthopedic surgeon in\n two weeks of the procedure.\n .\n # Diabetes, type II.\n - humalog insulin sliding scale with qid fingersticks\n - consider restarting metformin; previous medication lists indicate she\n was taking 1000 mg \n .\n # Anemia. Stable from previous admission.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2170-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 729785, "text": "82 year old Patient had just arrived at rehab .Discharged from\n to Rehab ( in ). Developed\n abdominal pain that subsided on its own then felt tired when coming\n back from bathroom when symptoms started. Felt palpitations and\n developed SOB. Family concerned so called 911. In route to hospital\n noted to be tachypneic and hypoxic. Arrived to out ED, started on IV\n and s/l nitro/lasix 40 mg IV/ASA and placed on BIPAP for a short\n periods of time. She was also noted to be hypertensive in the 180's\n with O2 sat in mid 60's in ST. wbc up to 16.1.BNP 14,871.Trop elevated\n but trending down from previous. Denies chest pain. EF 30-35 %.\n Pulmonary edema\n Assessment:\n Admitted early this am as CCU border. AOx3. Pleasant. Moves all\n extremities. Denies SOB or chest pain. Crackles at the bases. O2 4 l\n n/c with O2sat >94%. HR SR 80-90\ns with BP 120\ns syst.\n Recent left hip surgery. DSD left hip dry and intact. Dressing not\n opened due to patient instructions from orthopedic surgeon. Denies pain\n to hip. Full weight barring. Good urine output via foley. Family at\n bedside.\n Action:\n Restarted Lopressor and discharge meds.\n OOB to chair with 2 assist. Tolerated well.\n PT consult.\n Response:\n Good response to lasix. HR improved from 80\ns to 60\ns. Baseline 50\n per family.\n Crackles bases less pronounced than in am.\n Plan:\n Transfer to . Telemetry.\n Monitor urine output and respiratory status.\n" }, { "category": "Physician ", "chartdate": "2170-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 729771, "text": "Chief Complaint:\n CHIEF COMPLAINT: dyspnea.\n 24 Hour Events:\n . patient is an 82 yo woman with history of type II diabetes,\n peripheral vascular disease, , and hyperlipid who was\n recently admitted to CCU for respiratory distress in the setting of\n decompensated heart failure and NSTEMI. She presented to the ED last\n night from rehab less than 24 hours post-discharge for increasing\n shortness of breath.\n .\n She says that she arrived at rehab yesterday afternoon feeling\n generally well. She ate dinner after which she developed mild abdominal\n discomfort that resolved spontaneously. She then felt as if her heart\n was beating fast, and she also felt tired. There was no chest pain or\n pressure, lightheadedness or dizziness. She says she was diaphoretic at\n the time. Her daughter, concerned, called 911. En route to the\n hospital, she was noted to be tachypnic and hypoxic (per ED report).\n .\n Initially in the ED she was hypoxic to mid 60s. She was also\n hypertensive to 180s initially. EKG showed sinus tachycardia with LAD\n (unchanged). Widened QRS (114 ms) with ST elevations in anterior\n precordial leads (unchanged) and ST-depressions/T-wave inversions in\n lateral leads (unchanged). CXR showed bilateral perihilar\n consolidations worse from two days prior with persistent pleural\n effusions; overall impression was worsening pulmonary edema, although\n infection could not be excluded. ABG showed 7.43/36/124. Lactate was\n 2.4. Labs were notable for white count of 16.1 with 66.2% neutrophils\n and no bands. BMP showed a bicarb of 21 with anion gap of 12. Renal\n function was normal. Of note, her troponin was 2.63 (down from previous\n 6.41 on ) with flat CK. BNP was 14,871 (no prior for comparison).\n She was placed on a nitro drip intially; this was quickly weaned off.\n She was also placed on BiPAP intially. There were attempts made to wean\n her to face mask or nasal cannula. However, per ED report she became\n tachypnic to 30s with these measures, and therefore she was readmitted\n to the CCU.\n .\n At time of admission, her sats were 95-96% on NRB, RR 27-32, heart rate\n in the 90s with systolic BP 110s. In the ED she received aspirin 325 mg\n x1, levofloxacin 750 mg x1, and Lasix 40 mg IV x1.\n .\n Of note, during her previous admission ( to ), she was\n intubated for respiratory distress secondary to mitral regurgitation\n which was believed secondary to ischemia. This all had happened after\n an elective left total hip replacement at . She underwent\n echocardiogram that showed a new antero-apical wall motion abnormality\n and underwent cardiac cath that revealed LAD disease for which a bare\n metal stent was placed. She was started on Plavix and high-dose\n aspirin, as well as Lovenox with bridge to coumadin for apical akinesis\n (LVEF 30-35%) noted on echocardiogram. She worked with physical therapy\n for two days without chest pain or dyspnea and was felt to be ready for\n discharge to rehab.\n .\n REVIEW OF SYSTEMS: currently, patient denies shortness of breath, chest\n pain or pressure, lightheadedness or dizziness. She denies nausea,\n abdominal discomfort, cough, or sputum production.\n .\n PAST MEDICAL HISTORY:\n 1) Type 2 Diabetes\n 2) Peripheral vascular disease: s/p left common femoral to below-knee\n popliteal artery bypass with in situ saphenous vein and an open\n transluminal angioplasty of the anterior tibial and below knee\n popliteal arteries in .\n 3) \n 4) Hyperlipidemia\n 5) Hx of R breast ca s/p lumpectomy\n 6) Depression\n .\n MEDICATIONS (at discharge on ):\n - aspirin 325 mg qday\n - clopidogrel 75 mg qday\n - warfarin 3 mg qday\n - simvastatin 80 mg qday\n - multivitamin qday\n - ranitidine 150 mg qday\n - lisinopril 20 mg qday\n - enoxaparin 60 mg qday\n - acetaminophen 325 mg q6h prn\n - metoprolol 50 mg sustained release qday\n - Lasix (dose not clear)\n .\n MEDICATIONS (before and during recent admission; prior to discharge)\n .\n Home medications:\n - Metformin 1000mg PO BID\n - Lipitor 20mg PO daily\n - Prozac 20mg PO daily\n - Triamterene 25mg PO daily\n - Neurontin 300mg PO TID\n - Actonel 35mg PO weekly\n - ASA 81mg daily\n .\n Medications on transfer during previous admission:\n - lisinopril 5mg daily\n - lopressor 12.5 mg \n - trazadone 50 qhs\n - depakote 125mg daily\n - remeron 15mg bedtime\n - zocor 40mg daily\n - lasix 40mg IV q12-hours PRN\n - aricept 5mg daily\n - prozac 20mg daily\n - neosynephrine drip\n - IV heparin low dose\n - plavix 300mg x 1\n - ASA 325\n .\n ALLERGIES: no known drug allergies.\n .\n SOCIAL HISTORY: prior to discharge to rehab, she lived at home and was\n pretty independent in her ADLs, IADLs and very functional. Denies any\n history of smoking, alcohol or drug abuse.\n .\n FAMILY HISTORY: non-contributory.\n .\n EKG: sinus tachycardia with LAD (unchanged). Widened QRS (114 ms) with\n ST elevations in anterior precordial leads (unchanged) and\n ST-depressions/T-wave inversions in lateral leads (unchanged).\n .\n CXR: bilateral perihilar consolidations worse from two days prior with\n persistent pleural effusions.\n .\n Transthoracic echocardiogram (): The left atrium is mildly dilated.\n Left ventricular wall thicknesses and cavity size are normal. There is\n moderate regional left ventricular systolic dysfunction with severe\n hypokinesis of the distal halves of the anterior septum, anterior and\n inferior walls as well as apex. The remaining segments contract\n normally (LVEF = 30-35 %). [Intrinsic left ventricular systolic\n function is likely more depressed given the severity of valvular\n regurgitation.] No masses or thrombi are seen in the left ventricle.\n Tissue Doppler imaging suggests an increased left ventricular filling\n pressure (PCWP>18mmHg). Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets are mildly thickened (?#).\n No aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. Moderate (2+) mitral regurgitation is seen. There is mild\n pulmonary artery systolic . There is no pericardial\n effusion.\n IMPRESSION: Normal left ventricular cavity size with extensive regional\n systolic dysfunction c/w multivessel CAD (mid-LAD and PDA\n distributions). Increased PCWP. Moderate mitral regurgitation.\n Pulmonary artery systolic .\n .\n Cardiac catheterization ():\n 1. Two vessel coronary artery disease.\n 2. Biventricular diastolic dysfunction.\n 3. Mild pulmonary arterial .\n 4. Placement of a bare-metal stent in the proximal LAD.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 90 (90 - 90) bpm\n RR: 29 (29 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -400 mL\n Respiratory support\n SpO2: 97%\n ABG: ////\n Physical Examination\n Vitals: T 97.9, HR 93-94, BP 119-127/58-66), RR 12-20, sat 90-98% 5L\n Urine output: 400 cc\n General: elderly woman, generally anxious-appearing, lying comfortably\n in bed, speaking in complete sentences without pauses, no accessory\n muscle use or labored breathing\n HEENT: NC/AT, PERRLA, EOMI\n Neck: supple, no appreciable JVD\n Chest: RRR, normal s1/s2, systolic murmur loudest along left sternal\n border, radiating toward apex although not audible in axilla\n Lungs: crackles halfway up posterior fields\n Abdomen: soft, non-tender, normal bowel sounds\n Extremities: trace pitting edema to ankles bilaterally; feet warm and\n well-perfused\n Neurological: AAOx3, moving all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n .H/O CHEST PAIN\n ASSESSMENT AND PLAN: 82 yo woman with history of type II diabetes,\n peripheral vascular disease, , and hyperlipid recently\n admitted to CCU for respiratory distress in the setting of\n decompensated heart failure and NSTEMI, now presenting for acute\n worsening of shortness of breath.\n .\n # Hypoxia. Ddx flash pulmonary edema in setting of ,\n worsening heart failure, pneumonia, aspiration event, arrhythmia,\n pulmonary embolism. CXR consistent with worsening pulmonary edema.\n Patient had been treated previously with 20 mg IV Lasix (received on\n and ), now s/p 40 mg IV Lasix in the ED with urine output of\n 400 cc and overall improvement in symptoms. Blood pressure currently\n well-controlled.\n - continue recent discharge regimen lisinopril 20 mg qday\n - will increase metoprolol from 50 XL to 25 mg metoprolol tartrate tid\n - will add Lasix at dose 20 mg PO qday, goal I/O 500-1L negative\n - monitor on telemetry\n .\n # Leukocytosis. No bandemia. No fevers. No localizing signs for\n infection. UA negative. CXR could not definitively exclude pneumonia\n although pulmonary edema seems much more likely to account for\n symptoms. Patient is s/p 1 dose of levofloxacin in ED.\n - continue to trend white cell count\n - hold off antibiotics for now\n - team can consider repeating lactate if concern of infection\n .\n # ?Anxiety / history of depression. Patient previously had been treated\n with Prozac 20 mg daily and it is not clear why this medicine was\n stopped. I have added this back. Additionally, I would like to address\n with team getting a social work consult versus starting an anxiolytic,\n as it seems possible that anxiety may be contributing to her\n tachycardia and symptoms.\n .\n # Coronary artery disease. No new ischemic changes on EKG. First set of\n cardiac enzymes with normal CK, downtrending troponin.\n - continue Plavix and aspirin\n - continue simvastatin at 80 mg qday\n .\n # Pump. As above, her current presentation likely represents\n decompensation of known systolic CHF. Patient with good diuresis after\n 40 mg IV Lasix in ED. Will start on 20 mg PO Lasix daily and monitor\n Is/Os, aiming for 500-1L negative. Apical akinesis currently being\n treated with six months of anticoagulation.\n - continue Lovenox and coumadin\n - daily INR/PTT\n .\n # Rhythm. Currently in normal sinus rhythm. No active issues.\n .\n # S/p left hip replacement. She had a left hip replacement at \n prior to her previous admission. Communication with performing\n surgeon related that she was full weight bearing and she was evaluated\n by PT with a recommendation for rehab. She is on lovenox bridge to\n coumadin currently and she has follow-up with her orthopedic surgeon in\n two weeks of the procedure.\n .\n # Diabetes, type II.\n - humalog insulin sliding scale with qid fingersticks\n - consider restarting metformin; previous medication lists indicate she\n was taking 1000 mg \n .\n # Anemia. Stable from previous admission.\n .\n ICU Care\n # FEN. Diabetic, heart-healthy, low-sodium diet.\n .\n # Prophylaxis. On Lovenox and coumadin. Written for bowel regimen and\n standing Tylenol for pain related to recent hip surgery.\n .\n # Code status. FULL.\n .\n # Access: 20 guage IV\n # Communication. With patient.\n .\n # Disposition. Likely call-out to pending discussion with team.\n ------ Protected Section ------\n CCU Attending\n I agree with the detailed note by Dr. delineated above.\n History and Physical. I was present for the pertinent portions of the\n history and physical examination. I concur with the treatment plan\n outlined above. Addendum: Bilateral rales, creatinine 0.7 mg/dl.\n Urine output 400 ccs.\n Medical Decision Making. This 82 year old woman discharged yesterday\n following stent placement of the LAD and newly diagnosed CHF with\n ischemic MR , hypoxemia, and tachycardia after\n arrival at the Rehabilitation Center. She developed\nflash\n pulmonary\n edema that responded to diuresis and oygen. We will optimize her\n medicatlons including her lisinopril, furosemide, and metoprolol. We\n will coordinate with our CHF nursing unit for discharge planning.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 12:26 ------\n" }, { "category": "Nursing", "chartdate": "2170-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 729780, "text": "Patient had just arrived at rehab .Discharged from to\n Rehab ( in ). Developed abdominal pain that\n subsided on its own. Had just arrived to Rehab.Felt tired when coming\n back from bathroom and symptoms started. Felt palpitations and\n developed SOB. Family concerned so called 911. In route to hospital\n noted to be tachypneic and hypoxic. Arrived to out ED, started on IV\n and s/l nitro/lasix 40 mg IV/ASA and placed on BIPAP for a short\n periods of time. She was also noted to be hypertensive in the 180's\n with O2 sat in mid 60's in ST. wbc up to 16.1.BNP 14,871.Trop elevated\n but trending down from previous. Denies chest pain. EF 30-35 %.\n Pulmonary edema\n Assessment:\n Admitted early this am as CCU border. AOx3. Pleasant. Moves all\n extremities. Denies SOB or chest pain. Crackles at the bases. O2 4 l\n n/c with O2sat >94%. HR SR 80-90\ns with BP 120\ns syst.\n Recent left hip surgery. DSD left hip dry and intact. Dressing not\n opened due to patient instructions from orthopedic surgeon. Denies pain\n to hip. Full weight barring. Good urine output via foley. Family at\n bedside.\n Action:\n Restarted Lopressor and discharge meds.\n OOB to chair with 2 assist. Tolerated well.\n PT consult.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2170-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 729699, "text": "Chief Complaint:\n CHIEF COMPLAINT: dyspnea.\n 24 Hour Events:\n . patient is an 82 yo woman with history of type II diabetes,\n peripheral vascular disease, hypertension, and hyperlipid who was\n recently admitted to CCU for respiratory distress in the setting of\n decompensated heart failure and NSTEMI. She presented to the ED last\n night from rehab less than 24 hours post-discharge for increasing\n shortness of breath.\n .\n She says that she arrived at rehab yesterday afternoon feeling\n generally well. She ate dinner after which she developed mild abdominal\n discomfort that resolved spontaneously. She then felt as if her heart\n was beating fast, and she also felt tired. There was no chest pain or\n pressure, lightheadedness or dizziness. She says she was diaphoretic at\n the time. Her daughter, concerned, called 911. En route to the\n hospital, she was noted to be tachypnic and hypoxic (per ED report).\n .\n Initially in the ED she was hypoxic to mid 60s. She was also\n hypertensive to 180s initially. EKG showed sinus tachycardia with LAD\n (unchanged). Widened QRS (114 ms) with ST elevations in anterior\n precordial leads (unchanged) and ST-depressions/T-wave inversions in\n lateral leads (unchanged). CXR showed bilateral perihilar\n consolidations worse from two days prior with persistent pleural\n effusions; overall impression was worsening pulmonary edema, although\n infection could not be excluded. ABG showed 7.43/36/124. Lactate was\n 2.4. Labs were notable for white count of 16.1 with 66.2% neutrophils\n and no bands. BMP showed a bicarb of 21 with anion gap of 12. Renal\n function was normal. Of note, her troponin was 2.63 (down from previous\n 6.41 on ) with flat CK. BNP was 14,871 (no prior for comparison).\n She was placed on a nitro drip intially; this was quickly weaned off.\n She was also placed on BiPAP intially. There were attempts made to wean\n her to face mask or nasal cannula. However, per ED report she became\n tachypnic to 30s with these measures, and therefore she was readmitted\n to the CCU.\n .\n At time of admission, her sats were 95-96% on NRB, RR 27-32, heart rate\n in the 90s with systolic BP 110s. In the ED she received aspirin 325 mg\n x1, levofloxacin 750 mg x1, and Lasix 40 mg IV x1.\n .\n Of note, during her previous admission ( to ), she was\n intubated for respiratory distress secondary to mitral regurgitation\n which was believed secondary to ischemia. This all had happened after\n an elective left total hip replacement at . She underwent\n echocardiogram that showed a new antero-apical wall motion abnormality\n and underwent cardiac cath that revealed LAD disease for which a bare\n metal stent was placed. She was started on Plavix and high-dose\n aspirin, as well as Lovenox with bridge to coumadin for apical akinesis\n (LVEF 30-35%) noted on echocardiogram. She worked with physical therapy\n for two days without chest pain or dyspnea and was felt to be ready for\n discharge to rehab.\n .\n REVIEW OF SYSTEMS: currently, patient denies shortness of breath, chest\n pain or pressure, lightheadedness or dizziness. She denies nausea,\n abdominal discomfort, cough, or sputum production.\n .\n PAST MEDICAL HISTORY:\n 1) Type 2 Diabetes\n 2) Peripheral vascular disease: s/p left common femoral to below-knee\n popliteal artery bypass with in situ saphenous vein and an open\n transluminal angioplasty of the anterior tibial and below knee\n popliteal arteries in .\n 3) Hypertension\n 4) Hyperlipidemia\n 5) Hx of R breast ca s/p lumpectomy\n 6) Depression\n .\n MEDICATIONS (at discharge on ):\n - aspirin 325 mg qday\n - clopidogrel 75 mg qday\n - warfarin 3 mg qday\n - simvastatin 80 mg qday\n - multivitamin qday\n - ranitidine 150 mg qday\n - lisinopril 20 mg qday\n - enoxaparin 60 mg qday\n - acetaminophen 325 mg q6h prn\n - metoprolol 50 mg sustained release qday\n - Lasix (dose not clear)\n .\n MEDICATIONS (before and during recent admission; prior to discharge)\n .\n Home medications:\n - Metformin 1000mg PO BID\n - Lipitor 20mg PO daily\n - Prozac 20mg PO daily\n - Triamterene 25mg PO daily\n - Neurontin 300mg PO TID\n - Actonel 35mg PO weekly\n - ASA 81mg daily\n .\n Medications on transfer during previous admission:\n - lisinopril 5mg daily\n - lopressor 12.5 mg \n - trazadone 50 qhs\n - depakote 125mg daily\n - remeron 15mg bedtime\n - zocor 40mg daily\n - lasix 40mg IV q12-hours PRN\n - aricept 5mg daily\n - prozac 20mg daily\n - neosynephrine drip\n - IV heparin low dose\n - plavix 300mg x 1\n - ASA 325\n .\n ALLERGIES: no known drug allergies.\n .\n SOCIAL HISTORY: prior to discharge to rehab, she lived at home and was\n pretty independent in her ADLs, IADLs and very functional. Denies any\n history of smoking, alcohol or drug abuse.\n .\n FAMILY HISTORY: non-contributory.\n .\n EKG: sinus tachycardia with LAD (unchanged). Widened QRS (114 ms) with\n ST elevations in anterior precordial leads (unchanged) and\n ST-depressions/T-wave inversions in lateral leads (unchanged).\n .\n CXR: bilateral perihilar consolidations worse from two days prior with\n persistent pleural effusions.\n .\n Transthoracic echocardiogram (): The left atrium is mildly dilated.\n Left ventricular wall thicknesses and cavity size are normal. There is\n moderate regional left ventricular systolic dysfunction with severe\n hypokinesis of the distal halves of the anterior septum, anterior and\n inferior walls as well as apex. The remaining segments contract\n normally (LVEF = 30-35 %). [Intrinsic left ventricular systolic\n function is likely more depressed given the severity of valvular\n regurgitation.] No masses or thrombi are seen in the left ventricle.\n Tissue Doppler imaging suggests an increased left ventricular filling\n pressure (PCWP>18mmHg). Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets are mildly thickened (?#).\n No aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. Moderate (2+) mitral regurgitation is seen. There is mild\n pulmonary artery systolic hypertension. There is no pericardial\n effusion.\n IMPRESSION: Normal left ventricular cavity size with extensive regional\n systolic dysfunction c/w multivessel CAD (mid-LAD and PDA\n distributions). Increased PCWP. Moderate mitral regurgitation.\n Pulmonary artery systolic hypertension.\n .\n Cardiac catheterization ():\n 1. Two vessel coronary artery disease.\n 2. Biventricular diastolic dysfunction.\n 3. Mild pulmonary arterial hypertension.\n 4. Placement of a bare-metal stent in the proximal LAD.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 90 (90 - 90) bpm\n RR: 29 (29 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -400 mL\n Respiratory support\n SpO2: 97%\n ABG: ////\n Physical Examination\n Vitals: T 97.9, HR 93-94, BP 119-127/58-66), RR 12-20, sat 90-98% 5L\n Urine output: 400 cc\n General: elderly woman, generally anxious-appearing, lying comfortably\n in bed, speaking in complete sentences without pauses, no accessory\n muscle use or labored breathing\n HEENT: NC/AT, PERRLA, EOMI\n Neck: supple, no appreciable JVD\n Chest: RRR, normal s1/s2, systolic murmur loudest along left sternal\n border, radiating toward apex although not audible in axilla\n Lungs: crackles halfway up posterior fields\n Abdomen: soft, non-tender, normal bowel sounds\n Extremities: trace pitting edema to ankles bilaterally; feet warm and\n well-perfused\n Neurological: AAOx3, moving all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n .H/O CHEST PAIN\n ASSESSMENT AND PLAN: 82 yo woman with history of type II diabetes,\n peripheral vascular disease, hypertension, and hyperlipid recently\n admitted to CCU for respiratory distress in the setting of\n decompensated heart failure and NSTEMI, now presenting for acute\n worsening of shortness of breath.\n .\n # Hypoxia. Ddx flash pulmonary edema in setting of hypertension,\n worsening heart failure, pneumonia, aspiration event, arrhythmia,\n pulmonary embolism. CXR consistent with worsening pulmonary edema.\n Patient had been treated previously with 20 mg IV Lasix (received on\n and ), now s/p 40 mg IV Lasix in the ED with urine output of\n 400 cc and overall improvement in symptoms. Blood pressure currently\n well-controlled.\n - continue recent discharge regimen lisinopril 20 mg qday\n - will increase metoprolol from 50 XL to 25 mg metoprolol tartrate tid\n - will add Lasix at dose 20 mg PO qday, goal I/O 500-1L negative\n - monitor on telemetry\n .\n # Leukocytosis. No bandemia. No fevers. No localizing signs for\n infection. UA negative. CXR could not definitively exclude pneumonia\n although pulmonary edema seems much more likely to account for\n symptoms. Patient is s/p 1 dose of levofloxacin in ED.\n - continue to trend white cell count\n - hold off antibiotics for now\n - team can consider repeating lactate if concern of infection\n .\n # ?Anxiety / history of depression. Patient previously had been treated\n with Prozac 20 mg daily and it is not clear why this medicine was\n stopped. I have added this back. Additionally, I would like to address\n with team getting a social work consult versus starting an anxiolytic,\n as it seems possible that anxiety may be contributing to her\n tachycardia and symptoms.\n .\n # Coronary artery disease. No new ischemic changes on EKG. First set of\n cardiac enzymes with normal CK, downtrending troponin.\n - continue Plavix and aspirin\n - continue simvastatin at 80 mg qday\n .\n # Pump. As above, her current presentation likely represents\n decompensation of known systolic CHF. Patient with good diuresis after\n 40 mg IV Lasix in ED. Will start on 20 mg PO Lasix daily and monitor\n Is/Os, aiming for 500-1L negative. Apical akinesis currently being\n treated with six months of anticoagulation.\n - continue Lovenox and coumadin\n - daily INR/PTT\n .\n # Rhythm. Currently in normal sinus rhythm. No active issues.\n .\n # S/p left hip replacement. She had a left hip replacement at \n prior to her previous admission. Communication with performing\n surgeon related that she was full weight bearing and she was evaluated\n by PT with a recommendation for rehab. She is on lovenox bridge to\n coumadin currently and she has follow-up with her orthopedic surgeon in\n two weeks of the procedure.\n .\n # Diabetes, type II.\n - humalog insulin sliding scale with qid fingersticks\n - consider restarting metformin; previous medication lists indicate she\n was taking 1000 mg \n .\n # Anemia. Stable from previous admission.\n .\n ICU Care\n # FEN. Diabetic, heart-healthy, low-sodium diet.\n .\n # Prophylaxis. On Lovenox and coumadin. Written for bowel regimen and\n standing Tylenol for pain related to recent hip surgery.\n .\n # Code status. FULL.\n .\n # Access: 20 guage IV\n # Communication. With patient.\n .\n # Disposition. Likely call-out to pending discussion with team.\n" }, { "category": "General", "chartdate": "2170-02-22 00:00:00.000", "description": "Generic Note", "row_id": 729667, "text": "TITLE: Cardiology fellow CCU admit note\n Mrs. is a very pleasant 82-year-old woman with history of type\n II diabetes, peripheral vascular disease, hypertension, and\n hyperlipidemia recently admitted to the CCU following a perioperative\n MI that led to heart failure. At rehab yesterday, developed\n tachycardia, presumably sinus, then wasn\nt feeling right, then, when\n ambulance came, developed hypertension to the 180s-190s. After this,\n she became extremely dyspneic, requiring nonrebreather and eventually\n NIPPV. She received a nitroglycerin drip and an IV bolus of furosemide\n and has recovered significantly. I suspect she had hypertensive\n emergency leading to heart failure. The etiology of her acute\n hypertensive episode is unclear but may be related to anxiety. I would\n hold off on further diuresis until she slows her urine output from the\n initial furosemide bolus in the ED.\n" }, { "category": "Nursing", "chartdate": "2170-02-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 730009, "text": "Pt was discharged from to Rehab ( in ) where she developed abdominal pain that subsided without\n intervention. At that time she felt palpitations and developed SOB.\n Family called 911. En route to hospital noted to be tachypneic and\n hypoxic. Arrived to outside ED, started on IV and SL nitroglycerin,\n lasix 40 mg IV, and ASA. She was placed on BIPAP intermittently.\n Noted to be hypertensive in the 180's with O2 sat in mid 60's in ST.\n WBC 16.1, BNP 14,871. Troponin elevated but trending down. Denied\n chest pain. EF 30-35%.\n Recent Left Hip Replacement 2 weeks ago () in were she\n developed STEMI 2 days post operatively.\n Neuro: Alert and oriented x 3, MAE. C/o left hip pain, refusing to\n get OOB at this time. Medicated with Tylenol per orders.\n CV: NSR 70\ns, no ectopy. SBP 100\ns, receiving lisinopril and\n lopressor. Lasix po given Qam. Easily palpable pedal pulses\n bilaterally.\n Resp: Lungs with faint crackles bilaterally. O2 sat > 94% on 4 L NC.\n Cough and deep breathing encouraged.\n GI/GU: Abdomen soft, nd. BS positive. Tolerating PO intake. Foley\n to gravity, adequate hourly urine output. BUN/cr 33/0.7.\n Endo: FS QID, cover per humalog sliding scale.\n Skin: Left hip dsd cdi.\n Plan: Transfer to 3. Hip xray today. ? plan for increase pain\n control.\n" }, { "category": "Nursing", "chartdate": "2170-02-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 730012, "text": "Pt was discharged from to Rehab ( in ) where she developed abdominal pain that subsided without\n intervention. At that time she felt palpitations and developed SOB.\n Family called 911. En route to hospital noted to be tachypneic and\n hypoxic. Arrived to outside ED, started on IV and SL nitroglycerin,\n lasix 40 mg IV, and ASA. She was placed on BIPAP intermittently.\n Noted to be hypertensive in the 180's with O2 sat in mid 60's in ST.\n WBC 16.1, BNP 14,871. Troponin elevated but trending down. Denied\n chest pain. EF 30-35%.\n Recent Left Hip Replacement 2 weeks ago () in were she\n developed STEMI 2 days post operatively.\n Neuro: Alert and oriented x 3, MAE. C/o left hip pain, refusing to\n get OOB at this time. Medicated with Tylenol per orders. Team\n notified, family very anxious regarding pain, multiple phone calls from\n daughter and husband.\n CV: NSR 70\ns, no ectopy. SBP 100\ns, receiving lisinopril and\n lopressor. Lasix po given Qam. Easily palpable pedal pulses\n bilaterally.\n Resp: Lungs with faint crackles bilaterally. O2 sat > 94% on 4 L NC.\n Cough and deep breathing encouraged.\n GI/GU: Abdomen soft, nd. BS positive. Tolerating PO intake. Foley\n to gravity, adequate hourly urine output. BUN/cr 33/0.7.\n Endo: FS QID, cover per humalog sliding scale.\n Skin: Left hip dsd cdi.\n Plan: Transfer to 3. Hip xray today. ? plan for increase pain\n control.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Height:\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Angina, Arrhythmias, CAD, CHF, Hypertension, MI, PVD\n Additional history: Left hip replacement in \n (Degenerative arthritis-Done by Dr.). Mitral stenosis with\n insufficiency, hyperlipidemia, right hip replacement 3 years ago.\n Surgery / Procedure and date: Recent left hip replacement 2 weeks ago\n () in , STEMI 2 days post operatively and transferred\n to .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:46\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 69 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97 %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 24h total out:\n 420 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:20 AM\n Potassium:\n 3.6 mEq/L\n 04:20 AM\n Chloride:\n 108 mEq/L\n 04:20 AM\n CO2:\n 25 mEq/L\n 04:20 AM\n BUN:\n 33 mg/dL\n 04:20 AM\n Creatinine:\n 0.7 mg/dL\n 04:20 AM\n Glucose:\n 117 mg/dL\n 04:20 AM\n Hematocrit:\n 27.1 %\n 04:20 AM\n Finger Stick Glucose:\n 131\n 06:00 AM\n Valuables / Signature\n Patient valuables: cell phone\n Other valuables:\n Clothes: transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: none\n Credit Cards: none\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: CVICU A\n Transferred to: 3\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2170-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 729662, "text": ".H/O chest pain ADMIT NOTE A/O 82 YEAR OLD FEMALE TO CVICU AS A CCU\n BORDER NO PAIN OR RESP DISTRESS AT THIS TIME THIS PM PER FAMILY AND\n PT CHEST PAIN ABD PAIN AND RAPID HEART RATE FEELING LIKE FLUTTERING IN\n MY CHEST ALSO WEAKNESS PROGRESSIVELY NOTE 2 WEEKS POST LEFT HIP\n REPLACEMENT\n HEART S1S2 S3 HEARD PR .16 QRS .08 QT WNL\n NEG HJR DISTANT TONES PULSES POS 3 THRU OUT EDEMA LOWER EXTREMITY\n RESP RALES AT BASES NOTED 100 TO NP 4\n L SAO2 99 NO SOB TALKATIVE\n GI PO WELL NO N/V SOFT POS B/S U/O QS\n PLAN AWAITING CCU EVAL AND ORDERS AT THIS\n TIME FAMILY AT BEDSIDE GOOD SUPPORTIVE RELATIONSHIP\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2170-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 729966, "text": "82 year old patient had just arrived to rehab \n afternoon.(Discharged from to Rehab- in\n ). Felt tired after coming back from bathroom when\n symptoms started. Felt palpitations and developed SOB at rehab. Family\n concerned so called 911. In route to hospital noted to be more\n tachypneic and hypoxic. Arrived to our ED were she was started on IV\n and s/l nitro/lasix 40 mg IV/ASA and placed on BIPAP for a short\n periods of time. She was also noted to be hypertensive in the 180's\n with O2 sat in mid 60's in ST. wbc up to 16.1.Abebrile. BNP 14,871.Trop\n elevated but trending down from previous. Denies chest pain. EF 30-35\n % per echo in . (CCU Border). Recent Left Hip replacement on in (By Dr..Heffenreffer)\n Pulmonary edema\n Assessment:\n Patient had stable night, except she is experiencing L hip pain for the\n first time since the surgery. Fellow down to assess. Glucose 130 x 2\n and was covered by SS Humalog.\n Action:\n Tylenol scheduled. Ambien for sleep, trazadone x 1 last pm. Also had\n hot pack to that area. CCU team will discuss in rounds.\n Response:\n Pain continues. 4L n/c O2.\n Plan:\n Transfer to floor when bed available. Pain control.\n" }, { "category": "Physician ", "chartdate": "2170-02-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 729975, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 12:16 PM\n MRSA\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 78 (67 - 89) bpm\n BP: 107/46(61) {99/42(57) - 144/69(84)} mmHg\n RR: 20 (16 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 520 mL\n PO:\n 520 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,340 mL\n 320 mL\n Urine:\n 1,340 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Labs / Radiology\n 396 K/uL\n 9.2 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 108 mEq/L\n 141 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 04:20 AM\n WBC\n 11.2\n Hct\n 27.1\n Plt\n 396\n Cr\n 0.7\n Glucose\n 117\n Other labs: PT / PTT / INR:13.8/37.1/1.2, Ca++:8.5 mg/dL, Mg++:1.8\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n .H/O CHEST PAIN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2170-02-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 729977, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 12:16 PM\n MRSA\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 78 (67 - 89) bpm\n BP: 107/46(61) {99/42(57) - 144/69(84)} mmHg\n RR: 20 (16 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 520 mL\n PO:\n 520 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,340 mL\n 320 mL\n Urine:\n 1,340 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Labs / Radiology\n 396 K/uL\n 9.2 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 108 mEq/L\n 141 mEq/L\n 27.1 %\n 11.2 K/uL\n [image002.jpg]\n 04:20 AM\n WBC\n 11.2\n Hct\n 27.1\n Plt\n 396\n Cr\n 0.7\n Glucose\n 117\n Other labs: PT / PTT / INR:13.8/37.1/1.2, Ca++:8.5 mg/dL, Mg++:1.8\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PULMONARY EDEMA\n .H/O CHEST PAIN\n This 82 year old woman discharged yesterday following stent placement\n of the LAD and newly diagnosed CHF with ischemic MR \n, hypoxemia, and tachycardia after arrival at the\n Rehabilitation Center. She developed\nflash\n pulmonary edema that\n responded to diuresis and oygen. We will optimize her medicatlons\n including her lisinopril, furosemide, and metoprolol. We will\n coordinate with our CHF nursing unit for discharge planning.\n ..\n .H/O CHEST PAIN\n ASSESSMENT AND PLAN: 82 yo woman with history of type II diabetes,\n peripheral vascular disease, hypertension, and hyperlipid recently\n admitted to CCU for respiratory distress in the setting of\n decompensated heart failure and NSTEMI, now presenting for acute\n worsening of shortness of breath.\n .\n # Hypoxia. Ddx flash pulmonary edema in setting of hypertension,\n worsening heart failure, pneumonia, aspiration event, arrhythmia,\n pulmonary embolism. CXR consistent with worsening pulmonary edema.\n Patient had been treated previously with 20 mg IV Lasix (received on\n and ), now s/p 40 mg IV Lasix in the ED with urine output of\n 400 cc and overall improvement in symptoms. Blood pressure currently\n well-controlled.\n - continue recent discharge regimen lisinopril 20 mg qday\n - will increase metoprolol from 50 XL to 25 mg metoprolol tartrate tid\n - will add Lasix at dose 20 mg PO qday, goal I/O 500-1L negative\n - monitor on telemetry\n .\n # Leukocytosis. No bandemia. No fevers. No localizing signs for\n infection. UA negative. CXR could not definitively exclude pneumonia\n although pulmonary edema seems much more likely to account for\n symptoms. Patient is s/p 1 dose of levofloxacin in ED.\n - continue to trend white cell count\n - hold off antibiotics for now\n - team can consider repeating lactate if concern of infection\n .\n # ?Anxiety / history of depression. Patient previously had been treated\n with Prozac 20 mg daily and it is not clear why this medicine was\n stopped. I have added this back. Additionally, I would like to address\n with team getting a social work consult versus starting an anxiolytic,\n as it seems possible that anxiety may be contributing to her\n tachycardia and symptoms.\n .\n # Coronary artery disease. No new ischemic changes on EKG. First set of\n cardiac enzymes with normal CK, downtrending troponin.\n - continue Plavix and aspirin\n - continue simvastatin at 80 mg qday\n .\n # Pump. As above, her current presentation likely represents\n decompensation of known systolic CHF. Patient with good diuresis after\n 40 mg IV Lasix in ED. Will start on 20 mg PO Lasix daily and monitor\n Is/Os, aiming for 500-1L negative. Apical akinesis currently being\n treated with six months of anticoagulation.\n - continue Lovenox and coumadin\n - daily INR/PTT\n .\n # Rhythm. Currently in normal sinus rhythm. No active issues.\n .\n # S/p left hip replacement. She had a left hip replacement at \n prior to her previous admission. Communication with performing\n surgeon related that she was full weight bearing and she was evaluated\n by PT with a recommendation for rehab. She is on lovenox bridge to\n coumadin currently and she has follow-up with her orthopedic surgeon in\n two weeks of the procedure.\n .\n # Diabetes, type II.\n - humalog insulin sliding scale with qid fingersticks\n - consider restarting metformin; previous medication lists indicate she\n was taking 1000 mg \n .\n # Anemia. Stable from previous admission.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2170-02-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 730004, "text": "Pt was discharged from to Rehab ( in ) where she developed abdominal pain that subsided without\n intervention. At that time she felt palpitations and developed SOB.\n Family called 911. En route to hospital noted to be tachypneic and\n hypoxic. Arrived to outside ED, started on IV and SL nitroglycerin,\n lasix 40 mg IV, and ASA. She was placed on BIPAP intermittently.\n Noted to be hypertensive in the 180's with O2 sat in mid 60's in ST.\n WBC 16.1, BNP 14,871. Troponin elevated but trending down. Denied\n chest pain. EF 30-35%.\n Recent Left Hip Replacement 2 weeks ago () in were she\n developed STEMI 2 days post operatively.\n Neuro: Alert and oriented x 3, MAE. C/o left hip pain, refusing to\n get OOB at this time. Medicated with Tylenol per orders.\n CV: NSR 70\ns, no ectopy. SBP 100\ns, receiving lisinopril and\n lopressor. Lasix po given Qam. Easily palpable pedal pulses\n bilaterally.\n Resp: Lungs with faint crackles bilaterally. O2 sat > 94% on 4 L NC.\n Cough and deep breathing encouraged.\n GI/GU: Abdomen soft, nd. BS positive. Tolerating PO intake. Foley\n to gravity, adequate hourly urine output. BUN/cr 33/0.7.\n Endo: FS QID, cover per humalog sliding scale.\n Skin: Left hip dsd cdi.\n Plan: Transfer to 3. Hip xray today. ? plan for increase pain\n control.\n" }, { "category": "Nursing", "chartdate": "2170-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 729812, "text": "82 year old patient had just arrived to rehab \n afternoon.(Discharged from to Rehab- in\n ). Felt tired after coming back from bathroom when\n symptoms started. Felt palpitations and developed SOB at rehab. Family\n concerned so called 911. In route to hospital noted to be more\n tachypneic and hypoxic. Arrived to our ED were she was started on IV\n and s/l nitro/lasix 40 mg IV/ASA and placed on BIPAP for a short\n periods of time. She was also noted to be hypertensive in the 180's\n with O2 sat in mid 60's in ST. wbc up to 16.1.Abebrile. BNP 14,871.Trop\n elevated but trending down from previous. Denies chest pain. EF 30-35\n % per echo in . (CCU Border). Recent Left Hip replacement on in (By Dr..Heffenreffer)\n Pulmonary edema\n Assessment:\n Admitted early this am as CCU border. AOx3. Pleasant. Moves all\n extremities. Denies SOB or chest pain at this time. Crackles at the\n bases. O2 4 l n/c with O2sat >94%. HR SR 80-90\ns with BP 120\ns-140\n syst.\n Recent left hip surgery ( in ). DSD left hip dry and\n intact. Dressing not opened due to patient instructions from orthopedic\n surgeon. Denies pain to hip. Full weight barring. Good urine output via\n foley. Family at bedside.\n Action:\n Restarted Lopressor and discharge meds. CXray done.\n OOB to chair with 2 assist. Tolerated well.\n PT consult.\n Standing tylenol for hip pain.\n FS per individual sliding scale.\n Response:\n Good response to lasix. HR improved from 80\ns to 60\ns. Baseline 50\n per family.\n Crackles bases less pronounced than in am.\n Plan:\n Transfer to /Telemetry when bed available.\n Monitor urine output and respiratory status.\n Monitor hemodynamics.\n" }, { "category": "ECG", "chartdate": "2170-02-24 00:00:00.000", "description": "Report", "row_id": 308639, "text": "Sinus rhythm. Possible old anterior myocardial infarction. Intraventricular\nconduction delay. Compared to the previous tracing of the rate is\nslower.\n\n" }, { "category": "ECG", "chartdate": "2170-02-26 00:00:00.000", "description": "Report", "row_id": 308638, "text": "Sinus rhythm. Modest intraventricular conduction delay with left axis deviation\nmay be due to left anterior fascicular block. Left ventricular hypertrophy.\nConsider prior anterior wall myocardial infarction. ST-T wave abnormalities\nwith borderline prolonged/upper limits of normal QTc interval may be due to\nleft ventricular hypertrophy but clinical correlation is suggested. Since the\nprevious tracing of there is probably no significant change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2146-03-03 00:00:00.000", "description": "Report", "row_id": 74596, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 174\nBSA (m2): 1.93 m2\nBP (mm Hg): 111/50\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 15:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left atrium is markedly dilated. The right atrium is markedly dilated.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. The aortic valve leaflets (3) are mildly thickened.\n4. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2146-03-05 00:00:00.000", "description": "Report", "row_id": 1344846, "text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT CALLED OUT , BED AVAILABLE @ 1700 ON CC721. AWAIT TRANSFER ORDERS. DR PAGER# ON CALL FOR MICU TEAM TONIGHT. PT OOB TO CHAIR SINCE 0800, WELL. PT AMBULATED IN ROOM W/ NRSG ASSIST AND EXT 02 TUBING, DOE NOTED. 02 SAT 93-98%. ALBUTEROL/ATROVENT HHN GIVEN PRN AT 0800 AND 1600 W/ GOOD EFFECTS. CONGESTED PRODUCTIVE COUGH NOTED. SOLUMEDROL, CEFTRIAXONE, AND AZITHROMYCIN CONTINUE. AM WBC TRENDING DOWN FROM 23.2 TO 19.5. DILTIAZEM DOSE INCREASED TO 90MG QID. PT CONTINUES IN AFIB 90-110'S AT REST AND 120-130'S W/ ACTIVITY, MICU TEAM AWARE. PT DUE FOR COUMADIN TONIGHT, AM INR=1.2. NO FURTHER EPISODES OF CHOKING OR VOMITING. PT DIET WELL, FAIR APPETITE. FS QID ON S/S COVERAGE. SPEECH AND SWALLOW EVAL ORDERED, TO BE DONE SUN OR MON R/T ?ASPIRATION PNA. PT DENIES PAIN. VSS. SON VISITING AND UPDATED ON RELOCATION TO CC7 TONIGHT. DNR/DNI. PT STABLE AND READY FOR TRANSFER.\n" }, { "category": "Nursing/other", "chartdate": "2146-03-04 00:00:00.000", "description": "Report", "row_id": 1344842, "text": "neuro: alert and oriented. denies pain.\ncv/resp vss bp stable remains in afib rate controlled in the 80's. remains on dilt. gtt at 15. bp low 100's syst. very wheezy thruout. rx with atrovent. requiring 70% fio2 open mask. to keep sats in the mid to high 90's.\ngi/gu tol po's. no stools. uop via foley marginal.\ninteg. no issues\nplan wean dilt gtt as tol and change to po. pulm toilet/alb/atrovent as needed.\n? c/o to floor when dilt is dc'd\n" }, { "category": "Nursing/other", "chartdate": "2146-03-04 00:00:00.000", "description": "Report", "row_id": 1344843, "text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. DR PAGER # ON CALL FOR MICU TEAM TONIGHT. PT ALERT AND ORIENTED X3, DENIES PAIN, MAE, PERLA. LS= COARSE/DIM W/ EXP WHEEZES AT TIMES. ALBUTEROL AND ATROVENT HHN GIVEN @Q 6HRS PRN, LAST DOSE @ 1400. WEANED FROM &0% TO 40% FACE TENT THIS SHIFT. PT DENIES SOB AT REST, BUT DOE NOTED. CONGESTED COUGH AT TIMES. PT BECOMES W/ ACTIVITY. WEANED DILTIAZEM GTT FROM 15MG/HR TO OFF THIS SHIFT, PO LOPRESSOR X1 GIVEN AND PO DILTIAZEM STARTED QID. PT CONTINUES IN AFIB @ 73-106, COUMADIN ORDERED FOR TONIGHT. PT/INR WILL NEED TO BE DONE AM. AFEBRILE. AM WBC= 23.2. IV AZITHROMYCIN AND CEFTRIAXONE CONTINUE, DX W/ PNA. NBP=99-152/45-71. PIV X1, NS @ KVO. IV SOLUMEDROL STARTED TODAY. FS QID ON S/S COVERAGE. ABD SOFT/ NON-DISTENDED. PRESENT BS, NO BM THIS SHIFT. NEEDS CDIFF CX IF STOOLS. PT TOLERATING REGULAR DIET. DENIES N/V. ASSESSED FOR ASPIRATION. FOLEY CATH D/S/P DRAINING CLEAR YELLOW URINE 30-100CC/HR. SKIN INTACT, ECCYMOTIC S/P BLOOD DRAW. PALPABLE PEDAL PULSES, NO EDEMA NOTED. PT OOB TO CHAIR X1 ASSIST TODAY, TOL WELL X APPROX 6HRS. PT'S FAMILY VISITING AT THIS TIME. FULL CODE. PT STABLE. PT CALLED OUT AT APPROX 1630, READY TO TRANSFER WHEN BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2146-03-04 00:00:00.000", "description": "Report", "row_id": 1344844, "text": "ADDENDUM :\nCORRECTION CODE STATUS IS DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2146-03-05 00:00:00.000", "description": "Report", "row_id": 1344845, "text": "MICU NPN 7P-7A\nNEURO: AAOX3. SLEPT WELL. NO DEFICITS NOTED. PLEASANT AND COPPERATIVE. DENIES PAIN.\n\nCARDIAC: HR 87-107 AFIB WITH NO ECTOPY. ON DILT PO. BP 115-139/42-102. ON COUMADIN. INR 1.2. HCT STABLE.\n\nRESP: ON 40% FACE TENT WITH RR 21-33 AND SATS 88-96%. DESATTED TO 88% WITH MASK OFF. LS COARSE. NO C/O SOB.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. EATING DINNER ?ASPIRATED->COUGHING AND THEN VOMITED UNDIGESTED FOOD. NONE SINCE. UOP 20-55CC/HR YELLOW AND CLEAR.\n\nFEN: TOLERATED PO'S WELL UNTIL VOMITING. ABLE TO TAKE MEDS/LIQUIDS DURING THE NIGHT. LYTES PER CAREVUE. FS 263 @2200 AND COVERED WITH SS HUMALOG.\n\nID: TMAX 97 AXILLARY. WBC 19.5 DOWN FROM 23. CONTINUES ON AZITROMYCIN AND CEFTRIAXONE.\n\nSKIN: W/D/I.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: DNR/DNI. AWAITING BED ON FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2146-03-03 00:00:00.000", "description": "Report", "row_id": 1344840, "text": "MICU RN Note 0230-0700\n\nAdm Note: Pt is a 88yo female,presented to ED with acute onset back pain associated with difficulty walking and freq loose stools. Pt has Hx Spinal cord tumor x2 with resulting leg weakness uses walker and back brace. Neuro consult whhile being worked up for back pain/leukocytosis WBC 40, ?spinal abscess. CT chest/abs revealled L Lung PNA neg for AAA. Sedated for MRI which was unsuccessful became hypotensive BP 70's HR 120's afib recieved 4LNS desat 88% Dopamine initally then changed to Levophed, EKG revealled ST inversions CK Neg x1. Recived Lasiz 60mg, Placed On Mask Ventilation CPAP. PMH includes COPD, Afib on coumadin, HTN, Depression. Adm to MICU for futher minitoringand eval PNA/sepsis, BP support.\n\nEvents arrived in MICU @ 0230 Mask Vent CPAP wean to off, Levophed.\n\nNeuro: Awake alert oriented x3 follows commands Pupils 3mm equal react , random and to command. Equal strength. Initally c/o mid back pain resolved with positioning.\n\nCV: HR 100-122 Afib BBB, no ectopy. NBP labile Levophed 0.05mcg/kg/min wean to off with responding Drop BP to 80's Levo resumed currently weaning to gaol MAPS >60. Peripheral pulses 3+ DP/DT, Neg edema. IV Access 2 PIV, Plan cental access if Unable to wean Levo to recieve FFP prior for ^INR. EKG revealled new TW inversions, seriel CK #1 246 MB 5 Troponin 0.9. Labs: K+ 4.1 mag 1.6, Ca+ 8.0.\nHeme: Hct 41.8 , INR 4.1 /6.1.\n\nResp: RR 18-26 reg Nonlabored arrived On Mask Ventilation CPAP Sats 100% wean to NC 6l/min Sats 92-96%. BS coarse with Exp wheezes. recieve alb neb. Congested dry cough no sputum producton plan Sputum to be sent. Lactate 1.9, stem test completed result pending recieved decadron 4mg IV.\n\nID: afebrile T-max 97.8, WBC 40.3, Blood cult x2, Urine sent, Plan to sent sputum and stool when avail. Abx Cetrixone, levofloxin, Azithromycin.\n\nGU: Foley u/o 100-400cc/hr diuresis fom lasix in ED. BUN/Creat 17/0.9\n\nGI: abd soft distended + BS no stool, NPO.\n\nDerm: Skin intact\n\nSocial: Full code status, Son arrived with pt updated on Plan of care\n\nPlan: Cont to support O2 needs\n Neuro for follow. \\\n MRI\n Support BP. Wean Levo to Off as tol\n\n" }, { "category": "Nursing/other", "chartdate": "2146-03-03 00:00:00.000", "description": "Report", "row_id": 1344841, "text": "NPN 7a-7p\nMrs is a 88 y/o c COPD, HTN, Afib on Coumadin at home, and h/o spinal cord tumor s/p 2 surguries 20yrs ago. She presented to the Ed with acute severe back pain, increased weakness in extremities and loose stools. In ED she was being worked up for ? spinal abscess and ? AAA. CT revealed significant LLL PNA, no other findings. Pt was to have MRI but was not able to stay still during scan and given Morphine and Ativan. She became hypotensive to 70s, given 4L without response. SHe then desat'd to low 80s, and believed to have \"flashed.\" She was then diuresed with lasix and put on CPAP. Dopamine was started, which ultimately put her into rapid afib. Dopa changed to Levophed with good effect. She was then transfered to MICU for further eval.\n\nPt was recieved on 6L NC sats low 90s with dry hacking non-productive cough. She was then changed over to cool mist face tent fio2 50%. Sats 92-97%, and was able to produce some sputum. Pt was increasingly tachycardic 130s-140s, given 15mg Diltiazem IVP with good effect. She was then started on Dilt gtt @ 10mg/hr. BP has been labile, levophed has been titrated to maintain MAP>60. Currently Levophed has been off since 1400. SBP 90s-100s. AM Mg 1.6 repleted with 2g. INR 6.1, received Vit K.\n\nNeuro: Pt is alert and oriented x3. MAE ad lib, with normal strength. Very cooperative with care. Needs help with turns and repos. PERRL 3mm, . Pt has had no further back pain, or neuro changes. Neurology to f/u.\n\nCV: Afib/Afluttter, tachy 80s-100s. Dilt gtt currently @15mg/hr. SBP 90s-100s, MAP>60. Levophed off. No edema, pulses palpable.\n\nRESP: Cool mist face tent, 50% fio2. sats 92-97%. LS coarse with insp/exp wheezes. getting prn albuterol nebs. Pt has dry non-productive cough, improved with chest PT. RR 20s. ABG is pending as pt does not have a-line.\n\nGI: abd is soft nontender. no BM this shift. tolerating clears well, will advance as tolerated.\n\nGU: Foley draining just adequate amounts of yellow urine. >25cc/hr.\n\nID: Afebrile, on Ceftriaxone and azithromicyn for pna. Blood, urine, sputum cultures pending.\n\nACCESS: is a problem. Pt has only 2 PIVs. if pt continues to need vasopressors, will need central access. INR is 6.1, therefore FFP before any line placement.\n\nSOCIAL: son and HCP has been visiting with his wife all day. Very pleasant and cooperative with care.\n\nPLAN: Monitor BP, MAP goal>60. Monitor HR, goal <100. Continue Dilt gtt as needed. Pt will need ABG, ? central access and FFP. Will need stool spec. Advance diet as tolerated.\n\n\n" }, { "category": "ECG", "chartdate": "2146-03-10 00:00:00.000", "description": "Report", "row_id": 167756, "text": "Atrial fibrillation\nMarked right axis deviation\nRight bundle branch block\nNonspecific T wave changes\nSince previous tracing, slower rate\n\n\n" }, { "category": "ECG", "chartdate": "2146-03-09 00:00:00.000", "description": "Report", "row_id": 167757, "text": "Atrial fibrillation with right bundle branch block\nPossible prior anteroseptal myocardial infarction although is nondiagnostic\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-03-04 00:00:00.000", "description": "Report", "row_id": 167758, "text": "Atrial fibrillation with a controlled ventricular response. Right bundle-branch\nblock. Compared to the previous tracing of no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2146-03-03 00:00:00.000", "description": "Report", "row_id": 167976, "text": "Atrial fibrillation with a rapid ventricular response. Compared to tracing #2,\nno diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2146-03-02 00:00:00.000", "description": "Report", "row_id": 167977, "text": "Atrial fibrillation. Compared to tracing #1, no diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2146-03-02 00:00:00.000", "description": "Report", "row_id": 167978, "text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock. Possible anteroseptal myocardial infarction. Non-specific ST-T wave\nabnormalities. Compared to the previous tracing of right bundle-branch\nblock is new.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2146-03-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 900505, "text": " 2:47 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please assess for infarct, pneumonia, ? aspergillosis\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with shortness of breath, fever, h/o COPD and spinal tumor\n now with rounded lung mass in left lung\n REASON FOR THIS EXAMINATION:\n Please assess for infarct, pneumonia, ? aspergillosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 88-year-old woman with shortness of breath, fever.\n History of COPD and spinal tumor with question lung mass on chest x-ray.\n Evaluate for infarct, pneumonia, aspergillosis.\n\n COMPARISON: Multiple chest x-rays are available for comparison. The latest\n one dated .\n\n TECHNIQUE: Multidetector CT of the chest was performed without IV contrast.\n\n FINDINGS: There is a consolidation in the left upper lobe. A few other small\n round areas of consolidation are noted in both apices bilaterally. There is\n no evidence for pulmonary masses. There are small bilateral effusions and\n bibasilar atelectasis. A large hiatal hernia is visualized containing part of\n the stomach and colon. There are a few calcifications in the coronary\n arteries. A small amount of fluid is noted in the pericardial sac. There is\n enlargement of the right and left atrium. Coarse calcifications are also\n demonstrated in the thoracic aorta without aneurysmal dilatation. The airways\n are patent.\n\n CT BONES: There is a laminectomy at multiple levels in the thoracic spine.\n There are degenerative changes with osteophyte formation at multiple levels.\n No lytic or sclerotic lesions are visualized.\n\n The visualized portions of the upper abdomen demonstrate a 2.4-cm mass in the\n upper pole of the left kidney containing fat. This is consistent with an\n angiomyolipoma.\n\n IMPRESSION:\n 1. Left upper lobe infiltrate corresponding to the increased density seen on\n prior chest x-ray. This is consistent with pneumonia. A few other small\n consolidations are noted bilaterally at the lung apices. Findings are most\n consistent with infectious process. Followup imaging is recommended after\n resolution of the symptoms.\n 2. Large hiatal hernia.\n 3. Small bilateral pleural effusions and bibasilar atelectasis.\n 4. Status post thoracic spine laminectomy at multiple levels.\n 5. Left renal AML.\n\n\n (Over)\n\n 2:47 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please assess for infarct, pneumonia, ? aspergillosis\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2146-03-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 900006, "text": " 1:16 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for cardio/pulm processes.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with COPD and cough, sats at 92%\n REASON FOR THIS EXAMINATION:\n Please evaluate for cardio/pulm processes.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST .\n\n HISTORY: COPD and cough. Decreased oxygen saturation.\n\n IMPRESSION: PA and lateral chest compared to :\n\n There is a new roughly round 5-6 cm wide opacity in the left mid lung\n extending from the hilus to the lateral pleural surface. Although this could\n be an unusual fluid loculation in the interlobar fissure it is more concerning\n for pneumonia, mass or large pulmonary infarction.\n\n The intrathoracic stomach is fluid filled rather than gas filled on today's\n study. Heart is mildly-to-moderately enlarged though dimensions are\n exaggerated by the large hiatus hernia. Right lung is clear. Dr. was\n paged to report these findings at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-03-02 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 900007, "text": " 1:17 PM\n L-SPINE (AP & LAT) Clip # \n Reason: assess for compression fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with acute low back pain\n REASON FOR THIS EXAMINATION:\n assess for compression fracture\n ______________________________________________________________________________\n FINAL REPORT\n AP AND LATERAL LUMBAR SPINE\n\n INDICATION: 88-year-old female with acute low back pain. Assess for\n compression fractures.\n\n FINDINGS: No priors for comparison.\n\n There is scoliosis of the lumbar spine, convex right, apex at L1-2 level.\n There are multilevel compression deformities involving T10 through L2\n vertebral bodies, most severely affecting L2 which is approximately 50%\n compressed. There is slight retrolisthesis of L3 on L4, and grade 1\n anterolisthesis of L4 on L5 which measures approximately 1 cm. Degenerative\n change manifest as large anterior osteophyte formation is seen throughout the\n lumbar spine. There is also sclerosis and degenerative change involving the\n facet joints throughout the lumbar spine. Incidental note is made of diffuse\n vascular calcification involving the abdominal aorta.\n\n IMPRESSION: Multilevel compression deformities as described. All of the\n vertebral bodies are somewhat sclerotic at these levels, indicating\n chronicity. To exclude superimposed acute-on-chronic compression fracture, an\n MRI could be performed.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 900077, "text": " 12:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf, worsening infil\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n r/o chf, worsening infil\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia.\n\n CHEST, ONE VIEW: Comparison was done earlier today.\n\n The cardiac and mediastinal contours are stable. There is a persistent\n opacity in the left mid lung zone, which now appears more confluent. The\n hiatal hernia is again visualized. There is prominence of the interstitium,\n which could represent a small element of pulmonary edema. There may also be a\n small left pleural effusion. No pneumothorax.\n\n IMPRESSION: Increased opacity in the left lung, most consistent with\n pneumonia, but also considered are mass, or infarct as described previously.\n There may be superimposed volume overload as well as a small left pleural\n effusion. Follow-up is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2146-03-02 00:00:00.000", "description": "MR THORACIC SPINE", "row_id": 900047, "text": " 5:37 PM\n MR THORACIC SPINE; -52 REDUCED SERVICES Clip # \n Reason: Please evaluate for spinal cord lesions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please evaluate for spinal cord lesions. Hypotension and sepsis.\n\n TECHNIQUE: T1 and T2 weighted saggital images, as well as T1 weighted axial\n images of the thoracic spine were obtained without comparisons. Images both\n before and after gadolinium administration were obtained. Examination was\n limited due to patient's inability to tolerate the examination, with\n corresponding motion. The examination was aborted before completion, and\n although we were initially to bring back the patient for repeat imaging, this\n is not currently possible according to the inpatient clinical team.\n\n FINDINGS:\n\n Saggital images show a marked kyphosis of the thoracic spine, with the apex at\n the T8 level. There is decreased T2 signal at the posterior endplates at the\n C6-7 level, as well as the anterior T3-4 enplates and the posterior aspect of\n the T8 level extending into the pedicles. The T8 body and pedicles also shows\n corresponding increased signal on STIR images.\n\n Compression fractures are seen at the L1 and L2 levels. There is partial\n fusion of the anterior vertebral bodies at the T7-8 level.\n Large anterior briding osteophytes are present at the T6-7 and T10-11 levels.\n Posterior disk bulges are also seen at mutliple levels, including the C5-6,\n C6-7, T6-7, T9-10, T10-11, T11-12, and T12-L1 levels on the saggital T2\n images; we do not have corresponding axial images to quantify severity of\n these bulges.\n\n Linear increased T1 signal and decreased T2 signal is seen extending\n longitudinally in what appears to be an epidural location anterior to the cord\n at the T5-6 to T7-8 levels. Increased T2 cord signal is also suggested just\n inferior to a region with decreased T1 and T2 signal just to the left\n (extramedullary) of the cord at the T6-7 levels on T2-weighted saggital\n images, with suggestion of the corresponding finding on axial images series 4,\n images 39-40) although this cannot be better characterized due to a\n combination of the inability to cross reference images as well as the marked\n motion throughout the examintion.\n\n Bone marrow signal is abnormal, diffusely heterogeneous, of uncertain\n significance. As described above, the T8 body has elevated STIR signal and\n decreased T1 signal.\n\n There appears to be thoracic location of the stomach, presumably from large\n hiatal hernia (according to prior radiology reports).\n\n IMPRESSION:\n\n 1) Markedly limited examination, not of diagnostic quality.\n\n 2) Diffusely abnormal vertebral body signal, with focally abnormaly signal\n (Over)\n\n 5:37 PM\n MR THORACIC SPINE; -52 REDUCED SERVICES Clip # \n Reason: Please evaluate for spinal cord lesions.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n particularly affecting the T8 body. Metastases are not excluded--correlate\n with clinical history and primary neoplasm, if any.\n\n 3) Linear anterior epidural signal at the T5-6 thorugh T7-8 levels, of\n uncertain significance, probably postoperative. Please correlate with the\n supplied history of prior thoracic spine surgery. There is also suggestion of\n increased T2 cord signal at these levels, but repeat axial images of these\n levels would better characterize this finding.\n\n 4) Compression fractures at L1 and L2.\n\n 5) Multilevel disk bulges, not well characterized without corresponding axial\n images.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-03-02 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 900026, "text": " 3:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please evaluate for colitis and please evaluate the aorta.\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman c/o back pain, high WBC, decreased rectal tone.\n REASON FOR THIS EXAMINATION:\n Please evaluate for colitis and please evaluate the aorta.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT WED 4:11 PM\n no acute intrabdominal pathology. large hiatal hernia. diverticulosis w/o\n evidence of diverticulitis. extensive changes of the lumbar spine s/p\n laminectomy of L3-5 with lumbar dextroscoliosis, wedge deformities of L1 and\n L2, and grade 1 anterolisthesis of L4 on 5.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88-year-old woman who complains of back pain with high white blood\n cell count and decreased rectal tone.\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with oral and IV contrast. 150 cc Optiray. Coronal and sagittal reformatted\n images were obtained.\n\n CT ABDOMEN: There is bibasilar atelectasis. As seen on prior esophagram.\n There is a large hiatal hernia with axial and paraesophageal components. A\n loop of small bowel is also seen within the hernia. There is mild\n intrahepatic biliary ductal dilatation and prominence of the common bile duct\n (measuring up to 23mm), status post cholecystectomy. The pancreas is\n atrophic. The spleen and adrenal glands are unremarkable. There is a 2.5 x\n 1.8 cm focus in the mid pole of the left kidney of fat density consistent with\n an angiomyolipoma. Small bowel loops are unremarkable. There are scattered\n colonic diverticula. Extensive aortic calcifications are identified. The\n aorta is of normal caliber. There is no free air or free fluid. No\n mesenteric or retroperitoneal lymphadenopathy is identified.\n\n CT PELVIS: Foley catheter and air are observed in the bladder. There are\n extensive sigmoid diverticula without evidence of diverticulitis. The rectum\n is unremarkable. There is no free fluid and no pelvic or inguinal\n lymphadenopathy. Calcifications in the pelvis are consistent with\n phleboliths.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. The\n patient is status post L3-5 lumbar laminectomy. There are extensive\n degenerative changes with mild to moderate lumbar dextroscoliosis. Wedge\n deformities of L1 and L2 are noted and there is grade I anterolisthesis of L4\n on L5. At the L3 level, there is an osseous fragment which impresses on the\n right lateral and dorsal aspect of the spinal canal.\n\n IMPRESSION:\n\n (Over)\n\n 3:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please evaluate for colitis and please evaluate the aorta.\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No acute intra-abdominal pathology identified.\n\n 2. Large hiatal hernia.\n\n 3. Diverticulosis without evidence of diverticulitis.\n\n 4. Extensive degenerative changes of the lumbar spine as described above.\n\n 5. Left renal angiomyolipoma.\n\n 6. Intra and extra-hepatic ductal diltation; common bile duct measures up to\n 23mm. Comparsion with prior exams recommended to assess for stability, and\n exclude a distal ampullary lesion.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2191-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177334, "text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post extubation\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man who presented w/ bradycardia s/p extubation today for AMS\n REASON FOR THIS EXAMINATION:\n post extubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Bradycardia, status post extubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. Also removed is the\n external pacemaker on the right.\n\n There is no evidence of pneumothorax or other complications. However, the\n marked cardiomegaly persists, as does the mild interstitial lung edema.\n Moderate tortuosity of the thoracic aorta. No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1177543, "text": " 8:38 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate placement of pacemaker\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with bradycardia s/p pacemaker placement on \n REASON FOR THIS EXAMINATION:\n Please evaluate placement of pacemaker\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pacer placement.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the pacemaker leads. Continued enlargement of the cardiac\n silhouette with tortuosity of the aorta, but no acute pneumonia or vascular\n congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177476, "text": " 7:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: R/O pneumothorax\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man post PM implant via subclavian\n REASON FOR THIS EXAMINATION:\n R/O pneumothorax\n ______________________________________________________________________________\n WET READ: JBRe FRI 1:08 AM\n No PTX. No acute process. PM leads in place.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:47 P.M., \n\n HISTORY: Pacemaker implant via subclavian.\n\n IMPRESSION:\n AP chest compared to at 8:12 a.m.:\n\n As far as one can tell from a single frontal view a transvenous right atrial\n and right ventricular pacer leads are in standard placements. No\n pneumothorax, pleural effusion or mediastinal widening. Moderate cardiomegaly\n and large and tortuous thoracic aorta are chronic. I doubt pulmonary edema is\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177164, "text": " 10:38 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? temp wire location - unable to manipulate externally\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CAD (3 vessel disease), htn, hl, afib on coumadin who p/w\n symptomatic bradycardia, unable to float temp wire\n REASON FOR THIS EXAMINATION:\n ? temp wire location - unable to manipulate externally\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: CAD, Coumadin, temporal pacemaker wire.\n\n COMPARISON: .\n\n FINDINGS:\n\n As compared to the previous radiograph, the external pacemaker is no longer\n coiled within the superior SVC. The wire shows a hook-like configuration in\n the SVC. There is no evidence of complications, notably no pneumothorax.\n\n Newly placed nasogastric tube with a course widely deviated from the midline.\n However, the course does not indicate airway intubation. The tube must be\n advanced, given that the sidehole is located at the level of the middle third\n of the esophagus.\n\n Unchanged cardiomegaly with evidence of moderate pulmonary edema. No pleural\n effusions. No newly occurred focal parenchymal opacity suggesting pneumonia.\n\n The endotracheal tube is still located very high, its tip projects at the\n level of the clavicles.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177105, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with bradycardia, intubation\n REASON FOR THIS EXAMINATION:\n eval for ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old man with bradycardia and intubation.\n\n COMPARISON: None available.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show bilateral interstitial opacities. The\n cardiac silhouette is enlarged. The mediastinal silhouette is enlarged as\n well. An ET tube terminates 4.6 cm above the carina. No pleural effusions or\n pneumothoraces are present. A cardiac lead is noted coiled in the SVC.\n\n IMPRESSION:\n\n Cardiomegaly with mild pulmonary edema. The widened mediastinum may represent\n an enlarged aneurysmal thoracic aorta or an aortic dissection.\n\n" }, { "category": "Echo", "chartdate": "2191-02-23 00:00:00.000", "description": "Report", "row_id": 81563, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Congestive heart failure. Dilated cardiomyopathy. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 162\nBSA (m2): 1.85 m2\nBP (mm Hg): 117/55\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 14:03\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: 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. Moderately dilated LV cavity. Severely\ndepressed LVEF. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis. Paradoxic septal motion\nconsistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - patient unable to cooperate. Resting bradycardia (HR<60bpm).\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 is moderately dilated. Overall left ventricular systolic\nfunction is severely depressed (LVEF= 20-25 %) with global hypokinesis (and\ninferior akinesis). No masses or thrombi are seen in the left ventricle. There\nis no ventricular septal defect. with mild global free wall hypokinesis. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild to moderate (+)\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the LV appears\nmore dysynchronous.\n\n\n" }, { "category": "ECG", "chartdate": "2191-02-25 00:00:00.000", "description": "Report", "row_id": 201338, "text": "Atrial and ventricular paced rhythm at 60 beats per minute. Compared to the\nprevious tracing of paced rhythm is now appreciated.\n\n" }, { "category": "ECG", "chartdate": "2191-02-24 00:00:00.000", "description": "Report", "row_id": 201339, "text": "Sinus rhythm. A-V conduction delay. Left atrial abnormality. Left\nbundle-branch block. Compared to the previous tracing of the\nQRS complex remains wide and there is no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2191-02-23 00:00:00.000", "description": "Report", "row_id": 201340, "text": "Sinus bradycardia. P-R interval prolongation. Consider left atrial\nabnormality. Left bundle-branch block. Since the previous tracing of \nthe rate is slower. P-R interval is longer and the QRS width is wider.\nST-T wave abnormalities are more prominent. Clinical correlation is suggested.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792157, "text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval R sided infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration pna\n\n REASON FOR THIS EXAMINATION:\n eval R sided infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 8:43:\n\n INDICATION: Right sided infiltrates.\n\n COMPARISON: at 15:36.\n\n FINDINGS: Tip of the ETT is 8.2 cm above the carina. The left lung remains\n clear. The right lung is unchanged with dense consolidation of the upper lobe\n underlying air space is visualized and continued opacification over the right\n lower lobe. There is no pneumothorax.\n\n IMPRESSION: The ETT has migrated upwards slightly from 6 to 8 cm above the\n carina. Otherwise, no change in the appearance of the lungs.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792612, "text": " 2:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval picc position after manipulation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers s/p ETT\n advancement\n REASON FOR THIS EXAMINATION:\n eval picc position after manipulation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Repositioning of PICC line, please confirm position and page IV\n access team with results.\n\n Comparison is made with the study from two hours earlier.\n\n AP CHEST RADIOGRAPH: The repositioned PICC line tip now courses erroneously\n further down the left lateral thoracic vein, and needs to be repositioned. No\n pneumothorax. Again, the heart, lungs, and ET and nasogastric tubes are\n unchanged in appearance.\n\n IMPRESSION: PICC line should be repositioned.\n\n These results were dicussed with the IV access team at the time of\n interpretation as requested.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792174, "text": " 12:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm NGT placement for tube feeds\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration pna\n\n REASON FOR THIS EXAMINATION:\n confirm NGT placement for tube feeds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NGT placement.\n\n COMPARISON: at 08:43.\n\n FINDINGS: Tip of the ET tube is 7.8 cm above the carina. The NG tube is seen\n extending well below the diaphragm; its tip is beyond the inferior-most aspect\n of the film. The left lung remains clear. The right lung is unchanged, with\n extensive air space and interstitial disease. Heart remains normal.\n\n IMPRESSION: NG tube extends well below the diaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792088, "text": " 9:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 yo M intubated with aspiration pna, possible deep sulcus\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration pna\n\n REASON FOR THIS EXAMINATION:\n 61 yo M intubated with aspiration pna, possible deep sulcus sign on first AP,\n please repeat with good view of left base for further eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration pneumonia. Evaluate for deep sulcus sign.\n\n FINDINGS: No deep sulcus sign is present. There is improved aeration within\n the right lower lobe. The left lung remains clear. There is continued dense\n opacity overlying the right upper lung zone. The endotracheal tube is not\n visualized in this view which clips the lung apices.\n\n IMPRESSION: Improved aeration at the right lung base.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792605, "text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval picc placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers s/p ETT\n advancement\n REASON FOR THIS EXAMINATION:\n eval picc placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line placement.\n\n Comparison is made with the chest radiograph from four hours earlier.\n\n AP CHEST RADIOGRAPH: The newly inserted left sided PICC line makes an abrupt\n turn at the level of the mid clavicle, and then continues down a left lateral\n thoracic vein. The line should be repositioned. The appearance of the heart\n and lungs is unchanged in the short interval since the prior study. ET and\n nasogastric tubes remain in satisfactory position.\n\n IMPRESSION: PICC line makes an abrupt turn and continues down a left lateral\n thoracic vein, and should be repositioned.\n\n These results were discussed with the IV access team at the time of\n interpretation, as requested.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792845, "text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval RUL/LUL infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration wiht persistent fevers.\n\n REASON FOR THIS EXAMINATION:\n eval RUL/LUL infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Throat cancer with aspiration and fevers.\n\n PORTABLE AP CHEST, 1 VIEW: Comparison . There is an ET tube 6.2 cm\n above the carina. There is a right central line with tip in the SVC. No\n pneumothorax is appreciated. There is an NG tube extending below the\n diaphragm, tip not visualized. There is no significant change in appearance of\n the heart or lungs. Specifically, the multifocal air space opacities in the\n right lung and left upper lobe and the biapical cavitary lesions are\n unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792107, "text": " 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 yo M intubated, aspiration pna, ? PTX\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration pna\n\n REASON FOR THIS EXAMINATION:\n 61 yo M intubated, aspiration pna, ? PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Respiratory failure - aspiration pneumonia.\n\n PORTABLE AP CHEST: Comparison is made to previous films from 21:29.\n\n The tip of the ETT is 8.6 cm above the carina. The current study appears to\n have more opacity in the right lower lung versus most recent prior, when I\n review the study from at 19:41 shows no significant interval change.\n Therefore, I believe the interveening film apparent changes based on technical\n basis. There is no pneumothorax. The left lung remains clear of consolidation.\n\n IMPRESSION:\n\n No significant interval change versus at 19:41. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-09 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 792575, "text": " 8:09 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: eval for cholecystitis, ductal dilatation in pt with spiking\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man intubated with necrotizing pna\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis, ductal dilatation in pt with spiking fevers, elevated\n lft's\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND:\n\n INDICATION: Fever and elevated LFT's.\n\n FINDINGS: The gallbladder is normal in appearance with no evidence of\n gallstones. The common duct is not dilated measuring less than 6 mm in\n greatest dimension. There is no evidence of intrahepatic biliary ductal\n dilatation. The portal vein is patent with flow in an appropriate direction.\n The hepatic parenchyma demonstrates normal echogenicity with no evidence of\n focal mass. There is no free fluid identified within the abdomen. The aorta\n is of normal caliber throughout. The right kidney measures 11.5 cm. The left\n kidney measures 11.8 cm. There is no evidence of renal mass, stone, or\n hydronephrosis. The spleen is within normal limits. There is a soft tissue\n mass identified within the region of the splenic hilum which likely represents\n the pancreatic tail, a splenule, or collapsed bowel. This finding was\n confirmed by a CT of the chest performed on .\n\n IMPRESSION: Normal gallbladder with no evidence of biliary ductal dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792227, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progression of infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers.\n\n REASON FOR THIS EXAMINATION:\n eval progression of infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n CLINICAL INDICATION: Aspiration. Fever.\n\n Comparison is made to previous chest radiographs dated as well as\n an earlier radiograph of .\n\n An endotracheal tube is in satisfactory position. A nasogastric tube courses\n below the diaphragm and a short length vascular catheter terminates in the\n right brachiocephalic vein just proximal to the SVC. Cardiac and mediastinal\n contours are stable. There is extensive consolidation in the right lung which\n is most severe in the right upper lobe where there are also multiple gas\n collections. The left lung demonstrates apical emphysema with adjacent\n pleural fluid or thickening and a small amount of consolidation. The\n remaining portion of the left lung is grossly clear allowing for some motion\n in the left lower lung zone. Overall, there has been some interval slight\n improved aeration in the right middle and lower lobes compared to 1 day\n earlier, but more significant improvement is seen when compared to .\n Overall the degree of gas collection within the right upper lobe has increased\n compared to however.\n\n IMPRESSION:\n\n Extensive pneumonia in the right lung, most severe in the right upper lobe\n where there are also multiple gas collections. This is most concerning for\n necrotizing pneumonia with probable evolving abscess formation. Although the\n majority of involvement is in the right lung, there is also an area of\n involvement at the left apex.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 792312, "text": " 4:39 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 150CC NONIONIC CONTRAST Clip # \n Reason: HX CA TONGUE, S/P CHEMO AND XRT, ? RECURRENCE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of tongue CA s/p XRT/chemo, now with RUL pneumonia, ?\n aspiration vs. post-obstruction.Please do at same time as chest CT.\n REASON FOR THIS EXAMINATION:\n r/o tracheal obstruction, eval for recurrence of tongue CA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: History of lung cancer status post x-ray therapy and\n chemotherapy, now with right upper lobe pneumonia.\n\n CT SCAN OF THE NECK FOLLOWING AND DURING THE ADMINISTRATION OF 75 ML OF\n OPTIRAY-320:\n\n There are no prior studies for comparison.\n\n FINDINGS: Both an orotracheal and orogastric tubes were in place. There are\n abundant secretions in an oropharyngeal region. There is evidence of left\n neck dissection surgery with absence of the sternoicleidomastoid muscle. A\n definite abnormal mass within the neck is not identified. The orotracheal\n tube extends to the anterior aspect of this section and the airway cannot be\n adequately assessed. Disease of the lung apices will be better described on\n the patient's chest CT.\n\n IMPRESSION:\n\n No definite evidence of recurrence. Exam limited for reasons discussed above.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792748, "text": " 11:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement, last one poor study\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna s/p OGT revision.\n\n REASON FOR THIS EXAMINATION:\n NGT placement, last one poor study\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Throat CA with aspiration pneumonia. Status post OGT revision. NG\n tube placement. Prior study not demonstrating tip of NG tube.\n\n Single AP view targeted to the lower chest and upper abdomen is compared to\n chest study of 4.5 hours earlier. There is an NG tube seen with tip in the\n region of the distal antrum/proximal duodenum. The left subclavian line is\n partially visualized with tip in the SVC. The ET tube is not imaged. There is\n no change in the partially visualized lungs compared to the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 792311, "text": " 4:39 PM\n CT CHEST W/CONTRAST Clip # \n Reason: HX CA TONGUE, RUL PNA, ? ASPIRATION\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of throat CA s/p XRT, now with ? aspiration PNA on\n right side. intubated.\n REASON FOR THIS EXAMINATION:\n r/o endobrochial obstruction, mucus plug\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n \n\n HISTORY: 61 year old man with history of throat cancer, status-post radiation\n therapy, aspiration pneumonia, evaluate for endobronchial lesion.\n\n TECHNIQUE: Axial images of the chest were obtained after the administration\n of 75cc of Optiray per history of allergies.\n\n Comparison with prior chest x-rays dating back to .\n\n CT OF THE CHEST WITH IV CONTRAST: The endotracheal cuff is slightly\n overdistended. No endobronchial lesions are seen. There are a few small\n mediastinal and hilar lymph nodes, the largest one in the AP window measures\n 1.2 cm in short axis dimension. The heart is normal in size. There is a small\n pericardial effusion. There is a small right pleural effusion and a trace left\n pleural effusion.\n\n Lung windows demonstrate severe diffuse emphysema involving all lobes. There\n is an extensive area of low density consolidation involving predominantly the\n right upper lobe and extending to the right lower lobe, which contains\n multiple air fluid levels. There are surgical sutures in biapical regions\n adjacent to residual bullous changes. This is likely related to prior\n bullectomies. There are no lesions in the visualized portions of the liver,\n spleen, adrenals and the upper poles of the kidneys. The bones are\n unremarkable.\n\n IMPRESSION:\n 1) Necrotizing pneumonia with evolving abscess formation predominantly in the\n right upper lobe and to a lesser degree in the right lower lobe. Follow-up CT\n after appropriate antibiotic therapy is recommended to exclude a central\n necrotic mass is recommended and to evaluate resolution of mediastinal and\n hilar lymph nodes. There is no evidence of obstructing central endobronchial\n lesion.\n 2) Severe, diffuse emphysema.\n\n Findings were discussed with clinical team caring for the patient.\n\n\n (Over)\n\n 4:39 PM\n CT CHEST W/CONTRAST Clip # \n Reason: HX CA TONGUE, RUL PNA, ? ASPIRATION\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2101-06-10 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 792696, "text": " 11:28 AM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: following progression of necrotizing pna, ? abscess formatio\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of throat CA s/p XRT, now with ? aspiration PNA on\n right side. intubated.\n REASON FOR THIS EXAMINATION:\n following progression of necrotizing pna, ? abscess formation in setting of\n recurrent spiking fevers on abx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Throat cancer, S/P radiation therapy, evaluate for progression of\n necrotizing pneumonia with possible abscess formation, recurrent fevers.\n\n TECHNIQUE: Axial images of the chest were obtained after the administration\n of 100 cc of Optiray.\n\n Comparison with prior CT from .\n\n CT OF THE CHEST WITH IV CONTRAST: Again seen is diffuse severe emphysema\n bilaterally. Again seen is a large consolidation in the right lung involving\n predominantly the right upper lobe, superior segment of the right lower lobe,\n posterior aspect of the right lower lobe and the right middle lobe. There\n have been interval increase in the size of the patchy consolidation in the\n left upper lobe. Again seen are air fluid levels within cavities in the right\n upper lobe and there is a new air fluid level in a cavity of the left upper\n lobe. There is interval increase in the size of the right moderate sized\n pleural effusion, again seen is a small left pleural effusion. Again seen are\n surgical sutures in bilateral upper lobes. There is a new small pericardial\n effusion. The heart is normal in size. The maximum diameter of the superior\n trachea is 2.5 cm suggesting tracheomegaly, this may be related to over-\n distention of the balloon from the ET tube. No lesions are seen in the\n visualized portions of the liver, spleen, pancreas, adrenals and the upper\n poles of the kidneys. The bones are unremarkable.\n\n IMPRESSION: 1) Overall progression in bilateral pneumonia, cavitary lesions\n with air fluid levels may represent infected bullae versus abscess. There has\n been significant progression in the left upper lobe pneumonia.\n\n 2) Slight increase in partially loculated right effusion and slight increase\n in pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792738, "text": " 6:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval OGT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna s/p OGT revision.\n\n REASON FOR THIS EXAMINATION:\n eval OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Throat carcinoma and aspiration pneumonia, status post OG tube\n placement.\n\n TECHNIQUE: Single portable AP view of the chest is compared with yesterday's\n study.\n\n FINDINGS: An endotracheal tube and right-sided PICC catheter remain in\n appropriate position, with PICC terminating in mid SVC. The NG tube again\n terminates within the stomach, presumably after replacement. There is\n unchanged appearance of confluent right apical opacity with cavitation;\n an area of alveolar/interstitial opacity at the right lung base is\n also unchanged. There is relative preservation of the aeration involving the\n left lung. No pneumothorax. No definite pleural effusions.\n\n IMPRESSION: Overall unchanged appearance of the lungs, with NG tube in\n appropriate position.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 793338, "text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess placement of NCT tube in stomach- thanks\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration PNA, needs PEG\n REASON FOR THIS EXAMINATION:\n Please assess placement of NCT tube in stomach- thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n PORTABLE CHEST: Comparison is made to the film from four days earlier.\n The extreme lung apices are not included on the film.\n\n The right-sided PIC catheter tip remains in the SVC. There is a new\n nasogastric tube; its tip is off the film, but is below the level of the left\n hemidiaphragm.\n\n Multifocal bilateral infiltrates are again identified and demonstrate no\n interval change. No new pleuro-parenchymal abnormalities are identified.\n\n IMPRESSION: 1. New nasogastric tube tip below left hemidiaphragm.\n 2. No change lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792546, "text": " 8:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers s/p ETT\n advancement\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Throat cancer with aspiration pneumonia. Status post endotracheal\n tube advancement.\n\n TECHNIQUE: Portable chest X-ray.\n\n Comparison study from 2 hours earlier.\n\n FINDINGS: The tip of the endotracheal tube is at the level of the thoracic\n inlet, abutting the left lateral wall of the trachea and unchanged compared to\n prior study. There is a nasogastric tube with tip well above the diaphragm.\n Heart and mediastinum are stable in size. Again seen is a patchy opacity in\n the right upper lobe with multiple cavities and air fluid levels which have\n not changed in the interval. There is -apical pleural thickening. There is\n no pneumothorax.\n\n IMPRESSION: No significant change compared to prior study.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792543, "text": " 6:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers s/p ETT\n advancement\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: AP portable chest.\n\n INDICATION: 61 year old male with history of throat cancer status post\n aspiration pneumonia. Evaluate ET tube placement.\n\n Comparison is made to the prior exam earlier of the same day at 11:53 hours.\n\n FINDINGS: An ET tube is seen with its tip at the level of the clavicles,\n slightly more distal than previous. The cardiomediastinal borders are\n unchanged. An NG tube is seen coursing through the stomach and exits the\n field of view. There is a somewhat worsened appearance to the consolidative\n process with small air cavities seen in the right upper lobe, along with\n increased interstitial opacity seen in the right mid and lower lung zones as\n compared to prior exam. The pulmonary vasculature is normal. No pleural\n effusions seen. No pneumothorax identified.\n\n IMPRESSION:\n\n 1) ET tube with tip just slightly more distal than previous, at the level of\n the clavicles.\n\n 2) Slightly worsened appearance to consolidative process with air cavities in\n the right upper lobe, as well as interval worsening of interstitial opacity\n within the right mid and lower lung zones.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-10 00:00:00.000", "description": "CVL/PICC", "row_id": 792680, "text": " 9:51 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: 61 yo M with need for IV access\n Admitting Diagnosis: PNEUMONIA\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man intubated with necrotizing pna\n REASON FOR THIS EXAMINATION:\n 61 yo M with need for IV access\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Necrotizing pneumonia, needs PICC line for IV antibiotic therapy.\n\n RADIOLOGISTS: The procedure was performed by Drs. and \n , the attending radiologist supervising.\n\n PROCEDURE & FINDINGS: The patient was placed supine on the angiographic table\n and the right arm was prepped and draped in sterile fashion. Under local\n anesthesia and ultrsonographic guidance, the right basilic vein was accessed\n using a 21-gauge needle and a .018 wire was placed into the SVC. The needle\n was exchanged for a 5 French Peel-Away sheath. According to the marker on the\n wire, a 5 French double-lumen PICC line was trimmed to 39 cm in length and\n placed over the wire into the SVC. The sheath was removed and the line was\n secured using a Statlock. The line was flushed. The final x-ray showed the\n line in proper position.\n\n The patient tolerated the procedure well with no complications.\n\n IMPRESSION: Successful placement of a 5 French double-lumen PICC line with\n tip in SVC, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792493, "text": " 11:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion, worsening inflitrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers.\n\n REASON FOR THIS EXAMINATION:\n r/o effusion, worsening inflitrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Throat cancer, aspiration pneumonia, fevers, evaluate for\n worsening infiltrates.\n\n Comparison is made with the chest radiograph from .\n\n AP CHEST RADIOGRAPH: The ETT has either been retracted or removed with tip\n either now lying at the thoracic inlet or with an external piece of tubing\n superimposed over the superior trachea. Heart size, mediastinal contours and\n pulmonary vasculature are unchanged. Again identified is a complex\n consolidation with multiple air cavities in the right upper lobe. There is\n partial clearing of the illdefined opacity in the right lower lung zone, with\n concomittant worsening of the hazy opacity in the left upper lung zone. The\n waxing and quality is consistent with aspiration. There is mild\n blunting of both CP angles laterally which may be related to small pleural\n effusions. Osseous structures are stable.\n\n IMPRESSION: Stable complex consolidation in the right upper lobe. Improved\n right lower lobe opacities with concomittant worsening left upper lobe\n opacities, consistent with aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792574, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement, infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration pna with fevers s/p ETT\n advancement\n REASON FOR THIS EXAMINATION:\n eval ETT placement, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Throat cancer with aspiration pneumonia and fevers. Status post ET\n tube advancement.\n\n TECHNIQUE: Portable chest X-ray.\n\n Comparison study dated at 20:53.\n\n FINDINGS: Again seen is the tip of the endotracheal tube at the level of the\n thoracic inlet and abutting the left wall of the trachea, unchanged compared\n to prior study. There is a nasogastric tube with tip in the stomach. The\n heart is stable in size. Again seen is a patchy opacity in the right upper\n lobe which contains cavitation and air fluid levels and is slightly decreased\n in size in the interval. Again seen is -apical pleural thickening.\n\n IMPRESSION: 1) Slight improvement in right upper lobe necrotizing pneumonia,\n otherwise no change compared to prior study.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792077, "text": " 7:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 yo M recently intubated for resp distress\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration pna\n REASON FOR THIS EXAMINATION:\n 61 yo M recently intubated for resp distress\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration pneumonia.\n\n FINDINGS: The endotracheal tube is in satisfactory position with its tip \n cm above the carina. There is extensive opacity overlying the entire right\n lung. The left lung is clear. The heart size is normal.\n\n IMPRESSION: Extensive right lung opacity, consistent with history of\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792126, "text": " 3:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: moved tube, assess ETT; also white lung\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration pna\n\n REASON FOR THIS EXAMINATION:\n moved tube, assess ETT; also white lung\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: 15:36\n\n INDICATION: ETT repositioned.\n\n COMPARISON: at 10:39\n\n FINDINGS: The tip of the endotracheal tube is now 6.2 cm above the carina.\n The remainder of the study is unchanged with continued air space disease in\n the right lower lobe and extensive opacification of the right upper lobe\n showing air pockets as previously seen.\n\n IMPRESSION:\n\n ETT more distally located. No change otherwise.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-17 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 793322, "text": " 3:20 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: please assess neck for any evidence of CA recurrence/enhanci\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of tongue CA s/p XRT/chemo, hre with severe aspiration\n PNA requiring 10 day intubation.\n REASON FOR THIS EXAMINATION:\n please assess neck for any evidence of CA recurrence/enhancing lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: History of tongue cancer status post XRT/chemotherapy. Severe\n aspiration pneumonia requiring ten-day intubation, assess neck for any\n evidence of cancer recurrence or enhancing lesions.\n\n TECHNIQUE: Contiguous axial images were obtained through the neck after the\n administration of 100 cc Optiray. Nonionic contrast was used secondary to the\n patient's request.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube and NG tube have been removed in the interval.\n Again noted are changes secondary to prior left neck dissection, with absence\n of the sternocleidomastoid muscle. No abnormal mass lesions are identified in\n the neck. Evaluation of the tongue, the site of primary cancer, is severely\n limited due to dental artifact. However, no obvious large mass can be\n appreciated. The major vascular structures are unremarkable. No osseous\n abnormalities are appreciated. Limited evaluation of the lungs reveals\n extensive abnormality at the lung apices, greater on the right than on the\n left. Again noted are bullous changes with air fluid levels again identified.\n\n IMPRESSION:\n 1. Limited evaluation of the tongue due to extensive dental artifact. No mass\n lesions are identified in the neck on this study.\n 2. Abnormal appearance of the lung apices, as seen on prior neck and chest CT.\n Correlation with dedicated chest imaging is suggested.\n 3. Recommend follow-up MRI scan to better delineate the tongue.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-17 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 793283, "text": " 10:00 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspiration, repeat study\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man a/w aspiration PNA, failed study on .\n REASON FOR THIS EXAMINATION:\n eval for aspiration, repeat study\n ______________________________________________________________________________\n FINAL REPORT\n VIDEO OROPHARYNGEAL SWALLOW STUDY\n\n INDICATION: 61 year old male with aspiration pneumonia.\n\n TECHNIQUE: Fluoroscopic imaging performed during the ingestion of varying\n consistencies of barium material.\n\n FINDINGS: There is no epiglottic deflection. There is profound pharyngeal\n impaired motility with a large amount of pharyngeal residue. There was\n repeated aspiration with thin, nector, and pudding consistency barium,\n secondary to the patient's marked pharyngeal stasis. There was a relatively\n effective spontaneous cough. There was some improvement noted with the\n patient in a semi-reclined position and the patient using the \n maneuver.\n\n IMPRESSION: Repeated aspiration secondary to marked pharyngeal stasis. Please\n refer to a speech therapy report available on OMR for a more comprehensive\n evaluation of this video oropharyngeal swallow study.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792960, "text": " 3:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man hx of throat CA with aspiration s/p NGT placement.\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Nasogastric tube placement.\n\n A nasogastric tube has been placed, and terminates below the diaphragm. Distal\n tip is not included on the radiograph. A right PICC remains in satisfactory\n position. Cardiac and mediastinal contours are stable. Multifocal areas of\n consolidation are again demonstrated, most prominent within the right upper\n lobe and affected other portions of the right lung to a lesser degree. There\n is also an area of consolidation at the left apex centrally. These findings\n are not considered significantly changed. Areas of apparent cavitation are\n noted in the right upper lobe consolidation and there is also evidence of\n bolus emphysema in the lung apices. The right costophrenic sulcus area has\n been excluded from the study and cannot be assessed. There is some pleural\n fluid or thickening apically and laterally on the right which is unchanged.\n There has been interval extubation.\n\n IMPRESSION: Nasogastric tube terminates below the diaphragm. The distal tip is\n not included on the study.\n\n Otherwise no significant interval change since recent study.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-13 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 792944, "text": " 1:19 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for ? aspiration\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man a/w aspiration PNA, recently extubated.\n REASON FOR THIS EXAMINATION:\n eval for ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration pneumonia.\n\n FINDINGS: Fluoroscopic imaging obtained during the ingestion of barium of\n varying consistencies.\n\n There was evidence of incomplete laryngeal elevation and excursion. There is\n no evidence of significant propulsion. There is significant oropharyngeal\n residue with aspiration of both nectar and puree consistency barium. Chin\n tuck maneuver, acute cough, and spontaneous cough were inaffective.\n\n IMPRESSION: Abnormal study with aspiration with nectar and pureed consistency\n barium. Please refer to the speech therapy report available on OMR for more\n comprehensive evaluation of this video oropharyngeal swallow study.\n\n\n" }, { "category": "ECG", "chartdate": "2101-06-09 00:00:00.000", "description": "Report", "row_id": 178588, "text": "Normal sinus rhythm. Within normal limits. Compared to the previous tracing\nof the delayed R wave transition is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 178589, "text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nLow QRS voltages in precordial leads\nSince previous tracing of : the rate has increased and the voltage has\ndecreased with ST-T wave abnormalities\n\n" }, { "category": "ECG", "chartdate": "2101-06-04 00:00:00.000", "description": "Report", "row_id": 178590, "text": "Sinus rhythm\nNormal ECG\nNo previous tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-15 00:00:00.000", "description": "Report", "row_id": 1402635, "text": "MICU NPN 1900-0700\nNeuro: Pt is a&ox3, calm and cooperative. Flat affect. Denies pain. Rec'd 1mg ativan per OGT for sleep with good effect.\n\nCV: HR 80's-100, SR, no ectopy. BP 120's/50's. Afebrile overnight. Cont on Levaquin, flagyl, and vancomycin. WBC's 20, PLT 1000, HCT 30.\n\nResp: LS's diminished throughout. On 5l NC with O2 sat ranging from 94-97. Occasionally desaturates to 88% when he needs to cough. +productive cough for thick white secretions. RR 16-26, non-labored, denies feeling SOB.\n\nGI: Abd soft/+bs's. Tolerating TF of Ultracal at goal rate of 80cc/hr per OGT without residuals. Denies abdominal discomfort. No BM overnight.\n\nGU: Foley draining qs amount of tea colored urine.\n\nSkin: no breakdown noted to backside. Pt OOB to chair through most of day yesterday. Able to transfer to bed from chair with 1 assist, slightly unsteady, PT following. 2L PICC line, rt brachial position. Blue port clotted yesterday, TPA instilled last evening with good results. Port flushes and draws blood.\n\nPlan: Continue to monitor VS's, I&O, labs, resp status.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-15 00:00:00.000", "description": "Report", "row_id": 1402636, "text": "NPN\n\nNeuro: A&O, walked around the unit with PT, he did well, no assistance was needed, he sat in the chair for the morning and afternoon.\n\nCV: VSS, SBP 1 teens/60s, HR 80s.\n\nResp: He states that he does not feel as much of a need for 02, SATs mid to upper 90s on 4 L NC. LS scattered crackles on the R, clear on the L, he denies c/o SOB.\n\nGI: He is tolerating the TF, residuals have been 10cc, no abd pain. He remains NPO and will need a swallowing study later this week, his OGT will need to be removed for this study. Pt said that if at all possible he would not want a G tube, he enjoys eating and does not want a tube coming out of his body, he has needed one in the past and would like to avoid having one again.\n\nGU: Urine is amber and cloudy, u/o 25-125cc/hr.\n\nHeme: Plts remain elevated, dif is abnormal, we are awaiting a heme consult.\n\nDispo: Pt is being sent out to the floor today.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-09 00:00:00.000", "description": "Report", "row_id": 1402614, "text": "M/SICU NURSING PROGRESS NOTE.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Easily arousable to verbal stimulus, attempts to follow commands but is lethargic at times. Moving all extrem. Good sensation and pilses all extrem. Pupils are 3mm and sluggish. Temperature max. 100.4 rectal.\n\n Respiratory: Lung sounds are clear in upper fields, coarse in lower fields bilat. Ventilator settings are unchanged ps/.40/10/10. O2 saturation 95-100% on present ventilator settings. Suctioned for mod. amt thick yellow sputum. Cxr x 2 for ett placement. Ett readjusted to 25 sm at the lip.\n\n CV: Sinus rhythm to sinus tachycardia, rate low 80's to low 100's. Abp low 110's to mid 150's, elevate with repositioning and suctioning. Transfused 1 unit prbc's, tolerated well.\n\n GI/GU: Abdomen soft with + bs. No bm this shift. Ogt in good placement by auscultation, infusing tf osmolite at 80cc/hr. Residual at 40cc. Tf off at 0100 for possible procedure this am. Foley catheter patent and draining cloudy amber to clear yellow urine this shift.\n\n Endocrine: Riss in use, 118 at 0000.\n\n Social: S.o. went home last pm.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-09 00:00:00.000", "description": "Report", "row_id": 1402615, "text": "Resp Care: Pt continues intubated and on ventilatory support with psv 10/+10 peep/fio2 .4 maintaining Vt 600's with Ve 8-10 L, acceptable abg; ett repositioned and secured @ 25 @ lip, BBS equal, coarse, occ crackles, sxn thick tan secretions, rx with mdi albuterol/atrovent as ordered, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-09 00:00:00.000", "description": "Report", "row_id": 1402616, "text": "Resp. Note\nRemains intubated on support. Settings weaned - PSV/CPAP 10/5/ 40% with gases 7.45, 42,80. Sx thick yellow. Started flovent inhalers this pm also recieving albuterol and atrovent. TVS 700-900cc with RR <25bpm.\nWill wean PSV and cont inhalers/ ? exubation am.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-09 00:00:00.000", "description": "Report", "row_id": 1402617, "text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated vented and sedated. Decreased peep to 5/10psv. TV 600-800. RR 16-22..Still with small to moderate amts yellow sputum. Strong cough. ABG good. Sats 95-99%.\n ID: Afebrile till 16:00..temp spike to 102r..HO aware..has scheduled chest ct for am..Continues on triple antibiotics..PICC line placed by IV team..with ID's consent (Dr. despite high fevers 24hrs ago.\nUnfortunately pt has to go to interventional radiology in am for further positioning of PICC.\n GI: Had gall bladder ultrasound at bedside...TF restarted..minimal residuals..hypoactive BS..given reglan..lactalose..had large lose brown bm..ob-. culture sent for c-diff.\n GU: Good u/o..slightly positive by 1800.\n Neuro: More alert..cooperative..following commands..hands remain restrainded..does bring hands up towards face..when asked if he knew where he was shook his head no...Still on versed and fentanyl without any changes.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-13 00:00:00.000", "description": "Report", "row_id": 1402631, "text": "nsg progress note 7am-7pm 1745\ns/o-vss afebrile-tmax 98.5-doing well wheened off vent 6/15(am) Fentanyl and Versed d/c'd today-c/o mild pain with coughing-no pain meds needed. Pt. on 40% o2-wheened down during course of day from 70%-40%- o2 sats mid 90's-does desat when o2 off-recovers quickly LS course throughout Suctioned for mod amnt thick, sticky yellow sputum Cont on current course of ATB WBC-22.6 Abd soft non-tender +bs x1 soft BM-stool spec pending for O&P Failed video swallow eval today OGT reinserted confirmed via cxr Ultracal restarted @35cc/hr-goal 70cc/hr -residual\na/p-pt to have 2nd video swallow in 3-4days-cont TF while NPO\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-13 00:00:00.000", "description": "Report", "row_id": 1402632, "text": "add:\nHem/onc consult pending\nHIV test pending\n" }, { "category": "Nursing/other", "chartdate": "2101-06-14 00:00:00.000", "description": "Report", "row_id": 1402633, "text": "micu nursing progress 7p-7a\nreview of systems\nCV- vs have been stable with hr in the 80's-90's nsr with rare pvc noted. BP has been in the 120's-130's/.\nRESP-wearing cool neb at 15L with sats in high 90's%. he does desat with mask off.has a strong cough productive of large amts thick yellow sputum, plugs. uses yankauer sx independently.\nF/E-ivf infusing at kvo.urine output has been moderate.am labs are pnd.\nGI-abd is soft and nontender, has positive bowel sounds. had a moderate amt soft brown stool on bedpan.ultracal infusing- was increased to 50 /hr. tolerating well so far.\nID-afebrile. wbc pnd for today. continues on multiple antibx.\nNEURO-is alert and oriented x 3.requested sleeping med- tx with .5 mgs iv ativan with little effect- was repeated in ~1.5 hrs and pt dozing in short naps-has been using call light appropriately.\nIV ACCESS- has a PICC R arm\nSOCIAL- s.o. was in for several hrs this evening-seems supportive\na-uneventful night\nP-will continue to monitor resp status, encourage good pulm toilet.advance tube feeds as tolerated.be available for questions,support\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-14 00:00:00.000", "description": "Report", "row_id": 1402634, "text": "S/MICU Nursing Progress Note\nSee Carevue for Additional Objective Data\n#1:Respiratory Failure\nD:Remains extubated, FiO2 weaned down to 4L NC with RR:18-24/min SpO2:93-97% >95% when at rest. Cough productive for small-moderate amounts of thick yellow secreations. Decrease in secreations today. BS: crackles on R, clear on left\nAfebrile today, remains on Vanco,Levo and Flagyl\nHemodynamically stable\nAbd soft non-tender, +BS, large liq. brown OB-stool. Hct:24.9, plts:elevated. Difficulty with peripheral blood draws-blood slow to return, PICC line clotted x 1 port, unable to obtain blood from patent port. IV consulted\n\nA:Stool sent for Cx, Blood for coccidiomycosis\n Activity:OOB to chair most of shift, PT in for evaluation, ambulated patient in unit\n Hematology consulted re:elevated plt count, decrease hct\n TF advanced to 60cc/hr (goal:80)\n\nR:Progressing well post extubation, tolerating decrease in FiO2 and increase in activity, decrease secreations as well.\n Hematology denied formal consult, follow counts, TPA ordered for PICC line, infuse when obtained from pharmacy to dwell overnoc per IV, sent final stool for O&P, monitor results, advance TF as tolerated, call out to med floor in the morning\n" }, { "category": "Nursing/other", "chartdate": "2101-06-08 00:00:00.000", "description": "Report", "row_id": 1402610, "text": "SMICU nsg progress note\nNeuro- Lightly sedated on 50mc fent and 2mg versed. Pt c/o throat and back pain. Given additional 50mc fentx2 with improvement-pt falling asleep. With increase sedation pt resp rate down to 6-8. Sats stable. Resp in and pt placed on imv rate for night(see flow sheet) Will return to ps in am.\nResp- Cont intub/vented. Initially on 10ps/10peep with tv 650-900 rr 10-12 Sats 94-95% on 40%. As mentioned above, pt placed on imv rate for night with increased sedation. Suctioned for minimal amts clear secretions.\nID- Cont with temp spikes t-max 102.6 orally. Blood/urine/sputum and mouth culture sent and pt given tylenol with temp down to 97.6. No change in antibiotics. Cont with elevated wbc's (22.9 this am)\nCardiac- Stable bp/hr. Cont with good urine output. Given 10mg lasix at 12m. Without much change in uo.\nGI- Cont on goal tube feeds Ultracal at 80cc/hr. Abdomen slightly distended with hypoactive bowel sounds. No stool. ? start bowel meds.\nHeme- No s/s bleeding. Am hct back at 26.0 ? possible transfusion.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-08 00:00:00.000", "description": "Report", "row_id": 1402611, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Pt placed on SIMV overnoc, secondary to decreased spont breathing after sedation. Administering Albuterol and Atrovent MDI's in line with vent. Sxing thick white secretions from ETT. See flowsheet for more pt data, RSBI.\nPlan: Back to CPAP, wean as tolerable.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-08 00:00:00.000", "description": "Report", "row_id": 1402612, "text": "Resp. Note\nRemains intubated on vent support. PSV/CPAP 10/10/405. Tvs 500-750cc with RR <20 bpm. Sx thick yellow Q3-4. Received albuterol and atrovent MDIs. ETT pulled 2cm per CXR. Repeat CXR ordered. Abgs this afternoon acceptable-see flowsheet. Will cont support.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-08 00:00:00.000", "description": "Report", "row_id": 1402613, "text": " 4 ICU nursing progress note:\n Respiratory: Pt remains intubated,vented and sedated. Moderate amts of yellow secretions. Has been on 10ps/10peep all day. TV 600-700. RR 12-16. Has strong cough/gag when stimulated.\n ID: Continues to be febrile to 104.4 rectal. Multiple cultures have been sent in the past 12hrs. Vanco added to regime. Followed by ID. Cooling blanket and tylenol ordered.\n Neuro: Very lethargic,,barely responds to verbal stimuli. By this afternoon..much more responsive..moving all extremities..able to nod appropriatley.\n Cardiac: HR 100-110st..BP 120-150/...has had good u/o..neg 100cc. No IVF.\n GI: TF at goal..ultracal 80hr. 100cc residual this am..ob - ph6.\nHas had no stool..+BS..Hct down to 26..to recieve 1u RPC this evening.\nTo be NPO for ultrsound tomorrow..\n Social: Girlfriend spending most of day..in/out room. Appropriately concerned..team spoke with her and brought her up to date. Daughter also in to visit.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-07 00:00:00.000", "description": "Report", "row_id": 1402607, "text": "nursing progress note see careview for details\n\nneuro:pupils 2mm and perl,remains sedated on midazolam and fentanyl but is arousable to voice weaning gtts .follows commands at times,has positive gag and cough.\n\ncv:remains in nsr without ectopy hr 80 to 90.bp stable and no temp spikes.both feet warm with palpable dp and pt pulses present.extremites edematous.team stes that prior ekg changes have resolved.\n\nresp:breath sounds coarse on right side and clear on left.remains intubated on cpap with 10cm of peep and 10 of psupport.spontaneous tv 800c.resp rate 8 to 10,fio2 40%.suctioned for only clear white secretions today.\n\ngi:abd softly distened with positive bowel sounds present.has not had any stool today.team wound like stool for parasites.continues on tube feeding ultracal at goal of 80cc.feeding was held for high residuals,but was restarted.ngt placement was also verified by dr after ogt was moved to otherside of mouth by resp.residuals appeared to have bile and tube feedings.\n\ngi:foley to cd draining clear yellow urine, appears positional at times.\n\nskin:intact with no apparent breakdown.no rashes noted.\n\nlabs:potassium phosphate and mag repleted.\n\nendocrine will be covered by sliding scale.\n\nplan:iv access pic requested but iv nurse recommened waiting one day til cultures come back and to watch temp.id consult blood for rheumatoid factor sent,antinuclear antibody screen,anti neutrophil cytoplasmic antibody sent and anti gbm antibody sent.questionable if pt will need a vats procedure .questionable thoraic consult.\n\nsocial:significant other in to visit,daughter is coming to visit.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-07 00:00:00.000", "description": "Report", "row_id": 1402608, "text": "update: was seen by iv will recheck cultures in am and place pic line if no temp spikes,team aware 2 new peripherals placed,old ivs dcd.visited by daughter,,she was updated by team and spoke with id also.she is pregnant and was advised to wear mask.she spoke with her ob md also.daughter left list of people whom she wishes not to visit.fentanyl gtt was increased due to increase in bp .sliding scale written for blood sugar control.tube feeds remain at goal.urine more amber in color with sediment,urine sent for culture.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-12 00:00:00.000", "description": "Report", "row_id": 1402626, "text": "Smicu nsg progress\nS/O: Neuro- Alert oriented and cooperative sleeping in naps. Denies pain on 50mc fent and 2mg versed. No additional boluses given.\nResp- Cont on 5ps 5peep thoughout night with tv 600's resp rate 16-18 Sats 95-98% on 40%. Suctioned for minimal clear secretions. T-max 100.4po on levo/vanco/flagal.\nGi- Initially recieving tube feeds at goal. No stool. Tube feeds held after 2am for ?extubation in am.\nCardiac- Stable with adequate uo\nA/P: Cont to improve although still with low grade temp. ?extub in am. Cont to follow cultures.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-12 00:00:00.000", "description": "Report", "row_id": 1402627, "text": "RESPIRATORY CARE: PT. EXTUBATED THIS AM W/ RSBI 29\nAND GOOD COUGH. PRIOR TO EXTUBATION HAD AN EPISODE\nOF DESATURATION DUE TO PROBABLE MUCOUS PLUG WHICH\nRESOLVED AFTER AMBU BAG HYPERINFLATION AND SALINE\nLAVAGE. EXTUBATED TO 100 % AEROSOL THEN WEANED TO\n50 % WITH SPO2 96 %. COUGH STRONG AND PRODUCTIVE\nFOR THICK YELLOW SPUTUM. WILL FOLLOW RESPIRATORY\nSTATUS CLOSELY.\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2101-06-07 00:00:00.000", "description": "Report", "row_id": 1402609, "text": "Resp Care\nremains ett/vent support. changed to psv mode this morning..appears comfortable on ps 10/peep 10/40% with acceptable abg (although pao2 slightly down). sxned less secretions today..only small amts yellowish. sedated but with good cough. admin mdi's as ordered. c/w vent support. assess for further weaning in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-12 00:00:00.000", "description": "Report", "row_id": 1402628, "text": "MSICU NPN 0700-1900\nA&O x3. Cooperative. 1 episode of O2sats of 88%. Pt c/o SOB at this time. Suctioned for mod amt thin white sputum. No plugs noted. Pt desaturated again in 5min and was resuctioned for scant-small amt. CXR unchanged. Gd aeration in all lung fields. No further episodes. Extub without problems this am. Currently on 50% CN. O2sats mid 90s. Prod cough. Able to suction mouth on own. Versed decreased to 1mg/hr and Fentanyl decreased to 25ucgs/hr. Plan to dc when versed gtt is finished. TFs on hold for now. OGT still in place for meds. Plan to re assess this eve w/MD. T current 99.6 ax (po temps not registering). Continues to autodiurese. 1 lg soft stool, ob-,sent for O&P. S.O. and dgt both in .\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-13 00:00:00.000", "description": "Report", "row_id": 1402629, "text": "SMICU nsg progress\nResp- Remains extub on 60%neb with sats mid 90's. Cont with freq productive cough of thick sticky yellow plugs. Will desat to 87-88% with coughing but quicky returns. Recieving resp tx q4-6hrs which help with secretion clearing. Frequently encouraged to cough and deep breath.\nGi- Abdomen soft non-tender. Remains npo for swallow study in am. Recieving meds via og tube. No stool. Still needs additional o/p spec if pt stools.\nCardiac- VSS. Started on iv ns at 100/hr x1 liter. Cont with good uo.\nId- T-max 100.3 po. No change in antibiotics. Cont with high wbc 22.\nNeuro- Alert oriented and cooperative. Cont on versed at 1mg and fent 25mc. Will d/c versed in am. ? also d/c fent.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-13 00:00:00.000", "description": "Report", "row_id": 1402630, "text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs Q4hr. Tolerated well. HR 90's. RR mid teens to 20. Bs initially with crackles at R base, otherwise lungs clear and decreased bilaterally. Fio2 increased from 50% to 70% via cool mist/aerosol mask. O2 sats 96-99%. Productive cough of thick yellow sputum. Sx'd orally with yankeur. Strong cough effort.\nA/P: Bilateral Pna\n Pt. extubated yesterday and continues to do well. Bs improving over course of shift. Crackles resolving. Lungs remain clear and decreased bilaterally. Resp status stable.\nPlan: Will continue to follow Q4hr and wean Fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-11 00:00:00.000", "description": "Report", "row_id": 1402621, "text": "S/MICU Nursing Progress Note 7pm-7am\nSee Carevue for Additional Objective Data\n#1:Respiratory Failure\nD:Awake, opening eyes spontaneously, PERRL 4 mm. Periods of mild anxiety noted, responding well to reassurance and 1mg boluses of versed q 4-6 hours\n Remains intubated and mechanically ventilated, settings remain PSV:10 with 7 PEEP. Denies SOB RR:/min with MV:7-11 L/min SpO2:>97% BS:coarse R>L with some clearing in upper lung zones with suctioning. Suctioned q 1-2 hours for small-mod amounts of thin yellow secreations, Strong cough, able to raise secreations\n T max:100.6 remains on Clinda/Levo/Vanco, temp came down without tylenol\n U/O:30-80cc/hr I/O's from midnoc approx:-100cc\n Hemodynamically stable\n NPO, NGT in place CXR image from evenings unclear placement, repeated:results . C/O some nausea early in shift resolved without intervention\n\nA:Tolerated reduced pressure support (10) overnoc\n\nR:Stable overnoc, asymptomatic on 10 PSV, continue with supportive care, antibx, pulmonary hygeine.Restart TF when OGT placement confirmed, wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2101-06-11 00:00:00.000", "description": "Report", "row_id": 1402622, "text": "Respiratory Care:\n\nPatient remains intubated on Psv. Current vent settings Psv 10, Cpap 7, Fio2 40%. Tolerating Psv well with spont vols 600-750. RR 16-20. Bs slightly coarse bilaterally. Thick yellow secretions. Albuterol/Atrovent MDI's given Q4hr/Flovent . RSBI 28 this am. Improved from yesterday. O2 sats 97-98%. Chest CT yesterday revealed progression of bilateral Pna. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-11 00:00:00.000", "description": "Report", "row_id": 1402623, "text": "RESPIRATORY CARE: PT. W/ 7.5 ORAL ETT IN PLACE\nTAPED @ 25 LIP. VENTILATORY SUPPORT TAPERED TO\nPS 5/.40/5 PEEP AND DOING WELL. ALBUTEROL/ATRO\nVENT/FLOVENT MDI'S BEING GIVEN AS IN CAREVUE.\nSX FOR THICK YELLOW/TAN SPUTUM BUT SECRETIONS\nARE IMPROVING. RSBI 28 THIS AM. WILL FOLLOW\nRSBI AND CLINICAL STATUS FOR POSSIBLE EXTUB\nATION IN NEXT 24 - 72 HOURS.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2101-06-11 00:00:00.000", "description": "Report", "row_id": 1402624, "text": " 4 ICU NPN 0700-1900\nDozing on and off most of day but easily arousable and following commands. Versed remains at 2mg/hr and Fentanyl is at 50 ucgs/hr.\n\nOOB to chair all afternoon. Able to bear wt and pivot with 2 assists.\n\nU.O. adequate and he is ~300cc + since midnight. TFs at 80cc/hr. Min residuals. + bowel sds. No stool. Need spec for O&P.\n\nT max 102 po. Sputum culture sent. No BC MD. with decrease in temp. Clinda changed to Flagyl.\n\nWeaned to 5PSV/5PEEP and his TVs are ~600s w/ MV ~9L. Suct q2-4 for mod amt yellow-brown sputum. Able to expectorate alot into his ETT. Plan to keep on overnight as tol. ?extub tomorrow.\n\nS.O. in all afternoon. Dgt visited for a few hours also.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-12 00:00:00.000", "description": "Report", "row_id": 1402625, "text": "Respiratory Care:\n\nPatient remains intubated on Psv. Pt. weaned to Psv 5, Peep 5 with Fio2 at 40%. Tolerating well. Pt. continues on above settings and appears comfortable maintaining good vols. Spont vols 600's with RR mid to high teen. BS clear and decreased bilaterally. Albuterol/Atrovent MDI given Q4hr and Flovent . Sx'd for sm amount of thick yellow sputum. RSBI results this am 29. Plan: Continue to wean as tolerated. ? extubation later today.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-10 00:00:00.000", "description": "Report", "row_id": 1402618, "text": "M/SICU NURSING PROGRESS NOTE.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Easily arousable with verbal stimulus, opens eyes spontaneously, communicates by gestures and eye blinking. Versed at 2mg/hr, fentanyl at 50mcg/hr. MAE. Temperature max. 102.2 rectally. Tylenol 650mg per ogt\n\n Respiratory: Lung sounds are coarse in upper fields, coarse in rt base, diminished in lt base. Ventilator settings ps .40/800/8-16/5/10. O2 saturation on present ventilator settings are 95-98%. Suctioned several times for sm amts thick yellow sputum. C/o feeling like not getting enough air, suctioned and repositioned, ventilator settings changed for short period, given extra dose sedation. have anxiety componant to periods of feeling sob.\n\n GI/GU: Abdomen soft with + bs. Ogt in good placement, tf ultracal at 80cc/hr with 20cc residual max. No bm this shift> Foley catheter patent and draining clear yellow urine.\n\n CV: Sinus rhythm to sinus tachycardia with no ectopy noted, rate 90's to low 100's. Abp 120's to 160's systolic. Peripheral edema is much improved, only slightly noticable in lower extrem. Picc line in place but not able to use until position confirmed by ir.\n\n Endocrine: Riss in use, no coverage required at 0000.\n\n Plan: Continue to wean ventilator support. To Ir this am and ct this am, need to coordinate with both for single roadtrip.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-10 00:00:00.000", "description": "Report", "row_id": 1402619, "text": "Resp Care: Pt continues intubated and on ventilatory support with psv increased to 14 for c/o dyspnea/ +5 peep/Fio2 .4 maintaining Vt 6-900 ml with Ve 6-12 L, acceptable abg; BS coarse, diminished thruout L>R, sxn thick tan/yell secretions, rx with mdi albuterol/atrovent/flovent as ordered, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-10 00:00:00.000", "description": "Report", "row_id": 1402620, "text": " 4 ICU NPN 0700-1900\n\n PS decreased to 10. Fio2 40%, PEEP 7. RR 14-24 min. VT 620-880. BS coarse. Peroids of having copious thick, tan secretions requiring frequent bagging, lavage & suctioning. Sats high 90's. Chest CT scan done. Receiving MDI's.\n T-max 100.6R. BC from A-line on growing gm (+) cocci in prs/chains. Repeat BC X1 from A-line. A-line d/c'd. On clinda, levoflox vanco.\n Cont on versed & fentanyl gtts. Versed 1-2mg bolus X2 for anxiety. Awake or easily arousable, follows commands, appropriate. Attempts to mouth words.\n Ultracal TF at goal (80cc hr). Min residuals. C/o nausea. TF stopped. Nausea resolved after half hr. OGT re-advanced after it was noted to be out ~7inches ? r/t coughing. Awaiting CXR to confirm placement. Had lge OB neg loose brown stool. Colace held.\n UO excellant. 1.3L negative fld balance.\n PICC line replaced. PIV's d/c'd.\n Social worker in to see pt. She asked pt directly whether he wanted his dtr & son-in-law to make arrangements for them to visit from (Army). He appeared to understand & indicated he would think about it. will follow up Mon . S.O. & pt's dtr in to visit.\n No RSSI coverage needed.\n\nA/P: Stable on PSV 10- Follow VT, RR, sats.\n Temp curve down- Cont antibiotics. Follow WBC, cultures, temp\n Tol TF- Restart TF after CXR,/placement confirmed. Hold colace this eve. Restart .\n Social servie to follow.\n D/C RSSI.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-04 00:00:00.000", "description": "Report", "row_id": 1402596, "text": "Resp: pt on a/c 20/600/+5/60%. Ambu/syringe @ hob. Bs auscultated reveal bilateral coarse bs which clear with suctioning. Suctioned numerous times for thick copious yellow secretions, as well as in oral cavity. Re-taped & secured ETT. MDI's ordered this am Alb/Atr given @ 6:00 with no adverse reaction. 02 sats at this time remain 93-95%. Vent changes as follows: TV ^ 600, RR^ 20, and fio2 decreased to 60%. AM ABG's 7.39, 46, 96, 26, -0. RSBI=32. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-04 00:00:00.000", "description": "Report", "row_id": 1402597, "text": "M/SICU NURSING PROGRESS NOTE.\n SEE CAREVIEW FOR OBJECTIVE FOR OBJECTIVE DATA.\n\n Neuro: Easily arousable, opens eyes to verbal stimulus, follows commands. Sedated on versed at 4 mg, fentanyl at 100 mcg/min. Pupils are 2mm and sluggish. Temperature max. 101.1. Tylenol 650mg pr given with good results. Pan cx last evening.\n\n Respiratory: Lung sounds are clear throughout, diminished rt base. Ventilator settings are ac/.60/600/14/10. O2 saturation 94-98% on present ventilator settings. Cxr done this am shows white out on rt side. Et tube position changed, presently at 25cm. Suctioned scant amts thin green secretions. Weaning trial this pm was not succ.\n\n CV: Sinus rhythm to sinus tachycardiawith no ectopy noted, rate 80's to 110's. Abp in high 90's to low 110's systolic. Iv fluids ns at 100 cc/hr. Rsbi 32 this am.\n\n GI/GU: Abdomen soft with + bs. No bm this shift. No og or ng tube placed as of yet. Foley catheter patent and draining clear amber urine.\n\n Social: S.O., daughter and son in law in with pt, s.o. in throughout most of shift.\n\n ID: Clindamycin d/c'd this am. pan cx this am.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-05 00:00:00.000", "description": "Report", "row_id": 1402598, "text": "MICU NPN 7P-7A\nNeuro: Continues to be sedated with fentanyl 100mcg/hr and versed 4mg/hr, easily arousable to voice, wrists remains restrained for pt. safety.\n\nResp: No vent changes made overnoc, vent settings are as follows a/c 600 x16, fio2 60%. Lungs clear for the most part slight diminished on the right.\n\nCV: BP and HR stable see carevue for details. No ectopy noted.\n\nGI: NPO, no tube feeds. abd. soft bs +, no bm.\n\nGU: Urine output 20-40cc/hr. ho made aware, pt. to receive 500cc ns bolus, then iv to be changed over to D5NS @ 150cc/hr for remainder of infusion.\n\nHEME: Am crit 28.3, yest was 32.2.\n\nID: Temp. max 100.5 ax. med with 650mg tylenol supp.\n\nSocial: SO stayed all noc.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-05 00:00:00.000", "description": "Report", "row_id": 1402599, "text": "Resp: pt on a/c 16/600/+10/60%. Ambu/Syringe @ hob. Bs auscultated reveal LS clear with RS diminished. Suctioned x 3 small amounts of thick yellow secretions. MDI's administered Q4 hr Alb/Atr with no adverse reactions. RSBI=26 and no further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-03 00:00:00.000", "description": "Report", "row_id": 1402594, "text": "1630-1900 MSICU admit note\n61 yo with h/o tongue Ca trans from OSH for further mgmt of asp pneumonia. H/O aspirations s/p tongue surgery and XRT. A&O on admit though tachypneic. RR 38 w/O2sats 98% on 100% NR. Easily intub and copious amts yellow sputum obtained, sent for c/s and AFB. Currently sedated on propofol. T 101.1 po. Awaiting admit orders. ABG pnd. S.O./proxy in with pt and has been updated by MD.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-04 00:00:00.000", "description": "Report", "row_id": 1402595, "text": "micu/sicu npn 1900-0700\nneuro- patient at begin of shift on propofol, as high as 80 mcg/kg/min. pt still restless, gagging on ett. eventually switched over to versed now at 4mg/hr and fentanyl 100 mcg/hr. patient arousable to voice. following some commands and nodding appropriately.\n\ncv/resp- bp dropping to 80-90's last evening. cxr post extubation showing sm l sided pneumothorax. pt not tachycardic at this time.. repeat cxr done, ct surgery came by and it was decided that it was not clinically significant for ct insertion. ct will follow. per pt's s.o., the pt has a history when he was younger of spontaneous pneumothoraxes. o2 sats have been stable. pt remains on a/c 600x20, 60%, 5 peep. occasional 1-2 breaths above. am abg 96/42/7.39/26. hr remains in the 80's, no ectopy, bp has been mid 80's-100 sys, maps >60. ecg done showing some changes. ck's to be cycled. first one 292, mb pending. asa pr given.\n\ngi/gu- pt npo. no ngt d/t anotomical anomalies post mult throat surgeries. asa/tylenol given po, all other meds given iv. foley placed overnight as well, pt draining >40cc/hr amber urine.\n\nid- pt w/aspiration penumonia, r sided out by cxr. wbc last eve 25.3, 20.7 this am. pt spiked to 101.9 last eve, pan cultured. clinda and pipricillin for abx coverage.\n\nsocial- pt's s.o of 8 years and hc proxy at his bedside overnight. appropriately concerned for pt. very thankful for the wonderful care he is receiving here. very supportive to pt.\n\ncont to support pt through this event. wean vent settings, slightly as tolerated, ?bronch today for further w/u. cont to keep comfortably sedated while intubated for lung injury. cont to provide support for family.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 1402604, "text": "MSICU NPN 0700-1900\nVersed gtt remains at 2mg/hr and Fent gtt is at 50ucgs. Easily arousable. Follows commands but dozes when undisturbed. Calm when awake but BP increases to 190sys when coughing.\n\nNo vent changes. Bronch done,no foreign body or lesion noted. Suct q1-5hrs for mod-lg amts thick yellow sputum. Chest and neck ct scan done. Awaiting . Maintaining gd O2sats throughout day.\n\nT max 102.2 ax. Blood culture sent from femoral line and then line dc'd and tip sent for culture.\n\nNo stool. + bow sds. Tol TF at goal of 60cc now changed to ultracal w/ goal of 80cc/hr. Min residual.\n\nU.O. fair. Fluids at 150cc/hr. >2L + since midnight.\n\nS.O. in all day. Dgt in this evening.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-07 00:00:00.000", "description": "Report", "row_id": 1402605, "text": "SMICU nsg progress note\nNeuro- Alert and responding intermittently to questions by nodding head. C/o sore throat from et tube. Initially on versed gtt at 2mg/hr and fent at 50mc/hr. Called to room by significant other when pt waking up and becoming somewhat agitiated moving about in bed and attempting to sit up. Given additional 50mc bolus and fent gtt increased to 100mc with improvement. Pt still lightly sedated and easily aroused.\nResp- Remains intub/vented on ac 600x16 40% 10peep with 02 sats 94-95%. Will decrease to 91% with rt side down. Suctioned for minimal yellow secretions. Abg 79/49/7.41. Cont with low grade temps. T-max 100.3 ax. Given tylenol with temp down to 97.6ax. Cont on Levo/clinda\nGi- Tube feeds changed to ultracal advanced to goal of 80cc/hr. No stool.\nCardiac-Stable bp and hr. IV fluids d/c'd. Cont with adequate uo.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-07 00:00:00.000", "description": "Report", "row_id": 1402606, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 600, A/c 16, Fio2 40%, and Peep 10. PAP/Plateau 20/19. Bs course bilaterally. Less course L Lung. Sx'd for sm amount of thick yellow sputum. Albuterol/Atrovent MDI's given Q4hr. Abg results 7.41, 49, 79, 32, +4. No further changes made. Continue with mechanical support and wean to Psv as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-05 00:00:00.000", "description": "Report", "row_id": 1402600, "text": "M/SICU NURSING PROGRESS NOTE.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Easily arousable, opens eyes and follows commands well. Versed reduced to 1mg/hr and fentanyl reduced to 50mcg/hr, appears to be tolerating change very well. Moving all extrem. Pupils are 3mm and brisk. Temperature max 100.7 oral.\n\n Respiratory: Lung sounds are clear throughout though slightly diminished in lower fields. Ventilator settings changed to ps .50/5/10. O2 saturation 94-98% on present ventilator settings. Tolerating change well. Occn coughing sm to lg amts thin green secretions. Cxr appears to be improving.\n\n CV: Sinus rhythm to sinus tachycardia, rate 80's to low 100's with no ectopy noted. Abp low 100's to 150's systolic. Iv fluids d5ns at 150 continues.\n\n GI/GU: Abdomen soft with + bs. No bm this shift. Ogt placed with confirmation by cxr, tf promote with fiber started at 10 cc/hr with increases by 10cc every four hrs for goal of 60cc/hr. Stop for residuals greater than 100 and flush tube with 50cc/h2o. Foley catheter patent and draining adequate amts of clear amber urine.\n\n ID: Levaquin started for pnuemonia.\n\n Plan: Continue to wean ventilator as appropriate, wean sedation as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 1402601, "text": "MICU NPN 7P-7A\nNeuro: Continues to be lightly sedated with fentanyl @ 50mcg/hr and versed 2mg/hr. Opens eyes spont. follows commands.\n\nResp: Was placed back on a/c at to rest overnoc, vent settings are a/c 600x16, 40% fio2. Sx. copious amts. of thick white/brown sputum. Lungs diminished on the left clear on the right.\n\nCV: Hr and bp are stable see carevue for numbers.\n\nGI: Tf infusing well, increased to 30cc/hr goal is 60cc/hr, min. residual noted no bm's last noc.\n\nGU: U/0 20-40CC/HR urine is very conc. HO aware of this.\n\nID: Temp max. 101.7 tylenol elixer was given. Temp went down to 97.5 po, am temp 101.4 po, tylenol elixer 650mg given this am.\n\nSocial: SO stayed by bedside all noc.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 1402602, "text": "RESP: pt on ps5/+10/50%. Ambu/syringe @ hob. Auscultated bs reveal coarse bs on ls with diminished on rs. Suctioned thick copious yellow secretions x3 as well as from oral cavity. MDI's adminishered q4 hrs Alb/Atr with no adverse reactions. Vent changes as follows: AC 16/600/40% @ with no further changes during noc. RSBI=34.\n" }, { "category": "Nursing/other", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 1402603, "text": "Resp care\nremains ett/vent support via ac mode at 600x16x40%/10 peep. occ spont efforts noted. sxning mod to lg amts yellowish/ secretions. bronched today with specimen obtained. transported to ctscan for chest/neck scan. vent status stable t/out. albuterol/atrovent q4h.\nbs diminished right. c/w vent support. ?change to psv tonight.\n" } ]

[ { "category": "Radiology", "chartdate": "2147-11-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1214852, "text": " 8:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval s/p sdh evacuation\n Admitting Diagnosis: SUBDURAL HEMATOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with sdh on left\n REASON FOR THIS EXAMINATION:\n eval s/p sdh evacuation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MJMgb TUE 12:34 PM\n 1. Interval evacuation of left subdural hematoma with expected postoperative\n changes. No change in rightward shift of midline structures.\n 2. No evidence of new hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/p evacuation of a left subdural hematoma.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain.\n\n COMPARISON: Multiple prior CTs of the head, most recently on .\n\n FINDINGS: There is a new left parietal burr hole. The left convexity\n subdural hematoma seen on the prior studies demonstrated a septation dividing\n it into anterior and posterior compartment. In the anterior compartment, the\n fluid has been nearly completely evacuated and replaced by air, with unchanged\n left frontal sulcal effacement. In the posterior compartment, there is less\n fluid than on , and few small foci of air. There is interval\n improvement in left parietal and temporal sulcal effacement. There is no\n significant change in the mild rightward shift of midline structures and mild\n deformity of the frontal of the left lateral ventricle. The body of the\n left lateral ventricle has partially reexpanded, and the third ventricle has\n reexpanded. The imaged paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n\n S/p evacuation of septated left subdural hematoma. Decreased posterior\n compartment of the hematoma with decreased mass effect on the left parietal\n and temporal structures. In the anterior compartment of the hematoma, fluid\n has been replaced by air, and mass effect on the left frontal structures is\n unchanged.\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2147-11-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1214853, "text": ", J. NSURG SICU-A 8:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval s/p sdh evacuation\n Admitting Diagnosis: SUBDURAL HEMATOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with sdh on left\n REASON FOR THIS EXAMINATION:\n eval s/p sdh evacuation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Interval evacuation of left subdural hematoma with expected postoperative\n changes. No change in rightward shift of midline structures.\n 2. No evidence of new hemorrhage.\n MJMgb\n\n" } ]

[ { "category": "Echo", "chartdate": "2146-12-20 00:00:00.000", "description": "Report", "row_id": 68538, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 331\nBSA (m2): 2.61 m2\nBP (mm Hg): 120/70\nStatus: Inpatient\nDate/Time: at 13:57\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 moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated. LV systolic\nfunction appears depressed. Overall left ventricular systolic function cannot\nbe reliably assessed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTIC VALVE: The aortic valve leaflets are severely thickened/deformed. There\nis severe aortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is moderate\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left atrium is moderately dilated.\n2. The left ventricular cavity is mildly dilated. LV systolic function appears\ndepressed. Overall left ventricular systolic function cannot be reliably\nassessed.\n3. The aortic valve leaflets are severely thickened/deformed. There is severe\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n5. There is moderate pulmonary artery systolic hypertension.\n\n\n" }, { "category": "ECG", "chartdate": "2147-01-02 00:00:00.000", "description": "Report", "row_id": 147181, "text": "Regular supraventricular rhythm. P waves are probably present and are of low\namplitude and revealed in the atrial premature beat. Since the previous tracing\nof atrial pacing is no longer seen. Lateral ST-T wave abnormalities are\nstill present but less prominent.\n\n" }, { "category": "ECG", "chartdate": "2146-12-30 00:00:00.000", "description": "Report", "row_id": 147182, "text": "Atrially paced rhythm with intrinsic A-V conduction. Right bundle-branch\nblock. Compared to the previous tracing of the rhythm is now atrially\npaced. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2146-12-27 00:00:00.000", "description": "Report", "row_id": 147183, "text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Left axis\ndeviation - consider prior inferior myocardial infarction and left anterior\nfascicular block. Anterolateral ST-T wave abnormalities - are primary and\ncannot exclude in part, ischemia. Clinical correlation is suggested. Since the\nprevious tracing of ST-T wave changes are slightly less prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2146-12-27 00:00:00.000", "description": "Report", "row_id": 147184, "text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Left axis\ndeviation - consider prior inferior myocardial infarction and left anterior\nfascicular block. Anterolateral ST-T wave abnormalities - are primary and\ncannot exclude in part, ischemia. Clinical correlation is suggested. Since the\nprevious tracing of ST-T wave abnormalities have increased.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2146-12-22 00:00:00.000", "description": "Report", "row_id": 147185, "text": "Ectopic atrial rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nOld inferior infarct\nLateral T wave changes are nonspecific\nSince last ECG, atrial premature complexes absent\n\n" }, { "category": "ECG", "chartdate": "2146-12-21 00:00:00.000", "description": "Report", "row_id": 147186, "text": "Irregular ectopic atrial rhythm with atrial premature complexes\nMarked left axis deviation\nRBBB with left anterior fascicular block\nOld inferior infarct\n Lateral T wave changes are nonspecific\nSince last ECG, right bundle branch block, left anterior fascicular block,\ninferior myocardial infarction, ectopic rhythm\n\n" }, { "category": "Nursing/other", "chartdate": "2146-12-31 00:00:00.000", "description": "Report", "row_id": 1280213, "text": "NEURO: AWAKE, ALERT, ORIENTED X 3. MAE, FOLLOWS COMANDS.\nCARDIAC: MP SR WITH OCC PVC'S. NOREPI DOWN TO .01 M/K/M. S/BP ~120'S WITH MAP ^68. DOBUTAMINE/AMIODORONE CONTINUE. CO/CI ACCEPTABLE. PACER A DEMAND 70.\nRESP: CS DIMINISHED IN BASES. WEAK NONPRODUCTIVE COUGH THO TV ON SPIROCARE 1250.\nGI: TOLERATING ICE CHIPS/CLEAR LIQUIDS. HYPO BOWEL SOUNDS.\nGU: FOLEY IN PLACE, PATENT FOR ADEQUATE AMT AMBER URINE.\nENDO: FOLLOWING PROTOCOL, INSULIN GTT ^.\nPAIN: MEDICATED WITH IV MS WITH EFFECT.\nNO INTERACTION WITH FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-31 00:00:00.000", "description": "Report", "row_id": 1280214, "text": "POD #1AVR\nNSR WITH SOME PVCS, RARE COUPLETS. BRIEF SVT 130S/RESOLVED WITHOUT INTERVENTION. CONTINUES ON AMNIODARONE. DOBUTAMINE WEANED TO 4MCG/KG EARLIER TODAY. DOBUTAMINE TO BE WEANED VERY SLOWLY. CI CURRENTLY OVER 3. LOWER EXTREMITY EDEMA PRESENT.\n\nBREATHSOUNDS DIMINISHED AT BASES. AUDIBLE INSPIRATORY WHEEZE EARLIER TODAY. PT REPORTED TAKING SEVERAL INHALERS AND NEBULIZERS AT HOME. NEB RX GIVEN BY RESPIRATORY THERAPIST. WHEEZING RESOLVED FOLLOWING RX. OFM CHANGED TO NC. CHEST TUBES REMAIN IN DUE TO QUANTITY OF OVERNIGHT SEROSANGUINOUS DRAINAGE.\n\nTAKING SIPS OF WATER AND SOME JELLO ONLY. SOME BELCHING NOTED. ABD OBESE. BOWEL SOUNDS PRESENT. NO BOWEL MOVEMENT.\n\nURINE OUTPUT ADEQUATE. LASIX 40MG IV/BID STARTED TODAY. CRT ~2.1 EARLIER TODAY.\n\nMAE. CONVERSE. LIMITED MOBILITY IN BED D/T LARGE ABD. CBR TODAY D/T SVT EARLIER, ECTOPY AND WHEEZING. PT REMINDING STAFF THAT HE IS HARD OF HEARING.\n\nPERCOCET GIVEN FOR STERNAL AREA CHEST DISCOMFORT. PT VAGUE REGARDING TYPE OF DISCOMFORT HE IS HAVING. PT FREQUENTLY ASKING \"AM I DOING OKAY?\"\n\nCONTINUES ON INSULIN GTT FOLLOWING CSRU BLOODSUGAR MANAGEMENT PROTOCOL.\n\nPLAN TO MONITOR BLOODSUGARS, MONITOR CI/SVR, MONITOR ECTOPY, ASSESS FOR WHEEZING. PLAN TO ASSESS READINESS TO GET OOB TOMORROW. PLAN TO EVALUATE FOR ADDITIONAL DOBUTAMINE WEAN TOMORROW.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2146-12-31 00:00:00.000", "description": "Report", "row_id": 1280215, "text": "RESP CARE NOTE\n\nReceived Alb/Atr/ neb. Pt with bilateral wheezing. Good effect with a decrease in wheezing. Ordered or prn treatments.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-31 00:00:00.000", "description": "Report", "row_id": 1280216, "text": "UPDATE\nASSESSMENT UNCHANGED. VSS. PERCOCET GIVEN FOR STERNAL DISCOMFORT W/ C&DB; PT RESTING WELL AFTER. ADMITS TO BEING \"SCARED TO DEATH\". REASSURANCE GIVEN.\nCONT TO MONITOR LYTES, ENC PULM TOILET, DIURESE.\n" }, { "category": "Nursing/other", "chartdate": "2147-01-01 00:00:00.000", "description": "Report", "row_id": 1280217, "text": "NEURO: ALERT, ORIENTED TO TIME, PLACE AND EVENTS. ENGAGES IN APPROPRIATE CONVERSATION. PEARL AT 3MM. MAE ON COMMANDS. PERCOCET 2 PO X 1.\n\nPULM: LUNGS CLEAR. GOOD COUGH EFFORT AND USE OF IS. PC02 50 ON 4L, O2 DECREASED TO 2L. HX COPD. CHEST TUBES DRAINING SMALL AMTS SEROSANGUINOUS FLUID.\n\nCV: NSR WITH OCC-FREQ MFPVC'S, ON AMIO GTT AT 0.5. MAP 59-70, PAS 55-70/PAD 17-24. MVO2 72 WITH FICK CO 11.5 AND CI 4.18. ON DOBUTAMINE AT 4MCG. WEIGHT UP 3.8KG. PEDAL PULSES PALPATED L FOOT, DOPPLED R FOOT. K AND CA REPLACEMENT. AV WIRES ATTACHED, NOT CHECKED D/T ECTOPY.\n\nENDO: HX IDDM ON INSULIN GTT. SEE CAREVUE FOR Q1H DOCUMENTATION.\n\nGI: ABDOMEN OBESE, SOFT, + BOWEL SOUNDS. NO FLATUS OR BM. TOLERATING CLEAR LIQUIDS.\n\nGU: FOLEY TO CD DRAINING QS AMTS URINE. LASIX 40MG IV BID. WEIGHT UP. BUN 42/CREAT 2.0.\n\nSOCIAL: LIVES WITH HIS WIFE. USES /WALKER AT HOME. ? WILL NEED REHAB BEFORE RETURNING HOME.\n\nPLAN: SLOW WEAN OF DOBUTAMINE. MONITOR CO/CI Q2-4H. PERCOCET FOR PAIN Q4H PRN. ? REMOVE CHEST TUBES TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2147-01-04 00:00:00.000", "description": "Report", "row_id": 1280224, "text": "CSRU NPN\n\nNeuro: Alert, oriented, and pleasant. MAE w/ equal strength.\n\nCV: Neo gtt cont's to keep SBP > 120. Noted v pacing with VVI rate at 60->turned rate to 56 and still with occasional run of v paced beats (occasionally noted after PAC).\n\nResp: Soft audible expiratory wheeze noted w/ exertion. Using IS w/ good technique to 750cc. Cough productive of thick yellow sputum. Area of subcutaneous emphysema noted at anterior chest along chest incision on left and right, also extending to mid clavicular line on right. . CXR ordered->without PTX MD report. O2 sats occasionally drift down to 90% with exertion.\n\nGI: Abd large, soft. Small BM this am. Tol liquids.\n\nGU: Adequate u/o with IV lasix. Lytes repleted prn.\n\nID: Afebrile.\n\nEndo: SSRI per protocol. Oral hypoglycemics cont.\n\nSkin: No dng noted from superior portion of chest incision->left OTA.\nSkin to back/buttocks intact. Abrasion at lower back unchanged.\n\nComfort: Percocet 1 tab w/ good effect.\n\nA: Occasional v paced beats. Neo gtt. Sub q emphysema.\n\nP: Neo per orders. VVI. Pulmonary hygiene. Monitor for extention of sub q air. Glucose management. Increase activity as tolerated. Rehab screen.\n" }, { "category": "Nursing/other", "chartdate": "2147-01-04 00:00:00.000", "description": "Report", "row_id": 1280225, "text": "NEURO ALERT ORIENTED MOVES ALL EXTREMETIES NO DEFECITS NOTED\n\nC/V NSR NO ECT B/P STABLE GOOD PEDAL PULSES EPI WIRES INTACT NONFUNCTIONAL A WIRES V WIRES BACKUP RATE 56\n\nRESP NC 2L SATS 95-99% LUNGS CLEAR PRODUCTIVE SMALL AMTS TAN SECRETIONS USING IS WELL\n\nGU/GI ABD SOFT BOWEL SOUNDS HEARD SEVERAL SMALL LIQUID BMS ON BEDPAN OOB TO COMMODE WITH VERY LARGE SOFT FORMED BM ADEQUATE URINE OUT FOLEY DC/D 1800 DTV 2400-0200 CONDOM CATH ON TOL PO WELL\n\nACTIVITY OOB TO COMMODE AND CHAIR WITH WALKER AND 2 ASSIST TOL WELL GOOD WHT BEARING AND BALANCE STATES ONLY WALKS 40 FT AT HOME USES W/C FOR ANY DISTANCE\n\nPLAN CONTINUE TO INCREASE ACTIVITY AS TOL MONITOR URINE OUT WITH CONDOM CATH\n" }, { "category": "Nursing/other", "chartdate": "2147-01-05 00:00:00.000", "description": "Report", "row_id": 1280226, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative.\n\nCV: NSR with no ectopy noted, pacer on back up VVI 58, BP stable, afebrile, PP+ via doppler.\n\nRESP: Lungs clear, diminished at bases, using IS well, productive cough->thick yellow sputum, 02 @ @ 2L via NC, with sats.>95%.\n\nGI: Abd. soft , BS+\n\nGU: Foley dc'd during late evening yesterday, unable to void 8 hours later, straight cathed with 550ml out, clear yellow urine. DTV @ 0800.\n\nENDO: RISS per unit protocol.\n\nPAIN: Medicated with percocet for incisional pain with good relief.\n\n\nPLAN: Continue to monitor CV and RESP status, pulmonary toilet, increase activity, pain management, DTV.\n" }, { "category": "Nursing/other", "chartdate": "2147-01-01 00:00:00.000", "description": "Report", "row_id": 1280218, "text": "CSRU Nursing Progress Note\nNeuro: Pt A&O x3. Pt c/o occ pain relieved with percocet. Pt OOB to chair at 1700. Needs 2 person assist. Pt the most pt ever!\n\nCardiac: Pt in SR with frequent ectopy. Pts HR 70-80 BP 117-131/41-54, PAD 19-30, CVP 10-13. CO/CI 5.88-6.89/2.14-2.51 decreased to 2.5 dobitamine from 5. Tolerated changd very well. Pt c/o internal CP EKG done, no change. Pt has A/V wires, and A sensing. Amio gtt changed to PO. Afternoon lytes okay.\n\nResp: Pt on 2L NC, O2 sat 93-95% via ABG sat 97%. Pt is a CO2 retainer. BS clear decreased in the bases. CT's dc'd at 1700.\n\nGI: Pt has poor appetite. +BS, -BM.\n\nGU: Pt has f/c with adequate u/o. Pt on lasix, with minimal effect on 40mg, may need to be increased.\n\nEndo: Pt on insulin gtt currently on 5u/hr. q2 BG.\n\nID: Pt recieved #2 of 2 vanco, afebrile.\n\nAccess: R IJ SWAN, R rad .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2146-12-30 00:00:00.000", "description": "Report", "row_id": 1280212, "text": "S/P AVR\nS:\" HOW AM I DOING?\"\nO: CARDIAC: SR TO APACED TO SR 80'S, INCREASED PVC'S WITH A RUN OF VT TREATED WITH AMIODARONE 150 MG BOLUS AND GTT @ 1MG , DECREASED @ 2315 TO .5MG. VEA RARE NOTED SINCE ON AMIODARONE. SBP REQUIRING LEVO @ .025MCQ. MVO2 51-62. CI <2 REQUIRING 2.5 L LR TOTAL TO KEEP CI >2.2. STERNAL DSG WITH SANGUINOUS DRAINAGE NO FURTHER INCREASE. MEDIASTINAL DSG C+D. DOPP PP. FEET WARM TO TOUCH. HCT 28. K,CA,+MAG REPLACED.\n RESP: FAILED INITIAL CPAP TRIAL, AWOKE 2ND TIME AND PT VERY AGITATED , RECIEVED 1 MG VERSED WITH GOOD EFFECT. EXTUBATED @ WITHOUT INCIDENT. C+R SMALL AMOUNTS OF WHITE SPUTUM. BS DIMINISHED BIBASILAR, CLEAR UPPER. ABG PER FLOW.\n NEURO: PLEASANT, CALM, FOLLOWING COMMANDS, MAE, PERL.EASILY AROUSABLE + ORIENTED.\n GI: HAS REMAINED NPO, ABD SOFT, HYPOACTIVE BOWEL SOUNDS.\n GU: GOOD UO\n ENDO: INSULIN GTT CONTINUES @ 9 UNITS/HR.\n PAIN: MSO4 2 MG X3 WITH GOOD EFFECT.\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED\nA: STABLE AT PRESENT\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CONTINUE AMIO,DOBUTAMINE, AND LEVO,MONITOR MVO2, CI, RESP STATUS-PULM TOILET, NEURO STATUS, I+O< LABS. AS PER ORDERS.\n\n" }, { "category": "Nursing/other", "chartdate": "2147-01-03 00:00:00.000", "description": "Report", "row_id": 1280222, "text": "CSRU NPN\n\nNeuro: Alert and oriented. Pleasant in conversation. MAE w/ equal strength.\n\nCV: HR stable. Neo titrated to keep SBP > 120. Captopril held over night NP request. Hct stable at ~ 27.\n\nResp: BS clear, slightly diminished at lower lobes, left more than right at times. O2 sats 94% or greater on 4l NP. PcO2 slightly elevated this am however ABG checked while pt asleep. Uses IS up to 1L. Strong cough, unproductive most of times. MDI as ordered.\n\nGI: Obese abdomen. Tolerating liquids.\n\nGU: u/o > 50cc/hr. NP, 2200 lasix dose given in setting of mildly elevated Cr. Cr 2.0 this am.\n\nEndo: SSRI at 2200.\n\nSkin: Scant amt serousang dng at superior portion chest incision this am. MD aware.\n\nActivity/Comfort: Difficulty moving. c/o w/ coughing and deep breathing but is coopertative w/ requests to do so. Perc x 1 given. Did sleep x several hours overnight.\n\nA: Hemodynamically stable. Neo for BP--kidney perfusion. Stable pulmonary wise.\n\nP: Maintain neo to keep SBP > 120. Address when to restart captopril w/ team. Pulmonary hygiene. Monitor incision dng.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-01-03 00:00:00.000", "description": "Report", "row_id": 1280223, "text": "UPDATE\nCV: NSR W/ RARE PAC. NEO OFF @ 0900. SBP 120-150 SINCE. ; BIL LE EDEMA PERSISTS. CAPTOPRIL D/C'D THIS A.M.\n\nRESP: SOB W/ ACTIVITY BUT PT STATES IT IS LESS SEVERE THAN @ HOME. LUNGS CLEAR. USING I.S. W/ REMINDERS. C&R MOD AMTS THICK, TAN SPUTUM.\n\nNEURO: A&O, PLEASANT. TAKING 1 PERCOCET @ A TIME FOR INCISIONAL DISCOMFORT.\n\nACTIVITY: OOB TO CHAIR W/ ASSIST OF 2. STANDS UP WELL BUT HAS DIFFICULTY TAKING STEPS. ATTEMPTED TO WALK W/ P.T. BUT ONLY ABLE TO GO A FEW STEPS--> WINDED AFTER. ASSIST BTB BY 3, BOOSTED BY 4.\n\nG.I.: EATING MOD AMT OF SOLID MEALS. DULCOLAX TABS GIVEN THIS A.M.-ON COMMODE X 1 BUT PASSED GAS ONLY.\n\nENDO: TX W/ SSRI X 1. CONT ON GLYBURIDE.\n\nG.U.: ADEQ HUO VIA FOLEY.\n\nSKIN: ABRASION ACROSS BACK PINK, W/O DRNG. SKIN OTHERWISE INTACT.\n\nA/P: HEMODYNAMICALLY STABLE OFF NEO-MAINTAING SBP 120 OR> ON OWN. ?RESTART CAPTOPRIL. PT DOING GD JOB CLEARING SECRETIONS. ACTIVITY TOLERANCE STILL POOR BUT SUBJECTIVELY IMPROVED FROM PER PT. CONT TO ENC ACTIVITY AS TOL. CONT DIURESIS. NEED SUPP IF NO B.M. BY TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2147-01-02 00:00:00.000", "description": "Report", "row_id": 1280219, "text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative.\n\nCV: NSR with frequent PVC's, continues on dobutamine @ 2.5 mcg/kg/min, CI/CO WNL, PA pressures elevated during the night 75-80's/30's-> nitro. gtt. started, with some relief, one time dose of lasix 60mg given, in addition to chlorothiazide 500mg given->with good effect, SV02 56, PA pressures decreased to 59/25 after diuresis, EKG done with no changes noted, PP+ via doppler.\n\nRESP: Lungs clear, diminished at bases, 02 @ 2L via NC, Pa02 at one time was 60->face tent applied and increased to 88, sat's 89-95%, + nonproductive cough, using IS up to 1000ml.\n\nGI: Obese, abd. soft, BS+\n\nGU: Foley intact, draining clear yellow urine.\n\nENDO: RISS per unit protocol.\n\nPAIN: Medicated with MS04 for incisional pain with good relief.\n\nPLAN: Wean nitro. as PA pressure tolerates, continue to monitor CV and RESP status, encourage pulmonary toilet, monitor urine output, increase activity.\n" }, { "category": "Nursing/other", "chartdate": "2147-01-02 00:00:00.000", "description": "Report", "row_id": 1280220, "text": "RESPIRATORY CARE: PT. DOING PRETTY WELL WEARING\nO2 AT 4 LPM VIA NASAL PRONGS. ABG W/ STABLE ACID\nBASE AND OXYGENATION. BS ARE CLEAR ALTHOUGH A BIT\nDIMINISHED. GIVEN 2.5 MG ALBUTEROL/0.5 MG ATROVENT VIA\nSVN. MILD SUB/OBJ. RX TO TX. NPC. PT. UP TO COMMODE\nEARLIER TODAY W/ RN ASSIST.WILL FOLLOW FOR ALBUTEROL\nAND ATROVENT NEBS PRN.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2147-01-02 00:00:00.000", "description": "Report", "row_id": 1280221, "text": "NEURO: A&O, COOPERATIVE, MAE\n\nCV:NITRO AND DOBUT GTTS D/C'D THIS AM FOR STABLE BP'S SEE FLOWSHEET FOR #'S, BP DOWN TO 80'S/50'S W/MOVEMENT. STARTED ON NEO AT 1530 FOR LOW UOP AND BP 90'S-100'S, CAPTOPRIL STARTED AT 10AM HELD THIS PM. NSR W/ OCCASIONAL PVC'S AND PAC'S THIS AM NSR W/ NO ECTOPY THIS AFTERNOON.+PP AND DP PULSES VIA DOPPLER. REPLETED W/ KCL AND CA GLUC. TRANSFUSED 1 UNIT PRBC'S FOR HCT 26.2 UP TO 27.5. SWAN D/C'D.\n\nRESP:FT PRN FOR SOB ON EXERTION, SATS 92-99% ON 6L, O2 DOWN TO 4 L SATS REMAIN IN HIGH 90'S. LS CLEAR BILAT DIMINISHED AT BASES, OCCASIONAL PROD COUGH FOR THICK BROWN-> EXPECTORANT. C, DB ENCOURAGED.\n\nGI: OBESE, +BS, +FLATUS, NO BM\n\nGU: FOLEY PATENT DRG CLEAR YELLOW, GOOD UOP AFTER AM DOSE LASIX, NO RESULTS FROM 1X DOSE GIVEN FOR BLOOD. UOP IMPROVED W/ NEO GTT.\n\nENDO:COVERED W/ RISS, SEE FLOWSHEET\n\nACTIVITY:OOB TO CHAIR AND COMMODE MAX 3 ASSIST W/ WALKER VERY UNSTEADY\n\nPLAN:TITRATE NEO TO OFF, MAINTAIN GOOD UOP,RESP AND HEMODYNAMIC STAUS, ENCOURAGE C, DB,AND OOB\n" } ]

[ { "category": "Echo", "chartdate": "2105-10-21 00:00:00.000", "description": "Report", "row_id": 77062, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction, oost-op tumor excision.\nHeight: (in) 61\nWeight (lb): 149\nBSA (m2): 1.67 m2\nBP (mm Hg): 136/80\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 14:17\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic dysfunction.\nMildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; basal inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. Abnormal\nseptal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal.\nThere is mild regional left ventricular systolic dysfunction. Overall left\nventricular systolic function is mildly depressed. Resting regional wall\nmotion abnormalities include inferior hypokinesis and focal mid anteroseptal\nhypokinesis. The right ventricular cavity is mildly dilated. Right ventricular\nsystolic function appears mildly depressed. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\nThe aortic root is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. Trace aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\n\n\n" }, { "category": "ECG", "chartdate": "2105-10-16 00:00:00.000", "description": "Report", "row_id": 184693, "text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nSeptal ST changes are nonspecific\nST segment elevation in inferior leads - consider inferior myocardial\ninfarction\nAnterolateral ST segment depression in leads l, aVL, V4-V6 - consider ischemia\nwhich is new from previous\n\n" }, { "category": "ECG", "chartdate": "2105-10-16 00:00:00.000", "description": "Report", "row_id": 184694, "text": "Sinus tachycardia\nInferior T wave changes are nonspecific\nAnterolateral ST segment depressions resolved since last ECG\n\n" }, { "category": "ECG", "chartdate": "2105-10-17 00:00:00.000", "description": "Report", "row_id": 184695, "text": "Sinus rhythm\nInferior/lateral T changes are nonspecific\nNo change from previous\n\n" }, { "category": "Radiology", "chartdate": "2105-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887043, "text": " 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX?\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p anterior mediastonotomy\n REASON FOR THIS EXAMINATION:\n PTX?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n There is comparison from .\n\n CLINICAL HISTORY: Lung cancer, lymphoma, recent thoracotomy.\n\n FINDINGS: The heart size is normal. The lungs are clear. Two right-sided\n chest tubes are present, one left-sided chest tube is present. The\n endotracheal tube is above the carina, unchanged from the prior exam. A\n drainage catheter is seen in the central thorax. There is no pleural effusion\n or pneumothorax. A nasogastric tube is present with its tip in the region of\n the gastric fundus.\n\n IMPRESSION: Stable lines and tubes. No pneumothorax or focal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887260, "text": " 7:32 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: intrathoracic process\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p sternotomy/mediastinal mass removal/PTCA\n REASON FOR THIS EXAMINATION:\n intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:50 A.M. ON :\n\n HISTORY: Sternotomy for mediastinal mass.\n\n IMPRESSION: AP chest compared to and 30:\n\n Elevation of the base of the right lung is due in part to lower lobe collapse,\n as well as probable small right subpulmonic pleural effusion, worsened since\n , but stable since . The right upper lung and left lung\n are clear. Midline drains are still in place. There is no pneumothorax.\n Heart is normal size and the mediastinum is midline.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887137, "text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate PTX\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p sternotomy/mediastinal mass removal/PTCA\n\n REASON FOR THIS EXAMINATION:\n evaluate PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate pneumothorax.\n\n CHEST, SINGLE AP VIEW.\n\n Status post sternotomy, with mild prominence of the cardiomediastinal and\n right hilar silhouettes. No pneumothorax detected. The right hemidiaphragm\n is elevated, with blunting of the cardiophrenic angle suggesting pleural fluid\n and/or thickening. No CHF or left effusion. Right and left chest tubes\n present.\n\n IMPRESSION: No pneumothorax identified. Overall, no significant change\n compared with .\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 887451, "text": " 10:34 AM\n CHEST (PA & LAT) Clip # \n Reason: pneumo resolution?\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ant med mass, h/o Hodgkins, now s/p 2CT d/c\n\n REASON FOR THIS EXAMINATION:\n eval for pneumo resolution, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male with anterior mediastinal mass, history of\n Hodgkin's disease.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\n with the previous study of yesterday.\n\n The patient is status post median sternotomy for anterior mediastinal mass.\n Bilateral chest tubes have been removed. No pneumothorax is identified.\n There is continued small right pleural effusion with atelectasis in the right\n lower lobe. The heart is normal in size.\n\n IMPRESSION: No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 886935, "text": " 1:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CT placements\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p anterior mediastonotomy\n REASON FOR THIS EXAMINATION:\n CT placements\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-surgical chest tube placement.\n\n AP SUPINE CHEST RADIOGRAPH: Since exam the patient has\n undergone a sternotomy with wire sutures. Multiple tubes overlie the thorax\n with the tip of the right chest tube overlying an area proximal to the right\n hilum. No vascular congestion, consolidations, effusions, or PTX (recumbent\n exam). The mediastinum is prominent which is consistent with recent surgery\n as well as positioning. There is equivocal slight deviation of the trachea to\n the right.\n\n IMPRESSION: Normal postop radiograph with no PTX identified.\n\n" }, { "category": "Radiology", "chartdate": "2105-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887178, "text": " 1:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? R side pneumonia/atelectasis/CHF\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p sternotomy/mediastinal mass removal/PTCA\n\n REASON FOR THIS EXAMINATION:\n ? R side pneumonia/atelectasis/CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post sternotomy for removal of mediastinal mass, question\n pneumonia.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Rotated positioning.\n\n Low inspiratory volumes. Status post sternotomy. The right hemidiaphragm is\n elevated, unchanged. There is minimal atelectasis at the right base. Two\n left-sided chest tubes are present. No pneumothorax is detected. There is one\n right and one left chest tube. In addition, another piece of tubing loops\n around the chest -- this is of uncertain etiology or significance, unchanged\n with the earlier film.\n\n Compared with earlier the same day, I doubt significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2105-10-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 887300, "text": " 11:24 AM\n CHEST (PA & LAT) Clip # \n Reason: PTX, effusion\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ant med mass, h/o Hodgkins\n REASON FOR THIS EXAMINATION:\n PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST .\n\n HISTORY: Anterior mediastinal mass. Pneumothorax and pleural effusion.\n\n IMPRESSION: PA and lateral chest compared to and 31st:\n\n Elevation of the right lung base relative to the left is still in part to\n increase in small right pleural effusion and atelectasis. Followup advised to\n exclude developing phrenic nerve palsy. Left lung is clear. Tiny fissural\n component of left pleural effusion is stable. There is no pneumothorax.\n Mediastinum is midline.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 886971, "text": " 6:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: ANTERIOR MEDIASTINAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p sternotomy/mediastinal mass removal/PTCA\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post median sternotomy for mass removal.\n\n CHEST, ONE VIEW: Comparison with earlier the same day shows a new\n endotracheal tube in satisfactory position. There is also a left chest tube,\n an NG tube terminating in the stomach, and a femoral catheter in the left\n main pulmonary artery distribution, and a right chest tube. There is no\n pneumothorax, consolidation, or pleural effusion. Median sternotomy wires are\n present. The mediastinum is slightly less prominent.\n\n IMPRESSION: No pneumothorax.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-10-18 00:00:00.000", "description": "Report", "row_id": 1281097, "text": "ekg nsr, no ectopy, rate dropped from low 100 to 80s after increased lopressor. sbp stable, 90 when asleep. lowgrade temp 100. good uo, initially autodiuresing to 360cc/hr, now 140-160cc. maintenance iv at 50cc/hr, taking small amts po fluids. breath sounds clear on the right, coarse on the left, deep breathes well, coughs up small amts thick secretions, uses tonsil tip. uses incentive spirometer effectively. maintaining spo2 > 95% on 6l o2 via nc. chest and mediastinal dressings dry, intact, minimal serosang drainage from cts, no air leaks. abd soft, round, bowel sounds present. skin warm and dry, feet warm, dp and pt pulses palp bilat. r femoral sheath removed by dr. , no bleeding or obvious hematoma. alert and oriented,cooperative, depressed affect. c/o pain at change of shift, inadequately relieved by intermittent analgesic dosing. pca initiated, pt instructed as to purpose and use of system and used effectively, now states he is more comfortable. c/o headache x 1, relieved with 2 tylenol. slept for several hours after pca started. plan to advance diet and mobility today, monitor electrolytes, possibly transfer to f2.\n" }, { "category": "Nursing/other", "chartdate": "2105-10-18 00:00:00.000", "description": "Report", "row_id": 1281098, "text": "CSRU NSG:\n\nNEURO: A/OX3, no neural deficit noted.\n\nCV: SR/ST, no ectopy. Lopressor increased to 50 mg po QID, patient tolerating well. LIpitor started. 1 unit PRBC's given for HCT 27.7. F/U HCT pending. New IV's: #18 RAC, #20 LFA. L radial art line d/c'd without sequelae. 40 mEq KCL given po for K 3.9, repeat K pending. Magnesium 2gm IV given for Mag 1.9, repeat mag level pending.\n\nPULM: All chest tubes removed from wall suction per Thoracic Surgery attending MD, all 3 attachged to JP bulbs. LS clr throughout with SpO2 98-99% on O2 6L/NC in am. After getting OOB->Cair, R side becomess diminished throughout with SpO2 dropping to 94-095% on O2 6L/NC. CPT performed, CXR obtained. Febrile to 100.4po, now 98.6po after aggressive C/DB & IS. Improved aeration to R lung, SpO2 currently 96-98% on O2 6L/NC.\n\nGU: Lasix 20 mg IVP given with large diuresis. Urine clr, dilute.\n\nGI: +BSX4Q, diet advanced to cardiac. Eats jello for breakfast, 50% lunch.\n\nCOMFORT: Morphine PCA controlling pain well. See flow sheet for PCA demands vs. delivery.\n\nINTEG: Repositions self ad-lib. Skin intact.\n\nASSESS: Stable post-op.\n\nPLAN: Transfer to floor ASAP. Continue to encourage C/DB/IS.\n" }, { "category": "Nursing/other", "chartdate": "2105-10-16 00:00:00.000", "description": "Report", "row_id": 1281094, "text": "PT admitted to CSRU from cath lab. Pt was in cath lab s/p median/sternotomy s/p excision from mediastnal mass with ? reoccurence from non hodkins, pt became hemodynamically unstable and had EKG changes. Pt reintubated and sent to cath lab where he had stent of RCA. Plavix and ASA in cath lab arrived on Propofol. Assessment is as follows\nNeuro: On propofol, opens eyes to name and MAE. Perrla\nCV: ST 100-115 no ecotpy. EKG done. BP 90-110/70. Dopplerable pedal pulses. Rt groin swan( no cvp) PA numbers WNL. IVF 1/2 NS at 100cc/hr x2 Liters. Medistianl CT x3 to sx, marked upa and scant drng since.\nResp: intubated and sedated. to sedated overngith due to diffiuclt airway, and to receive steroids overnight and have HOB up. lungs clear\nGI: OGT to lcws, clear output. abd soft. hypoactive bs.\nGU: lg uop, light yellow. Foley patent\nSocial: family in to see pt, and spoke with attending. Updated on dx.\nPlan: Follow CK's. Remain intubated overnight. arterial sheath to be pulled by Dr. . Pull swan and ETT in am\n" }, { "category": "Nursing/other", "chartdate": "2105-10-17 00:00:00.000", "description": "Report", "row_id": 1281095, "text": "7p-7a\nNeuro: Pt sedated on propofol, arousable to verbal and painful stimuli. MAE, weakly. PERRLA. Pt medicated w/ Morphine for pain.\n\nCV: HR 90-110s SR/ST Rare PVCs noted. SBP 90-100 via Left Radial Aline. See Carevue for PA readings. S/P angioplasty to RCA, right arterial sheath pulled by RN at bedside, without complications. Right groin dsg CDI, area soft, no hematoma, no bleeding, + palpable pedal pulses. Bolused w/ 500cc of 1/2NS at beginning of shift secondary to low BP( SBP 85-90), w/ results bringing SBP to high 90s.\nLopressor IV started.\n\nResp: LS clear. Sats 98-100%. Orally intubated, FiO2 of 40%, PEEP 5, RTE of 15 on CMV mode. Suctioned for no secretions to scant yellow via ETT. Suctioned blood tinged via yankeur. 3 Chest tubes intact, dsgs intact, no crepitus, no air noted. Draining serosang. See Carevue for details.\n\nGI/GU: Abd soft round hypoactive BS. OGT to low wall suction draining clear. Foley draining adequate amts of yellow urine, approx. 100-150cc/hr.\n\nEndo: FS covered per riss.\n\nPlan: Monitor hemodynamics. Monitor right groin site. Monitor respiratory status. Plan to wean and extubate in am.\n" }, { "category": "Nursing/other", "chartdate": "2105-10-17 00:00:00.000", "description": "Report", "row_id": 1281096, "text": "CSRU NSG:\n\nNEURO: Propofol d/c'd in am, patient is neurologically intact after extubation. No neural deficit noted.\n\nCV: SR, 90's, no ectopy. BP stable. 0.45%NaCl @ 100cc/hr, rate changed to 50cc/hr per Dr. . R femoral Swan site D/I, no hematoma. Cardiac enzymes decreasing, next set of enzymes due 2400 hrs. CK/MB & Troponin to be drawn Q8H per Cardiology. K & mag repleted per Dr. . IV lopressor changed to 25mg po QID, 1st dose given.\n\nPULM: Extubated to 50% face tent in am, O2 titrated to 6L/NC. SpO2 98-100% on 6L/NC. LS Clr R, clr to coarse L. Chest tubes draining serosanguinous fluid after being stripped by Thoracic Surgery attending MD. C/DB well, IS to 500 with encouragement. Expectorating tan sputum.\n\nGU: Large urine output, clr, yellow. No lasix given.\n\nGI: Abdomen soft, NT, +BSX4Q. Declines meals, takes ice chips and thin liquids without aspiration. Swallows pills easily.\n\nASSESS: Stable, extubated. PO Lopressor started.\n\nPLAN: OOB -> chair after R fem sheath d/c'd. Encourage C/DB & IS. Encourage po intake. Transfer to floor tomorrow if stable.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-10-19 00:00:00.000", "description": "Report", "row_id": 1281099, "text": "ekg nsr, no ectopy. sbp stable. afebrile. adequate uo, occ autodiureses. breath sounds coarse to clear, decreased at l base, db and c well, uses is effectively and independently. maintaining spo2 > 95% on 6l nc. abd soft, bowel sounds present, tolerating po fluids, still has a maintenance iv at 59cc/hr. chest incision dry, mediastinal dressing dry. total 90cc drainage from jp bulbs. alert and oriented, using pca appropriately and moderately. slept in naps.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2124-07-02 00:00:00.000", "description": "Report", "row_id": 1667901, "text": "Nursing Progress/Admit Note.\n\nThis is a 51 yr old male who lives @ a and who developed resp failure requiring intubation @ ED for hypoxemic/hypercarbic resp failure. The pt has a long PMH which includes; COPD, CHF, HTN, LE Cellulitis, DVT's( filter in place), hypercholesterolemia, +cigs, s/p multi intubations, pt has a healed over neck stoma site noted. Pt was living @ receiving Vanco & Cipro antibx for recently dx b/l LE cellulitis. Pt evidently became SOB/dsypnea @ and was transferred to on a 100% NRB receiving cont nebs for prominent wheezing. Unfortunately the pt progressively grew tired and he was therefore intubated @ noontime today. Shortly after intubation the pt was sxn'ed for thick tan mucous plugs. Listed drug allergies include; Compazine, Heparin products, Codeine, Penicillins, Metformin. The pt has a history of MRSA, contact isolation precautions in place. The pt is a Full Code.\n\nRESP: Pt initially received on AC-12-100%-500-10 c nl sats, RR & resp effort on bed rest c adequate IV Propofol sedation in place. 15:30 ABG values; 7.39-87-297, pt changed to CPAP/PS 10/5 c 100% FiO2 in place shortly thereafter. Repeat ABG sent @ 18:20, c the following results; 7.35-91-289. FiO2 subsequently dropped to 40%. Team hoping to extubated tomorrow contingent on pt status. RN report, pt has low lung volumes. Lung sounds noted for mild exp wheezes throughout and diminished BS RLL. Small amounts of thin and frothy sputum per ETT today, sputum C&S sent for analysis. Bronchoscopy performed @ BS c multiple RLL collapsed on exam, BAL sent for analysis. Chest CT performed this afternoon to w/u lung failure, results currently pending. ETT was 23 ATL, pulled back to 21 ATL following bronch MD request. IV Vanco & IV Cefepime antibx dosing in place for antibx cov.\n\nCV: Hemodynamically stable and afebrile. NSR c no ectopy. +2 LE Edema noted c evident erythema 2nd pre-existing cellulitis. Good peripheral pulses noted. LUE AC single lumen PICC in place. 18# R wrist PIV in place. Foley cath in place c adequate hourly clear dilute yellow urine output noted.\n\nMS: Pt currently sedated on 50mcg/kg/min IV Propofol c pt opening eyes to verbal stimuli and consistantly following simple commands when prompted. Pt nodded affirmatively when asked if his ETT caused throat pain. Pt noted to become agitated c direct pt care(during bronch/CT)(and is quite strong) and has required multiple 1-2ml Propofol boluses to maintain pt safety. Pt seems quite comfortable when left alone. Nicotine patch treatment discussed c team for pt comfort.\n\nSOC: No calls or visitors thus far today. The pt has a HCP listed in his chart: .\n\nOTHER: Please see CareVue for additional pt care data/comments.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-02 00:00:00.000", "description": "Report", "row_id": 1667902, "text": "Respiratory Care:\nPt. intubated in E.D. due to exacerbation of COPD (after attempting continuous nebulized albuterol X 1 hour). Post intubation, Pt. required aggressive lavage/SXN, and mucomyst instillation to remove \"Massive single mucus plug\", which had to be hand grasped, and pulled out of the ETT. The plug occluded the ETT, in-line suction catheter, swivel adapter, and six inches of the ventilator circuit. Pt. taken to MICU for further care. Bronched in unit>>OET pulled back 2 cm from 23 @ lip to 21 @ lip. BAL of Rt. LL sent for Gram stain & CX. ABG's drawn times 2 to change Pt. to PSV, after initial A/C settings. Well oxygenated with fully compensated, hypercarbic, respiratory acidosis. Pt. taken for CT of chest. Results pending. Plan continued aggressive pulmonary hygiene, and possible extubation 1-2 days.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-05 00:00:00.000", "description": "Report", "row_id": 1667912, "text": "19:00-07:00\n\nNEURO:PT IS ALERT,ON MINIMAL SEDATION.SWITCHED FROM VERSED TO PROPOFOL AT THE START OF THE SHIFT.PROPOFOL AT 10MCG/KG/MIN.PT C/O BACK PAIN.HAD FENTANYL AND DILAUDID PRN WITH SOME RELIEF.MOVING ALL FOUR EXTREMITIES.\n\nPULM:WAS ON CPAP 40%/PEEP 8/PS 12.WEANED IT DOWN TO 40%/PEEP 5/PS 12.?FOR EXTUBATION TODAY.SAO2>90%.SUCTIONED PRN FOR THICK YELLOW SECRETION.\n\nCVS:IN NSR.ABP WITHIN LIMITS.\n\nGI: SOFT AND DISTENDED WITH POS BS.BOWEL MOVEMENT X3 OVERNIGHT.GUIAC NEG.TF 40MLS/HR,GOAL RATE.STOPPED THIS AM AT 6.00 IN VIEW FOR EXTUBATION.\n\nGU:FOLEY INSITU.PASSING URINE 30-100 MLS/HR.\n\nID:AFEBRILE.CONTINUES ON VANC/CEFEPIME.\n\nSOCIAL:NO PHONE ENQUIRIES.\n\nPLAN:?EXTUBATION THIS AM.MONITOR RESP STATUS.PAIN MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-09 00:00:00.000", "description": "Report", "row_id": 1667928, "text": "MICU Nursing Note 1900-0700\nEvents: Remains extubated, tolerating high flow neb mask with good Sats on 40 %, still requiring Q4hr neb treatments.\n\nNeuro: A+Ox3, pleasant and cooperative, at times anxious but does well with calm approach, follows all commands and moves all extremities, indep in activities except needs assist of 1 to get OOB to commode, c/o back pain (chronic) and med. with IV Dilaudid 2 mg. Q 4hours. Has fentanyl patch in place.\n\nCardiac: HR= 67- 112 SR/ ST, HR increases with all activity and then returns to baseline, occasional PVC's noted, Left radial Aline barely sutured in place and required steri-strip application to maintain placement and new DSD applied, Aline with good waveform and good correlation to NBP, BP= 108-136/80's. Left AC PICC site C/D/I and line patent.\n\nResp: Lungs coarse with exp. wheezes throughout, nonproductive cough noted, RR= , receiving alb/atr nebs Q4hr with good effect, denies increase in SOB, tolerating 40 % high flow mask with Sats= 91-96%.\n\nGI: Abd soft with + bowel sounds all quads, small BM x 1, taking good po intake.\n\nGU: Foley to CD draining clear yellow urine > 40 ml/hr\n\nEndo: fingersticks = 200's. Covered with sliding scale and NPH. Remains on IV steroids.\n\nID: WBC= 17, afebrile, remains off antibx.\n\nSocial: No contact from family or friends overnight.\n\nPlan: Continue Q 4hour nebs, wean FI02 as tolerated, increase activity as tolerated, med for pain prn, Possible transfer to floor for further medical management later today??, Support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2124-07-09 00:00:00.000", "description": "Report", "row_id": 1667929, "text": "Nursing Progress Note:\n\nUneventful shift. Pt. transxferred to 3 in stable condition. Please see Nursing Transfer note and flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-19 00:00:00.000", "description": "Report", "row_id": 1667930, "text": "51 yo man with a long standing history of COPD on home oxygen who has had several admits for copd flare requiring intubation. He was admitted for resp failure prob mucous plugging. He was tx as copd exacerbation with long steroid taper and antibx and was called out ot the floor. he was having resp distress with substantial volume loss despite vigorous pulm toliet he was bronched which showed only a very small opening in the trachea at the site of prior tracheostomy. He was transferred from IP with diagnosis of tracheal stenosis to micu for closer monitoring. PMH copd o2 at home, on prednisone, old trach site, DM2 RISS, CHF, osteo with a thoracic fracture, h/o MRSA (cleared by ID OSH), DVT, IVC filter, hep B. Social currently he lives at rehab, smokes cig a day, extensive ETOH hx now sober, used drugs quit, He is not married but does have children. His mother who lives in is his HCP. Allergies codeine, compazine, pcn, metformin, heparin agents\nNeuro alert to lethagic, oriented x3, mae, given dilaudid 4mg q 4hr for chronic back pain with good relief. He is lethagic but easily , his oxygen saturations improve from low 90% to > 97% after pain med, HR also goes from 120 down to 97.\nresp on 3lnp breath sounds diminished throughout, wheezing occasionally given albut and atrovent neb q 4hr\ncvs HR 97- occasional pvc K+ 3.5 tx with 40meqkcl iv, bp 103/76-123/71, hct 36.7, Na 145 skin w+d lower extremities erythematous R>L +2 edema pp+\ngu voiding well bun 9 cr .5\nGI abd soft non tender BS+ receiving lactulose, senna and colace no stool on DM diet\nendo NPH fixed and ss insulin\naccess PICC ltan\na tracheal stenosis, COPD with home o2, DM2, osteo with thoracic fracture requiring pain med, cellulitis s/p antibx tx\np. to OR thurs for tracheal stent placement, monitor resp status closely, inhalers and nebs as ordered on prednisone, ss and fixed dose insulin, pain med as ordered monitor resp status closely, monitor lower extremities edema increase erythema.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-19 00:00:00.000", "description": "Report", "row_id": 1667931, "text": "Resp Care\nPt ordered for nebs around the clock. BS: expiratory wheezing and decreased aeration at lung bases. BS improving post neb tx's. Pt currently on 2 L NC. Cont nebs as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-19 00:00:00.000", "description": "Report", "row_id": 1667932, "text": "npn\npt to ct scan of trachea and chest for preparation for tracheal stent placement.\nneuro: aox3 some anxiety concerning procedure tomorrow and r/t loss of pt's own pulse oximeter.\npain; pt has contant throbbing in pain in back r/t compression fracture. given dilaudid 2mg q 2 hours which pt states works well refuse po oxycodine. ativan 1 mg ivpo given with last 2 doses which seemed helpful.\n\ncad pt hr st 100-12o earlier now 120 to 130's st no md aware of hr over last few hours, nbp stable 124/80 to 100/71. ? hr or anxiety driven but pt states that this sometimes happens to him.\n\nresp: pt remains on 3l nc, sats mid 90's until he fell asleep in the chair and sats dropeed to high 80's when pt awoken and neck repositioned sats improved, ls are bronchial in upper lobes with i/e wheezing noted. has received nebs q 4 hours.\n\ngi: bs + no bm this shift, pt has hx of consitpation problems and is on bowel regime. appetite good\n\ngu: voiding adequates amt per urinal. > 1000 cc out overnight. am K+ of 3.6 repleted with 40 po also receiving neutrophos x 3 doses\n\nid: afebrile on no antibiotics\n\n\nplan: tracheal stent to be placed tomorrow at 930am continue with pain regiment and supplement with ativan to help control anxiety\n" }, { "category": "Nursing/other", "chartdate": "2124-07-05 00:00:00.000", "description": "Report", "row_id": 1667913, "text": "Nursing progress notes 0700-1900\nEvents: Extubated.\n\nNeuro: Alert, O x3, follow commands, pleasant, co-operative, equal strength to all extremities. C/o backpain, med with Fentanyl and Dilaudid PRN. Started on Lidocain patch for the backpain.\n\nResp: Received on ventilator CPAP with PS 12/+5/ fio2 40%, LS coarse, sat93-95%, sxn minimal thick yellow secretions via ETT. Weaned off gradually and extubated the Pt in the afternoon. Placed on showel mask with cool mist 70%, and decreased to 50% as sat maintained 92-93%, at the baseline. Neb rx given, Pt has good cough, able to expectorate sputum. Sips of water given as olerated. LS with exp wheezes. Pt has filter in place.\n\nCV: HR 73-90, NSR, MAP 95-104, A-line with good waveform, site WNL. Pneumoboots on. T max 99.2, cont on Cefepime/Vanco for BLE cellulitis.\n\nGI: Abd soft, distended, +BS, no BM this shift. TF held for extubation and OGT d/c'd during extubation. Sips of water tolerated well.\n\nGU: Urine output 35-60ml/hr.\n\nSocial: Called by the friend. Pt has money in the safe with the security guard.\n\nPlan: Cont to monitor resp status, urine output.\n Needs pain management.\n Advance oral fluids as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-05 00:00:00.000", "description": "Report", "row_id": 1667914, "text": "Resp Care\nPt extubated w/o incident. Cuff leak noted, no stridor present. Pt on cool aerosol facetent @ 50% FIO2.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-04 00:00:00.000", "description": "Report", "row_id": 1667907, "text": "19:00-07:00\n\nNEURO:PT WAS SEDATED ON 80MCG/KG/MIN OF PROPOFOL,RESPONDING TO ONLY DEEP PAINFUL STIMULI.WEANED PROPOFOL TO 30MCG/KG/MIN.PT SEEM TO BE COMFORTABLE ON THAT,RESPONDING TO VOICE AND OBAYING COMMANDS.REMAINS ON LIMB RESTRAINS.\n\nPULM:REMAINS ON PSV MODE.WAS ON 40%/PEEP 10/PS 10,GASES WERE 7.29/94/79.^PS TO 12.GASES THIS AM 7.42/65/101.REDUCED PEEP TO 8 AND CONTINUES ON THE SAME.SAO2>90%.RR 20-30.SUCTIONED PRN FOR THICK YELLOW SECRETIONS.\n\nCVS:WAS TACHYCARDIC AT THE START OF SHIFT.IN NSR NOW.ABP WITHIN LIMITS.\n\nGI: SOFT AND DISTENDED WITH HYPOACTIVE BS.NO BOWEL MOVEMENT THIS SHIFT.NGT IN PLACE.PT IS NPO FOR ?EXTUBATION.\n\nGU:PASSING URINE 30-80MLS/HR.\n\nID:TEMP ^99.8 AXILLARY.ACETAMINOPHEN GIVEN PRN.\n\nSOCIAL:NO PHONE ENQUIRIES OVERNIGHT.\n\nPLAN:WEAN VENT AND SEDATION AS TOLERATED?EXTUBATION THIS AM.FOLLOW CULTURE REPORT,CONT ABX.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-04 00:00:00.000", "description": "Report", "row_id": 1667908, "text": "Resp Care\nPt. remains intubated/sedated on PSV. Pt. abgs improving t/o shift. Received with profound resp. acidosis, ips increased by 2cm/ albuterol given aggressively with improved abgs t/o shift. Most recent reveals compensated resp. acidosis with adequate oxygenation.\nBs: diffuse exp. wheezes with prolonged exp. phase.\nPlan:Cont.to wean PEEP/ FIO2, cont. bronchodilators.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-04 00:00:00.000", "description": "Report", "row_id": 1667909, "text": "respiratory care\npt on the vent changes made tol fairly well. see respiratory apge oof carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-04 00:00:00.000", "description": "Report", "row_id": 1667910, "text": "NURSING PROGRESS NOTES 0700-1900\nNEURO: RECEIVED ON VENTILATOR CPAP WITH PS 12/+8/40%, PT , NODDING HEAD TO QUESTIONS, MOVES ALL EXTREMITIES IN BED. PROPOFOL INCREASED TO 40 MCG AND WENT UPTO 45 MCG AS NEEDED. REMAINS ON SOFT RESTRAINTS FOR PT'S SAFETY.\n\nRESP: RECEIVED ON VENTILATOR PS 12/+8/40%, LS COARSE TO RHONCHIOUS, SXN COPIOUS SECRETIONS VIA ETT AND ORALLY. VENT SETTINGS CHANGED, TO PS 5/+8/40%, PT DID NOT TOLERATE WELL, HR INCREASED, SAT DECREASED, SO BACK TO PS 12/+8/40% IN THE AFTERNOON, CONT SAME.\n\nCV: HR 87-122, SINUS RHYTHM, PT BECAME TACHYCARDIC IN THE AFTERNOON, C/O PAIN, MEDICATED WITH FENTANYL PRN. ATIVAN GIVEN FOR ANXIETY PRN. PNEUMOBOOTS ON. FLUID BOLUS 500ML NS BOLUS GIVEN FOR DEHYDRATION. VERSED GTT STARTED 2MG/HR, PROPOFOL D/C'D. HR IMPROVED.\n\nGI: ABDOMEN SOFT DISTENDED, +BS, LARGE BM X1. TF PULMONARY FULL STRENGTH 10ML/HR STARTED. ADVANCE AS TOLERATED TO THE GOAL. ON ASPIRATION COFFEE GROUND SECRETION, POSITIVE FOR OCCULT BLOOD. PLS CONTINUE TO MONITOR. GUIAC NEGATIVE.\n\nGU: URINE 60-320 ML/HR,\n\nID: T MAX 99.8, CONT ON VANCO/CEFEPIME.\n\nSOCIAL: NO CALLS FROM FAMILY TODAY.\n\nENDO: INSULIN PER S/S.\n\nPLAN: CONT TO WEAN SEDATION AND VENT AS TOLERATED.\n ADVANCE TF AS TOLERATED.\n MONITOR RESP AND HEMODYNAMIC STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-05 00:00:00.000", "description": "Report", "row_id": 1667911, "text": "Resp Care\nPt. remains intubated/sedated overnight on PSV mode. PEEP lowered to 5 this morning otherwise no changes made. abgs improved compensated resp. acidosis with adequate oxygenation.\nBs:exp. wheezes/ prolonged exp. phase. Secreations minimal yellow thick. Bronchdilators given agressively overnight.\nPlan: Rsbi 18, abgs normalized (given COPD hx). Most likely could tolerate extubation.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-08 00:00:00.000", "description": "Report", "row_id": 1667924, "text": "Resp: pt on f/t@70%. Bs are coarse bilaterally with noted exp wheeze. Nebs administered Alb/Atr with some improvement. Pt unable to cough up secretions and In-exsuffilator initiated, pt tolerated x3, although produced no results. 02 sats in 80's, then changed to Hi-flow 50%. 02 sats 93-95%. Will continue to monitor resp status and treat accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-08 00:00:00.000", "description": "Report", "row_id": 1667925, "text": "Resp Care\n\nPt receiving scheduled bronchodilators. Also receiving in-exsufflator treatments. Pt on 40% high flow neb. BS coarse.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-08 00:00:00.000", "description": "Report", "row_id": 1667926, "text": "Nursing progress notes 0700-1900\nNeuro; Alert, O x3, follow commands, co-operative, able to turn self in bed, OOB to commode once, c/o constant back pain, h/o hip fracture in the past. Fentanyl patch on. Dilaudid 2mg IV PRN given with good effect. MAE.\n\nResp: Received on showel mask 40%, Pt had periods of hypoxia early morning in mid 80's, multiple neb Rx given. ABG showed high Pco2, expected possible intubation today morning for resp distress, team discussed with the Pt, Pt wants to try with non-invasive methods, in-ex sufflator used couple of times. Pt was able to maintain sat 91-98%, LS exp wheeses and coarses throughout. Cont on furosemide PO with good effect. Cont with neb Rx. Pt had one episode of tachycardia in 120's while transfered to commode. Methylprednisone increased 125mg q8hrs for one day. X-ray chest done in the afternoon.\n\nCv: HR 70-100, NSR with rare PVC's. MAP 91-108, team aware. Cont on pneumoboots. Afebrile, antibiotics completed for cellulitis and PNA.\n\nGI/GU: Abdomen soft, +BS, small BM this shift, cont on bowel regimen. Pt has poor appetite, taken liquids PO. Insulin per s/s and fixed dose. Urine improved with Lasix.25-350ml/hr.\n\nSkin: Slightly excoriated at the periarea and inner thigh.\n\nAccess: Lt PICC line, A-line.\n\nSocial: No calls from family.\n\nPlan: Monitor resp status, ?intubation.\n Pain management.\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-09 00:00:00.000", "description": "Report", "row_id": 1667927, "text": "RESPIRATORY CARE:\n\nFollowing pt for Q4 hour bronchodilator rx's. BS's markedly diminished, with some coarseness. Cough strong, non-productive. Administering Albuterol/Atrovent nebs via face mask as ordered. See flowsheet for rx times, further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-03 00:00:00.000", "description": "Report", "row_id": 1667903, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\nMULTIPLE DRUG ALLERGIES, INCLUDING HEPARIN.\n\n51YR OLD MALE WITH SEVERE COPD ON HOME O2, MULTIPLE ADMISSIONS AND INTUBATIONS RELATED TO COPD FLARE,SMOKING, S/P IVC FILTER FOR DVT, PRESENTS FROM A NURSING HOME WITH RESP DISTRESS. IN PT WAS FOUND TO BE HYPOXIC IN 7OS/ INTUBATED/ SUCTIONED LARGE MUCOUS PLUG, POSS PNA. ADMITTED TO MICU FOR MANAGEMENT.\n\nPT RECEIVED AND REMAINS SEDATED WITH PROPOFOL/TITRATED 40(50) UNABLE TO TITRATE TO A LOWER DOSAGE AS PT BECOMES VERY RESTLESS. REQUIRES FREQUENT BOLUSES DURING CARE AND REPOS. PT ALERT, EASILY AROUSABLE. OPENS EYES ON VOICE STIMULATION, ATTEMPTS TO COMMUNICATE AND REPOS SELF. FOLLOWS COMMANDS. PEERLA. MAE.\n\nHEART RYTHM SINUS WITH NO ECTOPIES, HR:80S-100S/ SBP HIGH 90S-110S/\nAFEBRILE/ TMAX:97.9. WBC:14.9. REMAINS ON VANCO AND CEFEPIME.\nHOME MEDS ON HOLD: LASIX, ALDACTONE...\n\nPT INTUBATED ON PS 10/5, 40% FI02. NO VENT CHANGE THIS SHIFT. RESP EFFORT UNLABORED AND EVEN. LUNG SOUNDS DIMNINISHED THROUGHOUT. SATO2 92-96%. GOAL SAT 90-96% IN SETTING OF COPD AND HYPERCARBIA. SUCTION MOD-SMALL AMOUNT OF THIN WHITE SPUTUM. PT S/P BRONCH ON . CHEST CT PENDING. CHEST XRAY POS FOR SMALL EFFUSION. PER REPORT PT HAS VERY LOW LUNG VOLUME. RSBI >100. PLAN TO EXTUBATE PER TEAM DISCRETION. WILL CONSIDER NON INVASIVE VENTILATION POST EXTUBATION.\n\nABD OBESE, POS BS. NO BM. REMAINS NPO. OGT IN PLACE.\n\nFOLEY PATENT DRAINING CLEAR YELLOW URINE.\n\nSKIN W/D. BIL L EXT REDNESS CELLULITIS. TRACE EDEMA. MOUTH CARE AND REPOS FREQUENTLY.\n\nNO FAMILY CONTACT THIS SHIFT. REMAINS FULL CODE.\n\n\nMONITOR RESP STATUS/ POSS EXTUBATION, BUT RSBI>100\nCONT ANTBX.\nCONT IV STEROIDS\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-03 00:00:00.000", "description": "Report", "row_id": 1667904, "text": "Resp Care\nPt. received intubated on PSV mode. Intubated yesterday for mucous plug, resultant in resp. failure, subsequently bronch'd ( BAL PND).\nStable night Vt's 400-500cc with avg MV 5-7lpm. Last abg 1800 revealed compensated resp. acidosis with hyperoxygenation. Fio2 weaned.\nBS:prolonged exp. phase with diffuse exp. wheezes. Sxn'd for thick yellowish x2.\nPlan: Pt. desaturated to 87% during morning rsbi (116). Wean ips as tolerated during day.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-03 00:00:00.000", "description": "Report", "row_id": 1667905, "text": "respiratory care\npt on the vent changes made tol well. see respiratory care page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-03 00:00:00.000", "description": "Report", "row_id": 1667906, "text": "7a-7p MICU Nursing Progress Note\n\nEvents: Pt w/ episodes of ^ anxiety/agitation today. Propofol titrated ^ prn; ativan given prn as well.\n\nROS:\n\nNeuro: Pt sedated on Propofol gtt, currently @ 80 mcg/kg/min. He awakens to voice, follows commands. MAE. Pt able to communicate via writing today as well.\n\nResp: Pt intubated on PSV: 10/10/40%. Pt w/ ^ RR @ times. LS coarse. Sxn for thick secretions. Sats low-mid 90's. Pt continues on Vanco/\nCefepime for ? PNA. Also on MDIs/Steroids for COPD Exac.\n\nCV: HR in 100's-one teens most of day, ST, no ectopy noted. Art line placed today. ABP > 120's.\n\nGI/GU: Abd softly distended, +BS, no stool today. NPO except meds. OGT clamped. Foley in place, draining clear/yellow urine, uop marginal.\n\nPlan: Monitor resp status closely; Continue ABX/MDIs/Steroids for COPD Exac and ? PNA; wean vent as tolerated; titrate sedation prn; routine ICU care and monitoring.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-07 00:00:00.000", "description": "Report", "row_id": 1667922, "text": "Nursing progress notes 0700-1900\nNeuro: Alert, O x3, pleasant, co operative with care. Behaviour appropriate and anxious at times. MAE with normal strength. Continue with backpain, medicated with Dilaudid and Oxycodone PRN. Fentanyl patch increased to 50 mcg.\n\nResp: Cont on face tent 50%, LS with insp wheezes at the begining of shift,improved with neb rx. Desating on n/c while eating. RR 13-23, sat 94-96%. tapering Prednisone. Cont on neb Rx. Pt was OOB to chair for few hrs. Seen by PT, and cough encouraged.\n\nCV: 64-80, NSR, noted occasional PVC's in the afternoon with one episode of tachycardia while sitting in the chair, team notified. A-line with good waveform, MAP 108-115, pneumoboots on. Afebrile.\n\nGI/GU; Abd soft, +BS, no BM this shift, cont on bowel regimen. Appetite fair. Insulin per s/s and fixed dose. Cont on Lasix PO, urine output good.\n\nPlan: Cont monitoring on resp status, monitor labs and lytes.\n Tapering Prednisone.\n Needs pain management, cont neb Rx.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-08 00:00:00.000", "description": "Report", "row_id": 1667923, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHERE OBJ DATA\n\nMULTIPLE DRUG ALLERGIES INCLUDING HEPARIN\n\n51 YR OLD MALE WITH SEVERE COPD FLARE ON HOME O2, MULTIPLE ADMISSIONS AND INTUBATIONS RELATED TO COPD FLARE, SMOKER, S/P IVC FILTER, PRESENTS FROM A NH WITH RESP DISTRESS. IN , PT WAS FOUND TO BE HYPOXIC IN 70S/ POSSIBLY PNA, INTUBATED NOW EXTUBATED.\n\nEVENTS: PERIODS OF HYPPOXIA ON 70% FACE TENT, DESPITE MULTIPLE NEB TX. ABGS AS FOLLOWED: 7.38/95/65/24/58. REPEAT: 7.40/76/57. BIPAP ATTEMPTED, PT UNABLE TO TOLERATE.\n\nA/OX3, FOLLOWS COMMANDS, MAE. REPOS SELF IN BED. C/O BACK PAIN(HX OF CHRONIC BACK PAIN) DILAUDID 2MG X2DOSES GIVEN WITH SOME EFFECT. PT RESTING IN SHORT NAP/ UNABLE TO LIE FLAT.\n\nHEART RYTHM SINUS WITH NO ECTOPIES. TACHY ON EXERTION/ HR: 80S-110S. ABP:120-140S/DBP:70S-90S WITH MAP 100S. TEAM AWARE. SPIRINOLACTONE LISTED AS HOME MED. HAS NOT RESUMED YET.\nAFEBRILE/ TMAX:98.9/ WBC:18.9, ANTBX D/CED ON .\nDIURISING LARGE AMOUNT OF CLEAR YELLOW URINE/ REMAINS ON LASIX 6OMG PO BID. FLUID BALANCE: LOS NEG.\nRECEIVED LAST DOSE OF SOLUMEDROL/ WILL START ON PREDNISONE TODAY.\nREMAINS ON SSI AND FIXED DOSE NPH.\n\nRESP EFFORT MAINLY UNLABORED THROUGHOUT THE NIGHT. THIS AM, PT STARTED HAVING PERIODS OF HYPOXIA IN MID 80S. MULTIPLE NEB TX GIVEN. ABGS SHOW HIGH PCO2. WOB BECOME SLIGHTLY LABORED/ CONT WITH MULTIPLE NEB TX/BIPAP TRIAL UNSUCCESFUL. LUNG SOUNDS RHONCHIOUS AND WHEEZING THROUGHOUT. SATO2:80S-96 ON 70% FACE TENT. TEAM AWARE, CONT TO MONITOR. WILL CONSIDER INTUBATION IF PT RESP STATUS DOES NOT IMPROVE.\n\nABD SOFT,POS BS. NO BM. TOLERATES PO INTAKE.\n\nFOLEY PATENT, DRAINING CLEAR URINE IN LARGE AMOUNT.\n\nSKIN W/D/I. SKIN CARE DONE.\n\nNO FAMILY CONTACT THIS SHIFT.\n\nMONITOR RESP STATUS/ SERIAL ABGS PER TEAM DISCRETION\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-21 00:00:00.000", "description": "Report", "row_id": 1667939, "text": "Resp: Pt in presently on 4 lpm n/c. BS are diminished bilaterally. HHN given Q4 hrs Alb/Atr with good effect. Pt has t-tube in place. Will continue to follow. No resp. distress noted. PT 02 sats @ 95%.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-21 00:00:00.000", "description": "Report", "row_id": 1667940, "text": "NURSING PROGRESS NOTES 0700-1100\nNeuro: Alert, O x3, appropriate behaviour, c/o constant back pain, medicated with Hydromorphone 2 mg IV q 2hrs. Lidocaine patch off now. Pt is sitting in the chair, appears comfortable.\n\nResp: Pt cont on O2 2 lit/min via n/c, sat 93-97%, LS coarse upper lobes and diminished bases. T tube placed yesterday for tracheal stenosis. Able to speak with the tube capped. No cough, no shortness of breath noted. Able to ambulated in the hallway with the occupational therapist, tolerated well.\n\nCV: HR 98-114, SBP 95-123, temp 99.1, peripheral pulses palpable. Lt hand PICC line for access.\n\nGI/GU: Abdomen soft distended, +BS, no BM today. On diabetic diet, Insulin s/s with fixed dose. Urine output adequate, voids yellow clear urine.\n\nSocial: No calls from the family today.\n\nPlan; Cont to monitor resp status, suction PRN, possible c/o to the floor. ? taper Prednisone. Contact .\n" }, { "category": "Nursing/other", "chartdate": "2124-07-06 00:00:00.000", "description": "Report", "row_id": 1667918, "text": "MICU NPN 11AM-7PM:\nNeuro: Pt awake, alert and oriented , follows commands well. Turned side to side and tolerated light CPT. Able to assist with ADL's. Appears anxious and worried about his numbers on the monitor at times. received fentanyl patch 25mcg at 12 noon and was started on Po dilaudid which did not help his c/o back pain. Ordered and received IV dilaudid with better pain relief. Team will consult pain service.\n\nCV: Vital signs are stable. HR 70-90's NSR. BP 110-160's.\n\nResp: O2 50% face tent applied alternating with 6L N/C while eating. Continues to have stable O2 sat 94%-06%. Lungs with wheezes still and pt getting nebs albuterol/atrovent Q2-4hr. CPT did not help get any sputum production.\n\nGI: Tolerating PO's well. Abdomen is soft non-tender. No stool so far. Taking senna and colace as ordered.\n\nGU: Foley is draining 20-50cc/hr.\n\nEndo: Started on NPH insulin as well as QID sliding scale. Blood sugar 218 at 1800 and will cover accordingly.\n\nSocial: I called his Mother and updated her on his progress as he requested me to do.\n\nID: afebrile on vanco/cefipime.\n\nPlan: Continue to monitor resp status closely. Titrate O2 as needed.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-06 00:00:00.000", "description": "Report", "row_id": 1667919, "text": "MICU NPN Update:\nMICU Nursing Coverage 7PM-11PM:\n\nPt's vitals signs remains stable. Pt remains on 50% cool face tent with sats 93%-95%. Lungs with coarse rhonchi with exp wheezes. Pt seems to exhalation when I listen. Received Dilaudid 3mg IV just about every four to five hours for c/o back pain with some relief. Tolerating PO's, turns well in bed and assists with turns. PICC dressing changes as well as a-line dressing. Both sites look good.\n\nUO adequate via foley. ?transfer to floor tomorrow if stable overnight.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-07 00:00:00.000", "description": "Report", "row_id": 1667920, "text": "Resp: Pt rec'd on 50% f/t. Bs are coarse bilaterally with noted exp wheeze. Improvement over yesterday. Alb/Atr administered Q4 hrs with good affect. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-07 00:00:00.000", "description": "Report", "row_id": 1667921, "text": "Nursing progress note (2300-0700):\n\nROS:\n\nNeuro: A&O x 3, anxious at times. Pt awake the entire night. States \"I am afraid to sleep...last time I fell asleep I ended up in a coma\".\nFollows commands, MAE. Overall deconditioned, turns well in bed w/ supervision. Prefers to sit upright on back. C/O pain to back..given 2mg IV dilaudid w/ good effect..pain to 5/10.\n\nResp: LS w/ exp wheezes to bilateral apices and rhonchorous to bil bases. Given atrovent/alb nebs and MDIs. O2 sats 89-93%...increases to 94-96% after CDB. RR 13-20. Cont on FT of 10 lpm @ 50%. cont on guaifenesin.\n\nCV: SR. ABP 120s-130s/80s. no ectopy. Denies c/o CP or lightheadedness. + pedal pulses bilaterally.\n\nGI/GU: Abd soft, + BS, no BM. Tolerating diabetic diet. Urine clear/yellow. UOP @ 0500 low, but otherwise adequate. Will cont to monitor hourly. BUN increased 26(23), creat unchanged 0.5.\n\nID: afebrile. Cont on cefepime and vanco for PNA and BLE cellulitis.\n\nSkin: intact, warm, dry. BLE skin warm, no erythema noted.\n\nPlan:\ncont to monitor Resp status closely\nCont w/ neb txs/MDIs, encourage CDB, CPT.\nPain mgmt...? need for pain services to consult for chronic back pain.\nmonitor labs and replete lytes as needed.\nPhysical therapy consult.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-06 00:00:00.000", "description": "Report", "row_id": 1667915, "text": "Nursing progress note (0500):\n\n50 yo male admitted w/ severe COPD (on home O2) and hx of smoking. Pt was intubated for hypoxic Resp failure likely to mucous plugging and possible hospital acquired pna (RLL PNA & new pleural effusions). Extubated yest around 1430 w/o incident.\n\nEvents: FIO2 increased from 50% to 70% early this am for increased congestion/exp wheezing. Given 40mg IV lasix x 1. Per pt, \"breathing feels a little better\". CXR done, ABG drawn. Please refer to carevue for results.\n\nROS:\n\nNeuro: Pt alert and oriented x 3, follows commands, cooperative, MAE. Slightly anxious at times. Does not tolerate being flat for repositioning for very long d/t anxiety about his breathing...O2 sats maintain >90% while lying flat. Given 0.5mg IV ativan w/ some effect.\n\nResp: LS coarse throughout w/ exp wheezes to bilateral apices. Given alb/atrovent nebs tx's. RR regular. O2 sats 89-94%...increased FIO2 to 70%. Productive cough..thick/clear secretions. Cont on methylprednisone.\n\nCV: ABP 120s-150s/70s-80s, NSR, no ectopy. HR 70s-80s. AM labs pending. HCt stable @ 36.7(36.4). INR 0.9.\n\nGI/GU: Abd soft, BS present, no BM. Pt tolerating sips. Urine clear/yellow. UOP adequate.\n\nID: afebrile. Cont on vanco/cefepime.\n\nPain: pt c/o back pain . Given IV dilaudid w/ short term effect. ? Need for po long acting pain med.\n\nSkin: BLE pink/warm. Skin C/D/I. PPP bilaterally.\n\nplan:\n\nCont to monitor resp status closely, ? need for additional lasix, cont neb txs, ? switch to po steroids, pain mgmt (? need to switch to po pain meds), ADAT.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-06 00:00:00.000", "description": "Report", "row_id": 1667916, "text": "Resp: Pt rec'd on 70% f/t. BS are coarse bilateally with exp wheeze noted and spc. Lasix administered and nebs alb/atr Q4 hrs with noted improvement. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-20 00:00:00.000", "description": "Report", "row_id": 1667937, "text": "npn 0900-1900\n\nneuro;aoox3 mae to command perla oob to chair with min assistance.\n\nresp;lungs coarse upper diminished bilaterally with ins/exp wheeze improved after atrovent neb.t-tube capped on 2ln/c and 40% face tent. with sats 96-98% rr 18-20.\noob to chair and became disonnected from oxygen transiently sats dropped to 77 very slow to come back fio2 increased to 50% sutioned for mod amounts blood tinged secretions with sats improving to 91% given daily lasix dose of 60 mgs po with diuresisi sats 95% pt reamined witwithout distress though using accessory musclestalking in sentences using is to 1250. strong productive cough.small amount bloody secretions around t-tube dsd changedx3.\n\ncvs; tax 98.6 po sinus tach110-130's states baseline hr is around 110 usually.bp 96/45-102/70.\n\ngu; condom cath in place diuresing good amounts of clear yellow urine inresponse to po lasix.\n\ngi; taking oral fluids and trying dsolids swallowing pills without difficulty.bs on riss. soft no stool no flatus.\n\nskin; in good condition\n\npain; asking for pain medication every hour and a half dulaudid inceased to q2 but pt drowsy but veryeasily roused.\n\nsoc; no family calls or visits\n\na/p stable post ttuubepacement continue towean fio2 as poss encourage gentle pulmonary toilet.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-06 00:00:00.000", "description": "Report", "row_id": 1667917, "text": "Nursing 0700-1100\n\nNuero: pt alert to voice and oriented X 3. pt able to move all extremeties.\n\nCV: No chest pain or chest discomfort. +PP, good CSM. Pt in a SR with no ectopy. ABP 120-140/70-80's.\n\nRespiratory: LS with wheezes in all . No SOB or DOE noted or stated by the pt. Pt receiving neb treatment per . pt with a non-productive cough. Pt with face tent on at 10L on .70%.\n\nGI: Bowel sounds present, No BM. Pt taking PO. abdomen soft non-tender.\n\nGU: foley draing clear yellow urine.\n\nSkin/other: cellulitis resolving, pt c/o back pain pt given 2 mg of IV dilaudid pain down to 7/10. Additional dose of 2mg of IV dilauded given pain decreased .\n\nPlan: ? change pain medication, attempt to decrease O2 requirement. montior respiratory status.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-21 00:00:00.000", "description": "Report", "row_id": 1667938, "text": "NPN 1900-0700:\nPlease see CareVieu and Transfer Note for further details.\n\nNeuro: alert, oriented x3, sitting on the chair almost all the night, refused to go back to bed, claimed he is much more comfortable on the chair, c/o constant back pain, on Lidocaine patch applied at to be OFF at 0800, received 2 mg Dilaudid IV Q 2 hrs PRN with good effect.\n\nResp: Yesterday underwent T tube placement for tracheal stenosis, site cleaned with saline, able to speak with tube capped, suctioned occasionally for minimal thick yellowish secretions, on O2 NC received at 4 LPM, decreased to 2 LPM as sat was 100%, presently sat 90-96%, LS CTA with diminished at bases and occasional exp wheezes resolved by Alb/At tx.\n\nCV: NSR-ST HR 96-130, BP stable, with lt hand PICC line, palpable peripheral pulses, on Prednisone, insulin NPH and RISS.\n\nGI/GU: tolerating diet and taking whole pills well, abdomen soft, BS present, voiding freely and adequately.\n\nInteg: Afebrile, with MRSA in nares on contact precautions, with fungal rash on perineal area, antifungal cream applied with good effect.\n\nSocial: Full code, will call his mom in the morning, he has 5 children with whom his relation is not intimate, not calling.\n\nPlan: Taper prednisone, monitor FS and possibly stop NPH as he is not used to take it at home, but started in hospital for steroid tx hyperglycemia, suction PRN, possible call out to floor, transfer note written, needs to be updated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-20 00:00:00.000", "description": "Report", "row_id": 1667933, "text": "Resp: Pt rec'd on 3 lpm n/c with ^ wob noted. BS reveal bilateral exp wheeze with diminished bases. HHN nebs of alb/atr administered and Heliox initiated with no improvement. Pt was intubated without incident. Ett 6.5, taped @ 24 lip and placed on a/c 12/500/5+/50%. Xray revealed tube placement to be 2 cm above carina. Ett pulled out to 23 cm. 02 sats @ 100. See careview for abg's. Fio2 titrated to 35%. Audible cuff leak noted but receiving adequate Tv's of 500+. Pt is schedule to OR today for tracheal stent placement. RSBI=no resps/OR procedure.\n" }, { "category": "Nursing/other", "chartdate": "2124-07-20 00:00:00.000", "description": "Report", "row_id": 1667934, "text": "O. patient lethagic, tachycardic 127-131 ST, o2 sats 87-91% lungs very diminished, patient's effort to breathing worsening through the night. Heliox attempt without improvement in symptoms. ABG drawn at 0000am 7.16/pao2 89/arterial co2 59/ base excess 17. He stated that he was struggling to breathe, he was electively intubated at 0100. Placed on AC 50/500/12/5 abg 7.28/ p02 90 Arterial co2 51 excess 17 fi02 decreased to 35%. Lungs clear upper lobes, diminished lower lobes o2 sat improved, HR 90-110\ncvs HR improved after intubation, K+ 3.5, Hct 32.3 bp 85/ after intubation he was given 500cc NS x2 bolus bp remained 89/-103/ skin w+d pp+\nNeuro patient placed on fentanyl 50mcg q hr and versed 2mg q hr after intubation responds, mae, fc, pupils equal and reactive\ngu voiding well condom cath placed\ngi abd obese soft nontender bs+ no stool\nendo held nph pm dose pt npo, did not require ss insulin\naccess picc ltantecub\na. tracheal stenosis with increasing respiratory distress\np. to OR this am for tracheal stent placement\nreplete lytes, support patient\n" }, { "category": "Nursing/other", "chartdate": "2124-07-20 00:00:00.000", "description": "Report", "row_id": 1667935, "text": "NURSING ACCEPTANCE NOTE OR-MICU8.\n\npt returned from or accompanied by anaesthesia.after having t-tube placed by dr .placed ,on 100% trach mask by resp; with sats 99-1005 rr22-24 pt breathing looks laboured using accessory muscle .pt states that breathing much better. lungs sounds coarse upper diminished at bases.suctioned for mod amounts bloody secretions.min amount of bleeding around site.\n\npt aoox3 mae to command c/o of back pain given dilaudid 2mgsi.v.x2 with good effect.pt asking appropriate questions.st 100-110,bp 104-110/70 passing mod amounts of clear yellow urine via condom cath. denies nausea vomiting c/o of being dry.\n\ns/b dr , button placed over jtube pt talking and coomunicating need. placed on n/c sats 88% face tent added and weaned to 35% with 1 ln/c maintaining o2sats 94-95% strong cough with encouragement may start to have sma;ll amounts of clear liquids soon.per dr .\n\na/p stable s/p t-tube placement in trachea.\nencourage gentle pulmonary hygiene as tolerated .\ntreat pain with dilaudid advance diet as oredered. poss return to nursing home.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-07-20 00:00:00.000", "description": "Report", "row_id": 1667936, "text": "Respiratory Care Note\nPt taken to OR at start of shift. Pt received from OR at 9am - pt now has a T-tube in place. Pt placed on trach mask as noted. Pt's T-tube capped at 10am and tolerating fairly well. Unit dose Atrovent and half unit dose of Albuterol given at 12pm via neb. BS diminished bilaterally with improved aeration after neb. Atrovent neb given at 3p with improved aeration.\n" }, { "category": "ECG", "chartdate": "2124-07-10 00:00:00.000", "description": "Report", "row_id": 308793, "text": "Sinus tachycardia. Compared to prior tracing of the rate has slowed.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2124-07-04 00:00:00.000", "description": "Report", "row_id": 308794, "text": "Sinus tachycardia, rate 124. Since tracing of the technical\nartifacts are improved. Minimal slowing of the heart rate is seen. Slight\nimprovement in the ST-T wave abnormalities is noted.\n\n" }, { "category": "ECG", "chartdate": "2124-07-02 00:00:00.000", "description": "Report", "row_id": 308795, "text": "Sinus tachycardia. Technical baseline artifact. Since tracing of the\nrate is increased but there probably has been no other change.\n\n" }, { "category": "ECG", "chartdate": "2124-06-28 00:00:00.000", "description": "Report", "row_id": 308796, "text": "Sinus rhythm. Other than somewhat more rapid rate tracing is unchanged from\n and remains normal.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2105-03-11 00:00:00.000", "description": "Report", "row_id": 1822578, "text": "Nursing Progress Note\n\n\n2.O: Weight 3455 gms down 65 gms. On ad lib demand waking\nq4h for feeds. Mom nursed at 2300 then bottled him. He woke\nat 0330 and took 70cc's e20 bottling well. Abdomen soft,\npositive bowel sounds, no loops. Had a moderate green stool\nheme negative. PO Zantac given as ordered. No spits or\naspirates.\n A: Tolerating feeds. Not yet up to birth weight.\n P: Continue to monitor. Continue with present plan.\n3.O: Mom and Dad in at 2300. Mom nursed him and Dad bottled\nhim. They slept in for the 0300 feed.\n A: Loving and concerned parents.\n P: Inform and support.\n4.O: No vomiting or heme positive secretions noted. Abdomen\nbenign.\n A: Infant improving. Zantac seems to be working.\n P: Continue to observe.\n5.O: Waking for feeds. Active and for cares. Temp\nstable in a crib 98.2. Bottling well.\n A: Gestationally appropriate.\n P: Dc home possiblly today after 24 hours of Zantac.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-11 00:00:00.000", "description": "Report", "row_id": 1822579, "text": "Neonatology Attending\nDOL 5\n\nInfant remains in room air with no distress and no cardiorespiratory events.\n\nLow resting heart rate. No murmur.\n\nWt 3455 (-65) on ad lib demand feeds with fair intake and moderate breastfeeding skills. Abd benign. Stooling (guiac negative). On oral ranitidine.\n\nCircumcision today.\n\nA&P\n40 week GA infant s/p GI hemorrhage, presumptive gastritis\n-Hearing screen in progress\n-Hepatitis B to be administered\n-Will plan to discharge tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2105-03-11 00:00:00.000", "description": "Report", "row_id": 1822580, "text": "Neonatology Attending\nAddendum - Family Meeting\n\nFamily meeting attended by both , RN and myself. We reviewed course to date, diagnosis of presumptive stress gastritis, plan to treat with ranitidine until follow-up appointment with GI service, and physical signs and symptoms for which they should contact their pediatrician, including intolerance of feeds or changes in stool.\n\nTime 45 minutes\n" }, { "category": "Nursing/other", "chartdate": "2105-03-11 00:00:00.000", "description": "Report", "row_id": 1822581, "text": "Neonatology Attending\nAddendum - Family Meeting\n\nFamily meeting attended by both , RN and myself. We reviewed course to date, diagnosis of presumptive stress gastritis, plan to treat with ranitidine until follow-up appointment with GI service, and physical signs and symptoms for which they should contact their pediatrician, including intolerance of feeds or changes in stool.\n\nTime 45 minutes\n" }, { "category": "Nursing/other", "chartdate": "2105-03-11 00:00:00.000", "description": "Report", "row_id": 1822582, "text": "NPN 7a-7p\n\n\n#2: has been ad lib demand feeding, both breast and\nbottle feeding. Breastfed this am, with aid of LC. Was\nattempting to feed over an hours time, but only latch and\nfed intermittently. Per Mom infant feeds better from one\nside. After breastfeeding was awake 2hrs later and took\n60cc E20. 3hrs later woke and took 70cc E20. Mom will be\nhere for next feed and will try breastfeeding again.\nBottles with good coordination. Sm spits and sm wet burps\nnoted- all nml milk color, no blood noted. Conts on Zantac\nas ordered. Abd soft, and flat with + throughout.\nStooled x2 heme negative. S/P circ. this am. Tip of penis\nnow red with swollen edges. Underside of penis tip noted to\nhave small clot. Min bleeding noted. Base of penis with\nmild edema r/t lidocaine block. Sterile gauze with vaseline\napplied to tip of penis. A: tol'ing feeds, no bleeding from\nGI tract noted P:Cont to follow wt and exam. Monitor tol\nto feeds. Will start FeSO4 today as ordered. Tylenol given\nfor pain PRN. Will F/U with GI at TCH in 1mo.\n\n#3: in this am for feeding, and Mom in throughout\nthe rest of the day. Both updated. Indep with care and\nfeeding. Mom did work with LC this am. Agreeable to plan\nfor d/c home tomorrow. Aware that infant passed hearing\nscreen. Will need pedi appt. Info given on Hep B vaccine,\nawaiting consent. Mom considering . Family meeting ~1515.\nA: Involved family, eager to take infant home. P:Cont to\nsupport and educate. Prepare for d/c.\n\n#4: No dark red secretions noted thus far. Abd exam stable.\nSpits and wet burps nml milk color. Stool testing heme\nnegative. A: stable. P:Cont to monitor. Will arrange F/U\nGI appt.\n\n#5: Temps stable while swaddled in an open crib. Infant is\n/active with cares. Waking on own for feeds q2-4.5hrs.\nMAE. Fonts soft/flat. Sucks on pacifier. Settles with\nholding and containment. Passed hearing screen. A: AGA\nP:Cont to support dev needs. Hep B vaccine if/when consent\nsigned.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-10 00:00:00.000", "description": "Report", "row_id": 1822575, "text": "Neonatology Attending\nDOL 4\n\nRemains in room air with no distress and no cardiorespiratory events.\n\nWell-perfused.\n\nHct 39.5 yesterday.\n\nBilirubin 7.7/0.3 off phototherapy.\n\nWt 3795 (-100) on ad lib demand breastfeeding. Abd benign. On IV ranitidine. D-stick 60,64 overnight. Voiding. Meconium stools, no frank blood.\n\nTemperature stable.\n\nA&P\nTerm infant with UGI hemorrhage, resolving hyperbilirubinemia\n-Continue to monitor cardiorespiratory status and repeat hct prior to discharge\n-Transition to oral ranitidine today and monitor for another 24 hours prior to discharge\n-Will arrange family meeting for today\n" }, { "category": "Nursing/other", "chartdate": "2105-03-10 00:00:00.000", "description": "Report", "row_id": 1822576, "text": "Nursing Progress Notes.\n\n\n#2 O: Baby continues to breastfeed ad lib demand. Baby woke\nevery 2 to 4 hours. Abdomen benign, voiding and stooling\ntransitional stools. Stool guiac negative this afternoon.\nIV hep lock removed. Zantac changed to PO. Lactation\nconsult done with mom this morning. A: Learning to\nbreastfeed. Mom's milk is begining to come in. P: Continue\nto encourage breastfeeding.\n#3 O: parents called for each feeding as requested. A:\nParents supported to breastfeed. P: Continue to keep\ninformed. Plan for family meeting today.\n#4 O; No bleeding noted today. Stool transitional and\ntested guiac negative. Changed to oral Zantac today. A: No\nbleeding noted. P: Monitor on oral zantac for any bleeding.\n#5 O: Temp stable in open crib. Baby wakes to demand feed\nevery 2 to 4 hours and feeds well. Baby sleeps between\nfeeds and sucks his pacifier when offered. A: Appropriate\nfor age. P: Continue to support development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-10 00:00:00.000", "description": "Report", "row_id": 1822577, "text": "NPN 1500-2300\n\nRESPIRATORY/CARDIOVASCULAR\nInfant remains stable in room air with O2 sats 96-100%.\nRR mainly 30's-50's, LSC=. Well-perfused with normal pulses\nin all 4 extremities. Color pink/sl.jaundiced. No apnea,\nbradycardia or marked desaturations thus far this shift.\n\nFLUID AND NUTRITION\nInfant's wt this evening: 3455gms(-65). Infant feeding ad\nlib amts. Enfamil 20 PO if his mom is not available to\nbreastfeed; otherwise he is breastfeeding ad lib. Abd. soft\nand nondistended, no loops, B.S.(+). No emesis. Voiding and\nstooling q.s.---stool guiac neg. No evidence of bleeding\nthis shift. Started on PO Zantac at 1700.\n\nGROWTH AND DEVELOPMENT\nInfant awake, and active with care periods. MAE, AFOF.\nTemp. stable; 98.6(F) to 98.2(F) axillary. Infant swaddled\nin an open crib, wearing a t-shirt and diaper. Sucks on\npacifier while awaiting feedings. Slept well between feeds.\n\nPARENTING\nInfant's parents at his bedside on/off throughout the\nevening. Encouraged by this nurse to go to their room for\nsome rest/dinner break/quiet while sleeps. They plan\nto \"skip\" one of the night feedings so that they can rest.\nInfant's parents updated on his status and the plan for the\nnight by this nurse.\nParents requested infant have a circumcision while he is\nhere; Dr. \"in house\" this evening/tonight and stated\nthat she will get consent and will be available to do the\nprocedure tonight if they want (after she finishes up with\na laboring patient.)\nWill keep parents informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822571, "text": "Nursing Progress Notes.\n\n\n#1 O: Baby completed 48 hour rule out sepsis at 1400. A: 48\nhour antibiotics complete. P: Problem resolved.\n#2 O: Total fluids changed to breastfeeding ad lib. IV\nsaline locked this morning. Baby did not latch initially\nbut breastfed well after lactation consult and use of nipple\nshield. D/stix 76 off IV fluids. Abdomen soft, bowel\nsounds active, no loops, girth stable, voiding well and\npassing meconium. A: Learning to breastfeed with nipple\nshield. Tolerating feeds well. P: Continue to encourage\nfeeding ad lib.\n#3 O: Parents up to visit and hold baby at each feeding\nevery 2 to 4 hours. Baby is and fussy at times when\nhe has trouble latching. Mother is aware that baby may not\ngo home with her tomorrow. A: Involved family. P: Continue\nto keep informed.\n#4 O: No spits noted today, remains on zantac. A: resolving\nproblem on zantac. P: continue zantac until 1 month follow\nup with GI.\n#5 O: Temp stable on off warmer. Baby is swaddled and\nsettles with pacifier after feedings. Baby wakes about\nevery 2 hours to feed. A: Appropriate for age. P: Continue\nto support development.\n#6 O: Phototherapy discontinued at 0700 today. A: Improving\nbili. P: Check rebound bili in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822572, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in Ra. Active, , 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": "2105-03-10 00:00:00.000", "description": "Report", "row_id": 1822573, "text": "NPN 1900-0730\n\n\n2. WT TONOC 3.520GMS. DOWN 100GMS FROM YESTERDAY. CONT. TO\nBF ON DEMAND BUT NOW PARENTS WILLING TO TRY FORMULS TO\nSUPPLEMENT BABY. INFANT CONT. TO HAVE SOME DIFFICULTY\nLATCHING ON RIGHT AWAY. MOM USING SHIELD WITH SOME\nSUCCESS. STILL PRODUCING SMALL AMOUNTS OF COLOSTRUM. MOM\nFEELS MILK STARTING TO COME IN AS OF TODAY . BF Q3 HRS.\nTHEN TAKING IN APPROXIMITLY 20-25CC OF E20. D/S 60-64. NO\nINCREASE IN JITTERS NOTED. ABD SOFT, NO LOOPS. +BS. PASSING\nMEC STOOL. NO FRANK +BLOOD NOTED. VOIDING WELL.\n\n3, MOM IN FOR EACH FEEDING ATTEMPTING BF WITH EACH CARE.\nBECOMING MORE INDEPENDANT WITH DIAPER CHANGE AND TEMP\nTAKING. BOTJ PARENTS APPEAR LOVING AND CARING AS WELL AS\nOVERWHELMED. TEACHING DONE AND SUPPORT PROVIDED.\n\n4. NO FRANK =+ BLOOD NOTED IN STOOL. SMALL SPIT X1 WITHOUT\nBLEEDING NOTED. CONT WITH MEC STOOL.\n\n5. REMOVED FROM OFF WARMER TO OAC. TEPS STABLE. A/A WAKING\nFOR ALL CARES. POING ALL FEEDS.\n\n6. ATTEMPTED TO DRAW REBOUND BILI BUT U/A TO OBTAIN AFTER\nATTEMPS X5. NP AND STATES OKAY TO ATTEMPT ON DAY\nSHIFT. REMAINS SLIGHTLY JAUNDICE. STOOLING WELL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-10 00:00:00.000", "description": "Report", "row_id": 1822574, "text": "physical exam\ncomfortable in an open crib\nanterior fontanelle soft, open and flat. Equal air entry with clear breath sounds bilaterally. Regular rhythm with normal rate, no murmur. Abdomen soft, nonidstended with normal bowel sounds. Warm, well perfused\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822566, "text": "NPN\n\n#1 S. O. Infant continues on antibiotics as ordered. No\nsigns or symptoms of infection noted. A.R/O sepsis. P.\nCheck cx's.\n\n#2 S. O. Repogle d/c'd. early in the shift. Infant fussy\nand acting hungry. Mom putting infant to breast q 4 hours.\n Infant not latching on.Sucking vigorously on\npacifier.Abdomen soft with no loops. Piv infusing with d10w\nwith lytes. Advanced to 100cc/kg/day. D stick 86. Lytes\nand bili drawn. Voiding and passing black mec. A.\nInfant's condition improved . P. Monitor closely.\n\n#3 S. O. Parents updated at the bedside by this \nNNP.Parents holding infant and talking to infant. A.\nLoving ,concerned parents. P. support and keep updated.\n\n#4 S. O. Zantac given as ordeed. No blood tinged\nsecretions noted. Repogle tube d/c'd early in the shift.\nHct drawn and slightly improved. A. Stable at present\ntime. P. Monitor closely.\n\n#5 S. O. Infant waking and sucking vigorously on pacifier.\nResponding to voices. A. Term infant. P. Support.\n\n#6 S. O. Received infant under double phototherapy with\nmask on. Bili level improved. Phototherapy d/c'd at 0800.\nA. Hx of jaundice. P. Monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822567, "text": "6 hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 6 hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822568, "text": "Neonatology Attending Note\nLast line should read \"further evaluation not recommended...\"\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822569, "text": "Neonatology Attending Note\nLast line should read \"further evaluation not recommended...\"\n" }, { "category": "Nursing/other", "chartdate": "2105-03-09 00:00:00.000", "description": "Report", "row_id": 1822570, "text": "Neonatology Attending Note\nDay 3\n\nRA. RR40-60s. +Nasal congestion. Mild rtxns. HR 80-110s. BP 63/40, 49. No murmur.\n\nHct 39.5\n\nOff photot this am for a bili of 6.1/0.3.\n\nOn amp/gent.\n\nWt 3620, down 175. NPO. TF 100 cc/k/day D10 + 2 and 1. Started to BF last PM. Abd girths stable. Abd soft. Voiding 3.2. Passing guaiac positive stools. On zantac.\nd/s 86\n140/4.5/103/24\n removed last night.\n\nOn off warmer.\n\nA: FT infant with hematemesis, r/o sepsis\n\nP: HepLock IV and encourage BF, obtain lactation consultation\n check rebound bili in am\n cont Zantac, may switch to po once feeding better\n GI service feels further not recommended at this time, 1 month follow-up in clinic arranged\n" }, { "category": "Nursing/other", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 1822562, "text": "Neonatology Attending\nExam AF soft, flat, upper airway congestion, repogle in place, clear bs, no murmur, soft abd, nondistended, nontender, normal bs, no hsm, active, under phototherapy\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 1822563, "text": "Neonatology Attending\nExam AF soft, flat, upper airway congestion, repogle in place, clear bs, no murmur, soft abd, nondistended, nontender, normal bs, no hsm, active, under phototherapy\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 1822564, "text": "Neonatology Attending\n\nDOL 2 FT GI bleed\n\nStable in RA.\n\nHemodynamically stable. MAP 42-50s. BP 62/40 mean 47.\n\nNPO on D10W at 60 cc/kg/d. Repogle in with minimal drainage. No further fresh UGI bleeding. Last bleed yesterday evening. AG 28-28.5 cm. KUB unremarkable. On zantac. Voiding. Melanotic stools persist. 138/4.2/100/26 BUN 19 DS 103 Wt 3795 grams.\n\nNormal LFTs. SGOT 48 SGPT 13\n\nPT sl elevated at 21->second dose of Vit K->PT normal at 16.4. PTT normal at 34.8.\n\nBili 7/0.3. Triple->double phototherapy. BT A+/A-/Coombs neg\n\nHct stable at 37.7 (stable after drop from 59)\n\nInitial CBC hct 59 plt 250 wbc 25 (70P/2B). BC pending. On A/G.\n\nParents in and up to date. Pediatrician Dr. has been in.\n\nA: UGI bleed likely secondary to gastritis or ulcer. Hemodynamically stable despite large hct drop. Coags normalized. Hct stable. On zantac. Hyperbili being treated. Ruling out for sepsis.\n\nP: Monitor\n Maintain NPO\n Await GI input. Will likely need endoscopy\n Continue zantac\n Maintain repogle. No further lavage.\n Follow daily hct as long as he has no further bleeding\n Add lytes to IV\n Increase fluids to 80 cc/kg/d\n Continue phototherapy\n Follow bili\n Continue A/G for R/O\n Support parents\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 1822565, "text": "Nursing Progress Note:\n#1 - SEPSIS: Infant continues on amp and gent as ordered.\nCardiovascular and respiratory status stable. GI status\nseems to be improving at this point. Continue to assess.\nBlood cultures pending.\n# - F&N: TF at 80cc/kilo = 12.6cc/hour. NPO secondary to\nGI bleeding yesterday. No active bleeding noted today. Has\nhad two bloody stools - maroon in color. No frank blood\nnoted. Repoggal to LIWS without drainage. Flushed one time.\nabdomin soft and flat. +BS. GIrth 28cm. Voiding. GI team\nconsulted today - believe the history of bleeding points to\na gastritis from a stressful delivery. Baby seems to be\ndoing better at moment. Hct stable at 38.8 (noon) Plan is\nto stay NPO til . Continue to monitor for s/s of\nbleeding. Continue on Zantac. Lytes, Bili and HCt am.\n#3 - PARENTS: Mom and DAd in this afternoon. Mom held for\nsome time. Updated at the bedside by NICU and GI team.\nFamily given GI card to follow up in 4 weeks after discharge\nor sooner if needed.\n#5 - G&D: Temps stable on warmer. Alert and active at times.\nSUcking on pacifier. Acting hungry at times. MAE. AFSF.\n#6 - BILI: Decreased from triple to double phototherapy this\nam ~9. Bili at 12 - 6.5/0.3. Recheck bili in the am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-07 00:00:00.000", "description": "Report", "row_id": 1822559, "text": "NICU Nursing Admission Note:\nAdmitted baby boy from for vomiting of dark and dark-pink blood. Placed on warmer, active and alert, color pink/slightly ruddy. LS = and clear, no murmur heard. VSS, BPm40's. KUB done. Was lavaged woth normal saline via NGT, first infusion/removal (50cc's total using 10cc increments in/out yielded dark (old) blood and dark-pink bloody returns. 2nd infusion/removal of 40 cc's yeilded more clear/light brown returns. Is presently on intermittent suction, no returns in \"trap\" at present. Abdomen remains soft, active bowel sounds, and is pink. Planning to obtain LFT's, to repeat PT/PTT for accuracy, along with repeat Hct. PIV presently infusing D10W at 60cc/k/d, D/S upon admission:71. Parents in to visit, updated by Dr. at bedside. TCH Gastroenterology consulting. Infant sleeping comfortably at present, active with handling but settling well.\n" }, { "category": "Nursing/other", "chartdate": "2105-03-07 00:00:00.000", "description": "Report", "row_id": 1822560, "text": "Neonatology Attending Admit Note:\n\nAsked by Dr. to evaluate infant due to r/o UGI bleed.\n\nInfant born to a 33 year old G1P0 mother negative, RPR NR, RI, blood type A positive and antibody negative. EDC .\nBenign prenatal course. Mother presented on in spontaneous labor. Due to arrested descent, infant delivered by C/S on at 2221. Infant required PPV x 4 minutes. Bulb suctionned for thick secretions--not noted to be bloody. Transferred to for further care.\n\nIn newborn nursery, some spits of old blood noted overnight. Our team was contact at ~3 pm when infant vomitted a large amount of dark maroon colored blood. Had one good feed since birth. Vital signs stable. Brought to NICU for further evaluation.\n\nGBS negative, maternal low grade temp. ROM 5 hours prior to delivery. no meconium stained amniotic fluid.\n\nInitial PE: wt=3795g, HC=36.5cm, L=20 inches. BP mean=48 (68/40), HR=140's, RR=50's. well appearing infant in no distress, responsive, pink. AFOF, normal S1S2, no murmur, breath sounds clear, abdomen slightly distended yet soft, nontender, bowel sounds slightly decreased. ext warm, well perfused. tone aga.\n\nLabs: CBC: WBC=25 (70P,1Band,1nucleated RBC), crit=60%, plt=250\ninitial PT=21.6, PTT=36.5 INR=3.1\n\nKUB: normal gas pattern throughout\n\nIn NICU, infant lavaged with 90 cc normal saline. Initially, obtained old hemolyzed blood and then obtained bright red blood and ultimately, this cleared and no blood remained.\n\nImp/Plan: FT well appearing male infant with hematemesis at 17 hours of age, lavage showed bright red blood that has now cleared. Unlikely due to swallowed maternal blood since became bright red with lavage. Possibly due to gastritis, ulcer. Cannot r/o coagulopathy.\n\n--contact hematology lab-- test is not available.\n--add Zantac IV\n--give repeat Vitamin K (first Vitamin K administration was documented)\n--obtain LFT's to assess for liver dysfunction\n--monitor crit and BP\n--repeat coags since lab noted that if crit >55%, may not be reliable unless amount of anticoagulant within tube is titrated\n--NPO, D10W at 60cc/kg/d; if bleeding does not recur, will consider restarting feeds over next day or 2.\n--consulted GI in case endoscopy is needed.\n--I updated family at length.\n" }, { "category": "Nursing/other", "chartdate": "2105-03-08 00:00:00.000", "description": "Report", "row_id": 1822561, "text": "NPN\n\n#1 S. O. Infant started on ampiciliin and gentamycin as\nordered. No further secretions from repogle. A. R/o\nsepsis. P. check labs\n\n#2 S. O. Npo. D stick 103. Unsure if infant has voided due\nto loose stools. Piv of d10w infusing at 60cc/kg/day.\nZantac started iv.Infant having several large liquid dark\nredred/brown stoolsRepogle continues on intermittent\nsuction..Repogle adjusted 3cms in ,after kub done. Lavaged\nwith normal saline with no return. Attending and NNp\naware.a Lytes,lfts and bun done. See flow sheet. A.\nConcerning colored stools. P. Monitor closely.\n\n#3 S. O. Parent in several times and were updated at the\nbedside by this R.N,NNP and Attending. Mom held infant. A.\n Concerned,lving parents. P. Support and keep updated.\n\n#4 S. O. Repogle in place with no secretions obtained.\nRepogle continues on intermittent suction. Noted several\ndark red/black stools.Following q 2 hour hcts.Pt,Ptt drawn.\nSee lab flow sheet for results. A. Large drop in hct.now\nstabilizing. P. Monitor closely.\n\n#5 S. O. Infant quiet at the beginning of the shift,later\nmore alert and fussy. Npo. Sucking vigorously on pacifier.\nA. Infnt getting hungry. P. Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-12 00:00:00.000", "description": "Report", "row_id": 1822583, "text": "NPN:\n\nRESP: Sats 98-100% in RA. RR=40-50. BBS =/clear. No A&Bs or desats thus far tonight.\n\nCV: No murmur. HR=90-120s. BP=80/48 (54). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=3465g (+ 10g). AdLib/Demand feeds. Intake yestyerday = 78cc/kg/d. Mother breast fed x 1. Baby latched on intermittently but slept much of the session -> bottled well for 70cc BM/E-20 afterwards. Abd soft, flat, active bs, no loops. Voiding qs; yellow stool heme neg. No spits. Remains on Zantac.\n\nG&D: Term babe. Temp stable in crib. Active and w/cares. Probable discharge today. HBV given last eve. PKU to be done. Med (Zantac) given. to bring in prescription med today so that present dosage may be calculated. Pedi appt for . F/U GI appt to be made by . to be contact.\n\nSOCIAL: in. Mother breast fed. Loving and involved couple; handle baby well.\n" }, { "category": "Nursing/other", "chartdate": "2105-03-12 00:00:00.000", "description": "Report", "row_id": 1822584, "text": "Discharge Physical Exam\nAnterior fontanelle soft, open and flat. Red reflex present bilaterally. Palate intact. Clavicles intact. Equal air entry with clear breath sounds bilaterally. Regular rhythm with normal rate, 2/6 SEM LLSB with no radiation. Normal active bowel sounds, soft, nondistended with no organomegaly. 2+ femoral pulses, circumcised normal male. Patent anus, no dimple. Stable hips. Warm, pink. Normal tone, normal suck and normal grasp and moro.\n" }, { "category": "Nursing/other", "chartdate": "2105-03-12 00:00:00.000", "description": "Report", "row_id": 1822585, "text": "Neonatology Attending\nDOL 6\n\n remains in room air with no distress and no cardiorespiratory events.\n\nNo murmur noted this morning. BP 80/48 (54).\n\nWt 3465 (+10) on ad lib demand feeds with intake 78 cc/kg/day in addition to breastfeeding well. Voiding and stooling. On ranitidine orally.\n\nState screen sent, hearing screen passed. Circumcision healing. PMD updated yesterday.\n\nA&P\nTerm infant s/p upper GI hemorrahge presumed secondary to gastritis\n-Will discharge home today with follow-up with PMD, GI service (Dr. , \n-Parental education regarding medicatio administration completed\n-Discharge time > 30 minutes\n" }, { "category": "Nursing/other", "chartdate": "2105-03-12 00:00:00.000", "description": "Report", "row_id": 1822586, "text": "NPN 7a-3p\n is now dol 6. He conts breathing comfortably in RA, sats >/=96%. RR stable. BBS cl/=. No retractions noted. Soft murmur noted late in day. Dr. assessed. 4-ext. BP's taken-WNL per Dr. . Dr. to call and inform pedi, Dr. and he will follow. Dr. did discuss issue with . Hr stable. Conts with nml pulses and brisk cap. refill. Pale to slightly jaundice in color. WT 3465. Waking for feeds ~q1-3hrs. Conts to work on breastfeeding skills. Will latch and feed well for max of 20mins. Does tire at breast. Often appears asleep after breastfeeding, but when put down wakes and is actively rooting. Mom has expressed BM and offer supplemental bottles of Bm20/E20. Infant bottles well taking ~20-70cc. No spits noted. Abd soft, +, no loops. Voiding qs. Stooling yellow seedy heme negative stools. Circ site conts to heal. Tip of penis pink, edges slightly swollen. Sm amt of whitish/tan healing tissue noted. instructed not to remove. Reviewed circ care again, and application of vaseline. Conts on Zantac 3 times/day. did bring in prescription they had filled. Verified concentration and dose with Dr. . Taught how to draw up and give. Dad correctly drew up dose and gave to infant. Reviewed times to give med . Also reviewed not to give double dose if 1 dose is missed. Not to give more of med if infant spits it out. verbalized understanding. Assisted Mom with sponge bath. She did well. Aware that infant can have tub baths when cord falls off and circ site is completely healed. is /active with cares. Waking on own for feeds. MAE. Temps stable while swaddled in an open crib. indep with care and feeding. Mom conts to work with LC on breastfeeding. Does have naames and #'s of LC in her area to f/u with. aware of and agreeable to visit on Sat. Pedi appt tomorrow at 2pm. All info. given on f/u appt with Dr. on , 5. Phone # and attending,Dr. info given to in case need for insurance referral. Reviewed all d/c teaching with -see d/c checklist. Dad correctly positioned infant in carseat. Reviewed Safe Travels and Back to Sleep- gave written info. Also reviewed Tummy Time stressing that infant must be supervised at all times, and be awake. If falls asleep turn onto back. updated by Dr. . Eager for d/c. Immunization booklet given. Tags checked. D/C exam done. D/C order in chart. referral faxed. Infant d/c'ed home with in carseat.\n" }, { "category": "Radiology", "chartdate": "2105-03-07 00:00:00.000", "description": "BABYGRAM AP ABD ONLY", "row_id": 823073, "text": " 3:46 PM\n BABYGRAM AP ABD ONLY Clip # \n Reason: full term infant with upper gi bleed vs swallowed maternal b\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n full term infant with upper gi bleed vs swallowed maternal blood, normal exam,\n assess bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 1 day old term neonate with upper GI bleed versus swallowed maternal\n blood.\n\n COMPARISON STUDIES: None are available.\n\n FINDINGS: The bowel gas pattern appears normal. A paucity of bowel gas in\n the pelvis is likely related to a urine filled bladder. No abnormal masses or\n calcifications. Bony structures are unremarkable.\n\n IMPRESSION: Normal portable KUB.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-08 00:00:00.000", "description": "P BABYGRAM ABD WITH DECUB (74020) PORT", "row_id": 823094, "text": " 12:56 AM\n BABYGRAM ABD WITH DECUB () PORT Clip # \n Reason: evaluate bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with gastrointestinal bleeding\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 2 day old term neonate with GI bleeding.\n\n COMPARISON STUDIES: Portable KUB \n\n FINDINGS: Interval placement of an enteric tube with the tip projected over\n the stomach. The supine view is limited in that the right lateral aspect of\n the abdomen is not included on the image. The visualized bowel gas pattern\n appears normal. No abnormal masses or calcifications. Bony structures are\n unremarkable.\n\n The left lateral decubitus views shows no convincing evidence for\n pneumoperitoneum. The basilar lungs are clear.\n\n IMPRESSION:\n\n 1) Normal portable KUB's.\n\n 2) Interval placement of enteric tube.\n\n" } ]

[ { "category": "ECG", "chartdate": "2170-07-22 00:00:00.000", "description": "Report", "row_id": 187366, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of no\ndiagnostic interim change.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1252910, "text": " 9:39 PM\n CHEST (PA & LAT) Clip # \n Reason: PNA that could have been the trigger of DKA?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with DM I here with DKA\n REASON FOR THIS EXAMINATION:\n PNA that could have been the trigger of DKA?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetes mellitus type 1 with diabetic ketoacidosis.\n\n TECHNIQUE: PA and lateral views of the chest.\n\n COMPARISON: .\n\n FINDINGS:\n\n Right-sided Port-A-Cath tip terminates at the cavoatrial junction, unchanged.\n Cardiac, mediastinal and hilar contours are normal. Lungs are clear. No\n pleural effusion or pneumothorax is identified. Clips in the right upper\n quadrant indicate prior cholecystectomy.\n\n IMPRESSION:\n\n No acute cardiopulmonary abnormality.\n\n DFDdp\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-01-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 777462, "text": " 3:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P CATH; R/O BLEED.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: S/P bleed.\n\n NONCONTRAST HEAD CT:\n\n No prior studies for comparison.\n\n There is no evidence of acute hemorrhage. There is no evidence of an extra-\n axial fluid collection or mass effect. There are malacic changes in the right\n occipital pole with associated surgical changes in the calvarium in this\n location presumably representing encephalomalacia perhaps from prior stroke or\n hemorrhage. There is a persistent cavum septum pellucidum et Vergae. The\n ventricles and sulci are slightly prominent consistent with mild brain\n atrophy. The paranasal sinuses are clear.\n\n IMPRESSION: No evidence of acute hemorrhage. Malacic changes right occipital\n pole as described. Persistent cavum septum pellucidum et Vergae.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-17 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 777454, "text": " 2:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: S/P CATH LAB; R/O RETROPERITONEAL BLEED.\n Field of view: 45\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST:\n\n INDICATION: 67 YEAR OLD MALE STATUS POST CATH LAB RULE OUT RETROPERITONEAL\n BLEED.\n\n TECHNIQUE: Non contrast images of the abdomen and pelvis were performed.\n There is no prior examination for comparison.\n\n CT OF THE ABDOMEN WIHTOUT CONTRAST: The lung bases are clear. A hiatal hernia\n is noted. Arthrosclerotic calcification of the descending thoracic and\n abdominal aorta are noted. Non-contrast evaluation of the liver, gallbladder,\n pancreas, spleen and adrenal glands reval no abnormality. The kidneys are\n unremarkable for solid lesions, hydroneprosis or stones. Hypoattenuating well\n delineating lesions within both kidneys are noted consistent with simple renal\n cysts. There is no evidence of retroperitoneal or intraabdominal\n hemorrhage/hematoma. There is no ascites or free air. The bowel loops are\n unremarkable. There is no mesenteric or retroperitoneal lymph node\n enlargement. Note is made of non-specific minimal perinephric stranding.\n\n CT OF THE PELVIS WITHOUT CONTRAST: There is no evidence of retroperitoneal or\n intrapelvic hemorrhage. A ill defined, superficial, sporadic hematoma\n overlying the left groin is identified. This does not extend along the\n iliopsoai and remains superficial anterior to the fasciculata. No definite\n collection or pseudoaneurysm is noted. No free fluid is seen within the\n pelvis. The anterior pelvic bowel loops are unremarkable. The Foley catheter\n baloon tip was seen within the bladder.\n\n The osseous structures are unremarkable for suspcious or sclerotic lesions.\n\n IMPRESSION: 1. Superficial spreading hematoma overlying the left groin with\n no definite collection or pseudoaneurysm seen. No evidence of retroperitoneal\n or intraabdominal hemorrhage.\n 2. Incidental note of hiatal hernia and simple renal cyst.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-01-18 00:00:00.000", "description": "ART DUP EXT LO UNI;F/U", "row_id": 777539, "text": " 1:26 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: please assess L groin s/p cath with hematoma for av fisutula\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p cath c/b hematoma\n REASON FOR THIS EXAMINATION:\n please assess L groin s/p cath with hematoma for av fisutula, pseudo aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac cath, now with hematoma.\n\n FINDINGS: Duplex and color Doppler of the left inguinal area demonstrates\n no evidence of a pseudoaneurysm or an AV fistula.\n\n" }, { "category": "Echo", "chartdate": "2163-01-17 00:00:00.000", "description": "Report", "row_id": 74093, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotensive . r/o Pericardial effusion.\nBP (mm Hg): 162/60\nStatus: Inpatient\nDate/Time: at 14:14\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Basal inferior hypokinesis is present.\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened.\n4. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2163-01-18 00:00:00.000", "description": "Report", "row_id": 171169, "text": "Sinus bradycardia. Diffuse non-specific ST-T wave flattening. Compared to the\nprevious tracing of the rate has slowed. Otherwise, no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-01-17 00:00:00.000", "description": "Report", "row_id": 171170, "text": "Sinus rhythm. Diffuse non-specific ST-T wave flattening. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-17 00:00:00.000", "description": "Report", "row_id": 1445427, "text": "CCN Progress Note:\n\nS- sedated & confused.\n\nO- see flowsheet for all objective data.\n\ncv- Tele: NSR no ectopy- HR 63-66 B/P 124-144/ 25-66 L groin dsg D&I-\ngroin ecchymotic- feet = cool to touch- DP pulses absent bilaterally-\n(+) PT's with doppler- transfused only 90cc of PRBC's HCT 39.5- K 3.9\n\nresp- In O2 4L via NC- lung sounds coarse bilaterally- resp even,\nnon-labored- SaO2 97-99%- Pt has Hx lung Ca with mets to brain & prostate.\n\nneuro- oriented to person & place- periods of confusion noted- lethargic- received versed, fentanyl, phenergan, & benadryl in cath lab- moving all extremities- follows command.\n\ngi- abd lg soft (+) hypoactive bowel sounds.\n\ngu- foley draining hematurea- work-up for prostate Ca pending- U/O qs.\n\nskin- red rash noted on upper body & R groin/thigh area.\n\nA- allergic reaction to protamine post cath.\n\nP- monitor vs, lung sounds, I&O, & labs- give benadry PRN for itchyness- con't hydrating IV .45S @ 150cc/hr X 2L- first liter infusing- offer emotional support to Pt ( cares for wife who has MS)\nkeep him updated on plan of care- assess neuro status & note any changes.\n\nP-\n" }, { "category": "Nursing/other", "chartdate": "2163-01-18 00:00:00.000", "description": "Report", "row_id": 1445428, "text": "CCU Nursing Progress Note 1900-0700:s/p CATH\nMS: Pt MS improving. Currently A/O/X/3. Very pleasant and cooperative. No signs of dysarthra. C/o of back pain overnight and given Percocet times two with good effect.\n\nCV: HR 50s to 60s. NIBPs 120s to 150s. Lopressor dose given around MN and tolerating well. Groin site with continued slow ooze overnight. Dgs taking down because of saturated through over time. Small soft hematoma noted early in shift with no expansion overnight. Area ecchymotic. Pressure dsg applied around 4AM with no noted ooze since. Intially reported from prior shift that DP pulses not dopplerable but PTs were and BLE cool to touch. Since DPs now dopplerable and extremeties warm touch. Knee immobilizer in place for ooze. Post cath fluids given times one liter per Dr. due to pt's hypertensive.\n\nRESP: LS course. O2Sat 96-98% on 4LNP. No c/o SOB.\n\nGU/GI: UO adequate overnight. Abd soft-distended, (+)BSs. Eating toast and cofee this AM and tolerating POs fine. No BM overnight.\n\nID: Afebrile issues.\n\nA/P: s/p cath c/b by anaphalatic shock d/t protamine.\n\nContinue to follow hemodynamics.\nPossible call out to floor.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2185-11-12 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1217288, "text": " 11:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 19-year-old male with respiratory failure and history of dilated\n cardiomyopathy.\n\n COMPARISON: Chest radiograph from and and concurrent\n chest CT.\n\n PORTABLE SEMI-ERECT AP CHEST RADIOGRAPH: The endotracheal tube terminates 5.4\n cm above the level of the carina. Nasogastric tube courses below the\n diaphragm with the tip in the stomach. Consolidation within the right base\n may reflect aspiration or pneumonia, and is better characterized on concurrent\n CT. Silhouetting of the left hemidiaphragm suggests probable basilar\n atelectasis. The upper lungs are clear. The mediastinal and hilar contours\n are within normal limits. Moderately severe cardiomegaly is stable.\n\n IMPRESSION:\n 1. Standard position of lines and tubes.\n 2. Bibasilar consolidation which suggests atelectasis, though right base\n concerning for possible aspiration or pneumonia on concurrent CT.\n 3. Stable moderately severe cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2185-11-17 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1217976, "text": " 3:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: r dl picc 51cm iv \n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 51cm iv \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line placement.\n\n COMPARISON: Chest radiographs, .\n\n FINDINGS: One upright AP portable view of the chest. The right PICC line\n ends in the right atrium. There is moderate-to-severe cardiomegaly. The\n opacity of the right lung base is unchanged. The upper lungs are clear. The\n mediastinal and hilar contours are normal. There is no pulmonary vascular\n congestion.\n\n IMPRESSION:\n 1. Right PICC line ends in the right atrium. Suggest pulling back 3 cm.\n\n 2. Otherwise unchanged from study done five hours earlier.\n\n These findings were discussed with the IV nurse at 3:15 p.m. on by telephone.\n\n\n" }, { "category": "Echo", "chartdate": "2185-11-16 00:00:00.000", "description": "Report", "row_id": 94400, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Now on Milrinone.\nHeight: (in) 72\nWeight (lb): 204\nBSA (m2): 2.15 m2\nBP (mm Hg): 96/61\nHR (bpm): 109\nStatus: Inpatient\nDate/Time: at 13:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severe\nglobal LV hypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AS. Trace\nAR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Dilated main PA.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nseverely dilated. There is severe global left ventricular hypokinesis (LVEF\n~15 %). The right ventricular cavity is mildly dilated with severe global free\nwall hypokinesis. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. There is no aortic valve stenosis. Trace\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. There is no mitral valve prolapse. Mild to moderate (+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThe main pulmonary artery is dilated. There is no pericardial effusion.\n\nIMPRESSION: Severely dilated and severely hypokinetic left ventricle. Mildly\ndilated right ventricle with moderate global hypokinesis. At least mild\npulmonary hypertension. Mild-to-moderate mitral regurgitation.\n\nCompared with the prior study (images reviewed) of , left\nventricular cavity size is smaller and right ventricular function is slightly\nimproved.\n\n\n" }, { "category": "Echo", "chartdate": "2185-11-15 00:00:00.000", "description": "Report", "row_id": 94401, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary embolus. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 211\nBSA (m2): 2.18 m2\nBP (mm Hg): 105/70\nHR (bpm): 112\nStatus: Inpatient\nDate/Time: at 13:36\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Severe global RV free wall hypokinesis.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Dilated main PA.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The right atrium is markedly dilated. Left\nventricular wall thicknesses are normal. The left ventricular cavity is\nseverely dilated. with severe global free wall hypokinesis. 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. Mild to moderate (+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is moderate pulmonary artery systolic hypertension. The main pulmonary\nartery is dilated. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , right\nventricular systolic function is now more severely impaired. The left\nventricle is now more dilated. Mitral regurgitation is now slightly less\nprominent.\n\n\n" }, { "category": "ECG", "chartdate": "2185-11-16 00:00:00.000", "description": "Report", "row_id": 250553, "text": "Sinus tachycardia with ventricular premature beats. Low limb lead voltages\nwith prominent voltages in the precordial leads raise concern for a dilated\ncardiomyopathy. Poor R wave progression may be due to enlargement of the right\nventricle. Compared to tracing #1 ventricular premature beats are seen on the\ncurrent tracing. Other findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-11-15 00:00:00.000", "description": "Report", "row_id": 250776, "text": "Sinus tachycardia. Poor R wave progression. Presence of low limb lead\nvoltages and prominent voltages in the lateral precordial leads with ST-T wave\nchanges raises concern for dilated cardiomyopathy. Compared to tracing\nof the findings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2185-11-13 00:00:00.000", "description": "Report", "row_id": 250777, "text": "Sinus tachycardia. Low voltage complexes generally. Biatrial enlargement.\nProbable right ventricular overload. No significant change compared to the\nprevious tracing of . Voltage is much reduced compared to the previous\ntracing of . Cannot exclude pericardial effusion.\n\n" }, { "category": "ECG", "chartdate": "2185-11-12 00:00:00.000", "description": "Report", "row_id": 250778, "text": "Sinus tachycardia. Biatrial enlargement. Right ventricular overload. Left axis\ndeviation. Possible old inferior myocardial infarction. Compared to the\nprevious tracing of no new findings are seen.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2162-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544403, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n s/p ICH left sided hemiparesis, patient more somnolent, does not open\n eyes or follow commands this am, able to localize with right hand to\n sternal rub, withdraws with right sided extremities, flexes with left\n lower extremity, unable to move left upper extremity. PERL\n Action:\n taken to OR to have evacuation and removal of mass, MRI postop,\n intubated to protect airway, central line and NG placed and confirmed\n by chest XR, 23% hypertonic saline given intraop, propofol gtt started,\n nicardipine turned off due to lowered SBP,\n Response:\n Patient on sedation, woken up for q 1 hour neuro checks after MRI,\n neuro status unchanged, able to localize with right arm, no response\n with left arm, withdraws with right arm and leg to nail bed pressure\n and flexes with left lower extremity. PERL, unable to follow commands\n or open eyes.\n Plan:\n continue on sedation over night, wake ups q 1 hour, plan to extubate\n tomorrow morning\n" }, { "category": "Nursing", "chartdate": "2162-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544646, "text": "TITLE:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt restless and fidgety in bed. Arouses to voice oriented x \n (consistently to self). Lift/holding with right extremities.\n Inconsistently following commands. Opening eyes occasionally to voice.\n Pupils brisk and reactive at 3-4mm. C/o mild right shoulder pain.\n Action:\n Hourly neuro assessments. Treating pain with prn Fentanyl.\n Response:\n Pt occasionally annoyed at hourly questions refusing to answer at\n times. Arouses to voice. Remains oriented x (self and year).\n Inconsistently following commands on right side lift/holding right\n extremities. Decreased sensation noted in left extremities where not\n feeling simple touch but will withdraw LLE to nail bed pressure moving\n on bed. Not withdrawing on LUE to nail bed pressure however lift/falls\n LUE spontaneously. Pupils brisk and reactive at 3-4mm. Opening eyes\n when name called or to pain. Denies pain.\n Plan:\n Continue to monitor neuro status hourly.\n Hypertension, benign\n Assessment:\n Nicardipine drip on to maintain SBP <160. SBP 140-155.\n Action:\n Nicardipine weaned to off. Treating slight hypertension (SBP up to 165)\n with 10mg Hydralazine.\n Response:\n Nicardipine drip remains off with Hydralazine maintaining SBP <160.\n Plan:\n Continue to monitor hemodynamics. Maintain SBP <160 treating with\n Hydralazine if needed.\n Alteration in Nutrition\n Assessment:\n Receiving FS Replete with Fiber via Dobhoff at current rate of 40cc/hr.\n + BS. Maintenance fluids at KVO rate. Weight down.\n Action:\n Titrating tube feeds up every 4 hours by 10cc to goal rate of 60cc/hr\n with 50cc flush every 4 hours.\n Response:\n Tolerating well. No residuals. + Flatulus. Small soft brown BM.\n Plan:\n Continue to titrate tube feeds up to goal rate. Speech and swallow\n contact for bedside evaluation today. PT consulted to OOB pt today.\n" }, { "category": "Nursing", "chartdate": "2162-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544404, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n s/p ICH left sided hemiparesis, patient more somnolent, does not open\n eyes or follow commands this am, able to localize with right hand to\n sternal rub, withdraws with right sided extremities, flexes with left\n lower extremity, unable to move left upper extremity. PERL\n Action:\n taken to OR to have evacuation and removal of mass, MRI postop,\n intubated to protect airway, central line and NG placed and confirmed\n by chest XR, 23% hypertonic saline given intraop, propofol gtt started,\n nicardipine turned off due to lowered SBP,\n Response:\n Patient on sedation, woken up for q 1 hour neuro checks after MRI,\n neuro status unchanged, able to localize with right arm, no response\n with left arm, withdraws with right arm and leg to nail bed pressure\n and flexes with left lower extremity. PERL, unable to follow commands\n or open eyes.\n Plan:\n continue on sedation over night, wake ups q 1 hour, plan to extubate\n tomorrow morning, keep fi02 on 2 100% overnight per neurology.\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544454, "text": "TITLE:\n Hypertension, benign\n Assessment:\n During wake-ups/assessments SBP elevated as high as 200.\n Action:\n Restarted Nicardipine drip.\n Response:\n Titrating Nicardipine for goal SBP <160.\n Plan:\n Continue to monitor hemodynamics and titrate Nicardipine for goal SBP\n <160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt moving right side on bed while sedation on. Withdraws to nail bed\n pressure on LLE, no withdrawal on LUE. Pupils brisk and reactive at\n 2-3mm.\n Appears to grimace at times with HR into 110s.\n Action:\n Waking pt up hourly for neuro exams.\n Treating pain with Fentanyl.\n Response:\n While off sedation pt moving all extremities on own. Does not follow\n commands. Lift/holds right extremities. Moves LLE on bed spontaneously\n and withdraws to nail bed pressure. Noted LUE to move on own\n lift/holding however LUE does not withdraw to nail bed pressure. Pupils\n brisk and reactive at 3-4mm equal in size. No eye opening.\n HR in regular rate 80-100. No grimacing.\n Plan:\n Continue with hourly neuro exams.\n ? Extubate in am (? Depending on whether or not pt following commands)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear slightly diminished in bases. Suctioning for moderate\n amounts of thick white/blood tinged secretions. Strong cough. AC FiO2\n 100% Rate 14 TV 600s.\n Action:\n Pt over breathing vent during wake-up with rates into mid 20s. Weaning\n vent with goal to extubated in am. Currently CPAP/PS PEEP 5 PS 8 FiO2\n 75%.\n Response:\n Tolerating vent weans. TV 700-800 RR 20s. Most recent ABG WNL.\n Plan:\n Continue to monitor resp status, effort. ? am extubation.\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544556, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a and o x and open eyes to stimulation, moves all\n extremities with left sided weakness. Lifts and holds RUE, RLE and\n able to move left extremities on bed.\n Action:\n Put on face tent 40% fio2 and now NC 3 L, doboff placed\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544989, "text": "SICU\n HPI:\n Mr. (pronounced 'Joe-Quinn') is a 71-year-old right-handed man\n presents with acute headache and left hemiplegia, found to have ICH.\n His neurologic exam is notable for left neglect, left vf cut, left\n facial droop, left hemisensory loss, and left hemiplegia. This\n localizes to the right parietal lobe, which is where the ICH is seen on\n CT. now s/p rt crani & evacuation on \n" }, { "category": "Nursing", "chartdate": "2162-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544991, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2162-10-24 00:00:00.000", "description": "Intensivist Note", "row_id": 544228, "text": "SICU\n HPI:\n Mr. (pronounced 'Joe-Quinn') is a 71-year-old right-handed man\n presents with acute headache and left hemiplegia, found to have ICH.\n His neurologic exam is notable for left neglect, left vf cut, left\n facial droop, left hemisensory loss, and left hemiplegia. This\n localizes to the right parietal lobe, which is where the ICH is seen on\n CT.\n Chief complaint:\n LEFT hemiplegia s/p RIGHT CVA\n PMHx:\n CAD s/p stent, HTN\n Current medications:\n Acetaminophen 4. Bicitra 5. Docusate Sodium 6. Famotidine 7. Insulin 8.\n Influenza Virus Vaccine\n 9. Labetalol 10. Lidocaine Jelly 2% (Urojet) 11. Mannitol 20% 12.\n Mannitol 13. Metoprolol Tartrate\n 14. Metoclopramide 15. Pneumococcal Vac Polyvalent 16. Pravastatin 17.\n Quinapril 18. Senna\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 1.5 mg/min\n Mannitol - 0.8 grams/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:18 PM\n Other medications:\n Flowsheet Data as of 07:40 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.6\nC (96.1\n T current: 35.6\nC (96.1\n HR: 86 (84 - 91) bpm\n BP: 176/82(121) {176/82(121) - 176/82(121)} mmHg\n RR: 16 (12 - 17) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86 kg (admission): 86 kg\n Total In:\n 405 mL\n PO:\n Tube feeding:\n IV Fluid:\n 405 mL\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (LUE: Weakness), (LLE: No movement), No(t)\n Sedated, sedated but easily arousable\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n NAUSEA / VOMITING, INTRACEREBRAL HEMORRHAGE (ICH), ALTERED MENTAL\n STATUS (NOT DELIRIUM), HYPERTENSION, BENIGN\n Assessment and Plan: Mr. (pronounced 'Joe-Quinn') is a\n 71-year-old right-handed man presents with acute headache and left\n hemiplegia, found to have ICH. His neurologic exam is notable for left\n neglect, left vf cut, left facial droop, left hemisensory loss, and\n left hemiplegia. This localizes to the right parietal lobe, which is\n where the ICH is seen on CT.\n Neurologic: Neuro checks Q: 1 hr, Pain controlled, repeat CT scan\n tonight, follow up final CTA read, mannitol q6h, goal SBP<160mmHg,\n MAP<130mmHg, titration with labetalol drip\n Cardiovascular: hold all anticoagulation per primary team, pt npo until\n swallow eval. hold po meds (statin), goal SBP<160mmHg, labetalol drip,\n metoprolol, quilapril, ruleout MI with serial enzymes, 1st set negative\n Pulmonary: IS, satting well on nc\n Gastrointestinal / Abdomen: NPO until swallow eval in AM\n Nutrition: NPO, Speech and Swallow eval\n Renal: Foley, Adequate UO, follow CR and UOP, receiving mannitol for\n diuresis per primary team\n Hematology: check CBC in AM\n Endocrine: RISS\n Infectious Disease: no cultures pending, no signs of infection\n Lines / Tubes / Drains: Foley\n Wounds: no wound\n Imaging: CT scan head today, MRI brain this AM\n Fluids: NS, KVO, goal is to keep pt dry 1-2L\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Comments: NPO until swallow eval\n Glycemic Control: Regular insulin sliding scale, Comments: blood\n sugars under control\n Lines:\n 20 Gauge - 05:28 PM\n Arterial Line - 07:06 PM\n Comments: , \n Prophylaxis:\n DVT: Boots (no anticoagulation per primary team)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544558, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a and o x and open eyes to stimulation, moves all\n extremities with left sided weakness. Lifts and holds RUE, RLE and\n able to move left extremities on bed. Patient agitated at times during\n day.\n Action:\n Put on face tent 40% fio2 and now NC 3 L, doboff placed, PT consult\n ordered\n Response:\n Plan:\n Speech and swallow eval tomorrow\n" }, { "category": "Physician ", "chartdate": "2162-10-28 00:00:00.000", "description": "Intensivist Note", "row_id": 544845, "text": "SICU\n HPI:\n 71-year-old right-handed man presents with acute headache and left\n hemiplegia, found to have ICH. His neurologic exam is notable for left\n neglect, left vf cut, left facial droop, left hemisensory loss, and\n left hemiplegia. This localizes to the right parietal lobe, which is\n where the ICH is seen on CT. now s/p rt crani & evacuation on \n Chief complaint:\n PMHx:\n PMH: HTN, CAD\n Current medications:\n 1. 2. 1000 mL NS 3. 20 mEq Potassium Chloride / 1000 mL NS 4.\n Acetaminophen 5. Bisacodyl 6. Bicitra\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Dexamethasone 9.\n Dexamethasone 10. Dexamethasone 11. Dexamethasone\n 12. Docusate Sodium (Liquid) 13. Famotidine 14. Fentanyl Citrate 15.\n Heparin 16. HydrALAzine 17.\n 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol 22.\n Lidocaine Jelly 2% (Urojet)\n 23. Mannitol 24. Mannitol 25. Mannitol 26. Metoprolol Tartrate 27.\n Metoprolol Tartrate 28. NiCARdipine\n 29. Phenytoin 30. Phenytoin 31. Pneumococcal Vac Polyvalent 32.\n Potassium Chloride 33. Pravastatin\n 34. Propofol 35. Quinapril 36. Senna 37. Sodium Chloride 0.9% Flush 38.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n : MRI brain; went to OR for crani\n : Extubated; Speech and swallow not done because he was not\n cooperative\n Post operative day:\n POD#3 - right decompression craniotomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Gentamicin - 05:00 AM\n Infusions:\n Other ICU medications:\n Dilantin - 08:30 PM\n Metoprolol - 12:15 AM\n Labetalol - 07:45 AM\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Hydralazine - 08:23 AM\n Other medications:\n Flowsheet Data as of 09:38 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: 37.2\nC (98.9\n HR: 94 (85 - 110) bpm\n BP: 173/74(112) {139/59(88) - 173/74(112)} mmHg\n RR: 22 (16 - 24) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.4 kg (admission): 86 kg\n Height: 67 Inch\n CVP: 6 (3 - 11) mmHg\n Total In:\n 2,230 mL\n 659 mL\n PO:\n Tube feeding:\n 1,260 mL\n 518 mL\n IV Fluid:\n 650 mL\n 141 mL\n Blood products:\n Total out:\n 3,040 mL\n 1,100 mL\n Urine:\n 3,040 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -810 mL\n -441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bilateral at bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 468 K/uL\n 13.2 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 108 mEq/L\n 145 mEq/L\n 38.0 %\n 21.8 K/uL\n [image002.jpg]\n 05:32 PM\n 12:03 AM\n 12:13 AM\n 06:19 AM\n 09:34 AM\n 06:29 PM\n 02:03 AM\n 06:20 AM\n 05:15 PM\n 02:00 AM\n WBC\n 18.2\n 18.3\n 21.8\n Hct\n 31.9\n 35.2\n 38.0\n Plt\n \n Creatinine\n 0.9\n 0.9\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 25\n 25\n 28\n 28\n Glucose\n 147\n 193\n 151\n 144\n 130\n 126\n 129\n 125\n Other labs: PT / PTT / INR:11.8/24.2/1.0, CK / CK-MB / Troponin\n T:67//<0.01, Lactic Acid:2.6 mmol/L, Albumin:3.8 g/dL, Ca:9.6 mg/dL,\n Mg:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, TACHYCARDIA, OTHER, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), NAUSEA / VOMITING, INTRACEREBRAL HEMORRHAGE (ICH),\n ALTERED MENTAL STATUS (NOT DELIRIUM), HYPERTENSION, BENIGN\n Assessment and Plan: 71yoM with ICH\n Neurologic: Neuro checks Q: 1 hr, goal SBP<160, MAP<130, mannito being\n tapered, dilantin with level checks adjust does if needed, nicardipine\n drip, start to taper steroids\n Cardiovascular: lopressor 75 TID, hydralazine prn\n Pulmonary: OOB, PT/OT\n Gastrointestinal / Abdomen: S&S eval, cont TF\n Nutrition: Tube feeding, Speech and Swallow eval, speech and swallow\n eval today\n Renal: Foley, Adequate UO, f/u u/o\n Hematology: Hct stable\n Endocrine: RISS, blood sugars under control\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, Dobhoff, PIV, left subclavian CVL\n Wounds: Dry dressings, c/d/i\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Comments: tube feeding\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:06 PM\n Multi Lumen - 08:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2162-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544305, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n see neuro assessment and below for details\n Action:\n CT scan and MRI done to more fully evaluate head bleed,\n Response:\n deteriorating neuro status.\n Plan:\n OR later this am.\n Hypertension, benign\n Assessment:\n labetalol drip increased to max dosage of 10 mg/min with minimal effect\n of bp.\n Action:\n nicardipine drip added at 1 mcg/kg/min, with immediate response of bp\n to < 160. Labetalol quickly weaned to off.\n Response:\n sbp remained < 160 down to 120\ns, nicardipine titrated to 0.5\n mcg/kg/min to maintain sbp < 160. Labetalol remained off all night.\n Plan:\n continue to monitor bp and titrate nicardipine as needed.\n Altered mental status (not Delirium)\n Assessment:\n At beginning of shift pt was able to answer most questions, he knew the\n date, city, and was oriented to person. He followed commands with\n right side. As shift progressed, pt became less alert, less talkative,\n and followed commands less consistently. Pt went to MRI as ordered\n earlier, he was unable to lie still for procedure.\n Action:\n ativan 0.5 mg iv x 1 for sedation during MRI with good effect.\n Response:\n pt tolerated MRI well after ativan. He became less verbal, responding\n verbally only during sternal rub, saying\n and pushing my hand away.\n Perl, continues to move right side purposefully.\n Plan:\n monitor closely, to OR with Dr at 11 am.\n" }, { "category": "Physician ", "chartdate": "2162-10-25 00:00:00.000", "description": "Intensivist Note", "row_id": 544308, "text": "SICU\n HPI:\n HPI: Mr. (pronounced 'Joe-Quinn') is a 71-year-old right-handed\n man presents with acute headache and left hemiplegia, found to have\n ICH. His neurologic exam is notable for left neglect, left vf cut, left\n facial droop, left hemisensory loss, and left hemiplegia. This\n localizes to the right parietal lobe, which is where the ICH is seen on\n CT.\n Chief complaint:\n PMHx:\n PMH: HTN, CAD\n :. metoprolol, quinapril, pravastatin\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - START 07:06 PM\n MAGNETIC RESONANCE IMAGING - At 04:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nicardipine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:20 AM\n Famotidine (Pepcid) - 06:02 AM\n Other medications:\n Flowsheet Data as of 08:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.3\nC (97.3\n HR: 95 (82 - 99) bpm\n BP: 136/54(80) {118/54(78) - 191/95(137)} mmHg\n RR: 15 (12 - 19) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.3 kg (admission): 86 kg\n Total In:\n 749 mL\n 631 mL\n PO:\n Tube feeding:\n IV Fluid:\n 749 mL\n 342 mL\n Blood products:\n 289 mL\n Total out:\n 940 mL\n 513 mL\n Urine:\n 940 mL\n 513 mL\n NG:\n Stool:\n Drains:\n Balance:\n -191 mL\n 118 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///24/\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Decreased mental status ; R arm purposeful; R leg withdraws\n and moves spontaneusly;LUE and LLE withdraws. Got ativan for MRI\n Labs / Radiology\n 335 K/uL\n 12.5 g/dL\n 141 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 16 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.4 %\n 16.9 K/uL\n [image002.jpg]\n 07:49 PM\n 02:07 AM\n WBC\n 16.9\n Hct\n 34.4\n Plt\n 335\n Creatinine\n 1.0\n Troponin T\n <0.01\n <0.01\n Glucose\n 141\n Other labs: CK / CK-MB / Troponin T:29//<0.01, Ca:8.8 mg/dL, Mg:1.8\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n NAUSEA / VOMITING, INTRACEREBRAL HEMORRHAGE (ICH), ALTERED MENTAL\n STATUS (NOT DELIRIUM), HYPERTENSION, BENIGN\n Assessment and Plan: 71 yo male with R IPH worsening mental status for\n oR today\n Neurologic: Neuro checks Q: 1 hr, mannitol 25 Q6h;Urgent 23%saline for\n worsening status; OR at 11AM; Osm before next mannitol dose\n Cardiovascular: Beta-blocker, Lop 25bid; SBP<160; Nicardipine drip prn\n Pulmonary: Cont ETT, intubated now. ABG in 20min; Goal PCO2 30 preop\n Gastrointestinal / Abdomen: Place NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable; Type and cross for OR; DDAVP preop\n Endocrine: RISS\n Infectious Disease: No Issues\n Lines / Tubes / Drains: Foley, ETT, L subclavian being put in now\n Wounds:\n Imaging: CT scan head today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:28 PM\n Arterial Line - 07:06 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments: No Heparin\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 38 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2162-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544767, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to voice, very uncooperative with exam. Does not open eyes.\n PERRL 3mm bil. Speech clear. Disoriented. Deliious at times-pt states\n he is in\n on vacation\n. Knows the year. Able to lift and hold\n right side extremities. Left side withdraws to pain. Right side crani\n incision with staples OTA C/D/I.\n Action:\n Neuro checks q1-2, reorientation.\n Response:\n Neuro status unchanged. Neursurg and SICU teams aware.\n Plan:\n Continue neuro checks, Dilantin, Mannitol taper, monitor serum\n Os/lytes, ?taper Decadron as may be contributing to agitation and\n delirium. Repeat Speech&swallow and PT consult when pt more alert and\n cooperative.\n Hypertension, benign\n Assessment:\n SBP 150\ns-160\ns. Elevated to 170\ns at times.\n Action:\n Hydralazine 10 mg given prn. Metoprolol dose increased to 75 mg tid.\n Response:\n SBP maintained <160.\n Plan:\n Continue current meds and maintain goal SBP <160.\n Alteration in Nutrition\n Assessment:\n Pt uncooperative with Speech &swallow eval.\n Action:\n TF\ns via Dobhoff at goal 60cc/hr.\n Response:\n Pt tolerating TF\ns well.\n Plan:\n Continue TF\ns until pt able to participate in exam. Nutrition\n following.\n" }, { "category": "Physician ", "chartdate": "2162-10-29 00:00:00.000", "description": "Intensivist Note", "row_id": 544958, "text": "SICU\n HPI:\n Chief complaint:\n 71-year-old right-handed man presents with acute headache and left\n hemiplegia, found to have ICH. His neurologic exam is notable for left\n neglect, left vf cut, left facial droop, left hemisensory loss, and\n left hemiplegia. This localizes to the right parietal lobe, which is\n where the ICH is seen on CT. now s/p rt crani & evacuation on \n PMHx:\n HTN, CAD\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1130 18. Insulin SC\n (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1028\n 2. 1000 mL NS\n Continuous at 20 ml/hr\n Change to peripheral lock when taking POs Order date: @ 1130 19.\n Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1431\n 3. 20 mEq Potassium Chloride / 1000 mL NS\n Continuous at 75 ml/hr\n Change to peripheral lock when taking POs KVO once on tube feeds Order\n date: @ 1028 20. Labetalol 10-20 mg IV Q6H:PRN sbp>160mmHg Order\n date: @ 0152\n 4. Acetaminophen 325-650 mg PO/PR Q6H:PRN Order date: @ 1130 21.\n Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN Order date: @ 1130\n 5. Amlodipine 10 mg PO DAILY htn\n hold for sbp<90mmHg, hr<90bpm Order date: @ 0152 22. Mannitol\n 12.5 gm IV ONCE Duration: 1 Doses Start: \n mannitol taper Order date: @ 1021\n 6. Bisacodyl 10 mg PO/PR DAILY Order date: @ 1130 23. Metoprolol\n Tartrate 100 mg PO TID\n Hold for SBP < 100 or HR < 60 Order date: @ \n 7. Bicitra 30 mL PO QID:PRN heartburn Order date: @ 1130 24.\n Metoprolol Tartrate 5 mg IV Q4H:PRN sbp>160mmHg Order date: @\n 1130\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1806 25. Phenytoin 200 mg IV ONCE subtherapeutic level Duration: 1\n Doses Start: In am Order date: @ 1556\n 9. Dexamethasone 3 mg PO TID Duration: 3 Doses Start: After 4 mg\n tapered dose. Order date: @ 26. Phenytoin 200 mg IV Q12H\n Order date: @ 0656\n 10. Dexamethasone 2 mg PO TID Duration: 3 Doses Start: After 3 mg\n tapered dose. Order date: @ 27. Pneumococcal Vac Polyvalent\n 0.5 ml IM ASDIR Order date: @ 1431\n 11. Dexamethasone 1 mg PO TID Duration: 3 Doses Start: After 2 mg\n tapered dose. Order date: @ 28. Potassium Chloride IV\n Sliding Scale Order date: @ 1451\n 12. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1028\n 29. Pravastatin 40 mg PO DAILY Order date: @ 1130\n 13. Famotidine 20 mg IV Q12H heartburn Order date: @ 1130 30.\n Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 1130\n 14. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 2248\n 31. Quinapril 20 mg PO DAILY\n Hold for SBP < 100 Order date: @ 1609\n 15. Heparin 5000 UNIT SC TID Start: In am Order date: @ 1130 32.\n Senna 1 TAB PO BID Order date: @ 1130\n 16. HydrALAzine 10 mg IV Q6H:PRN SBP>160 Order date: @ 1028 33.\n 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: @ 1130\n 17. IV access request: CVL Place Indication: Steroids Urgency: Routine\n Order date: @ 1405 34. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN\n line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1130\n 24 Hour Events:\n BLOOD CULTURED - At 06:01 PM\n perip & from central line sent\n URINE CULTURE - At 06:02 PM\n FEVER - 101.9\nF - 10:00 PM\n Post operative day:\n POD#4 - right decompression craniotomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 01:40 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 01:00 AM\n Hydralazine - 01:30 AM\n Labetalol - 02:00 AM\n Other medications:\n Flowsheet Data as of 09:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.3\nC (99.1\n HR: 96 (83 - 110) bpm\n BP: 163/70(103) {133/54(79) - 199/78(114)} mmHg\n RR: 20 (18 - 25) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.4 kg (admission): 86 kg\n Height: 67 Inch\n CVP: 4 (-1 - 239) mmHg\n Total In:\n 2,243 mL\n 886 mL\n PO:\n Tube feeding:\n 1,440 mL\n 537 mL\n IV Fluid:\n 403 mL\n 190 mL\n Blood products:\n Total out:\n 2,410 mL\n 490 mL\n Urine:\n 2,410 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -167 mL\n 396 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No(t) Weakness, No(t) No movement), (LUE: No movement), (RLE: No(t)\n Weakness, No(t) No movement), (LLE: No movement), Moves R side with no\n weakness. L side no withdrawal UE LE\n Labs / Radiology\n 347 K/uL\n 12.8 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 30 mg/dL\n 108 mEq/L\n 145 mEq/L\n 36.6 %\n 13.5 K/uL\n [image002.jpg]\n 12:03 AM\n 12:13 AM\n 06:19 AM\n 09:34 AM\n 06:29 PM\n 02:03 AM\n 06:20 AM\n 05:15 PM\n 02:00 AM\n 01:53 AM\n WBC\n 18.2\n 18.3\n 21.8\n 13.5\n Hct\n 31.9\n 35.2\n 38.0\n 36.6\n Plt\n 47\n Creatinine\n 0.9\n 0.9\n 0.8\n 0.8\n 0.9\n 0.9\n 0.9\n TCO2\n 25\n 28\n 28\n Glucose\n 193\n 151\n 144\n 130\n 126\n 129\n 125\n 120\n Other labs: PT / PTT / INR:12.4/23.4/1.0, CK / CK-MB / Troponin\n T:67//<0.01, Lactic Acid:2.6 mmol/L, Albumin:3.8 g/dL, Ca:8.8 mg/dL,\n Mg:2.2 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, TACHYCARDIA, OTHER, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), NAUSEA / VOMITING, INTRACEREBRAL HEMORRHAGE (ICH),\n ALTERED MENTAL STATUS (NOT DELIRIUM), HYPERTENSION, BENIGN\n Assessment and Plan: 71 yo M acute headache and left hemiplegia, found\n to have ICH\n Neurologic: Neuro checks Q: 4 hr, Wean dexa and wean mannitol; Fentanyl\n prn\n Cardiovascular: Beta-blocker, Goal BP <160 restarted home meds\n Quinapril increased; and norvasc wa sincreased\n Pulmonary: IS, OOB today\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: No Issues\n Lines / Tubes / Drains: Foley, Dobhoff, CVL\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Replete (Full) - 01:12 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:06 PM\n Multi Lumen - 08:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2162-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 544395, "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 Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 17:00\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2162-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544613, "text": "TITLE:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt restless and fidgety in bed. Arouses to voice oriented x \n (consistently to self). Lift holding with right extremities.\n Inconsistently following commands. Opening eyes occasionally to voice.\n Pupils brisk and reactive at 3-4mm. C/o mild right shoulder pain.\n Action:\n Hourly neuro assessments. Treating pain with prn Fentanyl.\n Response:\n Pt annoyed at questions every hour refusing to answer at times. Arouses\n to voice. Remains oriented x (self and year). Inconsistently\n following commands on right side lift/holding right extremities.\n Decreased sensation noted in left extremities where not feeling simple\n touch but will withdraw LLE to nail bed pressure moving on bed. Not\n withdrawing on LUE to nail bed pressure however lift/falls LUE\n spontaneously. Pupils brisk and reactive at 3-4mm. Opening eyes when\n name called or to pain. Denies pain.\n Plan:\n Continue to monitor neuro status hourly.\n Hypertension, benign\n Assessment:\n Nicardipine drip on to maintain SBP <160. SBP 140-155.\n Action:\n Nicardipine weaned to off. Treating slight hypertension (SBP up to 165)\n with 10mg Hydralazine.\n Response:\n Nicardipine drip remains off with Hydralazine maintaining SBP <160.\n Plan:\n Continue to monitor hemodynamics. Maintain SBP <160 treating with\n Hydralazine if needed.\n" }, { "category": "Nursing", "chartdate": "2162-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544615, "text": "TITLE:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt restless and fidgety in bed. Arouses to voice oriented x \n (consistently to self). Lift holding with right extremities.\n Inconsistently following commands. Opening eyes occasionally to voice.\n Pupils brisk and reactive at 3-4mm. C/o mild right shoulder pain.\n Action:\n Hourly neuro assessments. Treating pain with prn Fentanyl.\n Response:\n Pt annoyed at questions every hour refusing to answer at times. Arouses\n to voice. Remains oriented x (self and year). Inconsistently\n following commands on right side lift/holding right extremities.\n Decreased sensation noted in left extremities where not feeling simple\n touch but will withdraw LLE to nail bed pressure moving on bed. Not\n withdrawing on LUE to nail bed pressure however lift/falls LUE\n spontaneously. Pupils brisk and reactive at 3-4mm. Opening eyes when\n name called or to pain. Denies pain.\n Plan:\n Continue to monitor neuro status hourly.\n Hypertension, benign\n Assessment:\n Nicardipine drip on to maintain SBP <160. SBP 140-155.\n Action:\n Nicardipine weaned to off. Treating slight hypertension (SBP up to 165)\n with 10mg Hydralazine.\n Response:\n Nicardipine drip remains off with Hydralazine maintaining SBP <160.\n Plan:\n Continue to monitor hemodynamics. Maintain SBP <160 treating with\n Hydralazine if needed.\n Alteration in Nutrition\n Assessment:\n Receiving FS Replete with Fiber via Dobhoff at current rate of 40cc/hr.\n + BS. Maintenance fluids at KVO rate. Weight down.\n Action:\n Titrating tube feeds up every 4 hours by 10cc to goal rate of 60cc/hr\n with 50cc flush every 4 hours.\n Response:\n Tolerating well. No residuals. + Flatulus. Small soft brown BM.\n Plan:\n Continue to titrate tube feeds up to goal rate. Speech and swallow\n contact for bedside evaluation today. PT consulted to OOB pt today.\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544443, "text": "TITLE:\n Hypertension, benign\n Assessment:\n During wake-ups/assessments SBP elevated as high as 200.\n Action:\n Restarted Nicardipine drip.\n Response:\n Titrating Nicardipine for goal SBP <160.\n Plan:\n Continue to monitor hemodynamics and titrate Nicardipine for goal SBP\n <160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt moving right side on bed while sedation on. Withdraws to nail bed\n pressure on LLE, no withdrawal on LUE. Pupils brisk and reactive at\n 2-3mm.\n Appears to grimace at times with HR into 110s.\n Action:\n Waking pt up hourly for neuro exams.\n Treating pain with Fentanyl.\n Response:\n While off sedation pt moving all extremities on own. Does not follow\n commands. Lift/holds right extremities. Moves LLE on bed spontaneously\n and withdraws to nail bed pressure. Noted LUE to move on own\n lift/holding however LUE does not withdraw to nail bed pressure. Pupils\n brisk and reactive at 3-4mm equal in size. No eye opening.\n HR in regular rate 80-100. No grimacing.\n Plan:\n Continue with hourly neuro exams.\n ? Extubate in am (? Depending on whether or not pt following commands)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear slightly diminished in bases. Suctioning for moderate\n amounts of thick white/blood tinged secretions. Strong cough. AC FiO2\n 100% Rate 14 TV 600s.\n Action:\n Pt over breathing vent during wake-up with rates into mid 20s. Weaning\n vent with goal to extubated in am. Currently CPAP/PS PEEP PS FiO2 75%.\n TV\n Response:\n Tolerating vent weans. Most recent ABG WNL.\n Plan:\n Continue to monitor resp status, effort. ? am extubation.\n" }, { "category": "Physician ", "chartdate": "2162-10-26 00:00:00.000", "description": "Intensivist Note", "row_id": 544514, "text": "SICU\n HPI:\n Mr. (pronounced 'Joe-Quinn') is a 71-year-old right-handed man\n presents with acute headache and left hemiplegia, found to have ICH.\n His neurologic exam is notable for left neglect, left vf cut, left\n facial droop, left hemisensory loss, and left hemiplegia. This\n localizes to the right parietal lobe, which is where the ICH is seen on\n CT\n Chief complaint:\n ICH\n PMHx:\n HTN, CAD\n Current medications:\n 1000 mL NS 3. 20 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen\n 5. Bisacodyl 6. Bicitra\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Dexamethasone 9.\n Dexamethasone 10. Docusate Sodium\n 11. Famotidine 12. Fentanyl Citrate 13. Gentamicin 14. Heparin 15.\n Influenza Virus Vaccine 16. Insulin\n 17. Labetalol 18. Lidocaine Jelly 2% (Urojet) 19. Mannitol 20.\n Metoprolol Tartrate 21. Metoprolol Tartrate\n 22. NiCARdipine 23. Phenytoin 24. Phenytoin 25. Pneumococcal Vac\n Polyvalent 26. Potassium Chloride\n 27. Pravastatin 28. Propofol 29. Quinapril 30. Senna 31. Sodium\n Chloride 0.9% Flush 32. Sodium Chloride 0.9% Flush\n 33.\n 24 Hour Events:\n INTUBATION - At 08:00 AM\n INVASIVE VENTILATION - START 08:00 AM\n MULTI LUMEN - START 08:28 AM\n OR SENT - At 09:30 AM\n OR RECEIVED - At 12:00 PM\n MAGNETIC RESONANCE IMAGING - At 04:00 PM\n Post operative day:\n POD#1 - right decompression craniotomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Gentamicin - 05:00 AM\n Infusions:\n Nicardipine - 1.5 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 04:05 AM\n Heparin Sodium (Prophylaxis) - 08:31 AM\n Famotidine (Pepcid) - 08:32 AM\n Other medications:\n Flowsheet Data as of 10:26 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: 37.7\nC (99.8\n HR: 113 (73 - 117) bpm\n BP: 139/64(91) {102/45(62) - 186/82(128)} mmHg\n RR: 17 (12 - 26) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84.8 kg (admission): 86 kg\n CVP: 10 (4 - 14) mmHg\n Total In:\n 4,627 mL\n 1,731 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,278 mL\n 1,671 mL\n Blood products:\n 289 mL\n Total out:\n 4,203 mL\n 1,990 mL\n Urine:\n 2,703 mL\n 1,810 mL\n NG:\n 180 mL\n Stool:\n Drains:\n Balance:\n 424 mL\n -259 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 601) mL\n Vt (Spontaneous): 732 (385 - 801) mL\n PC : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 75%\n RSBI: 34\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60.1 cmH2O/mL\n SPO2: 97%\n ABG: 7.48/36/115/25/4\n Ve: 13.2 L/min\n PaO2 / FiO2: 287\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 310 K/uL\n 11.6 g/dL\n 151 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 110 mEq/L\n 144 mEq/L\n 31.9 %\n 18.2 K/uL\n [image002.jpg]\n 08:50 AM\n 09:03 AM\n 09:46 AM\n 12:32 PM\n 12:50 PM\n 05:32 PM\n 12:03 AM\n 12:13 AM\n 06:19 AM\n 09:34 AM\n WBC\n 17.0\n 14.9\n 18.2\n Hct\n 31.9\n 33\n 31.4\n 31.9\n Plt\n 344\n 324\n 310\n Creatinine\n 1.0\n 1.0\n 0.9\n Troponin T\n <0.01\n TCO2\n 26\n 23\n 26\n 25\n 25\n 28\n 28\n Glucose\n 144\n 123\n 129\n 147\n 193\n 151\n Other labs: PT / PTT / INR:12.7/24.9/1.1, CK / CK-MB / Troponin\n T:67//<0.01, Lactic Acid:2.6 mmol/L, Ca:8.3 mg/dL, Mg:2.0 mg/dL,\n PO4:2.2 mg/dL\n Imaging: : MRI brain\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), NAUSEA / VOMITING,\n INTRACEREBRAL HEMORRHAGE (ICH), ALTERED MENTAL STATUS (NOT DELIRIUM),\n HYPERTENSION, BENIGN\n Assessment and Plan: 71-year-old right-handed man presents with acute\n headache and left hemiplegia, found to have ICH. His neurologic exam is\n notable for left neglect, left vf cut, left facial droop, left\n hemisensory loss, and left hemiplegia. This localizes to the right\n parietal lobe, which is where the ICH is seen on CT.\n Neurologic: Neuro checks Q: 1-2 hr, Phenytoin - therapeutic, Cont\n Dilantin and wean Mannitol.\n Cardiovascular: Beta-blocker, Keep SBP < 160. Cont Lopressor and\n increase with IV PRN and start Hydralazine PRN and wean Nicardipine.\n Pulmonary: Extubate today, Spontaneous breathing trial, PT / OT\n Gastrointestinal / Abdomen: Place Dobhoff\n Nutrition: Speech and Swallow eval, Start TF\n Renal: Foley, Adequate UO\n Hematology: Mild anemia\n Endocrine: RISS\n Infectious Disease: Periop antibx\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging: F/U with MRI read from yesterday\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:28 PM\n Arterial Line - 07:06 PM\n Multi Lumen - 08:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544595, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a/o x and opens eyes sometimes to stimulation,\n moves all extremities with left sided weakness. Lifts and holds RUE,\n RLE and able to move left extremities on bed. Patient agitated at\n times during day.\n Action:\n continued q 1 hour neuro checks, put on face tent 40% fio2 and now NC 3\n L, dobhoff placed and tube feeds started, PT consult ordered\n Response:\n neuro status unchanged, more awake at times, sats maintained >95%\n Plan:\n continue with q 1 hour neuro checks, speech and swallow eval tomorrow,\n OOB to chair with PT tomorrow\n Hypertension, benign\n Assessment:\n SBP 150-160\n Action:\n Continues on nicardipine gtt, prn Hydralazine\n Response:\n SBP down to 140\ns after Hydralazine, SBP continues at goal less than\n 160.\n Plan:\n Keep SBP < 160 per neuro , titrate to wean off nicardipine gtt\n with prn hydralazine\n Tachycardia, Other\n Assessment:\n HR 110-120 throughout day, patient denies pain, restless at times, T\n max 100.4\n Action:\n Given prn and standing doses of Lopressor, prn Fentanyl x1 after\n complaining of neck pain with repositioning, prn Tylenol x1, and\n repositioned for comfort\n Response:\n HR down to 100\n Plan:\n Continue with standing and prn doses of Lopressor, reposition and prn\n fentanyl and tylenol for comfort\n" }, { "category": "Nursing", "chartdate": "2162-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544763, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544599, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a/o x and opens eyes sometimes to stimulation,\n moves all extremities with left sided weakness. Lifts and holds RUE,\n RLE and able to move left extremities on bed. Patient agitated at\n times during day.\n Action:\n continued q 1 hour neuro checks, put on face tent 40% fio2 and now NC 3\n L, dobhoff placed and tube feeds started, PT consult ordered\n Response:\n neuro status unchanged, more awake at times, sats maintained >95%\n Plan:\n continue with q 1 hour neuro checks, speech and swallow eval tomorrow,\n OOB to chair with PT tomorrow\n Hypertension, benign\n Assessment:\n SBP 150-160\n Action:\n Continues on nicardipine gtt, prn Hydralazine\n Response:\n SBP down to 140\ns after Hydralazine, SBP continues at goal less than\n 160.\n Plan:\n Keep SBP < 160 per neuro , titrate to wean off nicardipine gtt\n with prn hydralazine\n Tachycardia, Other\n Assessment:\n HR 110-120 throughout day, patient denies pain, restless at times, T\n max 100.4\n Action:\n Given prn and standing doses of Lopressor, prn Fentanyl x1 after\n complaining of neck pain with repositioning, prn Tylenol x1, and\n repositioned for comfort\n Response:\n HR down to 100\n Plan:\n Continue with standing and prn doses of Lopressor, reposition and prn\n fentanyl and tylenol for comfort\n" }, { "category": "Nursing", "chartdate": "2162-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544918, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to voice although only will open eyes inconstantly\n Follows commands inconsistently when cooperative with exam\n Able to move right side spontaneously and to command when cooperative\n Withdraws left to nailbed only\n Increasingly lethargic with fever\n Na 145 / Osm 308\n Action:\n Q2 neuro exam\n Reorient frequently\n Tylenol and ice packs applied\n Mannitol dose given\n ok with current labs per Dr (sicu\n resident\n Response:\n Neuro exam improved when pt afebrile\n Remains uncooperative mostly\n Plan:\n Cont to monitor neuro status, maintain safety, tx fever, cont on\n mannitol taper.\n Hypertension, benign\n Assessment:\n SBP 150-170\n Goal SBP <160\n Action:\n Dr aware of BP\n PO lopressor dose increased\n PRN 5 mg iv lopressor given\n PRN hydralizine given\n PRN labetelol given\n Norvasc added\n Response:\n Minimal effect with increased po lopressor or iv lopressor\n Minimal response to hydralizine\n Effect noted from labetelol and norvasc\n Plan:\n Cont to monitor to maintain SBP <160 without restarting a gtt.\n Will taper up on po meds as needed.\n" }, { "category": "Nursing", "chartdate": "2162-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544807, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to voice, does not open eyes at all. Uncooperative with exam.\n States at times he is\nat home with wife\n. Does know the year. Right\n side with normal strength. Left side withdraws to pain.craniectomy site\n with staples clean, dry, and intact.\n Action:\n Neuro checks q2/hours overnight, reorient as needed.\n Response:\n Neuro status unchanged overnight.\n Plan:\n Continue neuro checks q 2. maintain safety.\n Hypertension, benign\n Assessment:\n Sbp 140\ns to 170\ns. elevated at times to 180\n Action:\n Medicated with labetelol 20 mg x 2 with good effect.\n Response:\n Sbp kept below desired parameters.\n Plan:\n Keep sbp<160.\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544432, "text": "TITLE:\n Hypertension, benign\n Assessment:\n During wake-ups/assessments SBP elevated as high as 200.\n Action:\n Restarted Nicardipine drip.\n Response:\n Titrating Nicardipine for goal SBP <160.\n Plan:\n Continue to monitor hemodynamics and titrate Nicardipine for goal SBP\n <160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt moving right side on bed while sedation on. Withdraws to nail bed\n pressure on LLE, no withdrawal on LUE. Pupils brisk and reactive at\n 2-3mm.\n Appears to grimace at times with HR into 110s.\n Action:\n Waking pt up hourly for neuro exams.\n Treating pain with Fentanyl.\n Response:\n While off sedation pt moving all extremities on own. Does not follow\n commands. Lift/holds right extremities. Moves LLE on bed spontaneously\n and withdraws to nail bed pressure. Noted LUE to move on own\n lift/holding however LUE does not withdraw to nail bed pressure. Pupils\n brisk and reactive at 3-4mm equal in size. No eye opening. Strong\n cough.\n HR in regular rate 80-100. No grimacing.\n Plan:\n Continue with hourly neuro exams.\n ? Extubate in am (? Depending on whether or not pt following commands)\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544437, "text": "TITLE:\n Hypertension, benign\n Assessment:\n During wake-ups/assessments SBP elevated as high as 200.\n Action:\n Restarted Nicardipine drip.\n Response:\n Titrating Nicardipine for goal SBP <160.\n Plan:\n Continue to monitor hemodynamics and titrate Nicardipine for goal SBP\n <160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt moving right side on bed while sedation on. Withdraws to nail bed\n pressure on LLE, no withdrawal on LUE. Pupils brisk and reactive at\n 2-3mm.\n Appears to grimace at times with HR into 110s.\n Action:\n Waking pt up hourly for neuro exams.\n Treating pain with Fentanyl.\n Response:\n While off sedation pt moving all extremities on own. Does not follow\n commands. Lift/holds right extremities. Moves LLE on bed spontaneously\n and withdraws to nail bed pressure. Noted LUE to move on own\n lift/holding however LUE does not withdraw to nail bed pressure. Pupils\n brisk and reactive at 3-4mm equal in size. No eye opening.\n HR in regular rate 80-100. No grimacing.\n Plan:\n Continue with hourly neuro exams.\n ? Extubate in am (? Depending on whether or not pt following commands)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear slightly diminished in bases. Suctioning for moderate\n amounts of thick white/blood tinged secretions. Strong cough.\n Action:\n Weaning vent with goal to extubated in am.\n Response:\n Tolerating vent wean. ABG WNL.\n Plan:\n Continue to monitor resp status, effort. ? am extubation.\n" }, { "category": "Respiratory ", "chartdate": "2162-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 544466, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Bronchial\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: High flow demand\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 Comments: Plan is to wean to extubation today\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt weaning pretty well but he has large amount of thick tan secretions.\n RSBI was ~ 40. Last ABG WNL. Pt currently weaned from AC ventilation to\n PSV 8/+5 Peep. FiO2 remains high at 75 % as part of the Neurology care\n plan for overnight.\n" }, { "category": "Nutrition", "chartdate": "2162-10-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 544732, "text": "Subjective\n Pt unable to answer all questions, son provided information\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 86 kg\n 83.4 kg ( 04:00 AM)\n 0\n 29.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 128%\n 72 kgs\n Diagnosis: Intracranial hemorrhage\n PMH : HTN, hyperchol, CAD, s/p MI years ago\n Pertinent medications: HISS, bowel regimen, heparin, famotidine, NS\n @75, others noted\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 06:20 AM\n Glucose Finger Stick\n 168\n 10:00 AM\n BUN\n 21 mg/dL\n 06:20 AM\n Creatinine\n 0.8 mg/dL\n 06:20 AM\n Sodium\n 146 mEq/L\n 06:20 AM\n Potassium\n 4.1 mEq/L\n 06:20 AM\n Chloride\n 110 mEq/L\n 06:20 AM\n TCO2\n 26 mEq/L\n 06:20 AM\n PO2 (arterial)\n 115 mm Hg\n 09:34 AM\n PCO2 (arterial)\n 36 mm Hg\n 09:34 AM\n pH (arterial)\n 7.48 units\n 09:34 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 09:34 AM\n Calcium non-ionized\n 9.1 mg/dL\n 06:20 AM\n Phosphorus\n 2.6 mg/dL\n 06:20 AM\n Ionized Calcium\n 1.14 mmol/L\n 09:34 AM\n Magnesium\n 2.4 mg/dL\n 06:20 AM\n WBC\n 18.3 K/uL\n 02:03 AM\n Hgb\n 12.3 g/dL\n 02:03 AM\n Hematocrit\n 35.2 %\n 02:03 AM\n Current diet order / nutrition support: Replete c/ fiber @60ml/hour\n GI: abd soft, +bs\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, recent surgery\n Estimated Nutritional Needs\n Calories: 1800-2160 (BEE x or / 25-30 cal/kg) based on adjusted body\n weight\n Protein: 86-108 (1.2-1.5 g/kg)\n Estimation of current intake: Inadequate\n 71 year old male p/w acute headache & left hemiplegia found to have R\n paretial hemorrhage. Pt now s/p crani c/ erac of hematoma. Since\n extubation swallow eval attempted x 3 but could not be completed; NGT\n placed for TF. Current TF underfeeding, will need to increase to better\n meet nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding / TPN recommendations: Increase TF to goal of 75ml/hour\n (1800 kcals & 112gm pro)\n Check residuals q 4 hours & hold if >200ml\n Check bs q 4 hours, continue insulin regimen\n Monitor hydration & continue flushes prn\n Monitor lytes & replete prn\n Diet consistency per SLP when able to evaluate\n Will follow, page c/ ?'s\n ------ Protected Section ------\n Agree c/ above note. Please note that current TF Rx providing 1440\n kcals and 89 gr aa. , RD, CNSD. #\n ------ Protected Section Addendum Entered By: , RD, \n on: 15:24 ------\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544583, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a and o x and opens eyes sometimes to stimulation,\n moves all extremities with left sided weakness. Lifts and holds RUE,\n RLE and able to move left extremities on bed. Patient agitated at\n times during day.\n Action:\n continued q 1 hour neuro checks, put on face tent 40% fio2 and now NC 3\n L, doboff placed, PT consult ordered\n Response:\n neuro status unchanged, more awake at times\n Plan:\n continue with q 1 hour neuro checks, speech and swallow eval tomorrow,\n OOB to chair with PT tomorrow\n Hypertension, benign\n Assessment:\n SBP 150-160\n Action:\n Continues on nicardipine gtt, prn Hydralazine\n Response:\n SBP down to 140\ns after Hydralazine, SBP continues at goal less than\n 160.\n Plan:\n Keep SBP < 160 per neuro , titrate to wean off nicardipine gtt\n with prn hydralazine\n Tachycardia, Other\n Assessment:\n HR 110-120 throughout day, patient denies pain, restless at times, T\n max 100.4\n Action:\n Given prn and standing doses of Lopressor, prn Fentanyl x1 for\n agitation, prn Tylenol x1, and repositioned for comfort\n Response:\n HR down to 100\n Plan:\n Continue with standing and prn doses of Lopressor, reposition and prn\n fentanyl and tylenol for comfort\n" }, { "category": "Nursing", "chartdate": "2162-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544899, "text": "Altered mental status (not Delirium)\n Assessment:\n P=rl..lf side weaker than rt..purposeful movements on rt\n Action:\n Lethargic but easily aroused..\n Response:\n Unchanged neuro status\n Plan:\n Continue with q2h neuro check..reorient frequently\n Hypertension, benign\n Assessment:\n When awake sbp 150/-190/ (cuff comp)\n Action:\n Given lopressor/labetalol/hydralizine & fent..\n Response:\n Sbp down 140/s on & off for short time ho aware\n Plan:\n Increase ca+channel blocker..if continue with htn ? start labetalol\n or nicardipine gtt\n" }, { "category": "Nursing", "chartdate": "2162-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544426, "text": "TITLE:\n Hypertension, benign\n Assessment:\n During wake-ups/assessments SBP elevated as high as 200.\n Action:\n Restarted Nicardipine drip.\n Response:\n Titrating Nicardipine for goal SBP <160.\n Plan:\n Continue to monitor hemodynamics and titrate Nicardipine for goal SBP\n <160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544897, "text": "Altered mental status (not Delirium)\n Assessment:\n P=rl..lf side weaker than rt..purposeful movements on rt\n Action:\n Lethargic but easily aroused..\n Response:\n Unchanged neuro status\n Plan:\n Continue with q2h neuro check..reorient frequently\n Hypertension, benign\n Assessment:\n When awake sbp 150/-190/ (cuff comp)\n Action:\n Given lopressor/\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544416, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n s/p ICH left sided hemiparesis, patient more somnolent, does not open\n eyes or follow commands this am, able to localize with right hand to\n sternal rub, withdraws with right sided extremities, flexes with left\n lower extremity, unable to move left upper extremity. PERL\n Action:\n taken to OR to have evacuation and removal of mass, MRI postop,\n intubated to protect airway, central line and NG placed and confirmed\n by chest XR, 23% hypertonic saline given intraop, propofol gtt started,\n nicardipine turned off due to lowered SBP,\n Response:\n Patient on sedation, woken up for q 1 hour neuro checks after MRI,\n neuro status unchanged, able to localize with right arm, no response\n with left arm, withdraws with right arm and leg to nail bed pressure\n and flexes with left lower extremity. PERL, unable to follow commands\n or open eyes.\n Plan:\n continue on sedation over night, wake ups q 1 hour, plan to extubate\n tomorrow morning, keep fi02 on 2 100% overnight per neurology.\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544574, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a and o x and opens eyes sometimes to stimulation,\n moves all extremities with left sided weakness. Lifts and holds RUE,\n RLE and able to move left extremities on bed. Patient agitated at\n times during day.\n Action:\n Put on face tent 40% fio2 and now NC 3 L, doboff placed, PT consult\n ordered, Fentanyl prn for agitation.\n Response:\n Patient not as agitated, neuro status unchanged\n Plan:\n Speech and swallow eval tomorrow, OOB to chair with PT\n Hypertension, benign\n Assessment:\n SBP 150-160\n Action:\n Continues on nicardipine gtt, prn Hydralazine\n Response:\n SBP down to 140\ns after Hydralazine, SBP continues at goal less than\n 160.\n Plan:\n Keep SBP < 160 per neuro \n" }, { "category": "Nursing", "chartdate": "2162-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 545018, "text": "71-year-old right-handed man presents with acute headache and left\n hemiplegia, found to have ICH. His neurologic exam is notable for left\n neglect, left vf cut, left facial droop, left hemisensory loss, and\n left hemiplegia. This localizes to the right parietal lobe, which is\n where the ICH is seen on CT. now s/p rt crani & evacuation on \n Extubated ..Hypertensive sbp >160/ requiring Nicardipine gtt with\n prn Hydralizine ,Lopressor & Labetolol..Off gtt now on\n Quinapril,Lopressor & Amiodripine with good pressor control. On\n Dilantin,Decadron & Mannitol(tapering Decadron & Mannitol)..Good\n huo\ns..Last BM \n Speech & Swallow attempted but pt not cooperating\n Altered mental status (not Delirium)\n Assessment:\n Oriented to person & occ date(year) ..pupils equal & react to\n light..moves Rt side..withdraws LF to painful stimuli..head incision\n open to air staples intact\n Action:\n Head ct done\n Response:\n Confused but will follow some simple commands\n Plan:\n Transfer to f11\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 86 kg\n Daily weight:\n 83.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CAD..HTN\n Additional history:\n Surgery / Procedure and date:\n RT CRANIOTOMY & EVACUATION\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:66\n Temperature:\n 100.6\n Arterial BP:\n S:130\n D:60\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 80 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 2% %\n 24h total in:\n 1,724 mL\n 24h total out:\n 1,120 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 07:04 AM\n Potassium:\n 3.6 mEq/L\n 01:53 AM\n Chloride:\n 108 mEq/L\n 01:53 AM\n CO2:\n 26 mEq/L\n 01:53 AM\n BUN:\n 30 mg/dL\n 01:53 AM\n Creatinine:\n 0.9 mg/dL\n 01:53 AM\n Glucose:\n 120 mg/dL\n 01:53 AM\n Hematocrit:\n 36.6 %\n 01:53 AM\n Finger Stick Glucose:\n 180\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: 11 SDU\n Date & time of Transfer: 1830\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544575, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a and o x and opens eyes sometimes to stimulation,\n moves all extremities with left sided weakness. Lifts and holds RUE,\n RLE and able to move left extremities on bed. Patient agitated at\n times during day.\n Action:\n Put on face tent 40% fio2 and now NC 3 L, doboff placed, PT consult\n ordered, Fentanyl prn for agitation.\n Response:\n Patient not as agitated, neuro status unchanged\n Plan:\n Speech and swallow eval tomorrow, OOB to chair with PT\n Hypertension, benign\n Assessment:\n SBP 150-160\n Action:\n Continues on nicardipine gtt, prn Hydralazine\n Response:\n SBP down to 140\ns after Hydralazine, SBP continues at goal less than\n 160.\n Plan:\n Keep SBP < 160 per neuro \n Tachycardia, Other\n Assessment:\n HR 110-120 throughout day, patient denies pain, restless at times\n Action:\n Given prn and standing doses of Lopressor, given prn Fentanyl for\n agitation, and repositioned for comfort\n Response:\n HR down to 100\ns at times\n Plan:\n Continue with standing and prn doses of Lopressor, reposition and prn\n fentanyl for comfort\n" }, { "category": "Nutrition", "chartdate": "2162-10-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 544722, "text": "Subjective\n Pt unable to answer all questions, son provided information\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 86 kg\n 83.4 kg ( 04:00 AM)\n 0\n 29.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 128%\n 72 kgs\n Diagnosis: Intracranial hemorrhage\n PMH : HTN, hyperchol, CAD, s/p MI years ago\n Pertinent medications: HISS, bowel regimen, heparin, famotidine, NS\n @75, others noted\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 06:20 AM\n Glucose Finger Stick\n 168\n 10:00 AM\n BUN\n 21 mg/dL\n 06:20 AM\n Creatinine\n 0.8 mg/dL\n 06:20 AM\n Sodium\n 146 mEq/L\n 06:20 AM\n Potassium\n 4.1 mEq/L\n 06:20 AM\n Chloride\n 110 mEq/L\n 06:20 AM\n TCO2\n 26 mEq/L\n 06:20 AM\n PO2 (arterial)\n 115 mm Hg\n 09:34 AM\n PCO2 (arterial)\n 36 mm Hg\n 09:34 AM\n pH (arterial)\n 7.48 units\n 09:34 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 09:34 AM\n Calcium non-ionized\n 9.1 mg/dL\n 06:20 AM\n Phosphorus\n 2.6 mg/dL\n 06:20 AM\n Ionized Calcium\n 1.14 mmol/L\n 09:34 AM\n Magnesium\n 2.4 mg/dL\n 06:20 AM\n WBC\n 18.3 K/uL\n 02:03 AM\n Hgb\n 12.3 g/dL\n 02:03 AM\n Hematocrit\n 35.2 %\n 02:03 AM\n Current diet order / nutrition support: Replete c/ fiber @60ml/hour\n GI: abd soft, +bs\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, recent surgery\n Estimated Nutritional Needs\n Calories: 1800-2160 (BEE x or / 25-30 cal/kg) based on adjusted body\n weight\n Protein: 86-108 (1.2-1.5 g/kg)\n Estimation of current intake: Inadequate\n 71 year old male p/w acute headache & left hemiplegia found to have R\n paretial hemorrhage. Pt now s/p crani c/ erac of hematoma. Since\n extubation swallow eval attempted x 3 but could not be completed; NGT\n placed for TF. Current TF underfeeding, will need to increase to better\n meet nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding / TPN recommendations: Increase TF to goal of 75ml/hour\n (1800 kcals & 112gm pro)\n Check residuals q 4 hours & hold if >200ml\n Check bs q 4 hours, continue insulin regimen\n Monitor hydration & continue flushes prn\n Monitor lytes & replete prn\n Diet consistency per SLP when able to evaluate\n Will follow, page c/ ?'s\n" }, { "category": "Nursing", "chartdate": "2162-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544569, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n S/P craniotomy, patient weaned off sedation and extubated. Able to\n follow commands, a and o x and open eyes to stimulation, moves all\n extremities with left sided weakness. Lifts and holds RUE, RLE and\n able to move left extremities on bed. Patient agitated at times during\n day.\n Action:\n Put on face tent 40% fio2 and now NC 3 L, doboff placed, PT consult\n ordered\n Response:\n Plan:\n Speech and swallow eval tomorrow\n" }, { "category": "Physician ", "chartdate": "2162-10-27 00:00:00.000", "description": "Intensivist Note", "row_id": 544693, "text": "SICU\n HPI:\n Mr. (pronounced 'Joe-Quinn') is a 71-year-old right-handed man\n presents with acute headache and left hemiplegia, found to have ICH.\n His neurologic exam is notable for left neglect, left vf cut, left\n facial droop, left hemisensory loss, and left hemiplegia. This\n localizes to the right parietal lobe, which is where the ICH is seen on\n CT. now s/p rt crani & evacuation on \n Chief complaint:\n ICH\n PMHx:\n HTN, CAD\n Current medications:\n 2. 1000 mL NS 3. 20 mEq Potassium Chloride / 1000 mL NS 4.\n Acetaminophen 5. Bisacodyl 6. Bicitra\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Dexamethasone 9.\n Docusate Sodium (Liquid) 10. Famotidine\n 11. Fentanyl Citrate 12. Heparin 13. HydrALAzine 14. Insulin 15.\n Influenza Virus Vaccine 16. Labetalol\n 17. Lidocaine Jelly 2% (Urojet) 18. Mannitol 19. Mannitol 20. Mannitol\n 21. Metoprolol Tartrate 22. Metoprolol Tartrate 23. Metoprolol Tartrate\n 24. NiCARdipine 25. Phenytoin 26. Pneumococcal Vac Polyvalent 27.\n Potassium Chloride\n 28. Pravastatin 29. Propofol 30. Quinapril 31. Senna 32. Sodium\n Chloride 0.9% Flush 33. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 10:21 AM\n INVASIVE VENTILATION - STOP 10:21 AM\n Post operative day:\n POD#2 - right decompression craniotomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Gentamicin - 05:00 AM\n Infusions:\n Mannitol - 2 grams/min\n Other ICU medications:\n Metoprolol - 02:45 PM\n Fentanyl - 09:16 PM\n Hydralazine - 06:30 AM\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:15 AM\n Other medications:\n Flowsheet Data as of 10:51 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: 36.4\nC (97.5\n HR: 106 (90 - 124) bpm\n BP: 139/59(88) {139/58(86) - 164/75(111)} mmHg\n RR: 20 (15 - 24) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.4 kg (admission): 86 kg\n CVP: 3 (3 - 11) mmHg\n Total In:\n 3,505 mL\n 961 mL\n PO:\n Tube feeding:\n 135 mL\n 449 mL\n IV Fluid:\n 3,160 mL\n 302 mL\n Blood products:\n Total out:\n 4,220 mL\n 1,230 mL\n Urine:\n 4,040 mL\n 1,230 mL\n NG:\n 180 mL\n Stool:\n Drains:\n Balance:\n -715 mL\n -269 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n No(t) Moves all extremities, (LLE: Weakness), restless\n Labs / Radiology\n 407 K/uL\n 12.3 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 110 mEq/L\n 146 mEq/L\n 35.2 %\n 18.3 K/uL\n [image002.jpg]\n 12:32 PM\n 12:50 PM\n 05:32 PM\n 12:03 AM\n 12:13 AM\n 06:19 AM\n 09:34 AM\n 06:29 PM\n 02:03 AM\n 06:20 AM\n WBC\n 14.9\n 18.2\n 18.3\n Hct\n 31.4\n 31.9\n 35.2\n Plt\n 324\n 310\n 407\n Creatinine\n 1.0\n 0.9\n 0.9\n 0.8\n 0.8\n Troponin T\n <0.01\n TCO2\n 26\n 25\n 25\n 28\n 28\n Glucose\n 129\n 147\n 193\n 151\n 144\n 130\n 126\n Other labs: PT / PTT / INR:12.4/27.4/1.0, CK / CK-MB / Troponin\n T:67//<0.01, Lactic Acid:2.6 mmol/L, Ca:9.1 mg/dL, Mg:2.4 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION, TACHYCARDIA, OTHER, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), NAUSEA / VOMITING, INTRACEREBRAL HEMORRHAGE (ICH),\n ALTERED MENTAL STATUS (NOT DELIRIUM), HYPERTENSION, BENIGN\n Assessment and Plan: 71M w/ HTN and CAD p/w ICH, s/p crani on \n Neurologic: Neuro checks Q: 1-2 hr, Phenytoin - therapeutic,\n Restraints, Taper Decadron; Cont to wean Mannitol; Fent PRN Pain\n Cardiovascular: Beta-blocker, Lopressor\n Pulmonary: PT/OT consult\n Gastrointestinal / Abdomen: No issues\n Nutrition: Tube feeding, Speech and Swallow eval, Cont TF\n Renal: Foley, Adequate UO\n Hematology: Hct WNL\n Endocrine: RISS\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Replete (Full) - 08:04 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:06 PM\n Multi Lumen - 08:28 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2162-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 545004, "text": "Altered mental status (not Delirium)\n Assessment:\n Oriented to person & occ date(year) ..pupils equal & react to\n light..moves Rt side..withdraws LF to painful stimuli..head incision\n open to air staples intact\n Action:\n Head ct done\n Response:\n Confused but will follow some simple commands\n Plan:\n Transfer to f11\n" }, { "category": "Radiology", "chartdate": "2162-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1047347, "text": " 8:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval placement of dobhoff tube.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with dobhoff pulled out, placed back in.\n REASON FOR THIS EXAMINATION:\n Please eval placement of dobhoff tube.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dobbhoff tube pulled out, now replaced, check position.\n\n Tip of the Dobbhoff tube lies at or just below the gastroesophageal junction.\n The lung fields are clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1047111, "text": " 4:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? source of fever\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever\n REASON FOR THIS EXAMINATION:\n ? source of fever\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: History of unexplained fever, identify or exclude lungs as source\n of infection.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n upright position is analyzed in direct comparison with a preceding similar\n study of , with patient in supine position. Previously\n identified NG tube remains in unchanged position in fundus of stomach pointing\n downwards. Left subclavian approach central venous line terminating overlying\n the SVC just to the right of the midline, some 2 cm above the level of the\n carina, unchanged. There is no pneumothorax or any other pulmonary\n abnormality. Lungs are not congested and no evidence of pulmonary parenchymal\n densities on either side. Diaphragmatic contours are clean and the lateral\n pleural sinuses are free. No suspicious density in retrocardiac area on left\n base.\n\n IMPRESSION: No evidence of pulmonary infiltrate as source of elevated white\n blood count as identified on this single chest view.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1046389, "text": " 11:49 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for post op changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with right parietal iph\n REASON FOR THIS EXAMINATION:\n eval for post op changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc MON 6:26 PM\n Patient is status post hemicraniotomy with expected postoperative changes and\n interval removal of large right parietal intraparenchymal hemorrhage. Stable\n in appearance intraventricular and subarachnoid hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 71-year-old male with right parietal\n intraparenchymal hemorrhage, status post resection. Evaluate for\n postoperative changes.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: Comparison to MR from and head CT from done at\n 5 a.m.\n\n TECHNIQUE: Contiguous axial non-contrast images of the brain were obtained.\n\n FINDINGS: The patient is status post right hemicraniotomy. There is a large\n amount of expected postoperative pneumocephalus. There is no evidence of\n hemorrhage at the previously seen intraparenchymal hemorrhage site. There is\n still seen to be a moderate amount of intraventricular hemorrhage that layers\n dependently, that is largely unchanged in size and appearance from prior\n examination from at 5 a.m. There is also a small amount of\n subarachnoid hemorrhage that is unchanged from prior examination from\n . There is no significant change in mass effect and shift from prior\n examination from . The size and configuration of the ventricles are\n largely unchanged. The partial opacification of the ethmoid air cells is\n unchanged. The maxillary, sphenoid, and mastoid air cells are well aerated.\n There is no evidence for acute fracture.\n\n IMPRESSION: Patient is status post hemicraniotomy with expected postoperative\n changes and removal of previously observed large right intraparenchymal\n parietal hemorrhage. Unchanged size and appearance of intraventricular and\n subarachnoid hemorrhage.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046718, "text": " 6:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check NGT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with NGT\n REASON FOR THIS EXAMINATION:\n check NGT placement\n ______________________________________________________________________________\n WET READ: AGLc WED 2:12 AM\n Dobhoff still terminating in proximal stomach.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the Dobbhoff\n tube is uncoiled and the tip lies in the proximal portion of the stomach.\n Otherwise little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1046390, "text": ", C. NMED SICU-A 11:49 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for post op changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with right parietal iph\n REASON FOR THIS EXAMINATION:\n eval for post op changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Patient is status post hemicraniotomy with expected postoperative changes and\n interval removal of large right parietal intraparenchymal hemorrhage. Stable\n in appearance intraventricular and subarachnoid hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2162-10-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1046257, "text": " 11:42 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change - PLEASE PERFORM AT 11:30 PM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R parietal ICH\n REASON FOR THIS EXAMINATION:\n eval for interval change - PLEASE PERFORM AT 11:30 PM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 1:12 AM\n Increase in amount of left hemispheric subarachnoid hemorrhage. The right\n hemispheric intracranial hemorrhage, with intraventricular extension and mass\n effect upon the right lateral ventricle are unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old male with right parietal intracranial hemorrhage.\n Evaluate for interval change.\n\n COMPARISON: CTA of the head from approximately 8 hours prior, and non-\n contrast head CT from approximately 11 hours prior ().\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There has been interval increase in the amount of left hemispheric\n subarachnoid hemorrhage.\n\n There is no significant change in the right parietal intraparenchymal\n hemorrhage, surrounding edema or mass effect upon the right lateral ventricle.\n The size and configuration of the ventricles are unchanged.\n\n The amount of intraventricular blood is stable.\n\n Partial opacification of ethmoid air cells is unchanged. Paranasal sinuses\n and mastoid air cells are otherwise well aerated.\n\n IMPRESSION: Increased amount of left hemispheric subarachnoid blood. Stable\n right parietal intraparenchymal hemorrhage, edema, mass effect upon the right\n lateral veitricle and intraventricular extension.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1046452, "text": " 3:24 PM\n MR HEAD W & W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for underlying mass\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with right IPH s/p evac of hematoma\n REASON FOR THIS EXAMINATION:\n eval for underlying mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc MON 8:36 PM\n Extra-axial air and fluid collection measuring 18 mm in its greatest\n transverse diameter causing mass effect with effacement of the right frontal\n lobe. No mass is identified. Small area of infarction adjacent to the\n post-evacuation site in the parafalcine right parietal lobe.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 71-year-old male with known right intraparenchymal\n hemorrhage status post evacuation of the hematoma. Please evaluate for\n underlying mass.\n\n EXAMINATION: MRI of the head with and without contrast.\n\n COMPARISONS: Comparison to MR study from done at 4:00 a.m. and CT of\n the head without contrast from at 12:00 p.m.\n\n TECHNIQUE: Sagittal short TR, short TE spin echo images were obtained through\n the brain. Axial imaging was performed with long TR, long TE, fast spin echo,\n FLAIR, gradient echo, and diffusion technique. After the administration of\n gadolinium contrast, axial, coronal, and sagittal short TR, short TE spin echo\n imaging were repeated.\n\n FINDINGS: There is an extra-axial air and fluid collection with the fluid\n layering dependently, that is located adjacent to the right frontal lobe\n causing some mass effect with effacement of the right frontal lobe sulci.\n There is associated mild midline shift to the left. The extra-axial collection\n of air measures 18 mm at its greatest transverse diameter.\n\n The patient is status post right parietal craniectomy. There is postoperative\n hemorrhage tracking along the craniectomy site, in the right parietal lobe.\n There is a mild amount of associated vasogenic edema at that site. In the\n parafalcine portion of the right parietal lobe, there is an area of slow\n diffusion suggesting acute infarction in the parenchyma adjacent to the\n postoperative evacuation site. There is no post-contrast enhancement that\n would be suggestive of an underlying mass.\n There is an unchanged amount of intraventricular hemorrhage. There is reduced\n effacement of the right lateral ventricle that would be expected\n postoperatively. There is fluid in the ethmoid sinuses and mucous retention\n cysts in the bilateral frontal sinuses.\n\n IMPRESSION:\n (Over)\n\n 3:24 PM\n MR HEAD W & W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for underlying mass\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Extra-axial air and fluid collection that measures 18 mm in its transverse\n diameter and causes mass effect with effacement of the right frontal sulci.\n 2. No masses identified underlying the evacuated hematoma.\n 3. Small area of slow diffusion adjacent to the post-surgical bed in the\n parafalcine right parietal lobe consistent with acute infarction.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1046258, "text": ", C. NMED SICU-A 11:42 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change - PLEASE PERFORM AT 11:30 PM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R parietal ICH\n REASON FOR THIS EXAMINATION:\n eval for interval change - PLEASE PERFORM AT 11:30 PM\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Increase in amount of left hemispheric subarachnoid hemorrhage. The right\n hemispheric intracranial hemorrhage, with intraventricular extension and mass\n effect upon the right lateral ventricle are unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1046453, "text": ", C. NMED SICU-A 3:24 PM\n MR HEAD W & W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for underlying mass\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with right IPH s/p evac of hematoma\n REASON FOR THIS EXAMINATION:\n eval for underlying mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Extra-axial air and fluid collection measuring 18 mm in its greatest\n transverse diameter causing mass effect with effacement of the right frontal\n lobe. No mass is identified. Small area of infarction adjacent to the\n post-evacuation site in the parafalcine right parietal lobe.\n\n" }, { "category": "Radiology", "chartdate": "2162-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1047499, "text": " 6:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 71 year old man s/p DHT placement, pleaese check position.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p DHT placement, pleaese check position.\n REASON FOR THIS EXAMINATION:\n 71 year old man s/p DHT placement, pleaese check position.\n ______________________________________________________________________________\n WET READ: DMFj SAT 8:26 PM\n NG tube with tip beyond edge of film, well within stomach.\n ______________________________________________________________________________\n FINAL REPORT\n DHT tube placed, check position.\n\n CHEST: Comparison is made with the prior chest x-ray of . The\n tip of the tube now lies in the region of the pylorus or the first part of the\n duodenum in a satisfactory position.\n\n The lung fields are clear. No failure is present.\n\n IMPRESSION: Tube in satisfactory position.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1046331, "text": ", C. NMED SICU-A 8:41 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval subclavian and NGT tip location.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p left subclavian, NGT.\n REASON FOR THIS EXAMINATION:\n Please eval subclavian and NGT tip location.\n ______________________________________________________________________________\n PFI REPORT\n Appropriate position of left subclavian line and NG tube, with the left\n subclavian line tip terminating at the junction of the left brachiocephalic\n vein and SVC. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2162-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046666, "text": " 3:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: correct dobhoff placement?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with dobhoff placement\n REASON FOR THIS EXAMINATION:\n correct dobhoff placement?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n a Dobbhoff tube that extends below the margin of the image into the stomach,\n then coils back on itself so that the tip lies close to the cardioesophageal\n junction. The endotracheal tube has been removed.\n\n Otherwise, little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1046280, "text": " 3:39 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: EVAL FOR UNDERLYING MASS AND FOR EVOLUTION OF HEMORRHAGE\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc MON 6:14 PM\n Evolving large right parietal intraparenchymal hematoma. No evidence for\n extension of hemorrhage. No evidence of associated mass.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 71-year-old male with right parietal lobe\n intraparenchymal hemorrhage. Please evaluate for possible underlying mass and\n for evolution of hemorrhage.\n\n EXAMINATION: MRI of the brain with and without contrast.\n\n COMPARISONS: Comparison to CT from and CTA from .\n\n TECHNIQUE: Sagittal short TR, short TE spin echo images were obtained through\n the brain. Axial imaging was performed with long TR, long TE, fast spin echo,\n FLAIR, gradient echo, and diffusion technique. Sagittal and coronal short TR,\n short TE spin echo imaging was repeated after the administration of\n intravenous gadolinium contrast.\n\n FINDINGS: There is a large area of intraparenchymal hemorrhage in the right\n parietal lobe that is unchanged in size from prior CT examination from\n . This large intraparenchymal hemorrhage demonstrates a fluid-fluid\n level and is heterogeneous in nature with dark areas on gradient echo\n sequences and bright internal areas on T2-weighted images, consistent with\n expected evolution changes of a large intraparenchymal hematoma. There are no\n associated diffusion abnormalities in areas adjacent to the intraparenchymal\n hemorrhage that would suggest sites of infarction. There is associated mass\n effect on the posterior portion of the right lateral ventricle. There is a\n mild amount of associated vasogenic edema. There is no associated shift of\n normally midline structures. There is no abnormal enhancement after contrast\n administration.\n\n IMPRESSION:\n 1. Evolving large right parietal intraparenchymal hematoma. No evidence of\n extension of hemorrhage. No evidence of associated mass.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1046281, "text": ", C. NMED SICU-A 3:39 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: EVAL FOR UNDERLYING MASS AND FOR EVOLUTION OF HEMORRHAGE\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n PFI REPORT\n Evolving large right parietal intraparenchymal hematoma. No evidence for\n extension of hemorrhage. No evidence of associated mass.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1046330, "text": " 8:41 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval subclavian and NGT tip location.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p left subclavian, NGT.\n REASON FOR THIS EXAMINATION:\n Please eval subclavian and NGT tip location.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 1:32 PM\n Appropriate position of left subclavian line and NG tube, with the left\n subclavian line tip terminating at the junction of the left brachiocephalic\n vein and SVC. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the subclavian line in NG tube tip\n location.\n\n Portable AP chest radiograph was compared to obtained at\n 12:44 p.m.\n\n The patient was intubated in the meantime interval with the ET tube tip being\n 7 cm above the carina. The NG tube tip is most likely in the stomach,\n although the tip itself is below the inferior margin of the field of view.\n Cardiomediastinal silhouette is stable. Lungs are well inflated and clear. No\n appreciable pleural effusion is seen. No pneumothorax is demonstrated.\n\n" }, { "category": "Radiology", "chartdate": "2162-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046194, "text": " 12:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R parietal stroke, nausea\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right parietal stroke with nausea and vomiting. Evaluate for\n pneumonia or CHF.\n\n No prior examinations.\n\n SINGLE AP SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPH: The patient is rotated. The\n lungs are clear with no evidence of pneumonia or pulmonary edema. There is no\n effusion or pneumothorax. The cardiomediastinal silhouette is normal given\n the AP semi-upright technique. The osseous structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-24 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1046209, "text": " 2:35 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval for aneurysm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R IPH\n REASON FOR THIS EXAMINATION:\n eval for aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SUN 4: of . Unchanged right parietal lobe hemorrhage. Final\n read pending 3D reconstructions.\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE CTA OF THE CIRCLE OF \n\n HISTORY: Right IPH. Evaluate for aneurysm.\n\n Comparison is made with unenhanced CT head from the same day.\n\n FINDINGS: There is a large right frontal hemorrhagic focus with significant\n surrounding edema which appears unchanged compared to the prior study. There\n is marked effacement of the right lateral ventricle. There is\n intraventricular extension and a small amount of subarachnoid hemorrhage.\n\n CTA demonstrates mildly prominent vascularity within the hematoma, but no\n convincing evidence for AVM is seen. Please note that a small AVM could be\n compressed by the hematoma and not be detectable at this time. There is no\n evidence for aneurysm.\n\n There is calcification of the cavernous carotid arteries.\n\n IMPRESSION:\n\n Large right frontal intraparenchymal hematoma. No definite aneurysm or AVM is\n seen. Please note that a small AVM can be compressed by the hematoma and not\n be detectable on CTA.\n\n" }, { "category": "Radiology", "chartdate": "2162-10-29 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1047333, "text": " 4:56 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: please do CTA of head to evaluate for right sided AVM?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n please do CTA of head to evaluate for right sided AVM?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YMf FRI 10:29 PM\n Hyperattenuating foci in the postoperative bed consistent with hemorrhage\n postoperative bed, slightly increased from postoperative study. The\n subarachnoid and intraventricular hemorrhage are similar. No shift of\n normally midline structures. Pneumocephalus decreased.\n No evidence of AVM.\n WET READ VERSION #1 YMf FRI 10:22 PM\n Hyperattenuating foci in the postoperative bed consistent with hemorrhage\n postoperative bed, slightly increased from postoperative study. The\n subarachnoid and intraventricular hemorrhage are similar. No shift of\n normally midline structures. Pneumocephalus decreased.\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY OF THE HEAD\n\n CLINICAL INFORMATION: Patient with postoperative changes for intracranial\n hematoma, evaluate for right-sided AVM.\n\n TECHNIQUE: Axial images of the head were obtained without contrast. Following\n this, using departmental protocol, CT angiography of the head was acquired.\n Reformatted images were obtained. Correlation was made with the CT\n examination of and MRI of .\n\n FINDINGS:\n\n HEAD CT:\n\n There is a right-sided craniotomy identified for evacuation of the previously\n noted intracerebral hematoma. Blood products are seen in the surgical bed\n with surrounding edema. Although from the previous CT of the blood\n products at the convexity appear slightly more prominent, they may be\n unchanged from the MRI obtained subsequently. There is subarachnoid\n hemorrhage and intraventricular blood identified. There is decrease in\n pneumocephalus with small air bubbles identified at the surgical bed. No\n midline shift seen. There is no change in ventricular size noted.\n\n CT ANGIOGRAPHY OF THE HEAD:\n\n The CT angiography of the head demonstrates normal vascular structures\n surrounding the circle of . In the right frontoparietal region, in the\n area of surgical procedure, a tiny extra-axial collection which appears\n postoperative is seen. In addition, there is mild displacement and\n (Over)\n\n 4:56 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: please do CTA of head to evaluate for right sided AVM?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n compression of the arterial structures noted in this region. No abnormal\n vascular structures are seen to indicate arteriovenous malformation. The\n superior sagittal sinus demonstrates normal flow without filling defects. The\n transverse sinuses in the deep venous system also appear normal.\n\n IMPRESSION:\n 1. Subarachnoid hemorrhage and intraventricular blood with postoperative\n changes in the right frontoparietal region with small amount of blood products\n at the surgical site. The blood products may not have significantly changed\n since the MRI of .\n 2. Mild vascular displacement and diminished and delayed filling of the\n frontoparietal arterial branches could be secondary to mild swelling and\n postoperative change in this region. No arteriovenous malformation is seen.\n No sinus thrombosis is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-10-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1046190, "text": " 11:53 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for extent of hemorrhage\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Communication regarding ventricular hemorrhage was relayed to Dr.\n at 9:30 p.m. on .\n\n\n\n 11:53 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for extent of hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R parietal hemorrhage\n REASON FOR THIS EXAMINATION:\n eval for extent of hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SUN 2:18 PM\n Large right parietal lobe collection with mass effect on the lateral\n ventricle. Hematocrit level suggests this is hemorrhagic but an underlying\n mass cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n STUDY: CT of the head without contrast,\n\n HISTORY: 71-year-old male with right parietal hemorrhage. Assess extent.\n\n COMPARISONS: There are no prior studies available for comparison.\n\n TECHNIQUE: 5-mm axial contiguous images of the head were obtained.\n\n FINDINGS: A large right parietal heterogeneous but predominantly dense mass\n is identified measuring 6.2 x 3.4 cm (2:23). A possible hematocrit level is\n identified more anteriorly (2:19). There is effacement of the surrounding\n sulci and mass effect on the right lateral ventricle. No significant shift of\n normally midline structures is observed. There are no other areas of acute\n intracranial hemorrhage. Small amount of mucosal thickening/polyp is\n identified within the right maxillary sinus. Otherwise, the visualized\n paranasal sinuses and mastoid air cells appear unremarkable. The soft tissues\n and osseous structures are intact. Calcifications of the cavernous portions\n of the internal carotid arteries bilaterally are also evident.\n\n IMPRESSION: Large mixed attenuation right parietal lobe finding with\n associated mass effect including compression of the right lateral ventricle.\n Possible hematocrit level suggests this is hemorrhagic in etiology, but an\n underlying mass cannot be excluded and MRI should be considered.\n\n ADDENDUM AT ATTENDING REVIEW: There is moderate right lateral ventricular\n blood, and a small amount of blood sedimenting in the left occipital \n region.\n\n\n" }, { "category": "ECG", "chartdate": "2162-10-24 00:00:00.000", "description": "Report", "row_id": 241315, "text": "Sinus rhythm. Borderline intraventricular conduction delay. Left atrial\nabnormality. Non-specific ST segment and T wave changes. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2184-08-05 00:00:00.000", "description": "Report", "row_id": 195229, "text": "Baseline artifact. Sinus tachycardia. Right inferior axis. Clinical correlation\nis suggested. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2184-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 927899, "text": " 5:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with asthma exacerbation\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old male with asthma exacerbation and a concern for\n pneumonia.\n\n PORTABLE FRONTAL CHEST: The heart size and cardiomediastinal contours are\n within normal limits. The pulmonary vasculature is unremarkable. The lungs\n are clear without focal consolidation, pleural effusion, or pneumothorax. The\n surrounding soft tissues and osseous structures are unremarkable.\n\n IMPRESSION: No pneumonia.\n\n" }, { "category": "Nursing/other", "chartdate": "2184-08-05 00:00:00.000", "description": "Report", "row_id": 1446978, "text": "Respiratory Care\nBreath sounds bilateral expiratory wheezes that never go away even after three set of continuous nebs treatments, stays into sinus tachycardia heart rate ranged 122 to 124, coughed up moderate thick yellow/blood-tinged secretions, is on solumedrole, is ordered to small volume nebulizer with Albuterol and Atrovent Q2 to 3Hrs.\n" }, { "category": "Nursing/other", "chartdate": "2184-08-05 00:00:00.000", "description": "Report", "row_id": 1446979, "text": "NPN 1630-1900\n\nPls refer to ICU admission history for HPI and PMH\n\nPt. arrived in a moderate respiratory distress speaking in word sentences, sitting bolt upright with great amount of activity intolerance. ABG drawn and CXR taken within short time frame. ABG revealing lactic acidosis w/ lactate of 9.2 and ABG 7.26/35/107/16. Pt. given 125mg of solumedrol and restarted on continuous combo (albuterol/ atrovent) nebs. Pt. now taken off cont. neb and on 2L NC, speaking in complete sentences and reports feeling more comfortable and less chest pressure. Intubation discussed. However, team feels that pt. will reverse quickly w/ nebs, steriods. They are questioning starting abx. and will look at CXR. CTA not ordered d/t low suspicion of PEs.\n" }, { "category": "Nursing/other", "chartdate": "2184-08-06 00:00:00.000", "description": "Report", "row_id": 1446980, "text": "1900-0700 NPN\nNEURO: easily agitated, anxious early pm. mae, tremors most prob. due to albuterol nebs now q 3 hr.\n\nCV: afebrile, sys 90's-120's, hr sinus tach 100-130. no ectopy noted. WBC this am 16.\n\nRESP: early evening continuous wheeze with mild distress, abg PO2 70's, lactate cont. elevated. sats 88-90's on 2 liters nasal cannula. Nebs for reactive airway with lengthy time to equilibrate after treatment. Able to speak in full sentences. Significant improvement by 2400, pt. able to lie flat, cough productive for clear sputum, robust cough, no wheeze noted through rest of shift. able to sleep without distress lying flat on room air with sats 93-95%\n\nGU/GI: urine qs vded, now progressed to reg. diet, pt. enc. to pace himself with eating. he ordered out salad, hamburger, onion rings, clam chowder and found himself unable to eat most. no bm.\n\nSKIN: intact\n\nPAIN: denies\n\nACCESS: two PIV with good return. able to draw bloods off of RFA.\n\nENDO: pt. on steroids, BS 160/136. started on sliding scale.\n\nSOCIAL: he is a chief stationed currently in RI with two children ages 1 and 7. feels supported by spouse. Easily agitated and anxious with high need to control his environment.\n\nPLAN: cont. nebs, increase mobility, monitor resp. status closely, including peak flow, cont. steroids, no antibiotics at this time., follow BS and respond with sliding scale. enc. fluids.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2105-11-15 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 893568, "text": " 4:53 PM\n TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: ORIF RT TIB FIB\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n EXAM DATE: .\n\n EXAM ORDER: Right tibia and fibula.\n\n HISTORY: ORIF tibial shaft fracture.\n\n RIGHT TIBIA AND FIBULA: Nine intraoperative fluoroscopic images of the right\n tibia and fibula were obtained during open reduction and internal fixation of\n essentially nondisplaced mildly comminuted mid tibial shaft fracture with an\n intramedullary rod and proximal and distal interlocking screws.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2105-11-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 893496, "text": " 8:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: fracture, bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p mvc w/ multiple head injuries\n REASON FOR THIS EXAMINATION:\n fracture, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SAT 9:32 PM\n Small left hemorrhagic contusions. No extra-axial hemorrhage. Extensive facial\n fractures, involving frontal bones, anterior floor of middle cranial fossa,\n orbital walls, but little displacement of those fractures. Sight displacement\n of right orbital fractures however. No mass effect of midline shift.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 20-year-old woman status post motor vehicle collision with\n multiple head injuries.\n\n COMPARISONS: None.\n\n FINDINGS: There is no mass effect, hydrocephalus, or shift of the normally\n midline structures. The ventricles, cisterns, and sulci are unremarkable\n without effacement. The -white matter differentiation is intact. There\n is a punctate hemorrhagic focus of 6 to 7 mm in diameter in the left frontal\n lobe with mild surrounding edema. There is also a second equivocal\n hemorrhagic contusion in the subinsular cortex on the left side, of about 3 mm\n in diameter. No other parenchymal abnormality is identified. In spite of the\n presence of multiple non-displaced, or only minimally displaced, fractures of\n the skull, there is no definite extra-axial hemorrhage.\n\n BONE WINDOWS: There are complex skull and facial fractures, which are\n discussed in the accompanying report of the same day. The paranasal sinuses\n show hemorrhagic contents that are also better assessed on the other study.\n There is orbital emphysema bilaterally, pronounced soft tissue swelling\n particularly over the right orbit and multiple facial fractures. The mastoid\n air cells are clear.\n\n IMPRESSION:\n 1. Hemorrhagic contusions, but no evidence of significant mass effect.\n 2. No definite extra-axial hemorrhage. However, given the presence of\n fractures of the frontal bones and orbital rooves, it would be appropriate to\n assess closely for extra-axial hemorrhage on a close follow-up CT, at which\n time the contusions can also be reassessed.\n 3. Complex orbital fractures, to be described in the accompanying report.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-11-14 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 893497, "text": " 8:18 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p mvc w/ multiple head injuries\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SAT 9:33 PM\n No evidence of cervical spine fracture. Soft tissue swelling cannot be\n assessed with intubation.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATIONS: 20-year-old woman, status post motor vehicle collision with\n multiple head injuries.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained,\n and sagittal and coronal reconstructions were also performed.\n\n FINDINGS: The patient is intubated. A nasogastric tube passes through the\n esophagus. The head is rotated towards the left side. There is no evidence\n of a fracture of the cervical spine. Serpiginous lucency in C6 most likely\n represents a nutrient foramen. Soft tissue swelling cannot early be well\n assessed due to intubation, and the presence of orbital and nasal fractures,\n with resultant hemorrhagic products within the oro- and nasopharynx. The\n complex facial and orbital fractures are described on the accompanying study.\n\n IMPRESSION: No evidence of cervical spine fracture. Head rotated toward the\n left, which may be positional, although rotatory subluxation is accordingly\n difficult to exclude by imaging.\n A linear lucenccy is the C6 vertebral body, most probably a nutrient foramen.\n If clinically warranted an MRI with STIR images may be performed to exclude a\n subtle abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2105-11-14 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 893498, "text": " 8:23 PM\n TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: fx, acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p mvc\n REASON FOR THIS EXAMINATION:\n fx, acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC.\n\n SINGLE AP VIEW OF THE RIGHT LOWER LEG: There is a mildly comminuted,\n essentially nondisplaced fracture of the mid tibial diaphysis. No fibular\n fracture is identified. The visualized portions of the knee are unremarkable.\n\n IMPRESSION: Right tibial diaphyseal fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-11-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 893538, "text": " 9:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with unrestrained MVC, intubated for decr GCS, contusion on\n initial head CT\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC, contusion on initial head CT, evaluate for interval change.\n\n COMPARISON: CT dated at 8:22 p.m.\n\n TECHNIQUE: Noncontrast images of the head were obtained.\n\n FINDINGS: Small focus of intraparenchymal hemorrhage in the left frontal lobe\n with a second tiny possible hyperdense focus in the left temporal lobe are\n unchanged. There is a hyperdense region overlying the right frontal convexity\n with maximal diameter of approximately 5 mm, present in retrospect on the\n previous study and not significantly changed. The ventricles are stable in\n size. No significant midline shift. The basilar cisterns appear patent. No\n definite new foci of hemorrhage seen.\n\n Bone windows again demonstrate multiple fractures with opacification of\n multiple sinuses. Orbital emphysema is also again seen.\n\n IMPRESSION:\n 1. Unchanged small focus of intraparenchymal hemorrhage in the left frontal\n lobe and possible tiny second focus in the left temporal lobe.\n\n 2. Right frontal convexity hyperdense extra-axial collection that likely\n represents a subdural hematoma, present in retrospect compared to the study of\n one day prior. This does not appear significantly changed.\n\n 3. Multiple skull fractures.\n\n This was discussed with Dr at approximately 10am on .\n\n\n" }, { "category": "Radiology", "chartdate": "2105-11-14 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 893505, "text": " 10:43 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE\n CT 100CC NON IONIC CONTRAST\n Reason: patient has hematuria after high speed MVC\n Admitting Diagnosis: BLUNT TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 16 year old woman with\n REASON FOR THIS EXAMINATION:\n patient has hematuria after high speed MVC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hematuria after high-speed MVC.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained following the administration of 150 cc of optiray contrast.\n\n CT OF THE ABDOMEN WITH CONTRAST: The lung bases are clear. There is an NG\n tube in place. The tip of the NG tube is within the body of the stomach. The\n liver, gallbladder, spleen, pancreas, and adrenal glands are normal. The\n kidneys enhance symmetrically and excrete normally. There is a duplicated\n ureter on the right side. The stomach has a fair amount of air within it. The\n stomach, small and large bowel are otherwise unremarkable. No free air or\n free fluid within the abdomen. The aorta is of normal caliber, and the\n proximal celiac, SMA, and are patent. No pathologically enlarged\n retroperitoneal or mesenteric lymph nodes.\n\n CT OF THE PELVIS WITH CONTRAST: There is a Foley catheter within the bladder.\n The uterus, rectum, and sigmoid are normal. The adnexa are normal. There is\n no free pelvic fluid. No pathologically enlarged pelvic or inguinal lymph\n nodes.\n\n BONE WINDOWS: There are no fractures identified. There are no suspicious\n osteolytic or sclerotic lesions seen.\n\n Multiplanar reformatted images were essential in delineating the anatomy and\n pathology in this case (grade 1).\n\n IMPRESSION:\n 1. No acute traumatic injury identified within the abdomen or pelvis.\n 2. The stomach is moderately distended with air. NG tube in place.\n 3. There is a duplicated ureter on the right side.\n\n (Over)\n\n 10:43 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE\n CT 100CC NON IONIC CONTRAST\n Reason: patient has hematuria after high speed MVC\n Admitting Diagnosis: BLUNT TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2105-11-14 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 893499, "text": " 8:35 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Trauma? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p mvc w/ facial injury\n REASON FOR THIS EXAMINATION:\n Trauma? fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SAT 9:37 PM\n Non-displaced fractures of frontal bones, floor of anterior cranial fossa, no\n definite adjacent intracranial hemorrhages. Globes and preseptal areas appear\n intact. Complex facial fractures generally with slight displacement only.\n Hemorrhage in sinuses.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 20-year-old woman with facial injury status post motor vehicle\n accident.\n\n TECHNIQUE: Axial non-contrast CT images were obtained through the maxillary\n facial bones, orbits and sinuses. This study is closely correlated with the\n CT scans of the head and cervical spine of the same day. Coronal\n reconstructions were also performed.\n\n FINDINGS: There is pronounced soft tissue swelling over the right orbit, and\n to a lesser extent over the left orbit. There is bilateral orbital emphysema,\n including air in the postseptal spaces bilaterally. The globes appear grossly\n intact, although there is some proptosis of the right side relative to the\n left, as well as mild inferior medial shift of the right globe. This is likely\n related to a small hematoma in the superolateral orbit, adjacent to the\n orbital roof fracture site.\n\n The maxillary and sphenoid sinuses show air-fluid levels consistent with\n hemorrhage. There is also soft tissue density, presumably hemorrhage in the\n nasal and oropharynx. The mastoid air cells are clear.\n\n There are multiple fractures involving the facial bones. There are bilateral\n nondisplaced frontal bone fractures. Also, the orbital grooves and medial\n orbital walls have multiple minimally displaced fractures bilaterally. The\n orbital roof fractures are displaced upwards by 1-2 mm as best seen on the\n coronal images. These fractures also involve the cribriform plates, without\n significant displacement, and the lateral orbital walls as well. In addition,\n there are multiple minimally displaced fractures in the ethmoid cells and of\n the nasal bones. Bilaterally, the maxillary bones show fractures along the\n anteromedial aspects of the maxillary sinuses, with a few mm of posterior\n displacement and impaction. There is no fracture evident involving either\n carotid canal.\n\n IMPRESSION:\n\n 1. Opacification of the paranasal sinuses with air-fluid levels, consistent\n (Over)\n\n 8:35 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Trauma? fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with hemorrhage. The presence of an air-fluid level in the sphenoid sinus can\n be suggestive of an occult skull base fracture as well although none is seen\n on this study.\n\n 2. Bilateral orbital emphysema and soft tissue swelling about the orbits,\n although the globes appear intact. The postseptal fat appears intact as well.\n Adjacent to the fracture of the right orbital roof, there is a small hematoma\n , lying outside the extraocular muscles, with mild downward displacement of\n the globe on the right side.\n\n 3. Complex facial bone fractures, with posterior displacement to a small\n extent of the nasal and anterior aspects of the maxillary bones.\n\n 4. Fractures of the orbital rooves and medial orbital walls, as well as the\n cribriform plates and frontal bones.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-11-14 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 893494, "text": " 7:57 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n SUPINE AP VIEW OF THE CHEST: An endotracheal tube is noted with tip at the\n carina. A gastric tube is seen with its side port in the stomach. The heart\n is normal in size. The mediastinal and hilar contours are normal. The lungs\n are clear. There are no effusions, pneumothorax, or focal areas of\n consolidation demonstrated. No gross rib fractures are noted.\n\n SUPINE AP VIEW OF THE PELVIS: No fracture, dislocation, or focal osseous\n abnormality is seen. The hips and sacroiliac joints bilaterally are\n preserved. The sacrum is intact. Soft tissues are unremarkable.\n\n IMPRESSION:\n\n 1. Low lying endotracheal tube with tip at the carina. Dr. was\n informed of these findings at 8:45 p.m. on .\n\n 2. No acute cardiopulmonary abnormality.\n\n 3. No fracture or dislocation within the pelvis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-11-18 00:00:00.000", "description": "Report", "row_id": 1293916, "text": "NPN 0700-1-500;\n\nEVENTS OOB TO CHAIR WITH MIN ASSIST\nREMAINED CALM AND COOPERATIVE THROUGHOUT TODAY.\n\nNEURO;LETHARGIC, AT TIMES DIFFICULT TO AROUSE. EYES REMAIN SWOLLEN SHUT UNABLE TO CHECK PUPILS .FOLLOWS SIMPLE COMMANDS ASSISTED OOB TO CHAIR AND BACK AGAIN PARTICIPATED IN SOME CAR ATTEMPTED TO OPEN EYES BUT IS UNABLE TO DO SO BECAUSE OF SWELLING.. MOVES ALL EXTREMITIES WELL. TO COMMAND AND SPONTANEOUSLY. PURPOSE FUL MOVEMNTS ABLE TO STATE NAME DOB MONTH AND YEAR. STATES DONT KNOW TO PLACE . REPLYING TO MORE QUESTIONS TODAY WITH LESS PERSISTANCE.\n\nRESP; LUNGS CLEAR UPPER DIMINSHED AT BASES.RR 18-20. STRONG PRODUCTIVE COUGH OF THICK WHITE SECRETIONS. SATS 100% WITH ENCOUAGEMENT.\n\nCVS; TMAX 99.6 PO NSR 85- 145 WITH AGITATION. BP 95-105/45.\n\nGU; CONTINUES TO PASS MOD AMOUNTS CLEAR YELLOW URINE VIA FOLET.\n CONTINUES TO MENSTUATE.\n\nGI; ABLE TO SWALLOW WATER WITHOUT INCIDENCE TOOK FEW SPOONFULS OF SOUP AND POSICLE WHEN TAKING MORE PO IV BE HEP LOCKED.\nMAINTAINANCE CHANGED TO D5.45 NS WITH 40 MEQ'S KCL /1000 AT 60 MLS/HR.\nNO COVERAGE ON RISS.K3.4 THIS AM GIVEN 20 MEQ'S ? NEEDS RECHECK THIS PM.\n\nWOUNDS LESS SWOLLEN THROUGHOUT PERIORITAL ARREA RT EYE STILL MORE SWOLLEN THAN LT. PT COOPERATIVE AND OPENED ABOTH EYES FOR PLACEMENT OF ERTHYO AFTER SOKING WITH WARM SALINE. LACERATION WNL. AWAITING TO CLEAR COLLAR BY TRAUMA. TRAUMA TEAM AWARE WILL RETURN LATER.\nPT OOB TO CHAIR WITH PT MIN ASSISTANCE NEEDS TO BE GIVEN SIMPLE ISOLATED INSTUCTIONS AND GUIDED THROUGH ACTIVITIES AND WILL AASSISST WITH ADL SUCH AS BRUSHING TEETH AND PLACEMENT OF EYE CREAM AND ECT.\n\nA/P STABLE DAY LESS AGITATED RESTRAINTS OFF CURRENTLY NO ATTEMPT MADE TO PULL ANYTHING OOUT PARENTS AT PTS BEDSIDE ARE VERY HELPFUL. SITTER ODERED FOR 7P-7A. PARENTS WILL RETURN TOMOORROW AT 7P. TRANSFER TO FLOOR TOMORROW, WHEN PRIVATE ROOM IS AVAILABLE DUE TO PTS AGE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-11-17 00:00:00.000", "description": "Report", "row_id": 1293912, "text": "addendum: pt staying at hotel at chidren's. stayed with her until 9 pm\n" }, { "category": "Nursing/other", "chartdate": "2105-11-16 00:00:00.000", "description": "Report", "row_id": 1293910, "text": "T/SICU Nursing Progress Note \nSee CareVue for specific data.\n\nEvents today:\nSelf extubation, removal of radial aline, and removal of foley catheter (replaced).\n\nNeuro: Sedation off at 0730 after self-extubation. Mental status gradually improving through day, at best says \"leave me alone\" or \"I want to go over there.\" Responds to voice, localizes painful stimuli, inconsistently follows command. Pupils 3mm equal, round, and reactive. Not opening eyes, however they are grossly edematous. MAE with very good strength except RLE (injured) which moves on bed.\n\nPain: Nods no when asked if in pain.\n\nResp: Self-extubated, SPO2 >97% immediately thereafter on 35% humidified face mask. Weaned to room air through course of day, maintained SPO297-100%. Productive cough clearing tan secretions. Lung sounds coarse initially, cleared through day. Equal bilat expansion, no apparent distress, RR14-16.\n\nGI: NPO. OGT out, had been sumping thin brown liquid. Hypoactive bowel sounds, soft and non-tender to palp.\n\nGU: Foley to gravity draining dilute yellow urine in copious amounts. Changed after auto-removal by patient.\n\nEndo: FSBS QID per orders, covered as ordered.\n\nSkin: Multiple lacerations, contusions, documented in CareVue. Primary lacerations on forehead closed with sutures; triple antibiotic ointment and bacitracin applied, weeping serosanguenous fluid.\n\nSupport: Parents at bedside for safety measures and support through much of day. Calm and appropriate, and have a soothing effect with patient.\n\nPOC:\nMaintain safety.\nPain management.\nNeuro exams; attempt to keep off sedative medications to obtain best exams.\nPulmonary toileting.\nNPO.\nDischarge/disposition planning.\nEmotional support.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-17 00:00:00.000", "description": "Report", "row_id": 1293913, "text": "npn 0700-1900\n\no;\" I want this off \" trying to remove collar.\nneuro; unable to do eye exam even with 3 people holding pt pt moves all 4 limbs with good strength. inconsistently follows commands will squeeze hands but does not answer questions occassionally says things which are diff to understand but at times is very clear e.g\" stop that. leave me alone. no sedation or pain med given shakes head when asked if in pain.only c/o pain when trying to do eye exam.\n\nresp lungs clear strong productive cough. of thick whhite secretion sat 99-100% rr 16-22 .\n\ncvs; tmax 99.8 po nsr 95-145 wiwth agitation. bp stable\n\ngu; autodiuresing 300 mls per hour. lytes repleted. serum osmo and na monitored and stable at this time.\n\ngi; npo attempted to place dobhoff but rt nares bleeding profusely\n threfor attenmpt abandomned.no cover required on riss.\n\nheme hct 24 at 3pm pt also menstruating.\n\nk3.4 received 20 meq's i.v and maintainance fluid changed to ns with 40 meq's at 60 mls/hr. until taking pos.\n\nface remain swollen and ecchymotic, incision c/d with bacitracin applied. abrasions dry.periorbital areas swollen and ecchymotic unable to open eyes without causing ts of distress weeping seous snquinous drainage from rt eye requiring frequent cleaning erythromycin applied with extreme difficulty requiring 2 persons.\n\ns/b pt and pt stood with min help but c/o of feeling dizzy and returned to bed , pt very mobile in bed.\n\nparents at bedside all day sitter ordered from 7p-7a.\n\na/p stable day intermittent periods of agitation lethargic aat times ? not answering.v unable to answer. continue to follow neuro obs more cooperative at times than others.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-18 00:00:00.000", "description": "Report", "row_id": 1293914, "text": "resp: o2 sats 99-100% on room air coughs but not raising secretions.lungs clear but diminished at bases.\n\ngi: pos bowel sounds .no bm. npo.\n\ngu: pt pulled out catheter at about 7 pm. did not void and became restless~ 2400. attempted bedpan but pt unccoperative so foley replaced. draining good amounts clear yellow urine. dipaer and jonny pants placed on patient to make it less accessible to pt to pull out.\n\nneuro: pt more verbal. obeys commands. pt unccoperative at times and agitated, restless. eyes are swollen shut and this rn is unable to visualize her pupils to check for size and reactivity. pt states\" I can't see\".pt cannot remember where she is and what happened so requiring frequent orientation.\n\ncv: bp stable hr 80-90's but occasionally increases to 140 st briefly when agitated and then decreasedwhen patient reoriented and settled in.\n\neyes are so swollen it is difficult to get oiintment in eyes and pt tries to move away and is uncooperative. cast on right lowere leg is intact and wrapped with acewrap.\n\nsitter is with patient . patient tries to pull neck splint off and tries to get her hands on iv's. She has pulled out her foley catheter several times.\n\nlabs: k=3.4 replaced with kcl 20 meq. mag 1.9 2 grams mag sulfate\n" }, { "category": "Nursing/other", "chartdate": "2105-11-18 00:00:00.000", "description": "Report", "row_id": 1293915, "text": "addendum: patient is menstruating. peripad dislodged with pt reslessness so diaper and jonny pants on. pad changed times 3 moderate amounts serosang aaaaaaand diaper changed times one. last change at 0700.\n\nneuro: pt much calmer and more cooperative this a.m.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-15 00:00:00.000", "description": "Report", "row_id": 1293906, "text": "resp care\nremains intub/vented in ac mode. remained sedated, plans to wean/extubate tomorrow. pt transported to head ct, also went to or. for repair of leg...thus no weaning done. abgs excellent. bs ess cta. by rn.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-15 00:00:00.000", "description": "Report", "row_id": 1293907, "text": "Nursing Post-Op \nPost-op addendum to daily assessment.\nSee CareVue for specific data.\n\nReturned from OR at approximately 1545.\n\nExam, by exception from prior note:\nChemically paralyzed in OR, returned with propofol @ 100mcg/kg/min, weaned to off for best neuro exam, remained off as patient calm and sedated. At best, exam improved to GCS E1/V1.0T/M5=7 (localized to painful stimuli). Moving extremities on bed, increasingly with time. Pupils sluggishly reactive at first, improved to briskly reactive over time.\nRLE wrapped in dsd, ace bandage and splinted. Pulses palpable 3+ under dressing.\nRepleated Magnesium and Calcium again. Transfused 1U PRBC's for falling hematocrit.\n\nParents and several friends visited this evening, understanding in plan of care. Parents initially hesitant to consent to blood transfusion, however after risks vs benefits discussed with MD, they agreed to one transfusion and will re-consider if further transfusions are needed.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-17 00:00:00.000", "description": "Report", "row_id": 1293911, "text": "eye exam done at onset of this Rn's shift. per opthal.. corneal abrasion left eye. erythromycin eye oitment qid initiated.\n\ncv: hr to 150 briefly during eye exam.. bp stable. hr at rest 84-. bp stable see careview.\n\nneuro:pt agitated and uncooperative. pt held down by a few staff for eye exam. an order for pain medication obtained but not given. pt back to sleep ;after exam. pt follows commands inconsistently. pt moves r leg on bed. pt moves left and r arm and left leg freely. ptaient ;ulls at collar and any tubes. pt has left arm wrapped with kerlex to protect 2 per iv's. r hand is restrained.left arm restrained multiple times but pt manages to get her arm free of restraint.she also tries to remove collar. she did remove it a few times and turns her head mitts appled to both hands BUT patient removes these with ease. so sitter requested . sitter to bedside.unable to check pupils with neuro checks. r eye swollen and unable to open it. left eye pt moves away when you try to check it.\n\ngi: npo. positine bowel sounds. no bm\n\ngu: foley draining good amounts yellow urine clear. a few hours pt made smaller amou8nts urine ~ 30 /hr but the next hour pt urine ouput much greater ~ 280 /hr see careview\n\nintegumentary: both eyes very swollen and ecchymotic. r eye tearing serosanguinous small amounts. l eye with corneal abrasion.. erythromyci ointment applied. r leg in ace wrap.serosanguinous weeping from nose. stitches on face clean and dry bacitracin applied. ennnntire face is swollen. r side of face more swollen that left.\n'\nresp: o2 sats 99-% on room air\n" }, { "category": "Nursing/other", "chartdate": "2105-11-16 00:00:00.000", "description": "Report", "row_id": 1293908, "text": "TSICU nursing progress note 1900-0700\nNeuro: Sedated on propofol 20mcg/hr and fentyanl 25mcg/hr. Pupils PERRL. Exam improved over night. At 0500 when lightened and asked \"can you hear me?\" nodded yes. Then asked \"are you having pain\" and again nodded yes. Still not squeezing hands to command, but moves all extremities with normal strength. Right lower extremity moving with less strength. Cannot open eyes due to orbital swelling, cannot check corneal reflex due to swelling. Spontaneous movements very purposeful goes right for ETT.\n\nCV: HR in 80's when calm, into low 100's when moving around. ABP 110's/50's. Palpable pulses in all accessible extremities. Unable to check pulses in right foot due to casting put on in OR for tibia fx. cap refill <3 seconds.\n\nResp: Vent weaned to CPAP 5/5. Tolerating well, gas WNL. Possible extubation this am. Breath sounds clear throughout, slightly diminshed at bases. Suctioned for small amounts of white/tan/blodd tinged secretions.\n\nGI: OGT to LCS draining brown to bilious fluid in small amounts. Positive bowel sounds. No BM.\n\nGU: Foley draining clear yellow urine small amounts of bloody tinged urine from pt. pulling on catherter when restless.\n\nEndo: FS 2400 150 covered with 2 units per sliding scale.\n\nID: Tmax 99.3 latest 98.4 oral, continues on antibiotics.\n\nSocial: Parents here around 8pm, got hotel room with help of hospital. Staying there for the night. Informed we would call with any changes. Parents called at 0500 for update.\n\nA: Tolerating vent weaning well. Mental status increasing, beginning to respond to questions.\n\nP: ?Extubation this am. Continue to monitor neuro assessment Q2H as per team. Continue to monitor injuries and treat as needed.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-16 00:00:00.000", "description": "Report", "row_id": 1293909, "text": "Respiratory Care Note:\n\nPt received orally intubated and sedated on vent support. We were able to switch to PSV o/n, now on minimal settings. RSBI done ~ 20, awaiting neuro exam and ? possible MRI if... We are sxtn snall to mod bloody to tan thick secretions from ETT. Plan: Continue present ICU monitoring and ? elective extubation.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-15 00:00:00.000", "description": "Report", "row_id": 1293904, "text": "TSICU nursing admit note\n\n16 year old female unrestrained backseat passenger MVA, 20 minute extrication. Brought to via intubated at the scene.\n\nNeuro: Sedated on propofol gtt and fentynal gtt. Neuro checks Q1H. When lightened wakes up pupils PERRL right smaller and more sluggish than left. Moves all extremities with normal strength. Goes for tube and anything in reach. Intact cough and gag. Vomited once, anzimet given. C-collar in place, logroll maintained.\n\nCV: Sinus rhythm in 90's after fetnynal gtt on. Occasional PAC's. BP 100's/50's. Palpable peripheral pulses in all extremities. Right open tib/fib fracture. Right lower extremity warm, cap refill <3 sec, and +pulses.\n\nResp: Intubated at scene. On CMV peep 5 tidal vol 450, o2 40% bpm22. Excellent oxygenation, maintaining CO2 30-35 per neuro. Lungs clear dim at bases, right more dim than left. Suctioned for moderate amounts of thick bloody secretions.\n\nGI: Positive bowel sounds, hypoactive. Abd firm nondistended. No BM vomited once, dark bloody fluid ~100cc.\n\nGU: Foley draining clear yellow urine in moderate amounts.\n\nSkin: Forehead laceration, star shaped sutured by plastics no drainage, OTA. Sm. lac right lip sutured, no drainage, OTA. Open tib/fib cleaned out and splinted in ER by ortho draining small amounts of bloody drainage. Will take to OR pending neuro assessments. Multiple facial fxs. Large periorbital edema very purple to blue in color bilaterally. Multiple abrasions and brusing.\n\nID: Tmax 100.6 (with blanket on) Started on antibiotics.\n\nEndo: FS 153; 2 units given per sliding scale.\n\npsych/social: Family here, updated with condition. Parents stayed the night very appropriate. Wants to stay with daughter but understands we need to assess her and they will step out.\n\nA: 16 year female with multiple facial fxs, open tib/fib, ?neuro status.\n\nP: Continue to monitor neuro status Q1H. Awaiting OR for tib/fib fx. Continue to follow vital signs and pain management. Social work consult today.\n" }, { "category": "Nursing/other", "chartdate": "2105-11-15 00:00:00.000", "description": "Report", "row_id": 1293905, "text": "Nursing \nSee CareVue for specific data.\nThis note encompasses pre-op period this AM.\n\nEvents today:\n- Repeat head CT\n\nNeuro: Propofol drip for sedation, fentanyl drip for pain management. Spontaneously and purposefully moves all extremities, right lower leg injured thus not moving much, however inconsistently and rarely follows commands, always localizes pain. Nods yes when asked if in pain. Pupils 2mm round and reactive; left pupil very slightly larger than right. Attempted to wean sedation (propofol) for best neuro assessment, however required boluses and continous drip during transport; turned back off upon return, however became agitated during prep for transfer to OR, so bolused again by nursing and sedated further by anesthesia for transport. C-collar, logroll precautions in place.\n\nPain: Nods yes when asked if in pain, unable to determine source. Fentanyl gtt @ 12.5mcg/hr with good effect (patient calm).\n\nResp: ETT 7.5 22@ lip, CMV vent FiO2 40%, Rate 22, Peep 5, TV 450mL; no changes this shift. Lung sounds clear, diminished at bases R>L. Equal chest rise and fall, no tracheal deviation, no crepitus on palpation. Suctioned for small to moderate amounts of bloody sputum. Per neurosurgery, goal of pCO2 30-35 no longer strict based on CT results. Attempted wean vent to CPAP with pressure support, however patient's spontaneous rate 4-5, so put back on CMV.\n\nCV: HR90's-100's, SBP goal 100-140; within goal except briefly SBP high 90's once in AM, promptly back with goal parameters. Pulses present in all extremities, including distal to right leg injury. Cap refill <2 seconds. Right radial a-line in place, transducing sharply. PIV x3; NS+40K @ 50 (reduced from 100/hr). Serial hct's, latest 24.1\n\nGI: OGT low continuous wall suction sumping thick coffee ground material. Heaving twice when OGT lost patency. Anzemet given at approx 1215 to prevent nausea. Hypoactive bowel sounds present. Abd soft, non-distended.\n\nGU: Foley to gravity, clear yellow, adequate amounts.\n\nEndo: FSBS qid, covered with RISS.\n\nID: Tmax 99.6 PO; on clindamycin and cefzolin.\n\nLytes: Potassium repleated on night shift, repeat level 3.8 this shift, 40k in maintenance fluids. Calcium repleated this shift as well, magnesium also needs repletion - reported to anesthesia.\n\nSkin: Multiple abrasions open to air. Forehead, right lip, left cheek injuries sutured, not draining, no signs of infection. Eyes swollen; iced gauze and lubrication frequently per opthamology.\n\nSocial: Parents and numerous friends and relatives in to visit this am, all calm and appropriate, participating and understanding plan of care. Social work involved to assist with lodging options.\n\nPlan:\nMaintain sedation for comfort and safety.\nPain management.\nKeep SBP between 100-140.\nAwait trauma team clearance of TLS spine.\nTaken to OR at approx 1400 for repair of right LE injury with orthopedics. Awaiting return to re-assess and formulate further plan of care.\n" } ]

[ { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 415990, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett for pain, last\n dose 9/26 1630.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200\ns improved with increased glargine. 1700 BS 280,\n Action:\n Receiving SSRI to control elevated blood sugars, received 8 units\n regular insulin @ 1730.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco unasyn. T max today 100.2 po, back down to\n 98.1 po in afternoon. CCU resident aware. LS clear with diminished at\n bases, dry NPC. O2 sats 92-98% on 4L NP..\n Action:\n Changed O2 to 40-70% face tent over night and backt to 4liter np .\n Receiving atrovent nebs q 6 hours.\n Response:\n Pt remains O 2 dependent, slight temp today.\n Plan:\n Continue to c& db, frequent position changes. Monitor O2 sats,\n lungs. Monitor Temp. pt to get OOB to chair.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds. OOB to chair\n Response:\n Left breast and panus area healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Heels ^ off of bed.Advance\n diet as tolerated.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n HR 80-90\ns with SBP 100-130 today. U/O ~ 60 cc/hour . Pt very\n thirsty, Na 147.\n Action:\n A-line d/c\nd. Lasix gtt, IV NTG and diuril all d/c\nd today. Goal to\n keep ~ even. Receiving catopril q6 hours. Allowed to drink to comfort\n today as per intern. Received K replacement this am.\n Response:\n Maintaining U/O off of lasix gtt, sats good on stable O2 level.\n Plan:\n Continue to monitor u/o, VS, K/Mg.\n ------ Protected Section ------\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n CORONARY ARTERY DISEASE\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 109 kg\n Daily weight:\n 104.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Diabetes - Oral \n CV-PMH: CAD, Hypertension, PVD\n Additional history: NIDDM x15yrs. Pleurisy 20yrs ago,\n hypercholesterolemia, peripheral neuropathy, melanoma 25yrs ago\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:47\n Temperature:\n 98.1\n Arterial BP:\n S:122\n D:59\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 90 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,364 mL\n 24h total out:\n 2,870 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:53 AM\n Potassium:\n 3.7 mEq/L\n 04:53 AM\n Chloride:\n 103 mEq/L\n 04:53 AM\n CO2:\n 35 mEq/L\n 04:53 AM\n BUN:\n 48 mg/dL\n 04:53 AM\n Creatinine:\n 1.9 mg/dL\n 04:53 AM\n Glucose:\n 140 mg/dL\n 04:53 AM\n Hematocrit:\n 27.2 %\n 04:53 AM\n Finger Stick Glucose:\n 280\n 05:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 1745\n ------ Protected Section Addendum Entered By: , RN\n on: 17:39 ------\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 415982, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett for pain, last\n dose 9/26 1630.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200 improved with increased glargine\n Action:\n Receiving SSRI to control elevated blood sugars.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco unasyn. T max today 100.2 po, back down to\n 98.1 po in afternoon. CCU resident aware. LS clear with diminished at\n bases, dry NPC. O2 sats 92-98% on 4L NP..\n Action:\n Changed O2 to 40-70% face tent over night and backt to 4liter np .\n Receiving atrovent nebs q 6 hours.\n Response:\n Pt remains O 2 dependent, slight temp today.\n Plan:\n Continue to c& db, frequent position changes. Monitor O2 sats,\n lungs. Monitor Temp. pt to get OOB to chair.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds. OOB to chair\n Response:\n Left breast and panus area healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Heels ^ off of bed.Advance\n diet as tolerated.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n HR 80-90\ns with SBP 100-130 today. U/O ~ 60 cc/hour . Pt very\n thirsty, Na 147.\n Action:\n A-line d/c\nd. Lasix gtt, IV NTG and diuril all d/c\nd today. Goal to\n keep ~ even. Receiving catopril q6 hours. Allowed to drink to comfort\n today as per intern. Received K replacement this am.\n Response:\n Maintaining U/O off of lasix gtt, sats good on stable O2 level.\n Plan:\n Continue to monitor u/o, VS, K/Mg.\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 415984, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett for pain, last\n dose 9/26 1630.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200\ns improved with increased glargine. 1700 BS 280,\n Action:\n Receiving SSRI to control elevated blood sugars, received 8 units\n regular insulin @ 1730.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco unasyn. T max today 100.2 po, back down to\n 98.1 po in afternoon. CCU resident aware. LS clear with diminished at\n bases, dry NPC. O2 sats 92-98% on 4L NP..\n Action:\n Changed O2 to 40-70% face tent over night and backt to 4liter np .\n Receiving atrovent nebs q 6 hours.\n Response:\n Pt remains O 2 dependent, slight temp today.\n Plan:\n Continue to c& db, frequent position changes. Monitor O2 sats,\n lungs. Monitor Temp. pt to get OOB to chair.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds. OOB to chair\n Response:\n Left breast and panus area healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Heels ^ off of bed.Advance\n diet as tolerated.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n HR 80-90\ns with SBP 100-130 today. U/O ~ 60 cc/hour . Pt very\n thirsty, Na 147.\n Action:\n A-line d/c\nd. Lasix gtt, IV NTG and diuril all d/c\nd today. Goal to\n keep ~ even. Receiving catopril q6 hours. Allowed to drink to comfort\n today as per intern. Received K replacement this am.\n Response:\n Maintaining U/O off of lasix gtt, sats good on stable O2 level.\n Plan:\n Continue to monitor u/o, VS, K/Mg.\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415845, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At found pt with respiratory rate 36-40 with audible expiratory\n wheezes. O2 sat 89-90% on 6l nasal prongs. SBP 164 with HR 106 ST.\n Action:\n IV Nitroglycerin restarted at 1mcg/kg/min and O2 changed over to 100%\n face tent. Lasix 40mg IVB and Lasix gtt increased to 20mg/hr (15mg)\n Received atrovent MDI\n Response:\n Respiratory rate decreased to 24 with LS BBR O2 weaned to 40% neb.\n Improvement in SBP 110-120 and HR <100\n Plan:\n Continue IV Ntiro/Lasix while po medications are adjusted. Keep cool\n mist neb for moisture as pt mouth is very dry. Goal to keep SBP<140.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Receiving Tylenol q6hrs and\n percocett q4hrs prn\n Response:\n Tylenol giving only fair relief and percocett one tab at HS with good\n effect. Back rubs are appreciated.\n Plan:\n Suggest percocett change to oxcodone 5mg q4hr, continue with Tylenol\n and backrubs.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood sugars 230-280 titrating up glargine 12units and\n SSRI, received total 32 units regular insulin for past 24hrs. Starting\n to eat regular food.\n Action:\n glargine increased to 20 units at HS\n Response:\n Fair BS control with SSRI before glargine increased.\n Plan:\n Continue to monitor blood sugars AC and HS.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n CXR substantial worsening of extensive pulmonary consolidation,\n bilateral pulmonary consolidation right greater than left particularly\n upper lobe. Previous sputum on Acinetobactor Baumanni complex,\n Klebsiella\n Pneumoniae, staph aureus coag+ Afebrile. Coarse BS with freq congested\n NPC.\n Action:\n Attempted to NT suction but unable to pass catheter d/t strong\n gag/emesis. Cough and deep breathe exercises with demonstration.\n Ampicillin day# 11 and vancomycin day#2.\n Response:\n Improvement in O2 saturations.\n Plan:\n Consult PT for CPT and for OOB chair with strengthening exercises.\n Bedside CPT q4-6hrs as needed with IS q1hr while awake.\n" }, { "category": "Nursing", "chartdate": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415772, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o pain related to sciatica\n Action:\n Given 1 percocet this am for above c/o, pain better after percocet.\n CCU team wrote for 1 dose of morphine, not given as pain free.\n Response:\n Pain relieved with percocett and position change.\n Plan:\n Reposition frequently, percocett for pain, if without relief, can have\n morphine dose.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds. Repositioned every 2 hours, and oob to\n chair for 2 hours.\n Response:\n Skin looks much improved from last Sunday, left breast and panus area\n healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Advance diet as tolerated.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Pt with sats ~ 90% this am on shovel mask. Afebrile. Vanco level this\n am 26 (not trough). Lungs with diminished breath sounds in bases.\n Afebrile\n Action:\n Given albuterol/atrovent nebulizer. O2 switched to 4L np. Repeated\n Vanco trough level @ 1530.\n Response:\n Sats improved to mid to high 90\ns. Trough level 22.\n Plan:\n Monitor lungs, sats, atrovent nebs as ordered. Vanco dose held, to\n repeat trough in am.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Continues to be volume overloaded. K and Mg low\n Action:\n Lasix gtt @ 20 mg/hour, paused @ 0930 awaiting lasix from pharmacy.\n PICC line clotted, given tPA via PICC with resolution. Lasix restarted\n @ 1200. U/O 120-280/hour. Diuril dose given @ 1700 when up from\n pharmacy. K and Mg replaced. IV NTG titrated as high as 1.5\n mcg/kg/min d/t SBP 160\ns. Restarted on captopril, monitored frequently\n after dose.\n Response:\n Diuresing well, but is even for the day d/t temporary loss of PICC\n line. SBP 120\ns-130\ns on IV NTG and captopril. No signs of allergic\n reaction to captopril. Repeat K/Mg ok.\n Plan:\n Continue to monitor u/o, VS, K/Mg. Assess for allergic reaction to\n captopril.\n" }, { "category": "Nursing", "chartdate": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415601, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At found pt with respiratory rate 36-40 with audible expiratory\n wheezes. O2 sat 89-90% on 6l nasal prongs. SBP 164 with HR 106 ST.\n Action:\n IV Nitroglycerin restarted at 1mcg/kg/min and O2 changed over to 100%\n face tent. Lasix 40mg IVB and Lasix gtt increased to 20mg/hr (15mg)\n Received atrovent MDI\n Response:\n Respiratory rate decreased to 24 with LS BBR O2 weaned to 40% neb.\n Improvement in SBP 110-120 and HR <100\n Plan:\n Continue IV Ntiro/Lasix while po medications are adjusted. Keep cool\n mist neb for moisture as pt mouth is very dry. Goal to keep SBP<140.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Receiving Tylenol q6hrs and\n percocett q4hrs prn\n Response:\n Tylenol giving only fair relief and percocett one tab at HS with good\n effect. Back rubs are appreciated.\n Plan:\n Suggest percocett change to oxcodone 5mg q4hr, continue with Tylenol\n and backrubs.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood sugars 230-280 titrating up glargine 12units and\n SSRI, received total 32 units regular insulin for past 24hrs. Starting\n to eat regular food.\n Action:\n glargine increased to 20 units at HS\n Response:\n Fair BS control with SSRI before glargine increased.\n Plan:\n Continue to monitor blood sugars AC and HS.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n CXR substantial worsening of extensive pulmonary consolidation,\n bilateral pulmonary consolidation right greater than left particularly\n upper lobe. Previous sputum on Acinetobactor Baumanni complex,\n Klebsiella\n Pneumoniae, staph aureus coag+ Afebrile. Coarse BS with freq congested\n NPC.\n Action:\n Attempted to NT suction but unable to pass catheter d/t strong\n gag/emesis. Cough and deep breathe exercises with demonstration.\n Ampicillin day# 11 and vancomycin day#2.\n Response:\n Improvement in O2 saturations.\n Plan:\n Consult PT for CPT and for OOB chair with strengthening exercises.\n Bedside CPT q4-6hrs as needed with IS q1hr while awake.\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 415935, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett for pain, last\n dose 9/26 0600.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200 improved with increased glargine\n Action:\n Receiving SSRI to control elevated blood sugars.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco unasyn. T max today 100.2 po. CCU resident\n aware. LS clear with diminished at bases, dry NPC. O2 sats 92-98% on\n 4L NP..\n Action:\n Changed O2 to 40-70% face tent over night and backt to 4liter np .\n Receiving atrovent nebs q 6 hours.\n Response:\n Pt remains O 2 dependent, slight temp today.\n Plan:\n Continue to c& db, frequent position changes. Monitor O2 sats,\n lungs. Monitor Temp. pt to get OOB to chair.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds.\n Response:\n Left breast and panus area healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Advance diet as tolerated.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n HR 80-90\ns with SBP 100-130 today. U/O ~ 60 cc/hour . Pt very\n thirsty, Na 147.\n Action:\n A-line d/c\nd. Lasix gtt, IV NTG and diuril all d/c\nd today. Goal to\n keep ~ even. Receiving catopril q6 hours. Allowed to drink to comfort\n today as per intern. Received K replacement this am.\n Response:\n Maintaining U/O off of lasix gtt, sats good on stable O2 level.\n Plan:\n Continue to monitor u/o, VS, K/Mg.\n" }, { "category": "Rehab Services", "chartdate": "2129-09-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 415756, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 414.00 / CAD\n Reason of referral: EVAL and Treat, CPT\n History of Present Illness / Subjective Complaint: 68 F with morbid\n obesity, HTN, NIDDM, hypercholesterolemia and severe 3V CAD who\n presented to OSH on with 2 week hx of CP, SOB and was found to have\n NSTEMI. She underwent a cardiac cath which showed severe multivessel\n CAD complicated by femoral artery laceration and retroperitoneal bleed\n requiring fluid resuscitation and pressors. She was intubated on \n post cath with hemodynamic instability and was transferred to for\n further management and evaluation for CABG. CT here on showed 6x6\n cm hematoma compressing her bladder. Pt had difficulty weaning from the\n vent with continued respiratory distress and developed VAP. Pt was\n extubated \n Past Medical / Surgical History: DM, PVD, HTN, Hyperlipidemia\n Medications: Lasix, nitroglycerin, unyasun, morphine\n Radiology: cxr: There has been substantial worsening of extensive\n bilateral pulmonary consolidation, worse on the right, particularly\n upper lobe than the left.\n Labs:\n 28.0\n 9.2\n 349\n 10.0\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: Lives with husband, has 3 grown children\n Living Environment: Private home + stairs\n Prior Functional Status / Activity Level: PTA I with ADLs + fall hx,\n has SC\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt A and O x3, at\n times tangential in thought process\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 82\n 128/96\n 24\n 95% 4L\n Rest\n /\n Sit\n 88\n 136/88\n 28\n 93% 4L\n Activity\n /\n Stand\n /\n Recovery\n 80\n 118/78\n 24\n 88-91% 5L\n Total distance walked:\n Minutes:\n Pulmonary Status: Weak nonproductive cough, LS diminished t/o R > L\n Integumentary / Vascular: R Aline, foley, L PICC\n Sensory Integrity: Diminished appreciation for LT B distal \n / Limiting Symptoms: Pt reports LBP and radiating R LE pain in\n sitting\n Posture: obese\n Range of Motion\n Muscle Performance\n B UE and LE WFT\n B UE > 3+/ 5\n B DF, Knee ext, >3+/5\n B hip flexion > \n Motor Function: No abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Transfer: Pt was slide to stretcher chair\n Rolling:\n\n\n\n\n T\n\n Supine /\n Sidelying to Sit:\n Mod x 2\n\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt tolerated sitting at EOB for less than 1 min, time limited\n by LBP. Pt was able to maintain sitting with Min A to CG with B UE\n support\n Education / Communication: Pt status discussed with RN, MD. \n on role of PT\n Intervention:\n Other: Pt was very uncomfortable in stretcher chair, regardless of\n multiple attempts at repositioning, at this time SaO2 was 88-90% on 5L,\n Respiratory therapy followed with a neb treatment, and MD made aware of\n situation and was ordering pain meds.\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Cough, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Posture, Impaired\n 5.\n Sensation, Impaired\n 6.\n Ventilation, Impaired\n Clinical impression / Prognosis: 68 yo f with complicated hospital\n course admitted from OSH c STEMI s/p cath with retroperitoneal bleed\n and difficulty weaning from vent. Pt presents with above impairments\n c/w deconditioning and pulmonary pump dysfunction. Feel pts SaO2 was\n poor in sitting due to severe discomfort that was c/w sciatic nerve\n pain. Feel if pain control improves pt will be able to tolerate\n increased time OOB and in upright postures which will intern facilitate\n improved pulmonary status. Pt will likely need rehab upon d/c\n Goals\n Time frame: 1wk\n 1.\n I bed mobility\n 2.\n Increase MMT t/o\n 3.\n Maintain SaO2 > 93% RA\n 4.\n Sit at EOB I\"ly > 5 mins\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n F/U balance, mobility, strength training, pulm hygiene\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n \n 1100-1215\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415880, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett 1 at HS and again\n this am.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200 improved with increased glargine\n Action:\n Receiving SSRI to control elevated blood sugars.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco day #3 pnd vanco level this am and unasyn day#\n 12 LS clear with diminished at bases, dry NPC. O2 sats 92-98% dropping\n to 88% with O2 off.\n Action:\n Changed O2 to 40-70% face tent over night and backt to 4liter np by am.\n Vanco trough level checked this am.\n Response:\n Improvement in O2 saturations however pt is still O2 dependant.\n Plan:\n Consult PT for CPT and for OOB chair with strengthening exercises.\n Bedside CPT q4-6hrs as needed with IS q1hr while awake.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds.\n Response:\n Left breast and panus area healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Advance diet as tolerated.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n HR 80-90\ns with SBP 100-160 urine output has increased to 250-400cc/hr.\n Action:\n Lasix gtt @ 20 mg/hour decreased to 15mg/hr U/O 120-280/hour. Diuril\n dose held this am. IV NTG titrated to .5-2mcg/kg/min to keep SBP <140\n tolerating captopril\n Response:\n Improved with aggressive diuresis, however pt still desats off O2.\n Plan:\n Continue to monitor u/o, VS, K/Mg. Encourage IS q1hr\n" }, { "category": "Radiology", "chartdate": "2129-08-27 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1032482, "text": " 6:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Status of retroperitoneal hemorrhage?PLEASE DO DELAYED IMAGE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD, Pulmonary edema and retroperitoneal hemorrhage. at\n 5PM\n REASON FOR THIS EXAMINATION:\n Status of retroperitoneal hemorrhage?PLEASE DO DELAYED IMAGES WITH CONTRAST TO\n ASSESS FOR ACTIVE BLEED\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN AND PELVIS CT FROM AT 18:43 HOURS\n\n HISTORY: Retroperitoneal hemorrhage. Assess for active bleed.\n\n COMMENT: CT of the abdomen and pelvis was performed with IV contrast.\n Comparison was made with non-contrast study done earlier in the day.\n\n CT OF THE ABDOMEN: bilateral pleural effusions and atelectasis at the\n lung bases is again seen with decrease in the left lower lobe atelectasis.\n Nasogastric tube with tip in the stomach. Again seen is a 1.2-cm\n indeterminate hypodense lesion in the dome of the liver (series 2A, image 14)\n possibly a cyst. The remainder of the liver is unremarkable. Spleen,\n pancreas, adrenals are unremarkable. Vicarious excretion of contrast by the\n gallbladder. Right renal artery calcification. Right kidney is unremarkable.\n Again seen is approximately 1.9-cm cyst mid left kidney and a subcentimeter\n probable cyst also in the mid left kidney. There are two such lesions seen in\n the mid left kidney on series 2a image 57 measuring 8 mm each. Proximal\n celiac, superior mesenteric and inferior mesenteric arteries are patent.\n Atherosclerosis in the abdominal aorta, which is normal in size.\n\n CT OF THE PELVIS: Again seen is right pelvic hematoma. This is stable in\n size measuring 6.1 x 5 cm. There is moderate stranding around the right\n external iliac vessels. No evidence of active extravasation.\n\n Bladder decompressed with Foley catheter. Colonic diverticulosis. Hematoma\n is again seen to extend superiorly posterior to the rectus muscles. No\n evidence of bowel obstruction. There appears to be callus formation around\n the posterior right ninth rib, suggestive of healing fracture. Correlate with\n history. Degenerative changes in the spine.\n\n Venous phase images were also obtained through the abdomen. The hepatic\n veins, portal vein, splenic vein, and superior mesenteric vein are patent.\n 5-mm probable cyst is seen in the mid right kidney. Additional subcentimeter\n cysts are seen in the left kidney.\n\n IMPRESSION: Stable size of predominantly right pelvic extraperitoneal\n hematoma. No evidence of active extravasation.\n\n (Over)\n\n 6:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Status of retroperitoneal hemorrhage?PLEASE DO DELAYED IMAGE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1034011, "text": ", E. 4:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: ELEVATED LFTS, EVALUATE FOR BLOOD FLOW AND PARENCHYMA FOR ABSCESS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with urobilinogen and bili on UA. Also ? hx of liver\n hypodensity.\n REASON FOR THIS EXAMINATION:\n evaluate for blood flow and parenchyma for abcess\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unremarkable flow within the main portal and hepatic veins. Gallbladder\n filled with sludge and stones.\n\n" }, { "category": "Radiology", "chartdate": "2129-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032543, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pulmonary edema status?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD and CHF.\n REASON FOR THIS EXAMINATION:\n Pulmonary edema status?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: CAD and CHF.\n\n REFERENCE EXAM: .\n\n FINDINGS: The endotracheal tube and NG tube are unchanged. There has been\n partial clearing of the alveolar infiltrates with improvement in the\n appearance of the upper lobes bilaterally. There is some residual infiltrate\n in the right upper lobe, right lower lobe and retrocardiac region. There is\n no effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033626, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CHF exacerbation s/p intubation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF exacerbation.\n\n FINDINGS: In comparison with the study of , _____ change in the\n appearance of the endotracheal and right central catheter. The tip of a\n nasogastric tube is difficult to see and may only be in the lower portion of\n the esophagus. Continued opacification at the left base consistent with\n effusion and atelectasis, though superimposed pneumonia cannot be excluded in\n the absence of a lateral view.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034651, "text": ", E. 9:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: fluid overload\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD s/p STEMI, septic shock has frequent VTach after\n receiving two units of blood.\n REASON FOR THIS EXAMINATION:\n fluid overload\n ______________________________________________________________________________\n PFI REPORT\n No evidence of failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033892, "text": " 5:07 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: New infiltrate?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with multifocal pna, intubated, now with increasing FiO2\n requirements.\n REASON FOR THIS EXAMINATION:\n New infiltrate?\n ______________________________________________________________________________\n WET READ: SBNa SAT 7:37 PM\n Retrocardiac opacity with air bronchograms concerning for pneumonia,\n unchanged. left pleural effusion and left mid lung atelectasis. Lines\n and tubes in unchanged position.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Multifocal pneumonia, intubated, question infiltrate.\n\n COMPARISON STUDY: Same day at 08:30 hours.\n\n FINDINGS:\n\n Endotracheal tube terminates at thoracic inlet. Nasogastric tube courses\n below the diaphragm but the tip is not seen. Right subclavian catheter\n terminates at the superior vena cava. Again noted is a dense left lower lobe\n consolidation with air bronchograms which could represent pneumonia. There is\n a dense right perihilar infiltrates. This is unchanged as well. Remainder of\n the lungs are clear. There is a probable left pleural effusion as well.\n\n IMPRESSION:\n\n Unchanged appearance of chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-08-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033300, "text": " 7:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumonia or infectious process?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with white count, low-grade fevers, and questionable\n bibasilar infiltrate on previous X-ray. Please evaluate.\n REASON FOR THIS EXAMINATION:\n Pneumonia or infectious process?\n ______________________________________________________________________________\n WET READ: JKPe WED 8:27 PM\n worsening lt effusion with persistent lower lobe opacities which may\n atelectasis or pna. central vascular fullness appears to be worsening over\n last few days likley related to fluid overload/edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Fevers, blood cell count.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the left-sided pleural\n effusion has minimally increased. Newly appeared focal parenchymal opacities\n that could represent pneumonia are not seen. The monitoring and support\n devices are in unchanged position. Unchanged mild signs of overhydration.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1034010, "text": " 4:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: ELEVATED LFTS, EVALUATE FOR BLOOD FLOW AND PARENCHYMA FOR ABSCESS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with urobilinogen and bili on UA. Also ? hx of liver\n hypodensity.\n REASON FOR THIS EXAMINATION:\n evaluate for blood flow and parenchyma for abcess\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb SUN 6:53 PM\n PFI: Unremarkable flow within the main portal and hepatic veins. Gallbladder\n filled with sludge and stones.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with bilirubin and UA.\n\n COMPARISON: Abdominal ultrasound .\n\n FINDINGS: Limited bedside evaluation of the liver was performed. A 10 mm\n homogeneously hyperechoic hepatic lesion in the right lobe anteriorly may\n represent a hemangioma. The main portal vein demonstrates normal\n hepatopetal flow. Flow within the main, right and left hepatic veins appears\n unremarkable. The gallbladder again demonstrates layering stones and\n sludge with debris. There is no definite gallbladder wall thickening or\n pericholecystic fluid. No free fluid is identified in the right upper\n quadrant. There is no intrahepatic biliary ductal dilatation.\n\n IMPRESSION: Cholelithiasis with sludge again identified. echogenic\n hepatic lesion likely represents a hemangioma.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-08 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1034725, "text": " 9:27 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 57 cm dl L bacilic PICC placed ?tip\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with\n REASON FOR THIS EXAMINATION:\n 57 cm dl L bacilic PICC placed ?tip\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:23 AM\n New left PICC with tip in right atrium. Otherwise, no change from study done\n earlier today. Findings were discussed with the IV service nurse.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bedside supine chest radiograph.\n\n HISTORY: 68-year-old woman with new left PICC placement.\n\n FINDINGS: A new, left PICC ends in the right atrium.\n\n Multiple support lines and tubes are unchanged from study done earlier on\n . The lungs, cardiomediastinal contours, soft tissues, and\n bony thorax are all unchanged from study done earlier on .\n\n IMPRESSION:\n 1. New left PICC with tip in the right atrium.\n 2. Otherwise, no significant change from study done earlier on .\n\n These findings were discussed over the telephone with nurse, Hopper from the\n IV service.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1034726, "text": ", E. 9:27 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 57 cm dl L bacilic PICC placed ?tip\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with\n REASON FOR THIS EXAMINATION:\n 57 cm dl L bacilic PICC placed ?tip\n ______________________________________________________________________________\n PFI REPORT\n New left PICC with tip in right atrium. Otherwise, no change from study done\n earlier today. Findings were discussed with the IV service nurse.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033939, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/p aortic balloon pump. Please check placement.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p aortic balloon bump.\n REASON FOR THIS EXAMINATION:\n S/p aortic balloon pump. Please check placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Status post aortic balloon pump, check placement.\n\n FINDINGS:\n\n Aortic balloon pump has been placed. Right subclavian catheter terminates in\n the superior vena cava. Swan-Ganz catheter is also present from a femoral\n approach. Terminates in the right main pulmonary artery. Again noted is a\n dense left lower lobe consolidation with air bronchograms and a pleural\n effusion. There is also a dense right perihilar infiltrate unchanged.\n Endotracheal tube terminates at the thoracic inlet in appropriate position.\n\n IMPRESSION:\n 1. New placement of aortic balloon pump and Swan-Ganz catheter.\n 2. No change in left lower lobe and right perihilar consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033401, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval progression\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD awaiting CABG, intubated\n REASON FOR THIS EXAMINATION:\n evaluate for interval progression\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:36 AM\n PFI:\n\n 1. Tubes and lines unchanged, with NG tube side-hole at the diaphragmatic\n hiatus.\n\n 2. Consistent lung volumes, left effusion and associated atelectasis, with\n patchy opacities in the left more than right lung, ? pneumonic.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST .\n\n HISTORY: 68-year-old woman with CAD, awaiting CABG; evaluate for interval\n progression.\n\n FINDINGS: Single bedside AP examination labeled \"semi-upright at 7:35 a.m.\"\n is compared with studies dated and . Allowing for changes in\n positioning, the overall appearance is not much changed. The lung volumes\n remain quite low, with persistent left effusion and associated atelectasis.\n There are patchy airspace opacities involving the left more than right lung,\n representing either additional atelectasis or pneumonic infiltrate.\n No pulmonary edema is seen. ET and NG tubes and right subclavian central\n venous catheter are unchanged in position; note that the side-hole of the NG\n tube remains in the region of the diaphragmatic hiatus.\n\n IMPRESSION:\n\n 1. Persistent low lung volumes, left effusion and atelectasis and left more\n than right patchy airspace opacities, which may be pneumonic.\n\n 2. Tubes and line, unchanged in position, with side-hole of NG tube at the\n diaphragmatic hiatus.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033402, "text": ", E. 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval progression\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD awaiting CABG, intubated\n REASON FOR THIS EXAMINATION:\n evaluate for interval progression\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Tubes and lines unchanged, with NG tube side-hole at the diaphragmatic\n hiatus.\n\n 2. Consistent lung volumes, left effusion and associated atelectasis, with\n patchy opacities in the left more than right lung, ? pneumonic.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034650, "text": " 9:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: fluid overload\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD s/p STEMI, septic shock has frequent VTach after\n receiving two units of blood.\n REASON FOR THIS EXAMINATION:\n fluid overload\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:12 AM\n No evidence of failure.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath after blood transfusion,\n suspected volume overload.\n\n Portable AP chest radiograph was compared to obtained at\n 08:52 a.m.\n\n The ET tube tip is 4 cm above the carina. The right subclavian line tip is in\n distal SVC. The NG tube tip is most likely in the stomach. The\n cardiomediastinal silhouette is unchanged including mild cardiomegaly. There\n is no change in left retrocardiac opacity consistent with atelectasis as well\n as right infrahilar opacity that also might represent a combination of\n atelectasis and aspiration. The current study demonstrates no vascular\n engorgement to suggest volume overload. No substantial increase in bilateral\n pleural effusions is demonstrated. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1034006, "text": " 4:12 PM\n PORTABLE ABDOMEN Clip # \n Reason: Evaluate for obstruction\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with possible bowel obstruction and potential feculent\n emesis.\n REASON FOR THIS EXAMINATION:\n Evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: Questionable feculent emesis, ? bowel obstruction.\n\n FINDINGS: Comparison is made with CT from and CXR from , . There is no evidence of ileus or obstruction. Retained oral\n contrast material is seen in the colon from prior CT. Retained intravenous\n contrast is seen in the kidneys, consistent with delayed excretion in the\n setting of acute renal failure. Two central lines ascend from the right groin,\n a femoral vein Swann Ganz catheter and a femoral artery intra-arterial balloon\n pump.\n\n IMPRESSION: No ileus or obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033842, "text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement/PNA?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with respiratory failure, increased WBC, fever\n REASON FOR THIS EXAMINATION:\n OG tube placement/PNA?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST \n\n CLINICAL INFORMATION: Respiratory failure. Increased white count.\n\n FINDINGS:\n\n Comparison is made to the prior study from .\n\n Nasogastric tube courses towards the stomach but the tip is not seen.\n Endotracheal tube terminates at the thoracic inlet. Right subclavian catheter\n terminates at the cavoatrial junction. There is no change in the appearance\n of the chest. There is continued left lower lobe consolidation with \n left pleural effusion. Right lung is relatively clear.\n\n IMPRESSION:\n\n No change in left lower lobe consolidation, pleural effusion.\n\n There is a probable right perihilar infiltrate as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-08-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1032557, "text": " 10:34 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new line placement, left subclavian, and swan\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with\n REASON FOR THIS EXAMINATION:\n new line placement, left subclavian, and swan\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW.\n\n HISTORY: New line placement.\n\n REFERENCE EXAM: at 7:40.\n\n FINDINGS: There is a new left subclavian Swan-Ganz catheter with tip in the\n pulmonary outflow tract. The endotracheal tube tip is 3.5 cm above the\n carina. The NG tube tip is in the stomach. The stomach is moderately\n distended. The right IJ line tip is in the SVC. There is bilateral lower\n lobe infiltrates, left greater than right, with a probable left\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033947, "text": " 7:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval progression\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD, CHF, pneumonia, now s/p IABP\n REASON FOR THIS EXAMINATION:\n evaluate for interval progression\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: CHF, pneumonia.\n\n COMPARISON STUDY: at 04:14.\n\n FINDINGS:\n\n Intraaortic balloon pump, Swan-Ganz catheter, ET tube, nasogastric tube, right\n subclavian line remain in appropriate position.\n\n Left lower lobe atelectasis and left pleural effusion, and right\n perihilar infiltrate are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034266, "text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with STEMI, possible sepsis, intubated.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter has\n been removed. The other monitoring and support devices are in unchanged\n position. The retrocardiac atelectasis has slightly increased. There is\n slight increase in left basal atelectasis. Otherwise, the appearance of the\n lung parenchyma is unchanged. There is no evidence of newly occurred focal\n parenchymal opacity suggestive of pneumonia. Removal of the aortic balloon\n pump. No other changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032968, "text": " 11:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement - rt subclavian\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with PNA\n REASON FOR THIS EXAMINATION:\n line placement - rt subclavian\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right subclavian line placement.\n\n FINDINGS: Comparison with study of , there has been placement of right\n subclavian catheter, extends to the lower portion of the SVC. Swan-Ganz\n catheter has been removed. Endotracheal tube and nasogastric tube remain in\n place. Basilar atelectasis with possible effusion is again seen on the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034711, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progression/resolution of PNA?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with septic shock, acinetobacter VAP\n REASON FOR THIS EXAMINATION:\n Progression/resolution of PNA?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:43 AM\n Slight increase in right lower lobe median consolidation. Stable left lower\n lobe retrocardiac consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Septic shock\n\n Comparison is made to prior study performed at 21:00 hours.\n\n There has been increase in right lower lobe medial consolidation. Left lower\n lobe retrocardiac consolidation is unchanged. ET tube is in standard\n position. Right subclavian catheter remains in place. There is no\n pneumothorax. If any there is pleural effusion.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2129-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034712, "text": ", E. 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progression/resolution of PNA?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with septic shock, acinetobacter VAP\n REASON FOR THIS EXAMINATION:\n Progression/resolution of PNA?\n ______________________________________________________________________________\n PFI REPORT\n Slight increase in right lower lobe median consolidation. Stable left lower\n lobe retrocardiac consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2129-08-31 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1033181, "text": " 9:42 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFT'S - EVOLUTION OF LIVER \"CYST\"\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with fever, elevated LFT's, possible liver cyst on abd CT.\n REASON FOR THIS EXAMINATION:\n Evolution of \"cyst\" in liver?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KKXa WED 2:52 PM\n No cyst is identified in the liver. The lesion seen on CT is not identified\n by ultrasound. Therefore, MRI of the abdomen is recommended, for further\n characterization of this indeterminate liver lesion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypodense lesion seen in the liver on abdominal CT. Fever and\n elevated LFTs. Assess lesion.\n\n COMPARISON: CT of the abdomen of .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal. Aside from\n a calcified granuloma in the right lobe near the liver dome, no additional\n focal liver lesion is definitely identified. Attention was turned to segment\n VIII near the dome in the area where the hypodense lesion was seen on CT, and\n no cystic lesion could be identified. In addition, a second lesion visible on\n CT in the segment V region could not be found with ultrasound. The main portal\n vein is patent with the appropriate direction of flow. There is no\n intrahepatic biliary ductal dilation.\n\n The gallbladder contains a shadowing stone in the neck with the patient\n supine, potentially measuring up to 1.8 cm. A amount of echogenic\n sludge are seen within the dependent portion of the gallbladder. The\n gallbladder is not distended, and there is no wall thickening or\n pericholecystic fluid. The common duct is not dilated, measuring 4 mm. The\n head of the pancreas was unremarkable by ultrasound. The body and tail are\n not well seen. The spleen is enlarged, measuring 13.6 cm. No ascites fluid\n is detected.\n\n IMPRESSION:\n 1. The oval hypodense lesion of segment VIII in the liver seen on CT was not\n visualized by ultrasound. In addition, a second lesion visible on CT in\n segment V is not apparent by ultrasound. Therefore, MRI of the abdomen is\n recommended, for further characterization of these indeterminate lesions\n seen at CT.\n 2. Splenomegaly.\n 3. Cholelithiasis and sludge.\n\n (Over)\n\n 9:42 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFT'S - EVOLUTION OF LIVER \"CYST\"\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2129-08-31 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1033182, "text": ", E. 9:42 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ELEVATED LFT'S - EVOLUTION OF LIVER \"CYST\"\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with fever, elevated LFT's, possible liver cyst on abd CT.\n REASON FOR THIS EXAMINATION:\n Evolution of \"cyst\" in liver?\n ______________________________________________________________________________\n PFI REPORT\n No cyst is identified in the liver. The lesion seen on CT is not identified\n by ultrasound. Therefore, MRI of the abdomen is recommended, for further\n characterization of this indeterminate liver lesion.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1033943, "text": " 8:32 AM\n RENAL U.S. PORT Clip # \n Reason: Hydronephrosis or ureteral obstruction to explain ARF?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with increasing creatinine and h/o retroperitoneal bleed s/p\n cardiac cath on .\n REASON FOR THIS EXAMINATION:\n Hydronephrosis or ureteral obstruction to explain ARF?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb SUN 11:18 AM\n No hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female with increasing creatinine.\n\n COMPARISON: Abdominal ultrasound .\n\n FINDINGS: A limited bedside son of the kidneys was performed. The right\n kidney measures 13.9 cm. The left kidney measures 12.5 cm. No\n hydronephrosis, stone, or renal mass is identified. The bladder is partially\n collapsed and appears unremarkable.\n\n IMPRESSION: No hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-04 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1033944, "text": ", E. 8:32 AM\n RENAL U.S. PORT Clip # \n Reason: Hydronephrosis or ureteral obstruction to explain ARF?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with increasing creatinine and h/o retroperitoneal bleed s/p\n cardiac cath on .\n REASON FOR THIS EXAMINATION:\n Hydronephrosis or ureteral obstruction to explain ARF?\n ______________________________________________________________________________\n PFI REPORT\n No hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034495, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with question of pneumonia and prolonged hypotension\n currently intubated.\n REASON FOR THIS EXAMINATION:\n Evaluate interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc WED 12:22 PM\n Left lower lobe collapse and right basilar atelectasis, unchanged since\n .\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bedside upright AP chest radiograph.\n\n HISTORY: 68-year-old woman with question of pneumonia and recent prolonged\n hypotensive episode.\n\n COMPARISON: Comparison is made to multiple chest radiographs from \n to 16, .\n\n FINDINGS: There is collapse of the left lower lobe, unchanged since . There is right basilar atelectasis, also unchanged. There are no new\n consolidations. There are no pleural effusions.\n\n The cardiomediastinal contours are normal.\n\n There is a nasogastric tube with tip in the stomach. There is an endotracheal\n tube with tip 4.5 cm cranial to the carina. There is a right subclavian\n central venous line with tip in the mid-SVC. There is no pneumothorax.\n\n IMPRESSION:\n 1. Left lower lobe collapse and right basilar atelectasis, unchanged since\n .\n 2. Multiple support lines and tubes as described above.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034076, "text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman intubated with pna.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc MON 11:48 AM\n No significant change from the study of , persistent left lung\n base opacity and minimal improvement in right perihilar opacity. Multiple\n support lines and tubes, unchanged from .\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Supine AP chest radiograph.\n\n HISTORY: 68-year-old woman with pneumonia.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There is an inferior, Swan-Ganz catheter, an intra-aortic balloon\n pump and right subclavian central venous catheter, all in good position. There\n is a nasogastric tube coursing into the stomach with the tip terminating\n caudal to the field of view and an endotracheal tube terminating 3.8 cm\n cranial to the carina. These are all unchanged from the past study.\n\n There is opacification of the left lung base, unchanged from the past study.\n The previously described right perihilar opacification is improved on the\n current study. There is no change in the minimal left-sided pleural effusion.\n There are no new consolidations.\n\n There is multiple level thoracic spine degenerative changes.\n\n IMPRESSION:\n 1) Overall, no significant change from the study of with\n persistent left lung base opacity and improved right perihilar opacity.\n 2) Multiple support lines and tubes as described above.\n\n" }, { "category": "Radiology", "chartdate": "2129-08-27 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1032443, "text": " 12:06 PM\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: Retroperitoneal hemorrhage after right femoral angiography w\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with severe CADx3, pulmonary edema.\n REASON FOR THIS EXAMINATION:\n Retroperitoneal hemorrhage after right femoral angiography w/hct drop from 36\n to 27.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS FROM \n\n HISTORY: Severe coronary artery disease. Pulmonary edema. Retroperitoneal\n hemorrhage after right femoral angiography with hematocrit drop. Assess for\n retroperitoneal blood.\n\n COMMENT: CT of the abdomen and pelvis was performed without oral or IV\n contrast. No prior studies for comparison.\n\n FINDINGS: Bilateral airspace disease is seen in the lungs on the topogram.\n This is also noted on the patient's chest radiograph from today and is\n probably due to the known pulmonary edema. Right IJ catheter, endotracheal\n tube, and nasogastric tubes are also noted.\n\n bilateral pleural effusions. Atelectasis versus consolidation in\n bilateral lung bases. Mitral annulus calcification. Minimal tree-in-\n nodularity seen in the right middle lobe, probably infectious in etiology.\n\n Nasogastric tube tip is in the stomach. Splenic artery calcification. 1.2 cm\n hypodense lesion in segment VIII of the liver (series 2, image 12), not\n characterized on this non-contrast study. If there are prior studies, they\n would be helpful for comparison. Also, suggest correlation with patient's\n history for any history of malignancy. Non-contrast appearance of the\n remainder of the liver is unremarkable.\n\n Non-contrast appearance of the spleen, pancreas, right kidney and adrenals is\n unremarkable. Vicarious excretion of contrast by the gallbladder. 1.6 cm\n probable cyst in mid left kidney and 8 mm hypodensity probably cyst, but\n too to characterize, in the mid left kidney, series 2, image 29. No\n hydronephrosis. Minimal calcification of abdominal aorta, which is normal in\n size. Periportal nodes measuring up to 1.2 cm.\n\n CT OF THE PELVIS: There is an extraperitoneal hematoma in the right side of\n the pelvis adjacent to the right external iliac vessels. This measures 6 x\n 6.4 cm. There is moderate stranding around the right external iliac vessels\n and extending superiorly anterior to the right psoas muscle. Findings are\n compatible with patient's history of catheterization. Bladder is decompressed\n with Foley catheter and has minimal gas. Colonic diverticulosis.\n\n (Over)\n\n 12:06 PM\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: Retroperitoneal hemorrhage after right femoral angiography w\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Findings of the study were discussed with Dr. on at 1315\n hours. Mild degenerative changes in the spine.\n\n IMPRESSION:\n 1. Retroperitoneal hematoma, predominantly in the right side of the pelvis\n adjacent to the external iliac vessels.\n 2. 1.2-cm hypodense lesion in the right lobe of the liver, not characterized\n on the current study. If there are prior studies, they would be helpful for\n comparison.\n 3. bilateral pleural effusions. Atelectasis versus pneumonia in both\n lower lobes. Minimal tree-in- nodularity in the right middle lobe\n concerning for bronchiolitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034496, "text": ", E. 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with question of pneumonia and prolonged hypotension\n currently intubated.\n REASON FOR THIS EXAMINATION:\n Evaluate interval change\n ______________________________________________________________________________\n PFI REPORT\n Left lower lobe collapse and right basilar atelectasis, unchanged since\n .\n\n" }, { "category": "Radiology", "chartdate": "2129-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034077, "text": ", E. 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman intubated with pna.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n PFI REPORT\n No significant change from the study of , persistent left lung\n base opacity and minimal improvement in right perihilar opacity. Multiple\n support lines and tubes, unchanged from .\n\n" }, { "category": "Radiology", "chartdate": "2129-09-05 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1034228, "text": " 10:52 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? PNA or abscess. Source of fever?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with fevers, purulent sputum, abdominal tenderness, elevated\n liver enzymes and previous liver hypodensity.\n REASON FOR THIS EXAMINATION:\n ? PNA or abscess. Source of fever?\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency;renal insufficiency\n ______________________________________________________________________________\n WET READ: JXKc TUE 3:46 AM\n Bilateral lower lobe consolidation, with pleural effusions. These may\n represent atelectasis; however, superimposed pneumonia can't be excluded.\n Gallstones are present with mildly distended gallbladder, correlate with any\n referrable symptoms to the RUQ. Diverticulosis without diverticulitis. Again\n noted is a right pelvic hematoma, with stranding surrounding the right\n external iliac vessels. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old woman with fevers, purulent sputum, abdominal\n tenderness, elevated liver enzymes and previous liver hypodensity, evaluate\n for abscess or source of fever.\n\n COMPARISON: ultrasound.\n\n TECHNIQUE: Helical CT acquisition from top of the lungs to pubic symphysis\n without administration of intravenous contrast. Oral contrast was\n administered for the study. Multiplanar reformations were generated.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: The patient is intubated with\n ET tube in standard location. NG tube is seen to extend into the stomach.\n Coronary artery calcifications are evident. Otherwise heart and great vessels\n are unremarkable. A right subclavian line is seen to terminate in the distal\n SVC. Mediastinal lymph nodes measuring up to 7 mm in short axis are evident.\n There is bilateral pleural effusion and bibasilar atelectasis.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Limited non-contrast\n evaluation of the liver is unremarkable. The gallbladder is distended\n measuring 7.8 x 6 cm with dependent sludge and stones, unchanged since the\n appearance yesterday. Limited non-contrast evaluation of spleen, pancreas,\n adrenals bilaterally, intra-abdominal bowel loops is within normal limits.\n The kidneys demonstrate some residual contrast material which is probably\n secondary to patient's recent cardiac catheterization. There are multiple\n low-attenuation lesions bilaterally the largest of which is noted in the\n interpolar region of the left kidney measuring 2.2 x 1.8 cm at a Hounsfield\n attenuation of 25, could represent a simple cyst. The other lesions are\n subcentimeter, too to characterize. There is no intraperitoneal free\n fluid or free air. There is no mesenteric or retroperitoneal adenopathy. The\n (Over)\n\n 10:52 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? PNA or abscess. Source of fever?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n largest retroperitoneal lymph node measures 9 mm in short axis.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: There is a pelvic hematoma\n extending into the right inguinal region and measuring 7.3 x 7 cm at\n intermediate Hounsfield attenuation of 64 consistent with hemorrhagic\n components. There is associated perihematoma stranding. There are no focal\n abscesses or fluid collections in this region to explain patient's fever. The\n uterus and the adnexa are unremarkable. The rectum, sigmoid colon and\n intrapelvic bowel loops are within normal limits. Bladder is completely\n collapsed.\n\n OSSEOUS AND SOFT TISSUE STRUCTURES: There is a minimal stranding around the\n left flank which could be due to dependent changes from patient positioning.\n No suspicious osteolytic or osteoblastic lesions are noted. There is\n multilevel degenerative changes.\n\n IMPRESSION:\n 1. 7 x 7 cm right pelvic hematoma extending into the inguinal region with\n mild perihematoma stranding. No focal abscesses or fluid collections to\n explain patient's symptoms.\n 2. Distended sludge and stone-filled gallbladder, unchanged since the\n appearance on ultrasound yesterday.\n 3. Bilateral pleural effusions and atelectasis.\n 4. Multiple hypoattenuating renal lesions the largest in the interpolar left\n kidney may represent a simple cyst, others are too to characterize.\n 5. Residual contrast in the kidneys from a recent cardiac catheterization\n suggesting acute renal failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032440, "text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD & Pulm. edema\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: ET tube placement.\n\n FINDINGS: There are no old films available for comparison. There is an ET\n tube with tip slightly low, 1.6 cm above the carina. The NG tube tip is in\n the stomach with the proximal port just below the GE junction. There are\n bilateral patchy alveolar infiltrates, right greater than left and upper lobe\n greater than lower lobe that could represent an infectious infiltrate versus\n pulmonary edema. There is a right IJ line with tip in the SVC.\n\n\n" }, { "category": "Echo", "chartdate": "2129-08-30 00:00:00.000", "description": "Report", "row_id": 87280, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 240\nBSA (m2): 2.14 m2\nBP (mm Hg): 122/47\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 13:21\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%\ndecrease during respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal 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; basal inferolateral - hypo; mid inferolateral -\nhypo; inferior apex - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No 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: 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 apical views.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrial pressure is indeterminate.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with focal\nhypokinesis of the inferior and inferolateral walls. The remaining segments\ncontract normally (LVEF = 45% %). Tissue Doppler imaging suggests an increased\nleft ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. There is no aortic\nregurgitation. The mitral valve leaflets are mildly thickened. Mild (1+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional\nsystolic dysfunction c/w CAD. Elevated left ventricular filling pressure. Mild\nmitral regurgitation.\n\nCompared with the prior study (images reviewed) of , right ventricular\nfunction appears more vigorous.\n\n\n" }, { "category": "Echo", "chartdate": "2129-08-27 00:00:00.000", "description": "Report", "row_id": 87281, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 65\nWeight (lb): 240\nBSA (m2): 2.14 m2\nBP (mm Hg): 100/57\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 18:20\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%\ndecrease during respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function\ndepressed.\n\nAORTIC VALVE: Three 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. Physiologic MR (within normal limits).\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\nventilator. Suboptimal image quality - patient unable to cooperate. The\npatient appears to be in sinus rhythm. Echocardiographic results were reviewed\nwith the houseofficer caring for the patient.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. There is severe hypokinesis of the inferior and posterior\n(inferolateral) walls. However, the overall left ventricular ejection fraction\nis preserved (LVEF is approximately 50%) due to the fact that the rest of the\nleft ventricle is hyperdynamic. The right ventricle appears hypokinetic. The\nright atrial pressure is indeterminate. There are three aortic valve leaflets.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Physiologic mitral regurgitation is seen (within normal limits).\nThere is no pericardial effusion.\n\nIMPRESSION\n1. Preserved LV EF with focal hypokinesis of the inferior and posterior walls.\n2. No significant mitral regurgitation.\n3. Significant mitral annular calcification is present.\n4. The right ventricle is hypokinetic.\n\n\n" }, { "category": "Echo", "chartdate": "2129-09-05 00:00:00.000", "description": "Report", "row_id": 87959, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. PCI to LCX. IABP.\nWeight (lb): 270\nBP (mm Hg): 92/49\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 10:20\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with severe\nhypokinesis of the inferior and inferolateral walls. The remaining segments\ncontract normally (LVEF = 40 %). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve is normal. The mitral valve leaflets are\nmildly thickened. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\nfunction is similar.\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": "2129-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035087, "text": " 7:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pneumo, ETT placement.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman ventilated with decreasing PO2.\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumo, ETT placement.\n ______________________________________________________________________________\n WET READ: JKPe FRI 8:48 PM\n ett 3cm from carina, other then increased rt infrahilar opacity (appeared\n like atelectasis on CT), exam is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, , 7:49 P.M.\n\n HISTORY: Worsening hypoxia. Check ET tube placement.\n\n IMPRESSION: AP chest compared to :\n\n Left lower lobe collapse and somewhat less severe right lower lobe atelectasis\n are unchanged. New perihilar opacification and vascular engorgement suggest\n cardiac decompensation. There is no appreciable pleural effusion. Heart size\n is top normal. ET tube in standard placement. Nasogastric tube passes below\n the diaphragm and out of view. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035810, "text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CHF and respiratory distress last night as well as\n resolving VAP.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 11:16 AM\n Severe multifocal consolidation, could be very asymmetric pulmonary edema or\n extensive pneumonia. Dr. paged.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:26 A.M., \n\n HISTORY: CHF, respiratory distress, resolving ventilator-associated\n pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n There has been substantial worsening of extensive bilateral pulmonary\n consolidation, worse on the right, particularly upper lobe than the left.\n This could be asymmetric pulmonary edema but is concerning for widespread\n pneumonia. Moderate cardiomegaly is longstanding. The pleural effusions, if\n any, are minimal. No pneumothorax. Dr. paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035811, "text": ", E. 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CHF and respiratory distress last night as well as\n resolving VAP.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n Severe multifocal consolidation, could be very asymmetric pulmonary edema or\n extensive pneumonia. Dr. paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035140, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Aspiration pna?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman, intubated and febrile.\n REASON FOR THIS EXAMINATION:\n Aspiration pna?\n ______________________________________________________________________________\n FINAL REPORT\n AP chest compared to through 19:\n\n Bibasilar atelectasis, lobar on the left, subtotal on the right, is unchanged\n over several days. Mild pulmonary edema, which developed on the 19th is\n unchanged. Heart size top normal. ET tube in standard placement.\n Nasogastric tube passes above the diaphragm and out of view. Dr. _____ paged\n to report these findings at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035748, "text": " 7:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Evaluate for pulmonary edema\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with increased shortness of breath after extubation\n yesterday.\n REASON FOR THIS EXAMINATION:\n Evaluate for pulmonary edema\n ______________________________________________________________________________\n WET READ: KYg TUE 8:48 PM\n SINCE THE LAST EXAM, THERE IS INCREASED PULMONARY EDEMA AND OPACITY IN THE\n THE MEDIAL RIGHT LUNG BASE AND LEFT RETROCARDIAC REGION, WHICH LIKELY\n REPRESENTS WORSENING ATELECTASIS, ALTHOUGH PNEUMONIA WOULD BE DIFFICULT TO\n EXCLUDE. THERE IS PROBABLY A LEFT PLEURAL EFFUSION. NO PNEUMOTHROAX.\n .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:32 P.M., \n\n HISTORY: Increasing shortness of breath after extubation.\n\n IMPRESSION: AP chest compared to and 23 at 8:37 a.m.:\n\n Greater consolidation in the lower lungs and hazy opacification around the\n right hilus could all be due to somewhat asymmetrically distributed pulmonary\n edema. Developing pneumonia needs to be considered. Mild cardiomegaly\n stable, right hilar vascular engorgement increased. left pleural\n effusion is new.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1036043, "text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with VAP, and pulmonary edema.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old woman with ventilator associated pneumonia, pulmonary\n edema, evaluate for change.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: Cardiac and mediastinal contours are stable.\n Multiple consolidations in the right greater than left lung are minimally\n improved compared to prior study. No definite new focal consolidations are\n identified. Pulmonary vascularity is unchanged. No new large pleural\n effusions are identified.\n\n IMPRESSION: Minimal change in bilateral consolidations, right greater than\n left, again consistent with pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035599, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change in volume status\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with recent inferior MI, pneumonia, now extubated. Please\n evaluate for interval change.\n REASON FOR THIS EXAMINATION:\n Interval change in volume status\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 11:14 AM\n PFI: Since , the patient was extubated and the nasogastric tube\n was removed. Bibasilar opacity, probably atelectasis, more marked on the left\n decreased. No overload.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 68-year-old woman with recent inferior MI, pneumonia, now\n extubated. Please assess for interval change.\n\n Since , the patient was extubated in the nasogastric tube was\n removed.\n\n Left-predominant bibasilar opacities, probably atelectasis, decreased. There\n is no volume overload. Heart size is top normal. Hilar contours are normal.\n There is no pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2129-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1035600, "text": ", E. 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change in volume status\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with recent inferior MI, pneumonia, now extubated. Please\n evaluate for interval change.\n REASON FOR THIS EXAMINATION:\n Interval change in volume status\n ______________________________________________________________________________\n PFI REPORT\n PFI: Since , the patient was extubated and the nasogastric tube\n was removed. Bibasilar opacity, probably atelectasis, more marked on the left\n decreased. No overload.\n\n" }, { "category": "ECG", "chartdate": "2129-09-07 00:00:00.000", "description": "Report", "row_id": 221916, "text": "Sinus rhythm. Possible inferior myocardial infarction of indeterminate\nage. Poor R wave progression. Non-specific anterolateral T wave flattening.\nCompared to the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2129-09-08 00:00:00.000", "description": "Report", "row_id": 221917, "text": "Sinus rhythm. Non-specific intraventricular conduction delay. Poor R wave\nprogression. Non-specific diffuse ST-T wave changes. Compared to the previous\ntracing of the QRS configuration in lead aVF has changed and is less\nsuggestive of a prior inferior myocardial infarction.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-09-07 00:00:00.000", "description": "Report", "row_id": 221918, "text": "Sinus rhythm. Inferior wall myocardial infarction of indeterminate age.\nAnterolateral ST-T wave changes. Cannot rule out myocardial ischemia.\nCompared to the previous tracing of multiple described abnormalities\npersist. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2129-09-06 00:00:00.000", "description": "Report", "row_id": 221919, "text": "Sinus rhythm. Slight ST segment elevations in leads II, III and aVF with\nST segment depressions in leads V2-V3. Compared to the previous tracing\nof the aforementioned changes are less dramatic suggesting\npartial resolution of transmural inferoposterior ischemia.\n\n" }, { "category": "ECG", "chartdate": "2129-09-05 00:00:00.000", "description": "Report", "row_id": 221920, "text": "Sinus rhythm. Inferolateral ST segment elevations and inferior Q waves\nconsistent with myocardial injury current. ST segment depressions and\nT wave inversions in leads V1-V3 consistent with reciprocal changes from\nposterior myocardial injury or myocardial ischemia. Compared to the previous\ntracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2129-09-04 00:00:00.000", "description": "Report", "row_id": 221921, "text": "Sinus rhythm. Compared to tracing #1 there are persistent inferolateral\nST segment elevations with deep T wave inversions and ST segment depression in\nthe anterior leads suggestive of inferolateral myocardial infarction, probably\nacute. Anterior ST-T wave changes may be a reciprocal pattern or myocardial\nischemia. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2129-09-03 00:00:00.000", "description": "Report", "row_id": 221922, "text": "Sinus rhythm. Occasional atrial premature beats. Ventricular bigeminal\npattern has resolved. There is now ST segment elevation in the inferolateral\nleads and ST segment depression in the anterior leads suggestive of inferior\nlateral myocardial infarction, possibly acute. Clinical correlation is\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-09-03 00:00:00.000", "description": "Report", "row_id": 222160, "text": "There is arm lead reversal. Sinus rhythm. Ventricular bigeminal pattern.\nPossible inferior wall myocardial infarction of undeterined age. Non-specific\nST-T wave changes.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2129-08-30 00:00:00.000", "description": "Report", "row_id": 222161, "text": "Sinus rhythm. Multiple abnormalities as previously described. Compared to the\nprevious tracing of the findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-08-29 00:00:00.000", "description": "Report", "row_id": 222162, "text": "Sinus tachycardia. Inferior myocardial infarction of indeterminate age.\nSlight residual ST segment elevations in leads II, III and aVF raise\nconsideration of a more recent myocardial infarction. Otherwise, there\nare diffuse non-specific ST segment abnormalities. Compared to the previous\ntracing of the findings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2129-08-29 00:00:00.000", "description": "Report", "row_id": 222163, "text": "Sinus rhythm. Inferior myocardial infarction of indeterminate age. Mild\nprecordial ST segment depressions are suggestive of myocardial ischemia.\nCompared to the previous tracing of inferior ST segment elevation\nis less pronounced and anterior ST segment depressions are less pronounced.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2129-08-28 00:00:00.000", "description": "Report", "row_id": 222164, "text": "Sinus rhythm. Inferior ST segment elevations suggestive of myocardial injury.\nCurrent anterior ST segment depressions are suggestive of myocardial ischemia\nor reciprocal changes from the inferior injury current. Compared to the\nprevious tracing of inferior ST segment elevations are new. Anterior\nST segment depressions are less pronounced.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-08-27 00:00:00.000", "description": "Report", "row_id": 222165, "text": "Sinus rhythm. Intraventricular conduction delay. Anterior ST segment\ndepressions suggestive of myocardial ischemia or reciprocal changes from\ninferoposterior injury current. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2129-09-09 00:00:00.000", "description": "Report", "row_id": 221915, "text": "Sinus rhythm. Modest non-specific intraventricular conduction delay. Diffuse\nmodest ST-T wave changes which are non-specific. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" }, { "category": "Nursing", "chartdate": "2129-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414232, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Bilateral lower lobe infiltrates\n Action:\n Continues on unasyn,\n Response:\n Afebrile, wbc 19 (24)\n Plan:\n Monitor temp curve, cont abx\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on full vent support,\n Action:\n Vent changed from AC to PS 12/5, given 40 mg iv lasix x2\n Response:\n Tolerating vent change, fair response to diuresis\n Plan:\n Cont wean as tol,, monitor u/o\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Improving renal fx\n Action:\n Response:\n Cr 2.4 (2.8)\n Plan:\n Monitor renal fx\n Shock, septic\n Assessment:\n Improving bp\n Action:\n Levo weaned and d/c 0930, vasopressin weaned and d/c at 1100,\n Response:\n Bp 105-119/44-52\n Plan:\n Monitor bp\n" }, { "category": "Respiratory ", "chartdate": "2129-09-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414227, "text": "Demographics\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / \n Ventilation Assessment\n Level of breathing assistance: Assisted spontaneous breathing.\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on PSV 12/5 40% today; tolerating settings well.\n Assessment of breathing comfort: No claim of dyspnea.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Continue with PSV setting as tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415442, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Acute heart failure decompensation at assoc. with . sats,\n hypertension and tachycardia.\n Action:\n placed on mask ventilation, rx with total 4 morphine iv, IV\n hydralazine, IV lopressor, lasix gtt started at 10mg/hr and titrated up\n to 15mg/hr. IV nitro started to max .86mcq/k/min. currently at\n .65mcq/k/min. goal SBP <140\n tolerated mask vent. X1hr. weaned to high flow mask 100% with 5lnc.\n Congested cough, non-productive. Atrovent neb x1. tol well.\n Response:\n u/o inc. 120-200cc/hr , neg. 400cc since MN.\n SBP contin. High 140-150/, HR . denies CP.\n ABG stable on high flow\nable to wean to 80%. Sats 94%.\n Plan:\n Monitor u/o on lasix gtt. Monitor lytes. Contin. Po lopressor and\n captopril. IV hydralazine for SBP >170 prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 240 in eve\n Action:\n 12 U glargine. SSRI\n Response:\n Pt. hungry, asking for ice chips. Taking pills either whole with\n applesause or crushed with applesauce.\n Plan:\n Contin. QID FS.\n" }, { "category": "Nursing", "chartdate": "2129-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413979, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Secretions sx q2-4hrs for thick yellow/tan via ett, bs are bronchial at\n bases w/ ronchi throughout.\n Action:\n Suctioned q2-4hrs, turned and postioned q2 hrs, followed vap protocol.\n Response:\n Sats cont 98-99%, no vent changes\n Plan:\n Cont vap protocol, cont aggressive pulmonary toileting, monitor in\n O2 sats <95%.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n u/o 30-100cc/hr. Creat down to 2.8\n Action:\n Monitored u/o qhr, all meds concentrated\n Response:\n Adequate u/o\n Plan:\n Cont close monitoring of u/o, creat\n Shock, septic\n Assessment:\n Pt on Levophed 0.147mcg/kg/min and Vasopressin 1.2units/hr. MAP\ns >60.\n Extremities warm to touch.\n IV ABX Unasyn 3gm q8hrs. T max 99.4 po/ 100 pr.\n Action:\n Weaned levophed to off by 1400, but required restart at 1715 for MAP<\n 60 and SBP < 90. Vancomycin dosed 1000mg x1. Acetaminophen 650pr x1.\n Response:\n Pt tolerated SPB 90/ and MAP >60x 3hrs, but required levophed restart.\n Plan:\n Monitor and maintain SBP >90 and MAP > 60, Attempt to wean levophed\n maintaining SBP >90 and MAP >60.\n" }, { "category": "Nursing", "chartdate": "2129-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414225, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Bilateral lower lobe infiltrates\n Action:\n Continues on unasyn,\n Response:\n Afebrile, wbc 19 (24)\n Plan:\n Monitor temp curve, cont abx\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on full vent support,\n Action:\n Vent changed from AC to PS 12/5, given 40 mg iv lasix\n Response:\n Tolerating vent change, fair response to diuresis\n Plan:\n Cont wean as tol,, monitor u/o\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Improving renal fx\n Action:\n Response:\n Cr 2.4 (2.8)\n Plan:\n Monitor renal fx\n Shock, septic\n Assessment:\n Improving bp\n Action:\n Levo weaned and d/c 0930, vasopressin weaned and d/c at 1100,\n Response:\n Bp 105-119/44-52\n Plan:\n Monitor bp\n" }, { "category": "Nursing", "chartdate": "2129-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414334, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n s/p VT episodes x3 - requiring shock\n amio load and IVgtt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 70\ns Sr. no VEA.\n Action:\n Amio at 1mg/hr x6hr->\n Response:\n No VT overnight\n Plan:\n Monitor lytes. Contin. Amio .5mg x18hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Good ABG on 60%.\n Action:\n Weaned FIO2 to 50%/contin. 8 peep. Suctioned for thick tan\n secretions.\n Response:\n Sats 99-100%.\n Plan:\n try CPAP again today. Follow plan with team.\n" }, { "category": "Respiratory ", "chartdate": "2129-09-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 415447, "text": "Demographics\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Expectorated / \n Comments: swallowed\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Accessory muscle use,\n Tachypneic (RR> 35 b/min); Comments: RR is often still 32-36 BPM.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Mask discomfort; Comments: Pt has\n tendency to talk with mask on, RR can get > 35\n Plan\n Next 24-48 hours:\n Monitor for signs of deteriorating respiratory status, monitor fluid\n balance\n Respiratory Care Shift Procedures\n Comments:\n Pt had severe episode of dyspnea and desaturation lasat night ~ \n hrs. She had Crackles and edematous high pitched wheezes bilaterally.\n Intubation seemed likely at the time but with lasix, NIV and O2 pt has\n slowly improved. She remains on high level O2 @ this time, 80% high\n output neb with nasal cannula @ 5 L under mask. RR ranges from 30-36.\n BS are much clearer at this time. Spo2 range from low of 91 5 to high\n of 96 % , occasionally better . She has developed a moderately\n effective cough which has a congested sound and is coughing amts\n of secretions to the back of her throat, then swallows. NIV is SB at\n this time.\n" }, { "category": "Respiratory ", "chartdate": "2129-09-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414329, "text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / \n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt was on CPAP/PS early in the shift but placed on full\n support following cardiac arrythmias\n Trigger work assessment: Triggering synchronously\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; Comments: No RSBI due to PEEP level.\n" }, { "category": "Nursing", "chartdate": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415576, "text": "Heart failure (CHF), Diastolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At found pt with respiratory rate 36-40 with audible expiratory\n wheezes. O2 sat 89-90% on 6l nasal prongs. SBP 164 with HR 106 ST.\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood sugars 230-280 titrating up received glargine 12units\n and SSRI, received total 34 units regular insulin SQ.\n Action:\n Glargine increased to 20 units at HS received\n Response:\n Plan:\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n CXR substantial worsening of extensive pulmonary consolidation,\n bilateral pulmonary consolidation right greater than left particularly\n upper lobe. Previous sputum on Acinetobactor Baumanni complex,\n Klebsiella\n Pneumoniae, staph aureus coag+ Afebrile. Coarse BS with freq congested\n NPC.\n Action:\n Attempted to NT suction but unable to pass catheter d/t strong\n gag/emesis. Cough and deep breath exercises with demonstration.\n Ampicillin day# 11 and vancomycin day#2.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415579, "text": "Pt is a 68 yo female admitted from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, re-cultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At found pt with respiratory rate 36-40 with audible expiratory\n wheezes. O2 sat 89-90% on 6l nasal prongs. SBP 164 with HR 106 ST.\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood sugars 230-280 titrating up received glargine 12units\n and SSRI, received total 34 units regular insulin SQ.\n Action:\n Glargine increased to 20 units at HS received\n Response:\n Plan:\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n CXR substantial worsening of extensive pulmonary consolidation,\n bilateral pulmonary consolidation right greater than left particularly\n upper lobe. Previous sputum on Acinetobactor Baumanni complex,\n Klebsiella\n Pneumoniae, staph aureus coag+ Afebrile. Coarse BS with freq congested\n NPC.\n Action:\n Attempted to NT suction but unable to pass catheter d/t strong\n gag/emesis. Cough and deep breath exercises with demonstration.\n Ampicillin day# 11 and vancomycin day#2.\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2129-09-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413963, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2129-09-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414086, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n ETT:\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / \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 Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: AM RSBI*-117\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2129-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414096, "text": "Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Lungs with scattered rhonci, bronchial aeration in LLL. No vent\n changes made with sats in the upper 90\n Action:\n Suctioned for scant/ amts thin yellow/white secretions. Conts on\n antibx, rec\ning vanco prn\n Response:\n Conts to improve sats\n Plan:\n Cont with pulm toilet/antibx\n Shock, septic\n Assessment:\n Hr 60-70\ns sr with no vea. Maps > 60 until approx 4am when drifting\n down to mid 50\ns. Of note BRBPR (pt has internal hemorrhoid/fissure)\n noted with hct down to 23.2.\n Action:\n Restarted low dose levophed. Rechecked hct. Team aware, to reveive 1\n unit prbc.\n Response:\n Maps ^ 60 again with levo.\n Plan:\n Transfuse when blood available. Wean off levo when able keeping map >\n 60.\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414736, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. Had PA line, IABP removed . Was also on\n levo/vasopressin, weaned to off . had 3 episodes of VT\n requiring cardioversion--? Related to reglan. Receiving unasyn and\n vanco for + blood culture and sputum, WBC falling. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose tid. Has had Hct drop, received a total of 3\n units PRBC, ?etio. Has had blood streaked stool, ? r/t hemorrhoids.\n ARF, ? contrast induced, Cr as high as 3.4, now 2.2. Access: R a-line\n and L PICC.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n TS to 101.3po , bloody secretions\n Action:\n CXR, Tylenol, pan cultured, contin unasyn for (+) PNA. HCT checked\n Response:\n Temp down to 99po. Secretions now tan/blood tinged. HCT 28.\n Plan:\n Monitor fever, Tylenol prn. follow culture results. Monitor for\n change in secretions\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Fluid overload on lasix gtt. , sats improved 96-98%. PO2 138\n Action:\n Stopped at 2230 d/t hypotension, peep decreased to 5 at 0630\n Response:\n u/o contin. 60-100cc/hr through night. Lasix gtt restarted at 0600.\n sats slightly down 93-95%\n Plan:\n Follow u/o, sats on decrease Peep\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with tachycardia and hypertension at time of fever - appearing\n agitated and uncomfortable.\n Action:\n . fent. 50mcq x2 given, additional 12.5mg lopressor given ,\n Response:\n BP dropping to 80\ns/ , gradually improving to baseline 100-120\ns/ by\n AM. Good response to fent.\n Plan:\n Prn fent boluses for pain. Contin. Comfort measures, skin care\n" }, { "category": "Nursing", "chartdate": "2129-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414305, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414307, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n s/p VT episodes x3 - requiring shock\n amio load and IVgtt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 70\ns Sr. no VEA.\n Action:\n Amio at 1mg/hr x6hr->\n Response:\n No VT overnight\n Plan:\n Monitor lytes. Contin. Amio .5mg x18hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Good ABG on 60%.\n Action:\n Weaned FIO2 to 50%/contin. 8 peep. Suctioned for thick tan\n secretions.\n Response:\n Sats 99-100%.\n Plan:\n try CPAP again today. Follow plan with team.\n" }, { "category": "Nutrition", "chartdate": "2129-09-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 414380, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 109 kg\n 116.3 kg ( 12:00 PM)\n 39.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 70 kg\n Pertinent medications: fentanyl, versed and amiodarone gtts.\n Labs:\n Value\n Date\n Glucose\n 150 mg/dL\n 04:48 AM\n Glucose Finger Stick\n 166\n 06:00 AM\n BUN\n 87 mg/dL\n 04:48 AM\n Creatinine\n 2.4 mg/dL\n 04:48 AM\n Sodium\n 141 mEq/L\n 04:48 AM\n Potassium\n 3.6 mEq/L\n 04:48 AM\n Chloride\n 108 mEq/L\n 04:48 AM\n TCO2\n 20 mEq/L\n 04:48 AM\n PO2 (arterial)\n 159 mm Hg\n 04:54 AM\n PCO2 (arterial)\n 31 mm Hg\n 04:54 AM\n pH (arterial)\n 7.45 units\n 04:54 AM\n pH (urine)\n 5.0 units\n 02:09 AM\n CO2 (Calc) arterial\n 22 mEq/L\n 04:54 AM\n Albumin\n 2.4 g/dL\n 05:46 AM\n Calcium non-ionized\n 7.6 mg/dL\n 04:48 AM\n Phosphorus\n 5.1 mg/dL\n 04:48 AM\n Ionized Calcium\n 1.03 mmol/L\n 03:00 AM\n Magnesium\n 2.8 mg/dL\n 04:48 AM\n ALT\n 60 IU/L\n 04:48 AM\n Alkaline Phosphate\n 138 IU/L\n 04:48 AM\n AST\n 36 IU/L\n 04:48 AM\n Amylase\n 49 IU/L\n 02:08 AM\n Total Bilirubin\n 1.9 mg/dL\n 04:48 AM\n Triglyceride\n 197 mg/dL\n 10:57 AM\n WBC\n 16.0 K/uL\n 04:48 AM\n Hgb\n 8.4 g/dL\n 04:48 AM\n Hematocrit\n 23.8 %\n 04:48 AM\n Current diet order / nutrition support: NPO\n GI: OGT w/ copious output; no bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1400 to 1750 (BEE x or / 20 to 25 cal/kg)\n Protein: 84 to 98 g (1.2 to 1.4 g/kg)\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations: Consider TPN if pt's condition does\n not stabilize to be able to restart TFs. Please consult if TPN recs\n are needed.\n" }, { "category": "Nursing", "chartdate": "2129-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414001, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Secretions sx q2-4hrs for thick yellow/tan via ett, bs are bronchial at\n bases w/ ronchi throughout.\n Action:\n Suctioned q2-4hrs, turned and postioned q2 hrs, followed vap protocol.\n Response:\n Sats cont 98-99%, no vent changes\n Plan:\n Cont vap protocol, cont aggressive pulmonary toileting, monitor in\n O2 sats <95%.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n u/o 30-100cc/hr. Creat down to 2.8\n Action:\n Monitored u/o qhr, all meds concentrated\n Response:\n Adequate u/o\n Plan:\n Cont close monitoring of u/o, creat\n Shock, septic\n Assessment:\n Pt on Levophed 0.147mcg/kg/min and Vasopressin 1.2units/hr. MAP\n >60. Extremities warm to touch.\n IV ABX Unasyn 3gm q8hrs. T max 99.4 po/ 100 pr.\n Action:\n Weaned levophed to off by 1400, but required restart at 1715 for MAP<\n 60 and SBP < 90. Vancomycin dosed 1000mg x1. Acetaminophen 650pr\n x1.\n Response:\n Pt tolerated SPB 90/ and MAP >60x 3hrs, but required levophed restart.\n Plan:\n Monitor and maintain SBP >90 and MAP > 60, Attempt to wean levophed\n maintaining SBP >90 and MAP >60.\n" }, { "category": "Nursing", "chartdate": "2129-09-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414004, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Secretions sx q2-4hrs for thick yellow/tan via ett, bs are bronchial at\n bases w/ ronchi throughout.\n Action:\n Suctioned q2-4hrs, turned and postioned q2 hrs, followed vap protocol.\n Response:\n Sats cont 98-99%, no vent changes\n Plan:\n Cont vap protocol, cont aggressive pulmonary toileting, monitor in\n O2 sats <95%.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n u/o 30-100cc/hr. Creat down to 2.8\n Action:\n Monitored u/o qhr, all meds concentrated\n Response:\n Adequate u/o\n Plan:\n Cont close monitoring of u/o, creat\n Shock, septic\n Assessment:\n Pt on Levophed 0.147mcg/kg/min and Vasopressin 1.2units/hr. MAP\n >60. Extremities warm to touch.\n IV ABX Unasyn 3gm q8hrs. T max 99.4 po/ 100 pr.\n Action:\n Weaned levophed to off by 1400, but required restart at 1715 for MAP<\n 60 and SBP < 90. Vancomycin dosed 1000mg x1. Acetaminophen 650pr\n x1.\n Response:\n Pt tolerated SPB 90/ and MAP >60x 3hrs, but required levophed restart.\n Plan:\n Monitor and maintain SBP >90 and MAP > 60, Attempt to wean levophed\n maintaining SBP >90 and MAP >60.\n ------ Protected Section ------\n Liver function abnormalities\n Assessment:\n LFT\ns elevated but are decreasing, Fentanyl 75mcgs/hr and Versed\n 1mg/hr. Eyes open, MAE, but does not follow commands. Utilizing non\n verbal cues for pain management. Pt grimaces w/ sx and turning and\n positioning\n Action:\n fentanyl to 50mcgs/hr so as to not oversedate pt as lft\ns normalize\n Response:\n Pt more awake, but does not appear more uncomfortable\n Plan:\n Medicate for pain utilizing non verbal cues,\n ------ Protected Section Addendum Entered By: , RN\n on: 18:30 ------\n" }, { "category": "Nursing", "chartdate": "2129-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414237, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Bilateral lower lobe infiltrates\n Action:\n Continues on unasyn,\n Response:\n Afebrile, wbc 19 (24)\n Plan:\n Monitor temp curve, cont abx\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on full vent support,\n Action:\n Vent changed from AC to PS 12/5, given 40 mg iv lasix x2\n Response:\n Tolerating vent change, fair response to diuresis\n Plan:\n Cont wean as tol,, monitor u/o\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Improving renal fx\n Action:\n Response:\n Cr 2.4 (2.8)\n Plan:\n Monitor renal fx\n Shock, septic\n Assessment:\n Improving bp\n Action:\n Levo weaned and d/c 0930, vasopressin weaned and d/c at 1100,\n Response:\n Bp 105-119/44-52\n Plan:\n Monitor bp\n Anemia, acute,\n Assessment:\n HCt drop 27.2 -> 22.3 , sm amt rectal bleeding ? hemorrhoids,\n ct neg\n Action:\n Tx 2 units prbc\n Response:\n Plan:\n Hct to be drawn 3 hr after blood completed\n" }, { "category": "Respiratory ", "chartdate": "2129-09-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414908, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / \n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Respiratory ", "chartdate": "2129-09-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414836, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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 / Thick\n Sputum source/amount: Suctioned / \n Comments :occasionally blood tinged.\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n 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 attempt PSV wean this eve.\n, RRT 17:11\n" }, { "category": "Respiratory ", "chartdate": "2129-09-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 415055, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / \n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n" }, { "category": "Nursing", "chartdate": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415588, "text": "Pt is a 68 yo female admitted from OSH with 3VD (100% RCA, 70% LAD, 80%\n LCX), s/p NSTEMI. Pt was transferred to for PCI or CABG.\n Hospital course c/b; retroperitoneal bleed requiring ETT, failure\n to be weaned d/t VAP and pulmonary edema-successfully extubated on\n . STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.)\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At found pt with respiratory rate 36-40 with audible expiratory\n wheezes. O2 sat 89-90% on 6l nasal prongs. SBP 164 with HR 106 ST.\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood sugars 230-280 titrating up received glargine 12units\n and SSRI, received total 34 units regular insulin SQ.\n Action:\n Glargine increased to 20 units at HS received\n Response:\n Plan:\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n CXR substantial worsening of extensive pulmonary consolidation,\n bilateral pulmonary consolidation right greater than left particularly\n upper lobe. Previous sputum on Acinetobactor Baumanni complex,\n Klebsiella\n Pneumoniae, staph aureus coag+ Afebrile. Coarse BS with freq congested\n NPC.\n Action:\n Attempted to NT suction but unable to pass catheter d/t strong\n gag/emesis. Cough and deep breath exercises with demonstration.\n Ampicillin day# 11 and vancomycin day#2.\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2129-09-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414546, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / \n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n" }, { "category": "Respiratory ", "chartdate": "2129-09-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 415037, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / \n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt has been on PSV then CMV x 2 hours alternating; will rest over noc\n on A/C at about 2100hrs. plan to extubate tomorrow\n Leave on SBT if RSBI is good. Secretions have been lightly blood\n tinged when some come out ; some sx attempts result in NO secretions.\n, RRT 18:42\n" }, { "category": "Nursing", "chartdate": "2129-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415172, "text": "Respiratory failure, acute (not ARDS/)/ VAP (pneumonia)\n Assessment:\n RSBI 40 on SBT- tolerated weaning\n Action:\n Extubated- pulmonary toileting- diuresing on lasix gtt\n Response:\n No resp distress- VSS- acceptable ABG\n Plan:\n Con\nt pulmonary toileting- maintain lasix gtt as ordered- encourage\n C&DB- IS while awake- Resp Rx & abx as ordered.\n Heart failure (CHF), Acute\n Assessment:\n Generalized edema- hypertensive\n Action:\n Lasix & NTG gtts\n Response:\n Good diuresis- (-) 2100cc since 12am.\n Plan:\n Goal output 2500cc today- maintain SBP <140\n" }, { "category": "Nutrition", "chartdate": "2129-09-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 415111, "text": "Subjective\n Extubated this am.\n Objective\n Labs:\n Value\n Date\n Glucose\n 150 mg/dL\n 04:29 AM\n Glucose Finger Stick\n 162\n 04:46 AM\n BUN\n 61 mg/dL\n 04:29 AM\n Creatinine\n 2.0 mg/dL\n 04:29 AM\n Sodium\n 146 mEq/L\n 04:29 AM\n Potassium\n 3.6 mEq/L\n 04:29 AM\n Chloride\n 109 mEq/L\n 04:29 AM\n TCO2\n 28 mEq/L\n 04:29 AM\n Albumin\n 2.4 g/dL\n 05:46 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:29 AM\n Phosphorus\n 3.6 mg/dL\n 04:29 AM\n Ionized Calcium\n 1.03 mmol/L\n 03:00 AM\n Magnesium\n 2.1 mg/dL\n 04:29 AM\n ALT\n 43 IU/L\n 04:13 AM\n Alkaline Phosphate\n 109 IU/L\n 04:13 AM\n AST\n 29 IU/L\n 04:13 AM\n Amylase\n 49 IU/L\n 02:08 AM\n Total Bilirubin\n 1.4 mg/dL\n 04:13 AM\n Triglyceride\n 197 mg/dL\n 10:57 AM\n WBC\n 9.1 K/uL\n 04:29 AM\n Hgb\n 9.7 g/dL\n 04:29 AM\n Hematocrit\n 29.6 %\n 04:29 AM\n Current diet order / nutrition support: TF Nutren Pulm goal 50ml/hr\n GI: +bs, ntnd\n Assessment of Nutritional Status\n Obese, at risk for malnutrition\n Pt at risk due to: NPO\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 68 yo F adm with PNA, pulm edema, pt extubated to face mask this am,\n will f/u re diet adv/po tol.\n Medical Nutrition Therapy Plan - Recommend the Following\n f/u re diet adv/ po tol\n d/c TF order in POE\n cont bg management\n please page if has ?\n" }, { "category": "Nursing", "chartdate": "2129-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415363, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n remains hypertensive\n Action:\n Lasix & Ntg gtts D/C\nd- tolerating increasing doses of lopressor &\n captopril\n Response:\n SBP 140-150\n Plan:\n Maintain SBP <140\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Fingerstick glucose 238-344 today.\n Action:\n Insulin sliding scale & evening glargine increased\n Response:\n Lower blood sugar\n Plan:\n Give increased glargine dose @ hs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Drops SpO2\ns when in bed.\n Action:\n Encouraged to C&DB- HOB > 30 degrees- IS while awake- OOB to chair.\n Response:\n Better oxygenation\n Plan:\n SpO2\ns WNL\n" }, { "category": "Nursing", "chartdate": "2129-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415167, "text": "Respiratory failure, acute (not ARDS/)/ VAP (pneumonia)\n Assessment:\n RSBI 40 on SBT- tolerated weaning\n Action:\n Extubated- pulmonary toileting- diuresing on lasix gtt\n Response:\n No resp distress- VSS- acceptable ABG\n Plan:\n Con\nt pulmonary toileting- maintain lasix gtt as ordered- encourage\n C&DB- IS while awake- Resp Rx & abx as ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Generalized edema\n Action:\n Lasix gtt @ 1mg/hr ->titrated to maintain U/O > 125cc/hr\n Response:\n Good diuresis- (-) 2100cc since 12am.\n Plan:\n Goal output 2500cc today\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415849, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett 1 at HS and again\n this am.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200 improved with increased glargine\n Action:\n Receiving SSRI to control elevated blood sugars.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco day #3 and unasyn day# 12 LS clear with\n diminished at bases, dry NPC. O2 sats 92-98% dropping to 88% with O2\n off. 40-70%face tent changed back to 4l np.\n Action:\n Response:\n Improvement in O2 saturations.\n Plan:\n Consult PT for CPT and for OOB chair with strengthening exercises.\n Bedside CPT q4-6hrs as needed with IS q1hr while awake.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o pain related to sciatica\n Action:\n Given 1 percocet this am for above c/o, pain better after percocet.\n CCU team wrote for 1 dose of morphine, not given as pain free.\n Response:\n Pain relieved with percocett and position change.\n Plan:\n Reposition frequently, percocett for pain, if without relief, can have\n morphine dose.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds. Repositioned every 2 hours, and oob to\n chair for 2 hours.\n Response:\n Skin looks much improved from last Sunday, left breast and panus area\n healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Advance diet as tolerated.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Pt with sats ~ 90% this am on shovel mask. Afebrile. Vanco level this\n am 26 (not trough). Lungs with diminished breath sounds in bases.\n Afebrile\n Action:\n Given albuterol/atrovent nebulizer. O2 switched to 4L np. Repeated\n Vanco trough level @ 1530.\n Response:\n Sats improved to mid to high 90\ns. Trough level 22.\n Plan:\n Monitor lungs, sats, atrovent nebs as ordered. Vanco dose held, to\n repeat trough in am.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Continues to be volume overloaded. K and Mg low\n Action:\n Lasix gtt @ 20 mg/hour, paused @ 0930 awaiting lasix from pharmacy.\n PICC line clotted, given tPA via PICC with resolution. Lasix restarted\n @ 1200. U/O 120-280/hour. Diuril dose given @ 1700 when up from\n pharmacy. K and Mg replaced. IV NTG titrated as high as 1.5\n mcg/kg/min d/t SBP 160\ns. Restarted on captopril, monitored frequently\n after dose.\n Response:\n Diuresing well, but is even for the day d/t temporary loss of PICC\n line. SBP 120\ns-130\ns on IV NTG and captopril. No signs of allergic\n reaction to captopril. Repeat K/Mg ok.\n Plan:\n Continue to monitor u/o, VS, K/Mg. Assess for allergic reaction to\n captopril.\n" }, { "category": "Nursing", "chartdate": "2129-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415859, "text": "Pt is a 68 year old female admitted from OSH with NSTEMI with heart\n catheterization 3CD 100% RCA, 70% LAD, 80% LCX. Pt was transferred to\n for PCI or CABG. Hospital course c/b; retroperitoneal\n bleed requiring ETT, failure to be weaned d/t VAP and pulmonary\n edema-successfully extubated on . Two episodes of pulmonary edema\n in setting of HTN. STEMI -BMS to LCX cardiogenic shock requiring\n IABP/vasopressors all weaned off by . AF with aberrancy rate 200 x3\n successfully cardioverted. + Blood culture and sputum +acinetobacter\n baumanni and Klebsiella pneumoniae on Unasyn/vanco.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o chronic back pain having h/o sciatica and lower back strain.\n Action:\n Freq back rubs with repositioning. Received percocett 1 at HS and again\n this am.\n Response:\n Fair- good effect. Back rubs with position change\n Plan:\n Continue with percocett and backrubs prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 160-200 improved with increased glargine\n Action:\n Receiving SSRI to control elevated blood sugars.\n Response:\n Improved BS control with SSRI/glargine\n Plan:\n Continue to monitor blood sugars AC and HS as pt appetite improves\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Acinetobactor Baumanni complex, Klebsiella Pneumoniae, staph aureus\n coag+ Afebrile.on vanco day #3 pnd vanco level this am and unasyn day#\n 12 LS clear with diminished at bases, dry NPC. O2 sats 92-98% dropping\n to 88% with O2 off. 40-70%face tent changed back to 4l np.\n Action:\n Response:\n Improvement in O2 saturations.\n Plan:\n Consult PT for CPT and for OOB chair with strengthening exercises.\n Bedside CPT q4-6hrs as needed with IS q1hr while awake.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breast, bilateral groin sites and panus\n Action:\n Areas cleansed with foam soap, dried, anti-fungal barrier cream\n applied, kerlex fan to folds. Repositioned every 2 hours, and oob to\n chair for 2 hours.\n Response:\n Skin looks much improved from last Sunday, left breast and panus area\n healed.\n Plan:\n Foam cleanser , anti-fungal barrier cream q am, kerlex change q 8\n hours. Continue with position changes. Advance diet as tolerated.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Pt with sats ~ 90% this am on shovel mask. Afebrile. Vanco level this\n am 26 (not trough). Lungs with diminished breath sounds in bases.\n Afebrile\n Action:\n Given albuterol/atrovent nebulizer. O2 switched to 4L np. Repeated\n Vanco trough level @ 1530.\n Response:\n Sats improved to mid to high 90\ns. Trough level 22.\n Plan:\n Monitor lungs, sats, atrovent nebs as ordered. Vanco dose held, to\n repeat trough in am.\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Continues to be volume overloaded. K and Mg low\n Action:\n Lasix gtt @ 20 mg/hour, paused @ 0930 awaiting lasix from pharmacy.\n PICC line clotted, given tPA via PICC with resolution. Lasix restarted\n @ 1200. U/O 120-280/hour. Diuril dose given @ 1700 when up from\n pharmacy. K and Mg replaced. IV NTG titrated as high as 1.5\n mcg/kg/min d/t SBP 160\ns. Restarted on captopril, monitored frequently\n after dose.\n Response:\n Diuresing well, but is even for the day d/t temporary loss of PICC\n line. SBP 120\ns-130\ns on IV NTG and captopril. No signs of allergic\n reaction to captopril. Repeat K/Mg ok.\n Plan:\n Continue to monitor u/o, VS, K/Mg. Assess for allergic reaction to\n captopril.\n" }, { "category": "Nursing", "chartdate": "2129-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415255, "text": "Heart failure (CHF), Diastolic, Acute\n Assessment:\n Hr remains elevated in the 90-100\ns sr/st with no vea. Bp remains\n slightly elevated 140-170\ns/60-70\ns. Lungs are clear throughout with\n sats in the mid to upper 90\n Action:\n Increased lopressor to tid and captopril increased to 12.5mg, iv ntg\n titrated ^ for bp control. Conts on lasix 1mg/hr.\n Response:\n Creat is down to 1.7 today thought Na is ^ 150. She was (-) approx\n 2600cc for yesterday and even for today bp/hr remain elevated, not much\n effect from increased doses of captopril/lopressor. Had fair effect\n from ^ in iv ntg.\n Plan:\n ? d/c of lasix gtt, ? euvolemic now. Cont to follow hr/bp with ? ^\n lopressor for hr/bp.\n" }, { "category": "Nursing", "chartdate": "2129-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415019, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas. Oral\n thrush.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning and\n improved skin integrity with current treatment plan. Team does not\n want to treat thrush at this time.\n Response:\n Macerated areas appear drier today and base more pink than yellow.\n Peri-anal site improved.\n Plan:\n Continue to wash sites and reapply kerlex fans q 8 hours,\n anti-fungal moisture barrier cream q am. Continue with freq positions\n changes. Careful assessment of skin. Desitin to peri-anal area.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes, although less grimacing today\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR. Pt hyperextends her neck, more comfortable without a pillow\n on bed.\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes. No pillow to HOB\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 14 days with PNA and pulmonary edema\n Action:\n Switched from ac to CPAP , ABG better than ABG on AC. PEEP\n decreased to 5. Continued with good ABG. For remainder of day,\n alternated 2 hours of CPAP () with 2 hours of AC, rate of 12, 5\n PEEP. Maintained sats >96%. Placed on dose of chlorothiazide,\n lasix gtt decreased to 15mg with addition of chlorothiazide. Later\n lasix decreased to 10mg/hour d/t u/o 400 cc/hour. 2L negative so far\n today. AM K 3.7\n40 po. Lytes PND from 1600. Pillow placed between\n legs to prevent legs from obstructing foley drainage, no leakage\n today. T max 99.5, remains on unasyn and dose vanco by trough. Less\n ET secretions today. Albuterol/atrovent MDI\ns continued. A-line with\n pinkness at insertion site, no tenderness, no drainage. Intern in to\n assess site\nwill leave a-line in overnight, with plan to pull a-line\n after extubation tomorrow.\n Response:\n Diuresing well ,improved oxygenation, making strides towards extubation\n tomorrow.\n Plan:\n Continue to monitor sats, lung sounds, secretions, T. HOB > 45\n degrees. Monitor fluid in balloon of foley, pillow between legs to\n keep pressure off of foley. Follow I/O and lytes. To place pt on A/c\n this evening and rest overnight. Please ^^sedation this evening to\n allow pt to sleep soundly\ndecrease sedation @ 0400). TF off @ 0400 as\n per team for extubation. Careful assessment of R radial a-line.\n Ventricular tachycardia, sustained\n Assessment:\n Last episode of VT \n Action:\n Receiving amiodarone \n Response:\n Occ PVC\ns this am in setting of K 3.7., QTc 0.46\n Plan:\n Monitor VEA, follow qtc.\n .\n ------ Protected Section ------\n Addendum: brown lesion noted on left upper chest, 11mm in diameter,\n irregular border, slightly raised/patchy. Dr. notified and in\n to examine. To place info in pt\ns discharge paperwork for follow up\n after acute illness.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:18 ------\n" }, { "category": "Nursing", "chartdate": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415409, "text": "Heart failure (CHF), Diastolic, Acute\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": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415575, "text": "Heart failure (CHF), Diastolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At found pt with respiratory rate 36-40 with audible expiratory\n wheezes. O2 sat 89-90% on 6l nasal prongs. SBP 164 with HR 106 ST.\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood sugars 230-280 titrating up received glargine 12units\n and SSRI, received total 34 units regular insulin SQ.\n Action:\n Glargine increased to 20 units at HS received\n Response:\n Plan:\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n CXR substantial worsening of extensive pulmonary consolidation,\n bilateral pulmonary consolidation right greater than left particularly\n upper lobe. Previous sputum on Acinetobactor Baumanni complex,\n Klebsiella\n pneumoniae, staph aureus coag+ Afebrile. Coarse BS with freq\n congested NPC.\n Action:\n Attempted to NT suction but unable to pass catheter d/t strong\n gag/emesis. Cough and deep breath exercises with demonstration pt is\n able to copy. Ampicillin day# 11 and vancomycin day#2.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415009, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas. Oral\n thrush.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning and\n improved skin integrity with current treatment plan. Team does not\n want to treat thrush at this time.\n Response:\n Macerated areas appear drier today and base more pink than yellow.\n Peri-anal site improved.\n Plan:\n Continue to wash sites and reapply kerlex fans q 8 hours,\n anti-fungal moisture barrier cream q am. Continue with freq positions\n changes. Careful assessment of skin. Desitin to peri-anal area.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes, although less grimacing today\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR. Pt hyperextends her neck, more comfortable without a pillow\n on bed.\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes. No pillow to HOB\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 14 days with PNA and pulmonary edema\n Action:\n Switched from ac to CPAP , ABG better than ABG on AC. PEEP\n decreased to 5. Continued with good ABG. For remainder of day,\n alternated 2 hours of CPAP () with 2 hours of AC, rate of 12, 5\n PEEP. Maintained sats >96%. Placed on dose of chlorothiazide,\n lasix gtt decreased to 15mg with addition of chlorothiazide. Later\n lasix decreased to 10mg/hour d/t u/o 400 cc/hour. 2L negative so far\n today. AM K 3.7\n40 po. Lytes PND from 1600. Pillow placed between\n legs to prevent legs from obstructing foley drainage, no leakage\n today. T max 99.5, remains on unasyn and dose vanco by trough. Less\n ET secretions today. Albuterol/atrovent MDI\ns continued. A-line with\n pinkness at insertion site, no tenderness, no drainage. Intern in to\n assess site\nwill leave a-line in overnight, with plan to pull a-line\n after extubation tomorrow.\n Response:\n Diuresing well ,improved oxygenation, making strides towards extubation\n tomorrow.\n Plan:\n Continue to monitor sats, lung sounds, secretions, T. HOB > 45\n degrees. Monitor fluid in balloon of foley, pillow between legs to\n keep pressure off of foley. Follow I/O and lytes. To place pt on A/c\n this evening and rest overnight. Please ^^sedation this evening to\n allow pt to sleep soundly\ndecrease sedation @ 0400). TF off @ 0400 as\n per team for extubation. Careful assessment of R radial a-line.\n Ventricular tachycardia, sustained\n Assessment:\n Last episode of VT \n Action:\n Receiving amiodarone \n Response:\n Occ PVC\ns this am in setting of K 3.7., QTc 0.46\n Plan:\n Monitor VEA, follow qtc.\n .\n" }, { "category": "Nursing", "chartdate": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415411, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\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": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415414, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Acute heart failure decompensation at assoc. with . sats,\n hypertension and tachycardia.\n Action:\n placed on mask ventilation, rx with total 4 morphine iv, IV\n hydralazine, IV lopressor, lasix gtt started at 10mg/hr and titrated up\n to 15mg/hr. IV nitro started to max .86mcq/k/min. currently at\n .65mcq/k/min. goal SBP <140\n tolerated mask vent. X1hr. weaned to high flow mask 100% with 5lnc.\n Response:\n u/o inc. 120-200cc/hr , neg. 400cc since MN.\n SBP contin. High 140-150/, HR . denies CP.\n ABG stable on high flow\nable to wean to 80%.\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415415, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n Acute heart failure decompensation at assoc. with . sats,\n hypertension and tachycardia.\n Action:\n placed on mask ventilation, rx with total 4 morphine iv, IV\n hydralazine, IV lopressor, lasix gtt started at 10mg/hr and titrated up\n to 15mg/hr. IV nitro started to max .86mcq/k/min. currently at\n .65mcq/k/min. goal SBP <140\n tolerated mask vent. X1hr. weaned to high flow mask 100% with 5lnc.\n Congested cough, non-productive. Atrovent neb x1. tol well.\n Response:\n u/o inc. 120-200cc/hr , neg. 400cc since MN.\n SBP contin. High 140-150/, HR . denies CP.\n ABG stable on high flow\nable to wean to 80%. Sats 94%.\n Plan:\n Monitor u/o on lasix gtt. Monitor lytes. Contin. Po lopressor and\n captopril. IV hydralazine for SBP >170 prn.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 240 in eve\n Action:\n 12 U glargine. SSRI\n Response:\n Pt. hungry, asking for ice chips. Taking pills either whole with\n applesause or crushed with applesauce.\n Plan:\n Contin. QID FS.\n" }, { "category": "Nursing", "chartdate": "2129-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414460, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd , ATN resolving, GIB w/ hct drop to 22,\n requiring tx\n Ventricular tachycardia, sustained\n Assessment:\n No episodes VT since last eve\n Action:\n On amiodarone gtt at 0.5 mg/hr\n Response:\n No VT on current gtt\n Plan:\n Monitor rhythm\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Probable slow GIB, w continued hct drop\n Action:\n Tx 2 units prbc\n Response:\n awaiting hct draw\n Plan:\n f/u hct 1900\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Failed ps wean\n Action:\n Placed back on previous vent settings, diuresed w/ 40 lasix x2\n Response:\n Stable on current vent settings, fair response to diuresis\n Plan:\n Pulmonary toilet, attempt ps wean in am, attempt 1 liter neg\n" }, { "category": "Respiratory ", "chartdate": "2129-09-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414466, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / 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: Tachypneic (RR> 35 b/min);\n Comments: pt had significant increase in WOB when switched to PSV 5/5\n so vent settings were increased back to a/c\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2129-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415066, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas. Oral\n thrush.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning and\n improved skin integrity with current treatment plan. Team does not\n want to treat thrush at this time.\n Response:\n Macerated areas appear drier today and base more pink than yellow.\n Peri-anal site improved.\n Plan:\n Continue to wash sites and reapply kerlex fans q 8 hours,\n anti-fungal moisture barrier cream q am. Continue with freq positions\n changes. Careful assessment of skin. Desitin to peri-anal area.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes, although less grimacing today\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR. Pt hyperextends her neck, more comfortable without a pillow\n on bed.\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes. No pillow to HOB. Decrease\n sedation-fentanyl & versed gtts-?xtubation in am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 14 days with PNA and pulmonary edema\n Action:\n Rested over night-cmv/assist 550x12 405 +8 w am abg-7.49 39 81 5 31.\n sedation increased-fentanyl/versed gtts to rest pt. continuing to\n diurese w lasix gtt & diuril.\n Response:\n Comfotable night. Less restless-slept. Excellent response to\n diuresis-negetive 3.3l @ 2300 (overall neg 8.8l). am rsbi-52.\n Plan:\n Continue to monitor sats, lung sounds, secretions, T. HOB > 45\n degrees. Follow I/O and lytes. Wean sedation im am. Dc tf early am.\n Place back on cpap/ps early am w goal-?extubation.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Documented pna-acinetobacter baumanii\n Action:\n Abx-ampicillin-sulbactram & evel dosed vanco.\n Response:\n Low grade t. am wbc pending.\n Plan:\n Contin abx. Follow t &reculture w spike.\n" }, { "category": "Nursing", "chartdate": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415549, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n CHF improving\n Action:\n Received pt on Ntg gtt, 80% Hi Flow mask + 5 l NC, Lasix gtt . Pt\n responding well to lasix gtt at 15 mg/hr. Received one dose hydralazine\n at 0930 for sbp 160, bp improved, NTG gtt weaned to off. Lopressor and\n captopril doses increased. O2 weaned to 6lnp.\n Response:\n Pt ~ 800 cc neg since mn. SATs mid 90\ns, tolerating increased doses\n captopril and lopressor\n Plan:\n Monitor resp status, response to ^ cv meds\n Diabetes Mellitus (DM), Type II\n Assessment:\n Continued hyper glycemia\n Action:\n ^ glargine dose started last eve, pt ^ PO intake, taking soft solids,\n liqs w/o difficulty. Pills crushed in applesauce.\n Response:\n Bs 200\n Plan:\n Reevaluate need for ^ glargine dose.\n" }, { "category": "Nursing", "chartdate": "2129-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415567, "text": "Heart failure (CHF), Diastolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414611, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414619, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. Had PA line, IABP removed . Was also on\n levo/vasopressin, weaned to off . had 3 episodes of VT\n requiring cardioversion--? Related to reglan. Receiving unasyn and\n vanco for + blood culture and sputum, WBC falling. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose tid. Has had Hct drop, received a total of 3\n units PRBC, ?etio. Has had blood streaked stool, ? r/t hemorrhoids.\n ARF, ? contrast induced, Cr as high as 3.4, now 2.2. Access: R a-line\n and L PICC.\n Ventricular tachycardia, sustained\n Assessment:\n Last VT . No VEA/VT today. Able to take meds via OGT (had had\n high residuals).\n Action:\n Amiodarone IV changed to OGT. QTc 0.47\n Response:\n No VEA\n Plan:\n Continue to monitor VEA, electrolytes PND.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimaces when turning on side, does not consistently shake head yes/ no\n when pain assessed. Neck hyperextended, does not answer yes/no to pain\n in area. Team notified\n Action:\n Remains on fentanyl and versed gtts, although fentanyl gtt weaned down\n to 100mcg to better assess neuro status. Given 2mg versed bolus and 25\n mcg fentanyl bolus prior to turning.\n Response:\n Better pain control, also able to assess neuro status\n Plan:\n Continue to assess non-verbal signs of pain, premedicate with\n repositioning, do not place pillow under pt\ns head\nappears more\n comfortable this way..\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated since . ETS\n sm to mod amt cream colored\n secretions.\n Action:\n PEEP weaned over course of morning, then changed to CPAP 10/5. Lasix\n gtt started (0.1 mg/kg/ bolus and 5mg/hour gtt).\n Response:\n Maintaining satisfactory ABG, sats low to mid 90\ns. Diuresing > 120\n cc/hour\n Plan:\n To titrate lasix gtt to maintain u/o >100cc\ns/hour, goal ~ 2L\n negative. To repeat electrolytes. Continue to assess tolerance of\n CPAP, ? decrease PS to 5 as able.\n Impaired Skin Integrity\n Assessment:\n Open skin under breasts, panus, peri-rectal area and bilateral groin\n sites. Dried open skin tear on L lower arm\n Action:\n Areas cleansed with soap/water, pat dry. Anti-fungal moisture barrier\n applied to all skin folds and peri-anal area. Kerlix\n applied to\n skin folds. Moisture barrier/desitin applied to rectal area. LL arm\n left open to air. Kinair bed not ordered as plan to extubate pt\n tomorrow\nwill then feed and get OOB. Impaired skin integrity not\n pressure related.\n Response:\n No change this shift.\n Plan:\n Continue to monitor sites, change kerlix . Moisture barrier to\n sites qd with bath. If unable to extubate in am, consider kinair bed.\n" }, { "category": "Nutrition", "chartdate": "2129-09-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 415486, "text": "Subjective\n Fair appetite!\n Labs:\n Value\n Date\n Glucose\n 193 mg/dL\n 04:26 AM\n Glucose Finger Stick\n 220\n 06:00 AM\n BUN\n 45 mg/dL\n 04:26 AM\n Creatinine\n 1.6 mg/dL\n 04:26 AM\n Sodium\n 145 mEq/L\n 04:26 AM\n Potassium\n 3.4 mEq/L\n 04:26 AM\n Chloride\n 106 mEq/L\n 04:26 AM\n TCO2\n 31 mEq/L\n 04:26 AM\n PO2 (arterial)\n 128 mm Hg\n 04:34 AM\n PCO2 (arterial)\n 42 mm Hg\n 04:34 AM\n pH (arterial)\n 7.50 units\n 04:34 AM\n pH (urine)\n 5.0 units\n 09:53 PM\n CO2 (Calc) arterial\n 34 mEq/L\n 04:34 AM\n Albumin\n 2.5 g/dL\n 04:26 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:26 AM\n Phosphorus\n 2.8 mg/dL\n 04:26 AM\n Ionized Calcium\n 1.03 mmol/L\n 03:00 AM\n Magnesium\n 1.8 mg/dL\n 04:26 AM\n ALT\n 38 IU/L\n 04:26 AM\n Alkaline Phosphate\n 89 IU/L\n 04:26 AM\n AST\n 31 IU/L\n 04:26 AM\n Amylase\n 49 IU/L\n 02:08 AM\n Total Bilirubin\n 1.3 mg/dL\n 04:26 AM\n Triglyceride\n 197 mg/dL\n 10:57 AM\n WBC\n 15.2 K/uL\n 04:26 AM\n Hgb\n 10.0 g/dL\n 04:26 AM\n Hematocrit\n 31.2 %\n 04:26 AM\n Current diet order: Regular, Ground solid, thin liquid\n Assessment of Nutritional Status\n Pt s/p S&S eval yesterday, ok\ned to diet adv. Spoke to RN, pt taking\n pills in apple sauce, and is able to tol soft solid , drinking liquid\n without issue.\n Medical Nutrition Therapy Plan - Recommend the Following\n Diet consistency per SLP\ns rec\n f/u re intakes\n please page if has ?\n" }, { "category": "Nursing", "chartdate": "2129-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414496, "text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414499, "text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414502, "text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414505, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n Course c/b ATN cr ^3.5- nonresponsive to lasix gtt, gradually improving\n cr 2.4. fevers now resolved. Rx for LLL pnx with Vanco and zosyn.\n HCT drop- to 22 transfused total 3 U PRBC since . CT scan \n showing no acute bleed.\n Failure to wean from vent\n failing pressure support wean.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n s/p transfusion . post HCT 2100\n 27. Guiac pos. stool- \n to med. Amts. Contin. NPO. (+) flatus. OGT to LIS.\n Action:\n No further transfusion tonight. Contin. NPO. Contin. Lactulose TID.\n Response:\n Stable. Med. Formed brown stool, guiac pos.\n Plan:\n Monitor HCT, contin. Lactulose. OGT to LIS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats dropping 90-93% on 5peep. LS diminished. PO2 80. u/o dropping <\n 100cc/hr from lasix given at 1700.\n Action:\n Peep increased to 8 (AC 550x12/40%). Suctioned for sm-mod. Amt. thin\n tan secretions. Lasix 40mg given , then 80mg given -\n Response:\n Sats inc. to 97-98%. u/o ^ 80-200cc/hr. neg. 1L for .\n Plan:\n Contin. Current vent settings. Anticipate PSV wean today. Monitor u/o\n response to diuresis. Monitor lytes.\n Ventricular tachycardia, sustained\n Assessment:\n No further VT or VEA. K+ 3.4 s/p diuresis\n Action:\n Amio gtt at .5mg/min. continues. Repleted total 40meq KCL IV.\n Response:\n Stable HR/BP.\n Plan:\n Contin. Amio gtt. Follow lytes.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with all turns, skin care etc. BP elevated to 160-190/60-80\n , HR 85-90\n Pt. with eyes open, nodding head\n when asked if she could hear\n RN. But could not stimulate pt. to follow commands. Moving\n extremeties purposefully to pain- withdraws. Pt. appears that she is\n listening.\n Action:\n Fent gtt inc. to 150mcq/hr and versed inc. to 4mg/hr.\n Response:\n Tolerating pt. care better, occas. fent. Boluses required. BP up to\n 120\ns/ with stimulation. Settles down on own. Versed decreased to\n 2mg/hr , tol. Well. HO aware .\n Plan:\n Titrate fent/versed for pain scale. Monitor response to verbal\n stimulation. Contin.to assess for neuron change.\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414720, "text": "Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414725, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. Had PA line, IABP removed . Was also on\n levo/vasopressin, weaned to off . had 3 episodes of VT\n requiring cardioversion--? Related to reglan. Receiving unasyn and\n vanco for + blood culture and sputum, WBC falling. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose tid. Has had Hct drop, received a total of 3\n units PRBC, ?etio. Has had blood streaked stool, ? r/t hemorrhoids.\n ARF, ? contrast induced, Cr as high as 3.4, now 2.2. Access: R a-line\n and L PICC.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n TS to 101.3po , bloody secretions\n Action:\n CXR, Tylenol, pan cultured, contin unasyn for (+) PNA. HCT checked\n Response:\n Temp down to 99po. Secretions now tan/blood tinged. HCT 28.\n Plan:\n Monitor fever, Tylenol prn. follow culture results.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2129-09-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 415153, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n 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:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Expectorated / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt extubated to a 50% cool neb. At present appears to be holding her\n own W/sat\ns in the mid 90\ns (usually)or better.\n Needs to be changed to Nebs for her inhaled RT meds. Will watch\n carefully..\n, RRT 17:04\n" }, { "category": "Respiratory ", "chartdate": "2129-09-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414642, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 / 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: Intolerant of\n weaning attempts, Cannot protect airway; Comments: PSV trial done today\n for 6 hours but she desturated and BP increased\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414721, "text": "Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414722, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. Had PA line, IABP removed . Was also on\n levo/vasopressin, weaned to off . had 3 episodes of VT\n requiring cardioversion--? Related to reglan. Receiving unasyn and\n vanco for + blood culture and sputum, WBC falling. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose tid. Has had Hct drop, received a total of 3\n units PRBC, ?etio. Has had blood streaked stool, ? r/t hemorrhoids.\n ARF, ? contrast induced, Cr as high as 3.4, now 2.2. Access: R a-line\n and L PICC.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414851, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose. Has had Hct drop, received a total of 3 units\n PRBC, ?etio, Hct now stable. Has blood streaked stool, ? r/t\n hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4, now 2.2.\n Access: R a-line and L PICC\n Constipation (Obstipation, FOS)\n Assessment:\n Pt with 2 episodes of liq stool, pink in color.\n Action:\n Team informed of liq pink stool\nnot new. Pt disimpacted of moderate\n amount of formed soft brown stool with blood streaking around it. Team\n informed, lactulose order changed to 30cc\ns qd, but not to give before\n this evening as per team. Had an additional moderate sized soft brown\n stool Nutren TF @ 20 cc\ns hour begun.\n Response:\n No further stool leakage. Residuals 4 hours after TF begun 80 cc\ns, TF\n paused\n Plan:\n Do not advance TF, lactulose this evening and qd as needed until bowel\n movements normalize. Restart TF @ @ 10 cc\ns/hour\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas. Oral\n thrush.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning.\n Discussed with unit based educator. Team does not want to treat thrush\n at this time.\n Response:\n Macerated areas appear drier today and base more pink than yellow.\n Peri-anal site less pink.\n Plan:\n Continue to wash sites and reapply kerlex fans, anti-fungal\n moisture barrier cream qd. Continue with freq positions changes.\n Careful assessment of skin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes, although less grimacing today\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR. Pt hyperextends her neck, more comfortable without a pillow\n on bed.\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes. No pillow to HOB\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 13 days with PNA and pulmonary edema\n Action:\n Attempted reducing PEEP from 10 to 5 this am, sats falling to 89-90%,\n see flow sheet for ABG. PEEP ^ to 8, sats maintaining >95%. IV lasix\n gtt titrated up to 15mg with goal of maintaining u/o >150 cc/hour. Pt\n ~1L negative since midnight, goal of 3L negative. Foley leaked, more\n fluid placed in balloon, and pillow placed between legs to prevent legs\n from obstructing foley drainage. T max 99.7, remains on unasyn and\n dose vanco by trough. Less ET secretions today. Albuterol/atrovent\n MDI\ns added\n Response:\n Diuresing well with improved oxygenation. No further leaking of\n catheter\n Plan:\n Team may add diuril and attempt PS trial later this evening. Continue\n to monitor sats, lung sounds, secretions, T. HOB > 45 degrees.\n Monitor fluid in balloon of foley, pillow between legs to keep pressure\n off of foley.\n Ventricular tachycardia, sustained\n Assessment:\n Last episode of VT \n Action:\n Receiving amiodarone \n Response:\n No VEA, QTc 0.42\n Plan:\n Monitor VEA, follow qtc.\n .\n" }, { "category": "Nursing", "chartdate": "2129-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415229, "text": "Heart failure (CHF), Diastolic, Acute\n Assessment:\n Hr remains elevated in the 90-100\ns sr/st with no vea. Bp remains\n slightly elevated 140-170\ns/60-70\ns. Lungs are clear throughout with\n sats in the mid to upper 90\n Action:\n Increased lopressor to tid and captopril increased to 12.5mg, iv ntg\n titrated ^ for bp control. Conts on lasix 1mg/hr.\n Response:\n Creat is down to 1.7 today thought Na is ^ 150. She was (-) approx\n 2600cc for yesterday and even for today bp/hr remain elevated, not much\n effect from increased doses of captopril/lopressor. Had fair effect\n from ^ in iv ntg.\n Plan:\n ? d/c of lasix gtt, ? euvolemic now. Cont to follow hr/bp with ? ^\n lopressor for hr/bp.\n" }, { "category": "Nursing", "chartdate": "2129-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415374, "text": "Pt is a 68 yo female adm from OSH with 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. remained intubated\n d/t PNA and pulmonary edema. had hypotension with ST ^ inf\nwent\n for BMS to LCx. (will probably need further PCI or CABG). Had PA line,\n IABP removed . Was also on levo/vasopressin, weaned to off .\n had 3 episodes of VT requiring cardioversion--? Related to\n reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. Disimpacted . On lactulose qhs. Has had Hct drop, received\n a total of 3 units PRBC, ?etio, Hct now stable. Has blood streaked\n stool, ? r/t hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4,\n now 2.1. Access: R a-line and L PICC\n Successfully extubated .\n Heart failure (CHF), Diastolic, Acute\n Assessment:\n remains hypertensive\n Action:\n Lasix & Ntg gtts D/C\nd- tolerating increasing doses of lopressor &\n captopril\n Response:\n SBP 140-150\n Plan:\n Maintain SBP <140\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Fingerstick glucose 238-344 today.\n Action:\n Insulin sliding scale & evening glargine increased\n Response:\n Lower blood sugar\n Plan:\n Give increased glargine dose @ hs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Drops SpO2\ns when in bed.\n Action:\n Encouraged to C&DB-IS while awake- OOB to chair- When in bed, keep head\n > 30 degrees.\n Response:\n Better oxygenation\n Plan:\n SpO2\ns WNL\n Event: 1830, SpO2\ns in low 80\ns- lung sounds w/ rhonchi throughout-\n resp Rx given- HO called- placed in 100% NRFM- lasix 80mg IV & morphine\n 2mg IV given- NTP 1\n applied- report given to night nurse.\n" }, { "category": "Respiratory ", "chartdate": "2129-09-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414702, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / \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 Reason for continuing current ventilatory support: Sedated / Paralyzed\n" }, { "category": "Nursing", "chartdate": "2129-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414912, "text": "Pt is a 68 year old female admitted from OSH with 3VD (100% RCA, 70%\n LAD, 80% LCx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose. Has had Hct drop, received a total of 3 units\n PRBC, ?etiology, Hct now stable. Has blood streaked stool, ? r/t\n hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4, now 2.2.\n Access: R a-line and L PICC\n Constipation (Obstipation, FOS)\n Assessment:\n Stooling x2- amt /soft/trace guiac positive.\n Action:\n Lactulose po given @ 2200. resume tf @ 2200.\n Response:\n Soft stool sm amt. tolerating slow increase in tf w minimal residuals.\n Plan:\n Contin qd lactulose. Tf-pulm w fiber up @ . minimal residuals.\n Increasing by 10ml q4hrs\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas. Oral\n thrush.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning.\n Response:\n Wo deterioration of sites.\n Plan:\n Continue to wash sites and reapply kerlex fans, anti-fungal\n moisture barrier cream qd. Continue with freq positions changes.\n Careful assessment of skin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes. Appears @ times to be frightened when\n stimulated-\nwide eye look!\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR. Pt hyperextends her neck, more comfortable without a pillow\n on bed.\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 13 days with PNA and pulmonary edema\n Action:\n Abx as ordered. Vanco level (random) sent w am labs. Diuresing-lasix\n gtt & prn diuril.\n Response:\n Low grade t. abx as ordered. Responding to diuril & lasix gtt. Negative\n approx 1.5l @ 2300. improved uo w increased lasix gtt-20mg/hr.\n Plan:\n Ck cultures-reculture w spike. Abx-?vanco level/dose. Contin lasix gtt\n & prn diuril. Goal uo >150ml/hr. follow labs-k replaced for k=3.8.\n" }, { "category": "Nursing", "chartdate": "2129-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414914, "text": "Pt is a 68 year old female admitted from OSH with 3VD (100% RCA, 70%\n LAD, 80% LCx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose. Has had Hct drop, received a total of 3 units\n PRBC, ?etiology, Hct now stable. Has blood streaked stool, ? r/t\n hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4, now 2.2.\n Access: R a-line and L PICC\n Constipation (Obstipation, FOS)\n Assessment:\n Stooling x2- amt /soft/trace guiac positive.\n Action:\n Lactulose po given @ 2200. resume tf @ 2200.\n Response:\n Soft stool sm amt. tolerating slow increase in tf w minimal residuals.\n Plan:\n Contin qd lactulose. Tf-pulm w fiber up @ . minimal residuals.\n Increasing by 10ml q4hrs\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas. Oral\n thrush.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning.\n Response:\n Wo deterioration of sites.\n Plan:\n Continue to wash sites and reapply kerlex fans, anti-fungal\n moisture barrier cream qd. Continue with freq positions changes.\n Careful assessment of skin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes. Appears @ times to be frightened when\n stimulated-\nwide eye look!\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR. Pt hyperextends her neck, more comfortable without a pillow\n on bed.\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 13 days with PNA and pulmonary edema\n Action:\n Abx as ordered. Vanco level (random) sent w am labs. Diuresing-lasix\n gtt & prn diuril.\n Response:\n Low grade t. abx as ordered. Responding to diuril & lasix gtt. Negative\n approx 1.5l @ 2300. improved uo w increased lasix gtt-20mg/hr.\n Plan:\n Ck cultures-reculture w spike. Abx-?vanco level/dose. Contin lasix gtt\n & prn diuril. Goal uo >150ml/hr. follow labs-replace lytes as\n indicated.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Known diabetic. Requiring coverage w fixed dose & ss.\n Action:\n Fsbs q6hrs-covered w riss. Fixed dose w glargine @ bedtime (2200).\n Response:\n Bs running 150-200 range requiring coverage w 2u sq regular insulin.\n Plan:\n Contin q6hr fsbs w appropriate coverage. Glargine @ hs-1/2 dose if npo.\n" }, { "category": "Nursing", "chartdate": "2129-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415541, "text": "Heart failure (CHF), Diastolic, Acute\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": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414830, "text": "Constipation (Obstipation, FOS)\n Assessment:\n Pt with 2 episodes of liq stool, pink in color.\n Action:\n Team informed of liq pink stool\nnot new. Pt disimpacted of moderate\n amount of formed soft brown stool with blood streaking around it. Team\n informed, lactulose order changed to 30cc\ns qd, but not to give before\n this evening as per team. Nutren TF @ 20 cc\ns hour begun.\n Response:\n No further stool leakage.\n Plan:\n Do not advance TF, lactulose this evening and qd as needed until bowel\n movements normalize.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning.\n Discussed with unit based educator.\n Response:\n Macerated areas appear drier today and base more pink than yellow.\n Peri-anal site less pink.\n Plan:\n Continue to wash sites and reapply kerlex fans, anti-fungal\n moisture barrier cream qd. Continue with freq positions changes\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes, although less grimacing today\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 13 days with PNA and pulmonary edema\n Action:\n Attempted reducing PEEP from 10 to 5 this am, sats falling to 89-90%,\n see flow sheet for ABG. PEEP ^ to 8, sats maintaining >95%. IV lasix\n gtt titrated up to 15mg with goal of maintaining u/o >150 cc/hour. Pt\n ~1L negative since midnight, goal of 3L negative. Foley leaked, more\n fluid placed in balloon. T max 99.7, remains on unasyn and dose vanco\n by trough. Less ET secretions today. Albuterol/atrovent MDI\ns added\n Response:\n Diuresing well with improved oxygenation.\n Plan:\n Team may add diuril and attempt PS trial later this evening. Continue\n to monitor sats, lung sounds, secretions, T.\n" }, { "category": "Nursing", "chartdate": "2129-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414831, "text": "Pt is a 68 yo female adm from OSH awith 3VD (100% RCA, 70% LAD, 80%\n Lcx), s/p NSTEMI. Intubated after R/P bleed. Has remained\n intubated d/t PNA and pulmonary edema. had hypotension with ST ^\n inf\nwent for BMS to LCx. (will probably need further PCI or CABG). Had\n PA line, IABP removed . Was also on levo/vasopressin, weaned to\n off . had 3 episodes of VT requiring cardioversion--? Related\n to reglan. Receiving unasyn and vanco for + blood culture and sputum,\n WBC falling, recultured for temp spike. CT of torso \n reported to be negative for infection, blood, but intestines full of\n stool. On lactulose. Has had Hct drop, received a total of 3 units\n PRBC, ?etio, Hct now stable. Has blood streaked stool, ? r/t\n hemorrhoids. ARF, ? contrast induced, Cr as high as 3.4, now 2.2.\n Access: R a-line and L PICC\n Constipation (Obstipation, FOS)\n Assessment:\n Pt with 2 episodes of liq stool, pink in color.\n Action:\n Team informed of liq pink stool\nnot new. Pt disimpacted of moderate\n amount of formed soft brown stool with blood streaking around it. Team\n informed, lactulose order changed to 30cc\ns qd, but not to give before\n this evening as per team. Nutren TF @ 20 cc\ns hour begun.\n Response:\n No further stool leakage.\n Plan:\n Do not advance TF, lactulose this evening and qd as needed until bowel\n movements normalize.\n Impaired Skin Integrity\n Assessment:\n Macerated areas under breasts, panus and bilateral groin areas.\n Action:\n Impaired areas washed with foam cleanser, pat dry, anti-fungal moisture\n barrier applied. Fanned kerlex placed under breasts, under panus and at\n R/L groin sites to keep skin surfaces from touching. Peri-anal area\n cleansed and desitin/moisture barrier cream placed. L lower arm skin\n tear dressing in place\nsite dry but dressing in place to protect from\n wrist restraint. Multipodous boots in place. No kinair bed ordered as\n skin impairment not related to pressure points, improving with current\n treatment and difficult to obtain upright position for vent weaning.\n Discussed with unit based educator.\n Response:\n Macerated areas appear drier today and base more pink than yellow.\n Peri-anal site less pink.\n Plan:\n Continue to wash sites and reapply kerlex fans, anti-fungal\n moisture barrier cream qd. Continue with freq positions changes.\n Careful assessment of skin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing with position changes, although less grimacing today\n Action:\n Remains on fentanyl gtt and versed gtt, with boluses for grimacing or\n ^^SBP/HR\n Response:\n Good relief with 25mcg fentanyll/2mg versed boluses\n Plan:\n Premedicate for position changes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for 13 days with PNA and pulmonary edema\n Action:\n Attempted reducing PEEP from 10 to 5 this am, sats falling to 89-90%,\n see flow sheet for ABG. PEEP ^ to 8, sats maintaining >95%. IV lasix\n gtt titrated up to 15mg with goal of maintaining u/o >150 cc/hour. Pt\n ~1L negative since midnight, goal of 3L negative. Foley leaked, more\n fluid placed in balloon. T max 99.7, remains on unasyn and dose vanco\n by trough. Less ET secretions today. Albuterol/atrovent MDI\ns added\n Response:\n Diuresing well with improved oxygenation.\n Plan:\n Team may add diuril and attempt PS trial later this evening. Continue\n to monitor sats, lung sounds, secretions, T. HOB > 45 degrees.\n Ventricular tachycardia, sustained\n Assessment:\n Last episode of VT \n Action:\n Receiving amiodarone \n Response:\n No VEA, QTc 0.42\n Plan:\n Monitor VEA, follow qtc.\n .\n" }, { "category": "Nursing", "chartdate": "2129-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414146, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n" }, { "category": "Nursing", "chartdate": "2129-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414289, "text": "Ventricular tachycardia, sustained\n Assessment:\n VT rate 200-250 x 3, pulseless. Unstable BP.\n Action:\n Shocked with 200 joules x 2 then 300 joules x 1 for each episode.\n Medical team at bedside. Ambued with 100 % o2 per RT. Full lab panel\n sent. Kcl 20 meq iv given. Amiodarone 150 mg iv bolus.\n Response:\n Conversion to NSR rate 50\ns (bradycardia), to NSR 80\ns. Stable bp, sbp\n >120. Placed on AC with increased peep and fio2.\n Plan:\n Start Amiodarone gtt at 1 mg/min x 6 hours, then decrease to .5 mg/min\n per orders. Monitor for further VT. Electrolyte repletion.\n" }, { "category": "Nursing", "chartdate": "2129-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414439, "text": "68yof w/ PMH HTN, NIDDM, pleurisy, inc chol, obesity, pvd and\n peripheral neuropathy presents to OSH w/ c/ intermittent cp, sob\n and fatigue x 3 weeks. R/I for NSTEMI. Cath at osh showing 100% RCA,\n 70% LAD, 80%LCX c/b r fem art laceration and r/p bleed, req IVF, PRBC\n and pressors. \n pt w/ hct and hypotension requiring intubation\n and tx to .\n \n pt hypotensive w/ Inf STE. Pt to cath lab for BMS to LCX/\n IABP/Swan.\n CCU Course c/b sepsis,(WBC 24.7- MSSA in sputum and BC), Acinetobacter\n baumanni, LLL infiltrate, ATN w/ creat up to 3.4(), and inc LFT\n Swan and IABP dc\nd \n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

[ { "category": "Echo", "chartdate": "2100-11-10 00:00:00.000", "description": "Report", "row_id": 92830, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for emergent CABG with IABP\nStatus: Inpatient\nDate/Time: at 11:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>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. Simple atheroma in aortic arch.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild MVP. Mild\nmitral annular calcification. No MS. Physiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nSuboptimal image quality. The patient appears to be in sinus rhythm. Results\nwere personally reviewed with the MD caring for the patient. Left pleural\neffusion.\n\nConclusions:\nPRE-BYPASS No spontaneous echo contrast is seen in the body of the left\natrium. No atrial septal defect is seen by 2D or color Doppler. Regional left\nventricular wall motion is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. There are simple atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are moderately thickened. There is mild\nmitral valve prolapse. Physiologic mitral regurgitation is seen (within normal\nlimits). The intra-aortic balloon tip is about 6 cm below the distal aortic\narch. Dr. was notified in person of the results in the operating\nroom at the time of the study.\n\nPOST-BYPASS The patient is atrially paced. There is normal biventricular\nsystolic function. The thoracic aorta appears intact after decannulation. No\nother significant changes from the pre-bypass study.\n\n\n" }, { "category": "ECG", "chartdate": "2100-11-10 00:00:00.000", "description": "Report", "row_id": 236037, "text": "Sinus rhythm with modest A-V conduction delay. Prior inferior myocardial\ninfarction. Low limb lead QRS voltage is non-specific. Diffuse ST-T wave\nabnormalities are non-specific but cannot exclude myocardial ischemia. Since\nthe previous tracing of same date the rate is slower, limb lead QRS voltage is\nlower and further ST-T wave changes are present.\n\n" }, { "category": "ECG", "chartdate": "2100-11-10 00:00:00.000", "description": "Report", "row_id": 236038, "text": "Sinus rhythm. Borderline P-R interval prolongation. Inferior wall myocardial\ninfarction. ST-T wave abnormalities. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2165-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774372, "text": " 10:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man ruled in for mi, EF 25%\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MI.\n\n PORTABLE UPRIGHT CHEST: There is mild cardiomegaly. There is no evidence of\n vascular congestion, pleural effusion, or focal consolidation. The right CP\n angle is not included on this film. No PTX.\n\n IMPRESSION: No evidence of CHF.\n\n" }, { "category": "Echo", "chartdate": "2165-10-22 00:00:00.000", "description": "Report", "row_id": 62337, "text": "PATIENT/TEST INFORMATION:\nIndication: Pre-op for CABG. S/P Myocardial infarction. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 212\nBSA (m2): 2.19 m2\nBP (mm Hg): 120/60\nStatus: Inpatient\nDate/Time: at 09:02\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 mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is severe regional left\nventricular systolic dysfunction. There is no resting left ventricular outflow\ntract obstruction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - akinetic; mid anterior - akinetic;\nbasal anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal\n- hypokinetic; mid inferoseptal - hypokinetic; anterior apex - akinetic;\nseptal apex- akinetic; inferior apex - akinetic; apex - akinetic;\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 leaflets are structurally normal. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated. There is severe\nregional left ventricular systolic dysfunction with akinesis/thinning of the\nanterior septum and and anterior wall, distal inferior wall and apex. The\nremaining walls are mildly hypokinetic. The apex is mildly aneurysmal. No\ndiscrete thrombus is seen, though apical views are suboptimal. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are structurally normal. Mild\n(1+) mitral regurgitation is seen. The estimated pulmonary artery systolic\npressure is normal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Left ventricular cavity enlargement with extensive regional\ndysfunction c/w CAD (proximal LAD infarction). 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": "Nursing/other", "chartdate": "2165-10-23 00:00:00.000", "description": "Report", "row_id": 1355881, "text": " 11PM TO 7AM: CSRU SHIFT SUMMARY NOTE;\n\nNEURO; ALERT, ORIENTED, FOLLOWS COMMANDS, AND MAE'S WELL\n\nRESP; PT EXTUBATED ON PREVIOUS SHIFT. LUNGS CLEAR TO DIM THRUOUT. 02 SAT'S 95-97% ON 5LN/C. NO NOTED PRODUCTIVE COUGH. WILL ENCOURAGE PT TO USE I.S. HOSPITAL STAY.\n\nCARDIOVAS; ST 100-110 NO NOTED ECTOPY. SBP AND MAP WNL AND NOT AN ISSUE OVER NOC. PT ON NTG GTT FOR RADIAL ART. GRAPH AND RUNNING AT 0.5 MCG/KG/MIN. PT TO START IMDUR PO THIS AM. C.I. > 2.00.\n\nGI; BS NEG. ABD SOFT, NONDISTENTED, AND NONTENDER TO PALPATION. PT DID C/O MILD INTERMITTENT ABD DISCOMFORT. STATES HE HAS NOT HAD A BM SINCE SAT. ? IF GAS PAINS AND INSTRUCTED TO LET STAFF KNOW IF DISCOMFORT INCREASES. TAKING AND TOLERATING ICECHIPS AND SIPS OF H20 WITH NO C/O'S NAUSEA.\n\nGU; HOURLY URINE OP WNL BUT STARTED TO DECREASE THIS AM. WILL ADDRESS IN ROUNDS.\n\nDRESSINGS. STERNAL DSD WITH VERY SM. SEROSANQ. OLD STAIN WITH NO INCREASE AND TRANSPARENT REMAINS CDI. LT RADIAL GRAPH DRESSING WITH ACE WRAP ON RT ARM AND DISTAL FINGERS WITH GOOD CSM 02 SAT WITH GOOD WAVEFORM AND ARM ELEVATED ON PILLOW. RT LEG ACE WRAP CDI WITH RT FOOT CSM WNL AND DISTAL PULSES ALL EASILY PALPABLE BILATERALLY EXCEPT RT DP PRESENT BY DOPPLER. FEET WARM BILATERALLY.\n\nCOMFORT; DID C/O DISCOMFORT WITH DEEP BREATHING AND PT MED WITH MS04 2MG IVP X2 WITH GOOD EFFECT.\n\nPLAN; CONT TO MONITOR AND ASSESS. TRANSFER TO 2 IF REMAINS STABLE\n" }, { "category": "Nursing/other", "chartdate": "2165-10-22 00:00:00.000", "description": "Report", "row_id": 1355880, "text": "PROB: S/P REDO CABG\n\nCV: SR NO VEA NOTED, VSS. PT ON NTG DRIP AT .5MCG FOR RADIAL GRAFT. CT DRAINAGE S/S 0-100CC/HR. K AND CA REPLACED. PACER A SENSES AND CAPTURES, THRESHOLD 18. V WIRES NOT SENSING OR CAPTURING CONSISTENTLY. DRESSINGS CLEAN AND DRY. MORPHINE X1. DEMEROL FOR SHIVERING X2 WITH EFFECT.\n\nRESP: WEANING, READY TO EXTUBATE. RESP CALLED.\n\nGU: UOP ADEQUATE, CLEAR YELLOW.\n\nGI: ABSENT BOWEL SOUNDS. NGT DRAINING MINIMAL BILIOUS DRAINAGE.\n\nNEURO: MAE. NODS APPROPRIATELY. PERL.\n\nSOCIAL: WIFE IN TO VISIT, UPDATED AND GIVEN PHONE NUMBER OF UNIT.\n\nASSESSMENT: DOING WELL. NTG FOR RADIAL ARTERY GRAFT.\n\nPLAN: CONT NTG\nCONT INSULIN DRIP, MONITOR BS Q 1HR.\nRECHECK K, HCT, Ca.\n" }, { "category": "ECG", "chartdate": "2165-10-21 00:00:00.000", "description": "Report", "row_id": 123270, "text": "Sinus rhythm. Since the previous tracing the rate has decreased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2165-10-20 00:00:00.000", "description": "Report", "row_id": 123271, "text": "Sinus tachycardia. Leftward axis. Low limb lead voltage. Q waves with\nST segment elevations in leads VI-V2 - consider old anterior myocardial\ninfarction. Since the previous tracing of the rate has increased.\nClinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2165-10-19 00:00:00.000", "description": "Report", "row_id": 123272, "text": "Sinus rhythm. Since the previous tracing of the axis is more leftward.\nAnterior ST segment elevation is less marked, but now with T wave inversion in\nthe anterolateral leads. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2104-04-24 00:00:00.000", "description": "PTA VENOUS", "row_id": 755666, "text": " 8:25 AM\n UK CATH CHECK Clip # \n Reason: SVC SYNDROME\n Contrast: OPTIRAY Amt: 85\n ********************************* CPT Codes ********************************\n * PTA VENOUS PTA VENOUS *\n * F/U STATUS INFUSION/EMBO *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82 year old female who was found to have SVC syndrome. She had an\n angiogram performed yesterday with overnight TPA infusion. The patient is\n here for followup examination and removal of the catheter.\n\n RADIOLOGISTS PERFORMING PROCEDURE:\n Dr. , Dr. and Dr. .\n\n Dr. (staff radiologist) was present and supervised the entire\n procedure.\n\n PROCEDURE/TECHNIQUE:\n After obtaining informed consent (yesterday) the patient was placed supine on\n the fluoroscopy table.\n\n An angiogram was performed through the 5 french sheath. This was followed by\n passing a glidewire to the IVC. The 5 french sheeth was exchanged for a 7\n french 11 cm sheeth. The 0.035 glidewire was exchanged for a 0.035 \n over a catheter. A 12 mm, 4 cm PTA powerflex catheter was advanced over the\n to the level of the SVC/right atrial junction and using an inflation\n device the balloon was inflated slowly to 8 atmospheres of pressure. A\n followup angiogram was performed with decreased opacification of the azygos\n system. The guidwire was removed since there was also a filling defect at the\n entry site of the subclavian line - which may be a piece of fibrin sheath. A\n repeat angiogram showed further improvement at this site but still residual\n minor filling defect.\n\n CONTRAST AND MEDICATIONS: A total of 40 cc of contrast were administered for\n the angiogram.\n\n Nonionic contrast indication were patient's debility.\n\n Patient was given 100 mcg of fentanyl.\n\n FINDINGS:\n On the initial angiogram of the central circulation, there is decreased\n (minimal residual) stenosed area of narrowing in the region of the subclavian\n (slightly before the jugular vein drainage). There is also a persistent\n narrowing at the level of the SVC (and right atrium). Therefore the 5 french\n sheath was removed and a 7 french sheath was placed over a guidewire through\n the right brachial vein. Angioplasty using the 12 mm balloon was performed\n over the area of narrowing in the distal SVC. This improved the area of\n narrowing. There is residual opacification of the azygos system and some\n narrowing, likely related to partial obstruction of the portocath. . There is\n (Over)\n\n 8:25 AM\n UK CATH CHECK Clip # \n Reason: SVC SYNDROME\n Contrast: OPTIRAY Amt: 85\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n also residual narrowing at the level of the subclavian vein and jugular vein\n drainage which again may represent a fibrin rsidue/ intimal hyperplasia at the\n catheters entry site. This is expected to improve upon catheter removal.\n\n COMPLICATIONS:\n No immediate complications.\n\n IMPRESSION:\n Successful angioplasty of the narrowing of the distal SVC to 12 mm. There is\n residual mild narrowing of the subclavian at the portocath entry site and as\n well as the distal SVC probably related to the Port-A-Cath which suggests that\n catheter removal will help the flow dynamics.\n\n The patient has been placed on heparin overnight through the sheath.\n\n The patient will have a followup evaluation tomorrow morning.\n\n The findings of the procedure were discussed with the patient through an\n interpreter.\n\n" }, { "category": "Radiology", "chartdate": "2104-04-22 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 755562, "text": " 4:31 PM\n CT CHEST W/CONT+RECONSTRUCTION; CT 100CC NON IONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: please evaluate for pulmonary embolus\n Field of view: 32 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with h/o colon CA and lymphoma presents with SVC syndrome\n from SVC/subclavian thrombus and chest pain.\n REASON FOR THIS EXAMINATION:\n please evaluate for pulmonary embolus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Patient with known SVC syndrome from subclavian thrombus presents with chest\n pain. Evaluate for pulmonary embolus.\n\n TECHNIQUE:\n Postcontrast images were obtained through the lungs after the administration\n of 100 cc Optiray nonionic IV contrast. Optiray was used given the rapid rate\n of bolus required for the CT angiogram protocol.\n\n Multiplanar reconstructions were then computed.\n\n CT was compared with study from and next CT from the prior\n day.\n\n CT CHEST AFTER IV CONTRAST:\n Multiple collateral vessels are seen within the mediastinum. A clot is again\n seen along the right subclavian catheter, extending into the SVC. No pulmonary\n embolus is seen. The airways are open to at least the subsegmental levels.\n There is interval development of a small left-sided pleural effusion tracking\n into the fissure and some atelectasis in the left lung base. Septal lines are\n seen in the periphery. Ground glass opacities seen throughout the bases. The\n pulmonary nodule seen at the right lung base is unchanged in appearance. Bone\n windows show no suspicious lytic or blastic lesions.\n\n Multiplanar reformats confirm the above findings.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolus.\n 2. Parenchymal findings indicative of fluid overload.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2104-04-21 00:00:00.000", "description": "CT 150CC NONIONIC CONTRAST", "row_id": 755490, "text": " 7:28 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 150CC NONIONIC CONTRAST Clip # \n Reason: This 82 yo woman presents with facial/neck swelling and is s\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with h/o colon CA and lymphoma as above, page with\n result.\n REASON FOR THIS EXAMINATION:\n This 82 yo woman presents with facial/neck swelling and is s/p adenoCA and\n lymphoma with R portacath. Please r/o SVC syndrome or major vessel thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Facial and neck swelling in a patient with a right-sided port-a-\n cath and history of adenocarcinoma and lymphoma.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n skull base to the level of the pulmonary artery trunk after the administration\n of 150 cc of Optiray.\n\n CT NECK AND UPPER CHEST WITH CONTRAST: A port-a-cath is noted entering via\n right subclavian line with the tip in the lower SVC. There is thrombus noted\n around the catheter extending from the right subclavian vein into the superior\n vena cava. The azygos vein is prominent and the collateral vessels extending\n along the arch of the aorta consistent with collateralized flow. The lung\n windows reveal clear lungs. There is no evidence of enlarged or cervical\n lymph nodes. No abnormal masses are seen in this study.\n\n IMPRESSION: Thrombus is noted in the right subclavian vein extending into the\n superior vena cava along the course of the right-sided port-a-cath. These\n results were discussed with Dr. covering for the referring\n physician, . .\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2104-04-21 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 755499, "text": " 11:51 PM\n CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: 83 yo with R arm/L leg weakness (? new) and SVC syndrome-pls\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SVC syndorme and hx of colon ca and lymphoma histoyr\n REASON FOR THIS EXAMINATION:\n 83 yo with R arm/L leg weakness (? new) and SVC syndrome-pls eval for head mets\n prior to heparinization.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD, \n\n INDICATION: SVC syndrome, history of colon cancer and lymphoma.\n\n TECHNIQUE: Axial imaging was performed from the skull base through vertex both\n prior to and following the administration of IV contrast.\n\n FINDINGS: There is no intracranial hemorrhage or shift of normally midline\n structures. There is a 3.3 x 1.9 cm calcified dural based mass along the falx\n in the right occipital region. No additional mass lesions or areas of\n pathologic contrast enhancement are identified to suggest metastases. The\n ventricles and sulci are age appropriate. There is no evidence of major or\n minor vascular territorial infarction. Bone windows reveal no skull fracture\n or other significant abnormality. The visualized portions of orbits and\n paranasal sinuses are unremarkable.\n\n IMPRESSION: Calcified right occipital parafalcine meningioma. No evidence of\n metastatic disease.\n\n" }, { "category": "Radiology", "chartdate": "2104-04-23 00:00:00.000", "description": "EXTREM UNILAT VENOGRAPHY", "row_id": 755580, "text": " 8:23 AM\n BILAT SUBCLAV Clip # \n Reason: please perform tpa injection, potential stential on right \n Contrast: OPTIRAY Amt: 95CC\n ********************************* CPT Codes ********************************\n * INJ-/PAC/HICKMAN INCL INTR EXTREM UNILAT VENOGRAPHY *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with large cell lymphoma and cecal carcinoma presents with\n svc syndrome from thrombus in right subclavian/svc.\n REASON FOR THIS EXAMINATION:\n please perform tpa injection, potential stential on right subclavian/svc\n ______________________________________________________________________________\n FINAL REPORT\n This procedure was previously dictated, but the dictation was not typed, and\n appears to be erased from the dictation data base. Therefore, I am dictating\n this procedure for the second time, based on the obtained images and the data\n in our computer data base.\n\n CLINICAL HISTORY: Suspect thrombus/stenosis in right subclavian vein/SVC.\n\n PROCEDURE: Right upper extremity venogram was performed with additional\n subtracted images obtained over the right shoulder and right hemithorax. A\n total of 95 ml Optiray 60% was used during this study. The obtained\n angiographic images show good caliber axillary vein and right subclavian vein\n to the level of the Port-A-Cath entry site, where the subclavian vein has a\n mild to moderate degree of liminal narrowing. The SVC appears normal in\n caliber without obvious filling defects. My recommendation is to remove the\n Port-A-Cath and then reassess the degree of subclavian vein stenosis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2104-04-25 00:00:00.000", "description": "INJ-VENO/PAC/HICKMAN INCL INTRO OF CATH", "row_id": 755787, "text": " 2:11 PM\n PORT CHECK/REPO Clip # \n Reason: PORT A CATH REMOVAL\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * REMOVAL IMPLANT INJ-/PAC/HICKMAN INCL INTR *\n * -51 MULTI-PROCEDURE SAME DAY SVC GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Port-A-cath removal.\n\n PORT CHECK: The patient is well known to us with SVC syndrome and a right\n sided port-A-cath with surround clot.\n\n RADIOLOGIST: Dr. , Dr. and Dr. \n\n Dr. (staff Radiologist) was present to supervise the entire\n procedure.\n\n PROCEDURE/TECHNIQUE: After obtaining informed consent (through a translator\n and son). The patient was placed supine on the fluoroscopy table and the\n right chest was prepped and draped in the usual sterile fashion. After\n localizing the port, a 2 cm incision was made and using meticulous care, the\n port was removed. The site was held until adequate hemostasis was achieved.\n The incision was sutured using vicral subcutaneously.\n\n The patient has a 7 French sheath within the right arm, that was used to\n perform a post procedural angiogram.\n\n Fluorosocopy unit was used to localize the port.\n\n Judicious use of Lidocaine was used.\n\n The right brachial sheath was then removed and compression was applied over\n the site until hemostasis achieved.\n\n CONTRAST/MEDICATION: At total of 30 cc of contrast was administered for the\n post procedural venogram.\n\n 1 mg of Versed and 15 mcg of Fentanyl were given.\n\n FINDINGS: After achieving adequate anesthesia in the local region, a\n successful removal of the dual port was performed. Adequate hemostasis was\n achieved.\n\n The venogram showed opacification of the subclavian vein and superior vena\n cava. There is is residual mild narrowing at the level of the catheter entry\n site probably representing areas of thrombus and/or fibrosis. No\n opacification of the azygous system was identified.\n\n COMPLICATIONS: No immediate complication.\n\n (Over)\n\n 2:11 PM\n PORT CHECK/REPO Clip # \n Reason: PORT A CATH REMOVAL\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful removal of the dual port indwelling catheter.\n\n The 7 French right arm sheath was also removed. The angiogram performed of\n the right subclavian vein and superior vena cava demonstrate a mild narrowing\n in the region of the catheter entry, that is slightly decreased and may\n represent residual thrombus and/or fibrosis.\n\n The findings were discussed with the house staff as well as treatment options\n including the need for anticoagulation.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-04-24 00:00:00.000", "description": "Report", "row_id": 1474949, "text": " 4 ICU nursing progress note:\n Neuro: Remains alert/oriented..TPA @.2mgm/hr...bleeding noted thru upper arm dsg..small amt..IR notified..\nPt returned to IR..angioplasty done to clot..TPA dc'd..Heparin had been restarted this am..now increased to 500u/hr..Catheter remains in place till am..\nPulses good..no further bleeding noted..Following coags..\nTo return to IR in am for arm catheter removal..\n\n" }, { "category": "Nursing/other", "chartdate": "2104-04-25 00:00:00.000", "description": "Report", "row_id": 1474950, "text": "MICU NPN:\nNEURO: Alert and oriented with no neuro deficits noted. Follows commands and MAE. C/o R arm pain and given percocet with good relief. Ativan po prn for nausea r/t percocet. One episode of itching noted during night over UEs and chest but no visible rash or hives noted. Cream applied and no further itching noted.\n\nCV: HR 60s-80s SB/SR with occasional PACs. BP stable with slight hypotension noted while sleeping- easily arousable. Heparin shut off at 6am as ordered with last PTT at 3am =50.0. Hct 32.5. No CP or SOB. Both IVs intact with no bleeding noted.\n\nRESP: 2L O2 NC with O2 Sat > 92%. Lungs CTA. No cough.\n\nGI/GU: Abd. soft with bowel sounds present. One small liquidy BM- brown and unable to guiac due to mixed with urine. Using bedpan and voiding clear yellow urine in adequate amts.\n\nSKIN: R arm site with dsg intact and no bleeding noted. Plan to go back to IR this am.\n" }, { "category": "Nursing/other", "chartdate": "2104-04-25 00:00:00.000", "description": "Report", "row_id": 1474951, "text": " 4 ICU nursing progress note:\n Neuro: Pt remains alert/orientated..able to make needs known..back to IR x2..eventual removal of TPA line and old porta-cath..Heparin remains off..??to be restarted in am..\n Cardiac: Pt c/o chest discomfort late this am..got worse with inspiration..EKG..no change..Ho aware..Felt pleuritic.\n Pain: c/o r arm..chest (post porta cath removal) pain.. given percocett upon return from IR. Right arm swollon..skin tear from tape..Lotion applied..\n GI: Has been NPO since last eve...IVF 75hr...now able to take po...no stool today...\nPt is ready for transfer to floor when bed available..family aware.\n" }, { "category": "Nursing/other", "chartdate": "2104-04-26 00:00:00.000", "description": "Report", "row_id": 1474952, "text": "MICU-NPN\n\nNEURO: Pt. A&O, non-english (farsi) speaking except for a few words, able to make needs known.\nCV: afebrile, HR 64-81 NSR with occasional PVC's noted, BP 83-126/28-61, hypotensive at times while asleep, easily arousable. Am PTT to be drawn and Heparin to be restarted @6am per protocol.\nRESP: LS clear, SAO2 92-99% RA, no SOB, c/o pleuritic CP with inspiration, MD aware and in to assess pt.\nGI: abdomen soft and non-distended, BS present, no stool this shift, pt. has a kosher diet and grandsons will bring in meal for pt, takes po liquids. IVF @ 75cc/hr.\nGU: pt. voiding adequate amt's of clear, yellow urine.\nSKIN: Right arm ecchymotic, bandaid with old staining, no new drainage noted. skin tear right forearm, tegaderm applied. Left forearm IV - will need new one today as it will be 3 days old.\nPAIN: pt. c/o headache at times, MD aware and in to assess pt, no neuro changes, percocet with good relief.\n" }, { "category": "Nursing/other", "chartdate": "2104-04-26 00:00:00.000", "description": "Report", "row_id": 1474953, "text": "MICU-addendum\n\nam PTT 28.7, bolused with 2000U Heparin and started Heparin gtt @ 500 Units/hr as per protocol. Due for PTT @ 12pm.\n" }, { "category": "Nursing/other", "chartdate": "2104-04-23 00:00:00.000", "description": "Report", "row_id": 1474947, "text": "MICU/SICU nursing acceptance\n82 yo F with PMH: NHL, cecal adeonca, hemicolectomy , admitted on c/o neck swelling. A contrast nect CT revealed a subclavian thrombus extendidng into the SVC. Pt sent to IR for investigation of thrombus and possible intervention. A 5 Fr sheath with infusion catheter was placed in the cephalic vein to the thrombus and a bolus of 2mg tPa was infused, then an infusion of tPa was initiated at 1mg/hr. Pt admitted to MICU/SICU overnight for monitoring.\n\nROS:\n\nNeuro: pt is A&Ox3 per translator, pt speaks Farsi only, MAEW, denies pain\n\nResp: SpO2 99% on 2L NP, LS- rales at bases.\n\nCV: no active issues, please see CareVUe for details\n\nSkin: mostly intact, right arm puncture site dsg c/d/i\n\nGI/GU: abd obese, soft, NT/ND, faint BS present, DTV\n\nLines: # 20 angio in left forearm, introducer and infusion catheter in left cephalic vein beneath dsg\n\nA:\n\nhigh risk for injury r/t risk for bleeding, thromboembolism\n\nP:\n\ncontinue to monitor as per plan, infuse tPa as ordered, heparin as ordered, plan to return to IR in am for follow up\n" }, { "category": "Nursing/other", "chartdate": "2104-04-24 00:00:00.000", "description": "Report", "row_id": 1474948, "text": "MICU NPN:\nNEURO: Pt. is alert and oriented- verified with family over phone. Speaks little english but able to use communication cards at bedside and translation over phone with grandson. MAE. Complaining of H/A around 1130pm- IR fellow informed and percocet 1tab given with good effect. To watch for changes in neuro status since on TPA and with meningioma. No neuro deficits noted and continue to monitor.\n\nCV: Afebrile. HR 60s-80s SR with occasional PAC. BP stable with MAPs >60. TPA infusing at 0.2mg/hr or 6cc/hr. TPA turned down at from 0.5mg/hr. Heparin d/c'd at 1900 per IR's orders. No signs or symptoms of bleeding noted. Skin warm and dry and palpable pulses distally x4. R arm up on pillow and pt. states it has been sore. R arm appears same size and no further swelling noted- elevated on 2 pillows.\n\nRESP: O2 2L NC with O2Sat > 94%. Lungs clear and diminished both bases. No c/o SOB. RR 12-20.\n\nGI: Abd soft with bowel sounds present. No BM. Sipping on water and no nausea or vommitting. Swallows without difficulty.\n\nGU: Using bedpan with assist. Voiding clear yellow urine.\n\nSKIN: Eccymotic areas to BUEs from blood draws, otherwise no skin breakdown noted. Dsg to R arm intact with catheter in place. Iv to L arm with slight reddness but no swelling or bleeding- flushes easily and good blood return.\n\nSOCIAL: Grandson's phone number on board in rm and states it is okay to call anytime for translation. Plan to take pt to IR again this am.\n" } ]

[ { "category": "Radiology", "chartdate": "2109-09-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1158227, "text": " 9:28 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bypass grafting, evaluate for effusion.\n\n COMPARISON: Prior radiographs dating back to .\n\n FINDINGS: Midline sternotomy wires are satisfactory in position. Left lower\n lobe atelectasis is stable since but has progressed since .\n Blunting of the both costodiaphragmatic angle are stable, indicating a small\n effusions. New right lower lobe heterogenous opacity is consistent with\n either acute right lower lobe pneumonia or atelectasis. The cardiac size is\n normal.\n\n IMPRESSION:\n 1. Acute right lower lobe density could represent either atelectasis or\n pneumonia.\n 2. Small bilateral pleural effusion since .\n 3. Persistent left lower lobe atelectasis since .\n\n" }, { "category": "Radiology", "chartdate": "2109-09-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1157784, "text": " 2:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY. Page Court\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CABG\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY. Page with issues.\n Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old man status post CABG.\n\n COMPARISON: .\n\n SINGLE SUPINE VIEW OF THE CHEST AT 1435 HOURS: The endotracheal tube\n terminates above the thoracic inlet, approximately 8 cm from the carina. An\n enteric tube extends into the stomach, with the side port above the GE\n junction. A right internal jugular catheter approach Swan-Ganz catheter\n terminates at the pulmonary outflow tract. Mediastinal drains and a left\n chest tube are in place. Sternal closure wires and mediastinal clips are\n present.\n\n Lungs are clear without consolidation or pleural effusion. There is no\n pneumothorax. The heart size is normal. There is no hilar or mediastinal\n enlargement. Pulmonary vascularity is normal.\n\n IMPRESSION: Appropriate postoperative appearance following CABG.\n Endotracheal tube terminates above the thoracic inlet, approximately 8 cm from\n the carina.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1158070, "text": " 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p ct pull\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chest tube removal, comparison for interval change.\n\n FINDINGS: As compared to the previous radiograph, all monitoring and support\n devices, including the left-sided chest tube, have been removed. There is no\n evidence of larger left pneumothorax. Small bilateral basal areas of\n atelectasis. Borderline size of the cardiac silhouette without pulmonary\n edema. Otherwise, no newly appeared focal parenchymal opacities, notably none\n suggesting recent pulmonary infection.\n\n\n" }, { "category": "Echo", "chartdate": "2109-09-24 00:00:00.000", "description": "Report", "row_id": 63749, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 11:03\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast is seen in the LAA.\nGood (>20 cm/s) LAA ejection velocity. No thrombus 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: Normal LV wall thickness. Normal LV cavity size. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. No AR.\n\nMITRAL VALVE: 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\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 patient received antibiotic\nprophylaxis. The TEE probe was passed with assistance from the anesthesioology\nstaff using a laryngoscope. No TEE related complications. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-CPB: 1. The left atrium is normal in size. No spontaneous echo contrast is\nseen in the left atrial appendage. No thrombus is seen in the left atrial\nappendage.\n2. No atrial septal defect is seen by 2D or color Doppler.\n3. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is mildly depressed\n(LVEF= 50 %).\n4. Right ventricular chamber size and free wall motion are normal.\n5. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n6. There are three aortic valve leaflets. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen.\n7. Mild (1+) mitral regurgitation is seen. Mild posterior MAC is seen.\nDr. was notified in person of the results.\n\nPOST-CPB: On infusion of phenylephrine, a-pacing. Preserved biventricular\nsystolic function. Mitral regurgitation remains 1+. Aortic contour normal post\ndecannulation.\n\n\n" }, { "category": "ECG", "chartdate": "2109-09-24 00:00:00.000", "description": "Report", "row_id": 125011, "text": "Sinus rhythm. Non-diagnostic inferior Q waves and T wave abnormalities. Since\nthe previous tracing of probably no significant change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2165-07-24 00:00:00.000", "description": "Report", "row_id": 1543415, "text": "pmicu nursing progress 7a-3p\nreview of systems\nCV-vs have been stable with hr in the 70's-80 and bp 100-110/.no c/o dizziness with standing up.\nGI-abd is soft with positive bowel sounds.has been npo for bronch.c/o hunger.on po zantac.no stool\nID-afebrile.no antibx.\nNEURO-a+o x 3. cooperative and pleasant.can stand and walk.up to chair.currently receiving ativan and fentanyl for bronch.\nF/E-receiving maintainence ivf.has been voiding in sufficient quantities.urine is clear yellow.has been npo.\nRESP-has been off o2 all day with sats >95%.lungs a bit coarse at bases.this am ~10 am began to have hemoptysis again-several dime sized spots of bright red blood-no coughing or vomitting- pt just cleared his throat and brought up blood.no chest/pleuritic pain with this.no change in vs.went for a chest CT which was preliminary negative.is currently having a bronch done to help locate source of bleeding.\na-stable but recurring hemoptysis\np-will monitor during bronch and then recover from conscious sedation.\nassess for further hemoptysis.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-24 00:00:00.000", "description": "Report", "row_id": 1543416, "text": "pmicu nursing progress addendum\nHEME-hct this am=39.6, with ptt 40.3.has expelled ~30 ccs bright red blood. no changes in vs. would check another hct tonight.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-24 00:00:00.000", "description": "Report", "row_id": 1543417, "text": "Resp Care Note\nAssisted Pulmonary today with bronchoscopy via oral airway. Pt given 2% nebulized Lidocaine prior to procedure. Pt tolerated procedure well, results in pt chart.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-24 00:00:00.000", "description": "Report", "row_id": 1543418, "text": "NPN 3PM-7PM:\nPt is alert and oriented times three. MAE. Tem minutes after the bronch he wanted to get up to sit in a chair and remained there most of the shift. He is sleeping on/off while sitting in the chair. Pt is afebrile. VSS Coughs small amts dark blood at times and lungs have some ins/exp wheezes noted. I recommended pt take his albuterol which helped. Following the bronch and with the activity of getting into the chair he dropped his O2 sat to 89% off the O2. I had him put the O2 back on and by 7PM his O2 sat is up to 97% sitting at rest. He has now taken the O2 off again and his sat is 94%. He is taking clear liquid diet as ordered and started on levofloxacin for possible bronchial infection. Will need to be watched closely overnight for further bleeding. If he bleeds a significant amt the plan is for him to go to angio.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-25 00:00:00.000", "description": "Report", "row_id": 1543419, "text": "pmicu npn 7p-7a\n\npt had an uneventful noc.\n\nreview of symtoms\n\nrespiratory-> lung exam notable for expiratory wheezing despite mdi use although pt denies c/o sob. sat range 91-95% on room air. he had no further episodes of hemoptysis overnoc and a repeat hct last evening was ~40.\n\ncardiac-> hr 90's, nsr w/frequent vea overnoc; will repeat lytes this morning. he has been hemodynamically stable.\n\nneuro-> a&o x3; slept undisturbed for most of the noc.\n\ngi-> tolerating clear liqs but states he is hungry. he continues to receive maintainence fluids. ?advancing diet this morning.\n\ngu-> voiding via urinal w/o incident.\n\ndispo-> anticipate tx to medicine later today if his status remains unchanged. teansfer note is located at the front of the pt's blue chart.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-07-24 00:00:00.000", "description": "Report", "row_id": 1543414, "text": "pmicu nsg admission note\n\n briefly, the pt is a 61yow man with a h/o bronchitis who developed hemoptysis 3 days pta. he did see his pcp who made arrangements for him to have a chest ct later this month since the hemoptysis seemed to have stopped. last noc, however, he began coughing up a moderate amt of blood just before going to bed. he subsequently drove himself to ew. he again had stopped bleeding once he arrived at the hospital. he was transferred to the ~2:00am for a further w/u to possibly include a bronch.\n\npmh: colon ca s/p colectomy; copd w/recent bronchitis flare; skin ca of the nose; right shoulder dislocation; left knee surgery; 50pk pk year of tobacco use (quit last year but states that he still cheats occationally).\n\nnkda\n\nreview of systems\n\nrespiratory-> lung exam notable for exp wheezing t/o although pt denies c/o sob. he arrived on 2l supplemental o2 w/sats ~95%. he has not had any further episodes of hemoptysis tonoc. anticipate further w/u.\n\ncardiac-> hr 70's, nsr w/o ectopy. sbp 120-130's. no c/o chest pain.\n\nneuro-> a&o x3; he is independent at baseline and fully able to make decisions re: his care.\n\ngi-> abd is soft, nontender w/+bs. no c/o abd pain or n/v/d. he has been npo since last noc.\n\ngu-> voiding via a urinal at bedside.\n\nid-> pt is afebrile.\n\naccess-> (2) #18g angios were placed in either arm at and are working well.\n\nsocial-> pt is divorced and has a son who lives in . the pt is debating about whether or not to call his son to notify him of his admission to the hospital.\n" }, { "category": "ECG", "chartdate": "2165-07-24 00:00:00.000", "description": "Report", "row_id": 155855, "text": "Sinus rhythm with frequent ventricular ectopy. Otherwise, normal tracing. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-24 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 740657, "text": " 12:16 PM\n CT CHEST W/CONTRAST Clip # \n Reason: hemoptysis, ? tumour, ? active bleed\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with COPD/chronic bronchitis, colon cancer w/ intermittent\n hemoptysis over past week, now presenting w/ ~150cc hemoptysis without other\n symptoms.\n REASON FOR THIS EXAMINATION:\n hemoptysis, ? tumour, ? active bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Colon CA, hemoptysis.\n\n TECHNIQUE: Helically acquired CT images of the lung apex to the lung bases\n with contrast.\n\n CONTRAST: 100 cc of Optiray secondary to shortness of breath and bronchitis.\n\n\n CT CHEST WITH CONTRAST: No prior examination is available for comparison.\n\n Soft tissue windows demonstrate normal sized heart. No pericardial effusion\n is seen. There are shotty mediastinal nodes predominantly seen in the\n precarinal region but none are pathologically enlarged and are less than 7 mm\n in short axis dimension. (These can be seen in series 3A, image 44). No\n hilar or axillary adenopathy is seen. There is however a non pathologically\n enlarged pericardial node measuring 7.4 mm. Also adjacent to the IVC, there\n is a 9 mm node seen in image 122. No pleural effusions are present.\n\n LUNG WINDOWS: Lung windows demonstrate diffuse moderate paraseptal emphysema\n predominantly at the lung apices. No pulmonary nodules are identified. There\n is minimal scarring at both bases. The airway is patent to the level of the\n segmental bronchi bilaterally with no endobronchial lesions identified.\n However there is apparent thickening of the peripheral bronchi predominantly\n seen at the bases raising the question of chronic inflammation like chronic\n bronchitis.\n\n The visualized abdomen which includes to the level of the upper renal poles\n demonstrates a normal appearing liver dome with a too small to characterize\n low attenuation area in the posterior segment of the right lobe likely\n representing a cyst. The upper left renal pole demonstrates a 2.5 cm simple\n cyst otherwise the upper renal poles are unremarkable. The pancreas and\n spleen appear normal.\n\n BONE WINDOWS: Bone windows demonstrate no suspicious lytic or blastic\n lesions.\n\n IMPRESSION: 1) Paraseptal emphysema predominantly at the apices. No lung\n nodules are identified.\n\n 2) Incidental left renal cyst.\n (Over)\n\n 12:16 PM\n CT CHEST W/CONTRAST Clip # \n Reason: hemoptysis, ? tumour, ? active bleed\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3) Probable small liver cyst but too small to characterize.\n\n 4) Multiple non pathologically enlarged nodes as described above.\n\n 5) Thickened peripheral bronchi predominantly in the bases which raises the\n question of chronic inflammation like chronic bronchitis.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2185-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1148220, "text": " 8:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: decreased breath sounds left lower lung\n Admitting Diagnosis: CARDIAC TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 y/o female with PMHx CAD who presents from hospital with concern of\n pericardial effusion/tamponade.\n REASON FOR THIS EXAMINATION:\n decreased breath sounds left lower lung\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible pericardial effusion or tamponade with decreased breath\n sounds in left lung.\n\n FINDINGS: No previous images. There is enlargement of the cardiac silhouette\n in a patient with a dual-channel pacemaker device. Pulmonary vascularity is\n within normal limits and the discordancy could be a reflection of pericardial\n effusion.\n\n There is increased opacification with air bronchograms in the retrocardiac\n region with the obliteration of the left hemidiaphragm. This appearance could\n reflect any combination of volume loss, pleural effusion, and superimposed\n pneumonia. If clinically warranted, CT would differentiate among these\n possibilities.\n\n\n" }, { "category": "Echo", "chartdate": "2185-08-01 00:00:00.000", "description": "Report", "row_id": 89977, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Pericarditis. Tamponade.\nHeight: (in) 63\nWeight (lb): 126\nBSA (m2): 1.59 m2\nBP (mm Hg): 104/63\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 21:52\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\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: Mildly thickened tricuspid valve leaflets.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: Large pericardial effusion. RV diastolic collapse, c/w impaired\nfillling/tamponade physiology.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Emergency\nstudy performed by the cardiology fellow on call. Echocardiographic results\nwere reviewed by telephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal.\nOverall left ventricular systolic function appears preserved. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is a large sized pericardial effusion.\nThere is right ventricular diastolic collapse, consistent with impaired\nfillling/tamponade physiology.\n\n\n" }, { "category": "ECG", "chartdate": "2185-08-01 00:00:00.000", "description": "Report", "row_id": 236846, "text": "Sinus rhythm and occasional atrial ectopy. Left bundle-branch block. Low\nlimb lead voltage. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2116-07-15 00:00:00.000", "description": "Report", "row_id": 154598, "text": "Sinus rhythm, rate 63\nFirst degree AV block\nIndeterminate QRS axis\nRight bundle branch block\nNonspecific lateral T waves abnormalities\nAbnormal ECG\n\n" }, { "category": "Nursing/other", "chartdate": "2116-07-15 00:00:00.000", "description": "Report", "row_id": 1467675, "text": "s/p cabg x 3\no: arrived on 50 mcq of propofol + .5mcq of neo sbp 150's therefore neo off, propofol increased to 60 mcq. sbp labile iv ntg /neo. recieved 2.5 l lr ci 1.9 to 2.02. 2230 ci 1.95 therefore recieved 500 ml hespan. sb to sr cuplet noted x 1. kcl replaced x2. dopa @ 3 mcq , however even with ntg increase to 5 mcq sbp 140-150's , ntg dc'd after nipride started @ .5mcq. labile sbp persists ho aware. ct drainage 20-40ml/hr. dsgs d+i. jp drained 35 ml. extubated @ 2100 without incident . continues on 60% face mask. coughing without raising db well. easily , , perl, denies pain , since toradol given.denies nausea. uo decreasing as shift progressed. daughters into visit and updated. sliding scale insulin x 2.\na: sbp continues labile. sr 60's , pacer vv1 @ 50.\nP: monitor comfort,, hr and rythym, sbp, ct drainage, i+o, uo, hct, k, glucose, resp status, is, as per orders.\n" }, { "category": "Nursing/other", "chartdate": "2116-07-16 00:00:00.000", "description": "Report", "row_id": 1467676, "text": "shift summary\n\n NEURO-AAO X3, MAE'S WELL. ASSISTING WITH ALL ACTIVITY. MEDICATED WITH TORODAL IV AND MSO4 SQ FOR ADEQUATE PAIN RELIEF. PATIENT PLEASANT, MOSTLY SLEEPING.\n\n RESP- EXTUBATED WITHOUT DIFFICULTY TO FACE TENT @ 60% WEANED TO 4L NC WITHOUT PROBLEMS. ABLE TO TAKE GOOD DEEP BREATHS WITH MOIST COUGH AT TIMES, LUNGS COARSE AND DIMINISHED.\n\n CV- RHYTHM RSR/SB, WITH RARE EPISODE OF BRADYCARDIA IN 40'S, V-WIRES SET FOR 50. A-WIRES ATTACHED BUT NOT WORKING, MD'S AWARE. WT STABLE. IVF GIVEN FOR HEMODYNAMIC IMPROVEMENTS. NIPRIDE GTT TITRATED FOR LABIAL SBP. SEE CAREVIEW FOR DETAILS.\n\n GI/GU- TAKING ICE CHIPS WITHOUT N/V. OG D/C WITH EXTUBATION. U/O MARGINAL ALL NOC. 20MG IV LASIX GIVEN AT 0630.\n\n INTEG- RT ACE CDI WITH JP DRAIN, NO DRAINAGE DURING NIGHT. MIDSTERNAL DSG CDI WITH CT'S AND WIRES DSG.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-07-16 00:00:00.000", "description": "Report", "row_id": 1467677, "text": "Sinus rhythm until 1545, afib with rate 50-70's, SBP unchanged. Pt. OOB shortly after, SBP lower, nirpride stopped. Amiodarone bolus given, gtt started 1mg/min at 1700. SBP now 120's. A wires D/C'd by PA. Swan D/C'd. Trauma line in place, new PIV started left lower arm. Lasix given with marginal response. Potassium being replaced. Pt ate 50% breakfast and 50% lunch, no dinner. Pt has not wanted any pain meds up to this point. Family at bedside during day. Pt. OOB with PT. Lungs clear, diminished in bases. Pt using incentive spirometer, 250 x 10. Weak cough, no sputum. Plan: Keep in ICU, monitor rhythm, BP.\n" }, { "category": "Nursing/other", "chartdate": "2116-07-17 00:00:00.000", "description": "Report", "row_id": 1467678, "text": "SHIFT SUMMARY\n\n\n NEURO==COMPLETELY INTACT. MAE'S WELL. ASSISTING WITH ALL ACTIVITY. DENIES ANY PAIN OR DISCOMFORT. OOB TO CHAIR MOST OF EVENING SHIFT, TOL WELL.\n\n RESP==NC 2L SATS WNL. NO DISTRESS. LUNGS CLEAR. USING ISB INDEPENDENTLY. CT'S INTACT. PT HAS GOOD PRODUCTIVE COUGH.\n\n CV==INITALLY RHYTHM WAS AFIB, AMINO GTT 'D .5 AS ORDERED AT 2300. PT CONVERTED BACK TO RSR/SB THIS AM, PACER @ VVI 'D TO 50BPM. BP STABLE, NO HTN NOTED.\n\n GI/GU==TAKING PO WELL,NO N/V. + FLATUS. U/O MARGINAL ON EVENINGS, 'D <20CC/HR, DR. AWARE, NO TX AT THAT TIME. U/O REMIANS LOW.\n\n MISC==FAMILY UPDATED, QUESTIONS ANSWERED. PLAN- INC U/O, STABLIZE RHYTHM AND TRANSFER?\n" }, { "category": "Nursing/other", "chartdate": "2116-07-17 00:00:00.000", "description": "Report", "row_id": 1467679, "text": "transfer note~\n\nPleasant cooperative 82 year old s/p unevntful cabgx3 on . extubated on post op noc. HTN and atrial fib~main issues post op.\n\n nipride weaned to off~amiodarone load and drip intiated for afib.\n\n converted back into sr at 0430-0500 this am. lopressor d/c'd. captopril statred. Amiodarone changed to 400mg po bid. Hct of 25.3 treated with 1 unit of prbc per Dr , follwed by 20mg iv lasix.\n\nneuro~a+ox3, tordol dosing completed~no further c/o pain this am.\n\ncv~sb-sr without ectopy. Pacer on v demand with ventricular capture at 4~placed on ma of 6. Sensing only at present. ***awires not working since or and are grounded to abd**** Palpable dp pulses.\n\nresp~weaned to ra with sats 95-96%. Coughing and raising yellow sputum~using with encouragement. Ct d/c'd without incident.\n\ngi~hypoactive bs~tolerating po's without n/v.\n\ngu~lasix post blood with excellent diuresis.\n\nskin~l leg intact with ace wrap. r leg dsd d+i. Sternum ota with steri strips.\n\npt ambualted with assist of 2~tolerate well.\n\nplaN~TRANSFER TO 6 WHEN BED AVAILABLE.\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005614, "text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: KIDNEY STONE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with pyelonephritis, s/p fluid resus for hypotension, with\n crackles, decreased sat\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fluid treatment for hypotension, to evaluate for overhydration.\n\n FINDINGS: In comparison with study of , there are substantially lower\n lung volumes, which most likely account for the increased prominence of the\n cardiac silhouette. Prominence of interstitial markings persists as on the\n previous study. No evidence of acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-28 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1005488, "text": " 11:22 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for kidney stones, and caliber of aorta\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with acute onset right flank pain, with h/o kidney stones.\n REASON FOR THIS EXAMINATION:\n please eval for kidney stones, and caliber of aorta\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:01 PM\n New enlarged R kidney (and fat stranding) w/mod hydroureteronephorosis w/\n obstructing 5mm stone in R distal ureter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right flank pain.\n\n COMPARISON: \n\n TECHNIQUE: Multiple MDCT axial images were obtained from the base of the\n lungs through the proximal thighs without the administration of intravenous or\n oral contrast.\n\n FINDINGS: In the visualized portion of the thorax, there is new right basilar\n atelectasis. The visualized heart and great vessels appear normal.\n\n The right kidney appears edematous, and there is marked new right perirenal\n stranding with a 2.5cm renal cyst, laterally, unchanged. There is a tiny\n nonobstructing calculus and two previously seen pelvicaliceal calculi are not\n demonstrated on today's scan. There is stable right hydronephrosis but\n markedly increased hydroureter relative to prior, with some periureteral fat\n stranding, leading to a 5-mm obstructing calculus in the distal ureter. The\n left kidney, liver, pancreas, adrenals, stomach, duodenum and visualized\n abdominal loops of small and large bowel appear normal. There is a persistent\n 1.3-cm gallstone. The abdominal aorta is not aneurysmally dilated measuring\n 2.3 cm with mild calcification.\n\n In the pelvis, pelvic loops of bowel appear normal. There is no free air,\n free fluid or pelvic lymphadenopathy.\n\n OSSEOUS STRUCTURES: Persistent round calcification/ossification, in the\n epidural space, dorsal to the T11 vertebral body, likely a calcified disc\n fragment, appears to indent the ventral aspect of the cord. No suspicious\n lytic or blastic lesion is demonstrated.\n\n IMPRESSION:\n 1. Worsening right hydroureter with obstructing 5-mm right distal ureteral\n calculus, and unchanged hydronephrosis with new marked perinephric\n stranding; while the fat-stranding may simply reflect bland forniceal rupture,\n infection proximal to the obstruction, ie. pyonephrosis, is a consideration.\n 2. Stable appearance of likely calcified disc herniation or free fragment at\n the T11 level, which indents the ventral cord (there is only lumbar, but no\n dedicated thoracic spinal MR imaging on PACS).\n (Over)\n\n 11:22 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for kidney stones, and caliber of aorta\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Cholelithiasis, without evidence for cholecystitis.\n\n Findings posted to the ED dashboard and reviewed, in person, with Dr. \n (Urology service houseofficer).\n\n" }, { "category": "Nursing/other", "chartdate": "2193-03-29 00:00:00.000", "description": "Report", "row_id": 1668848, "text": "Nursing note 7a-7p:\nNursing Assessment:\n\nPt is a 65 yo admit from ED with c/o R flank pain similar to prior episodes associated with kidney stones. Pt was found to have occluding ureteral stones and to OR on the for a right stent and cystoscopy. Pt hypotensive requiring 4 liters of fluid in ED and only voided 250cc of urine. Tachycardic to 130s. Pt to pacu and then to sicu for tele monitoring and for ?urosepsis with elevated wbc, fevers, chills, tachycardia, and hypotension. Pt arrived alert and orientated from Pacu via ACL ems. o2 increased to 4 liters/min pt with hx of copd and empysema without home o2 use. Lungs coarse and diminished pt with productive cough and per pt sputum is green to yellow in color. Abdomen soft. Foley cath patent with pink=tinged urine in adequate amounts. This morning pt's blood pressure trending down and given 500cc LR bolus for 80s/-40s. resulting 70s/30s and another 500cc LR bolus and placed on neo gtt. HR down to 70s following neo gtt and boluses. Aline attempts by sicu failed and peripheral iv attempts failed as well. IV nurse able to place a second 20 gauge iv. ?need for central line for neo gtt/boluses/ cvp monitoring and lab draws. Neo gtt increasing and currently at 2.5 mcq/kg/min. MD has been notified of all. Pt continues to mentate well throughout all. Plan: central line, aline, cont to monitor bp and hr closely. HUO. Emotional suppport. PLease refer to fhp and to carevue for further details.\n" }, { "category": "Nursing/other", "chartdate": "2193-03-29 00:00:00.000", "description": "Report", "row_id": 1668849, "text": "SICU NURSING PROGRESS NOTE 0700-1900\nNEURO--GROSSLY INTACT. PT AMBULATED OUT AND AROUND UNIT AND ON INITIAL STANDING, PT C/O FEELING DIZZY. SBP AT THIS TIME 140/60. RESOLVED ON OWN.\n\nCARDIAC--NEO WEANED OFF WITH SBP 110-120'S/60'S. HR TACHY 100-110. NO OBSERVED ECTOPY. IV'S HEP LOCKED.\n\nRESP--BREATH SOUNDS IN UPPER LOBES ARE COARSE, OCCASIONALLY WHEEZY. BLL HAVE CRACKLES -> NOW DIMINISHED. WEARING O2 AT 5L NC WITH SAO2 < 95%. BECOMES WINDED EASILY. DESATS TO 86% WHEN O2 IS OFF.\n\nGI--TOLERATING HOUSE DIET WITHOUT N/V. NO STOOL. PASSING FLATUS.\n\nGU--FOLEY CATH PATENT. PT >200CC HR OF PINK TINGED URINE.\n\nENDO--BS 162, COVERED WITH 2USSRI. LAST BS 123. OTHERWISE UNREMARKABLE.\n\nSKIN--GROSSLY INTACT. AMBULATED AROUND AND OUT OF UNIT WITH ASSIST OF 1.\n\nID--REMAINS ON GENT AND AMP. PLS CHECK TROUGH LEVEL AT 2130 PRIOR TO GIVING 2200 DOSE. T MAX 99.0.\n\nPAIN--C/O R FLANK PAIN X1. GIVEN 1GM TYLENOL WITH RESOLUTION OF PAIN.\n\nCOPING--HUSBAND IN TO VISIT AND HAS BEEN UPDATED ABOUT PLANS. DAUGHTER PHONED AND WAS UPDATED BY THIS RN. SHE ALSO SPOKE WITH HER MOM.\n\nA--TOL. NEO WEANED. MINIMAL PAIN.\n\nP--CON'T TO MONITOR. PLAN TO TX TO FLOOR TOMORROW AM. SEND GENT LEVEL. OFFER SUPPORT AND PROMOTE INDEPENDANCE IN ADL'S.\n" }, { "category": "Nursing/other", "chartdate": "2193-03-30 00:00:00.000", "description": "Report", "row_id": 1668850, "text": "Nursing Progress Note\nPlease see carvue and Nursing Transfer Note for specifics:\nPt with uneventful night. Vicodin X2 for pain control with effect. Urine fruit punch colored and clear. Pt with c/o mild bladder spasm X1 relief with pain med. Pressors remain off. Pt making adequate urine and taking adequate PO fluids. HR-88-110's over noc. Sat's 90-93% when asleep. IS encourage while awake. + strong productive cough. WBC's trending down and remains on IV amp/gent. Plan: Cont with current plan of care. ? trnf to east today\n" } ]

[ { "category": "Echo", "chartdate": "2129-07-22 00:00:00.000", "description": "Report", "row_id": 97266, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 08:20\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the body of the\n LAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal;\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter. Normal descending aorta diameter. Focal\ncalcifications in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area\n1.2-1.9cm2). 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. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPREBYPASS\nThe left atrium is normal in size. No spontaneous echo contrast is seen in the\nbody of the left atrium or left atrial appendage. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nfree wall contractility is normal. The ascending aorta is borderline mildly\ndilated. The aortic valve leaflets (3) are mildly thickened. There is mild\naortic valve stenosis (valve area 1.6cm2) with peak/mean gradients of \nmmHg. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. There is no pericardial\neffusion.\n\nPOSTBYPASS\nThe patient is in sinus rhythm and is not on any infusions. Left ventricular\nfunction continues to be normal (LVEF>55%). Trace mitral regurgitation, trace\naortic regurgitation, and mild tricuspid regurgitation persist. Normal\nthoracic aorta.\n\nDr. was notified in person of the results at the time of the study.\n\n\n" }, { "category": "Echo", "chartdate": "2129-07-21 00:00:00.000", "description": "Report", "row_id": 97267, "text": "PATIENT/TEST INFORMATION:\nIndication: Unstable Angina s/p catherization with left main disease.\nHeight: (in) 67\nWeight (lb): 212\nBSA (m2): 2.07 m2\nBP (mm Hg): 183/83\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:20\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is\n0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and regional/global systolic function (LVEF>55%). Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened. There is mild aortic valve stenosis\n(valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal\nbiventricular function. Mild aortic stenosis.\n\n\n" }, { "category": "ECG", "chartdate": "2129-07-24 00:00:00.000", "description": "Report", "row_id": 286289, "text": "Sinus rhythm. ST segment elevation in leads I, II, aVL and V5-V6 consistent\nwith myocardial infarction or pericarditis. Compared to the previous tracing\nof ST segment elevations are more marked and more diffuse.\n\n" }, { "category": "ECG", "chartdate": "2129-07-22 00:00:00.000", "description": "Report", "row_id": 286290, "text": "Sinus arrhythmia. Inferior myocardial infarction, age undetermined.\nNon-specific anterolateral ST-T wave changes. Cannot exclude ischemia.\nCompared to the previous tracing of the lateral ST-T wave changes are\nnot as apparent on the current tracing, although the evolution suggests that\nthese may have been due to ischemia.\n\n" }, { "category": "ECG", "chartdate": "2129-07-21 00:00:00.000", "description": "Report", "row_id": 286291, "text": "Sinus rhythm. T wave abnormalities are non-specific but cannot exclude\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-07-20 00:00:00.000", "description": "Report", "row_id": 286292, "text": "Sinus bradycardia. T wave abnormalities are non-specific but cannot exclude\nmyocardial ischemia. Clinical correlation is suggested. No previous tracing\navailable for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1381422, "text": "PT. IS A DNR/DNI.\n\nPT. HAS ALLERGIES TO BOTH ANTIHISTAMINES, AND KEFLEX.\n\nPT. REMAINS ON CONTACT PRECAUTIONS UNTIL R/O FOR C-DIFF.\n\nPT. REMAINS A/A/O X2. OTHERWISE PT. IS PLEASANTLY CONFUSED AT BASELINE. PT. DENIES ANY PAIN OR DISCOMFORT THROUGHOUT THIS SHIFT. PT. FOLLOWS ALL COMMANDS, AND REMAINS AFEBRILE. PT. HAS CONSTANT TWITCH WHICH IS DOCUMENTED AS HIS BASELINE.\n\nPT. HAS REMAINED AFIB IN A CONTROLLED RATE RANGING 58-80'S WITH NO NOTED ECTOPY. B/P REMAINS SUPPORTED BY LEVOPHED GTT WHICH HAS BEEN WEANED DOWN SLIGHTLY THROUGHOUT THIS SHIFT FROM .145-.095. B/P HAS BEEN RANGING 90-120'S/50-60'S. CVP HAS BEEN . PT. HAS RECEIVED A TOTAL OF 1.5 LITERS OF N/S IN BOLUSES FOR DROPPING CVP, U.O. AND B/P PT. RESPONDS VERY WELL TO THESE BOLUSES. INR HAD BEEN 12.3 AT LAST EVENING, AT PRESENT IT IS 4.3. PT. REMAINS PALE, BUT ORDERS TO ONLY TRANSFUSE IF HCT IS <30, PRESENTLY 31.5.\n\nLUNGS ARE CLEAR THROUGHOUT, RESP RATE IS CONTROLLED AND O2 SATS REMAIN >95% ON 2L/MIN VIA N/S. PT. DOES EXHIBIT SLEEP APNEA, BUT NO BREATHING WHICH AS WELL HAS BEEN PREVIOUSLY DOCUMENTED.\n\nABD. REMAINS SOFT, BOWEL SOUNDS EASILY AUDIBLE AND NO STOOL THIS SHIFT. STOOL SPECIMEN TO BE COLLECTED TO R/O CDIFF. FOLEY CATHETTER REMAINS INTACT WITH SMALL AMT'S OF SEDIMENT-CLEAR YELLOW URINE NOTED. PT. AGAIN RESPONDS NICELY TO BOLUSES. BUN/CREAT REMAIN ELEVATED AND UNCHANGED FROM LAST EVENING, REFER TO CAREVUE FOR VALUES.\n\nSKIN EXHIBITS HEMATOMA AT RIGHT I.J INSERTION SITE. THIS HAS NOT WORSENED, AND REMAINS SOFT. RIGHT TLC CONTINUES TO WORK, AND FUNCTION WELL, WITH CVP MONITORED. PIV'S REMAIN INTACT AND PATENT. COCCYX/PERINEUM REMAINS SLIGHTLY RED WITH FREQUENT TURNS PERFORMED.\n\nPLAN TO WEAN LEVOPHED GTT OFF. SUPPORT AND MONITOR RENAL FUNCTION. AND MONITOR INR THROUGH BLOOD DRAWS. CONTINUE PT. ON IV ANTIBOITIC REGIME ORDERED, VANCO, FLAGYL, AND CIPROFLOXIN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-27 00:00:00.000", "description": "Report", "row_id": 1381423, "text": "Nursing Progress Note MICU 7\n0700-1900\n\nAdmx Date: \nCode: DNR/DNI\nAllergies: Antihistamines, Keflex\nAccess: Right IJ TLCL, 2 peripheral IV's\n\nNeuro: Oriented times 2. Agitated, yelling out, non-cooperative.\n\nCV: Pt. weaned off Levophed gtt today. BP very labile ranging from 90's to 130's systolic. CVP 6-12. In A-fib with a HR of 60's to 70's at beginning of shift, now HR 80's to 90's. Occassional PVC's. Received KCL 20 mEq's IV and Mag 400mg for K of 3.4 and Mag of 1.7. Hct 31.5. INR 4.3 down from 12. Was on Coumadin for A-fib.\n\nResp: LS CTA. Sating 93-94% on RA. CXR was non-impressive.\n\nID: Pt. afebrile. WBC 14.7 down from 22. On Flagyl, Vanco, and Cipro. Blood cultures pending. UA with negative leuks. Needs stool for C-Diff when goes.\n\nGI: Abdomen softly distended. positive bowel sounds. Slightly tender in lower quadrants on palpation. No stool today, but was having diarrhea for 2 weeks prior to admission. Had abdominal scan which showed possible dilation. ? toxic megacolon. If continues with no BM consider repeat KUB. need surgical consult.\n\nGU: Foley draining urine with some sediment. CR 2.4. Will continue to monitor renal status.\n\nSocial: Has supportive family. Two sons visiting today. Son is HCP.\n\nPlan: Monitor BP. Await cultures. Monitor GI status. Continue abx. PT consult.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-28 00:00:00.000", "description": "Report", "row_id": 1381424, "text": "MICU 7 RN REPORT 1900-0700\n\nNEURO: Pt is alert and oriented x2. Confused about the place and date. Slept well @ night. @ 0445 received morphine 2mg IVP for pain on the hands. Lt index finger joints redened refused for hot packs. MAE. Does'nt like turning or any sort of movements otherwise coopertive w/ care.\n\nCV: HR 70-100 A fib w/ rare to occ ectopics. SBP 90-130/60-85. RIJ TL patent CVP 3-7.\n\nRESP: LS clear dim, Sats > 93% on room air. No SOB.\n\nGI/ GU: Abd soft distended, BS hypoactive. On regular diet swallow pills whole without difficulty. No BM in this shift. Foley draining yellow sedimented urine. UO > 30cc/hr.\n\nSKIN: Dry and intact.\n\nID: T max 98.9. Abx ciproflox flagyl and vanco.\n\nSOCIAL: DNR, DNI. No family contact in this shift.\n\nPLAN: Stool for c diff when possible\n Pain management.\n Restart coumadin if INR wnl\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2189-11-26 00:00:00.000", "description": "Report", "row_id": 296430, "text": "Baseline artifact. Sinus rhythm with significant atrial ectopy. Occasional\nventricular premature beats. Left axis deviation. Right bundle-branch block.\nOld inferolateral myocardial infaction. ST-T wave abnormalities. Compared to\nthe previous tracing of there is probably no significant diagnostic\nchange and multiple abnormalities persist. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2126-01-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851977, "text": " 8:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?aspiration\n Admitting Diagnosis: DELERIUM TREMONS,ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with fevers, DT and ?aspiration\n\n REASON FOR THIS EXAMINATION:\n ?aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 39-year-old man with fever, aspiration.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with the chest radiograph dated .\n\n FINDINGS:\n\n The heart is normal in size. The mediastinal and hilar contours are within\n normal limits. Note is made of increased patchy opacities in bilateral lower\n lobes, most likely presenting aspiration versus aspiration pneumonia. No\n evidence of CHF is noted. No definite evidence of pleural effusion is noted.\n\n IMPRESSION:\n\n Increased patchy opacities in lower lobes, representing aspiration versus\n aspiration pneumonia.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2126-01-23 00:00:00.000", "description": "Report", "row_id": 1601080, "text": "See carevue for objective data.\n\nAlert and oriented-cooperative at this time. Restraints dc'd at 0900\nand pt compliant with safety measure instructed to him. Sitter also dc'd at 1500. Frequent checks on pt maintained. No seizure activity.\nBP elevated up to 150 systolic which responds to valium IV. Requiring 10 mg IV Q3H for CIWA>10(much improved from ED). MSO4 2mg Q2H for C/O\nright leg pain and left shoulder pain with good effect.\nMaintaining O2 sats on RA. L/S-clear. Strong cough and + gag.\nNPO awaiting to go to the OR for ankle. Right leg in splint with adeqaute cap refill to great toe. Bedrest until leg surgically repaired.\nProximal to left antecubital area noted to have reddened area,warm to touch. Area marked this AM and it has extended to posterior portion of arm and also distally. Also, right hand is now swollen and reddened and was NOT swollen/red this AM. MD up to evaluate. XRAY and US completed this PM. Cefazolin IV Q8H ordered.\nCPK trending down to 8000. IV hydration continues. Received banana bag this AM. Phosphate also repleted IV. Excellent urine output- in color.\nPt states he has no family and contact a friend to let him know he was in the hospital.\nNicotine patch to be ordered after surgery-smokes 1PPD.\nSocial worker aware of pt-assisting pt with meds and financial issues.\n\nAwaiting to be called to OR-? pt will go to floor after PACU recovery\nif remains cooperative and not requiring large doses of valium to control ETOH withdrawal.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2126-01-24 00:00:00.000", "description": "Report", "row_id": 1601081, "text": "Nursing Progress Note\n 1900->0200\n\nS/O\n\nNEURO: A&O x3, MAES, speech clear and appropriate. Impulsive and impatient with increased delay over course of night in acting upon impulses and giving time to comsider consequences of actions.\nC/O pain in right ankle, right wrist, left upper arm, and left hand -> morphine 2mg IV x2 with short-term relief; Tylenol goven x1 with same result. MICU B team -- Dr in to examine pt due to pt c/o numbness in left hand which appears to be due to compression on nerve from upper arm swelling -> neuro consult planned. Pt is able to move hand, hand remains warm, was elevated.\n\nAt 00:10, pt became very agitated about not sleeping -> Valium 10mg with return to calm state, easily arousable and appropriate.\n\n\nCV: NSR 70's-90's, no ectopy; SBP 120's-150's. Right foot warm to touch, blanches, capillaryu refill < 3seconds; left pedal pulses strongly palpable.\n\nRESP: LS clear, on room air, no distress.\n\nGI: Abd soft, no nausea, BS +. No BM. Tolerating house diet.\n\nFEN: IVF changed from D5NS to D5NS with KCL 20mEq/l at 150mL/hr to comtinue rhabo tx.\n\nGU: Foley draining large amnts yellow urine. See flow sheet.\n\nSKIN: Forehead with 3 scabbed abraions. Left upper arm with redness, tenderness and swelling ? d/t bruise; left hand -- 1st 3 fingers -- numb -> see NEURO sxn. Scattered and few abrasions over extremities. Right wrist tender and swollen; MICU B team , , aware; reported negative u/s results for clot.\n\nA/P\n Transfer to 5.\nContinue comfort interventions.\nCOntinue CIWA monitoring and interventions.\nPrepare for OR on to repair right akle.\nFollow up with medical team regrding consults for right wrist swelling and pain and left upper arm swelling with left hand numbness and weakness.\nConinute current care.\n" }, { "category": "Nursing/other", "chartdate": "2126-01-23 00:00:00.000", "description": "Report", "row_id": 1601079, "text": "Nursing Admission Note\n 0600->0730\n\nPt arrived from Er on stretcher, monitored, in 3-point leather restraints and right ankle splinted, and with D5W with NaHCO3 3amps/L infusing at 250mL/hr via #20 gauage right forearm IV. Pt transferred to MICU B bed, monitor and iV pump.\n\nROS:\nNEURO: Required prompting for knowing locationa nd date. Pt restless, trying to sit up, CIWA 17 -> Valium 10mg IV given with + restfulness without somnolence.\nCV: NSR 80's, no ectopy. Hypertensive at 150's systolically. Pedal and post tib pulses on left strongly palpable; right blocked by splint but foot not edematous, + blanching with cap refill < 3 seconds and toes warm.\nRESP: No distress. LS clear.\nGI: Abd soft, non-tender. Pt c/o h/o nausea, moderate-minimal at present -> Valium given as CIWA scale tx.\nFEN: D5W with NaHCO3 3 amps/L conitnuing toinfus at 250mL/hr for tx of rhabdo. See CCCC for lab results from ER; CK dropping from max of >12,000 to 8000's. Pt received 11L before arrival.\nGU: Foley to straight drainage with yellow urine, 1000mL upon arrival from ER; u/o ~ 5000 before arrival/\nSKIN: Lac's er forehead, maximum size 0.5cmX2cm. Red and swollen bruise over left medial upper arm. Right ankle splinted by ortho prior to arrival.\n\n\nA/P\n\nPrepare for OR. NPO.\nContinue CIWA scale and tx.\n" }, { "category": "Radiology", "chartdate": "2126-01-25 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 852301, "text": " 2:14 PM\n ANKLE (AP, MORTISE & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \n Reason: ORIF R ANKLE\n Admitting Diagnosis: DELERIUM TREMONS,ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture followup/fixation.\n\n Three intraoperative radiographs of the right ankle. Since exam , the patient has had a plate and screws placed across the distal fibular\n fracture. The ankle mortise is congruent with the talus.\n\n" }, { "category": "Radiology", "chartdate": "2126-01-24 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 852205, "text": " 6:09 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LUE SWELLING AND ERYTHEMA\n Admitting Diagnosis: DELERIUM TREMONS,ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man admitted for DTs and ankle fxr, now with LUE swelling and\n erythema. was recorded on prior O/S request as RUE in error.\n REASON FOR THIS EXAMINATION:\n venous thrombus?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ankle fracture, left upper extremity swelling and erythema.\n\n LEFT UPPER EXTREMITY ULTRASOUND: 2D, color and Doppler wave form imaging was\n obtained of the left internal jugular, brachial, subclavian, basilic, axillary\n and cephalic veins. Normal compressibility, wave form and augmentation was\n demonstrated. No intraluminal thrombus was identified.\n\n IMPRESSION: No evidence of left upper extremity deep vein thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2126-01-23 00:00:00.000", "description": "RP WRIST(3 + VIEWS) RIGHT PORT", "row_id": 852026, "text": " 1:25 PM\n WRIST(3 + VIEWS) RIGHT PORT; HAND (AP, LAT & OBLIQUE) RIGHT PORTClip # \n Reason: eval for fxr\n Admitting Diagnosis: DELERIUM TREMONS,ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with trauma s/p fall.\n REASON FOR THIS EXAMINATION:\n eval for fxr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall. Evaluate for fracture.\n\n RIGHT HAND, THREE VIEWS: There is no acute fracture, dislocation, or\n destructive bone lesion. The joint spaces are maintained. There are no soft\n tissue abnormalities. There is radial and volar angulation of the distal\n fifth metacarpal consistent with an old healed boxer-type fracture.\n\n IMPRESSION: No acute fracture of the right hand.\n\n" }, { "category": "Radiology", "chartdate": "2126-01-23 00:00:00.000", "description": "RP UNILAT UP EXT VEINS US RIGHT PORT", "row_id": 852034, "text": " 2:09 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: DELERIUM TREMONS,ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man admitted for DTs and ankle fxr, now with RUE swelling and\n erythema.\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 39-year-old man admitted for delirium tremens and ankle\n fracture, now with right upper extremity swelling and erythema. Please\n evaluate for deep vein thrombosis.\n\n FINDINGS:\n\n scale and Doppler waveforms of the right jugular, subclavian, axillary,\n basilic, brachial, and cephalic veins were performed. All vessels\n demonstrated normal flow, waveforms, compressibility, and augmentation. No\n intraluminal thrombus is identified.\n\n IMPRESSION:\n\n No evidence of intraluminal thrombus in the veins of the right upper\n extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-01-26 00:00:00.000", "description": "L FOREARM (AP & LAT) LEFT", "row_id": 852436, "text": " 7:07 PM\n FOREARM (AP & LAT) LEFT; HUMERUS (AP & LAT) LEFT Clip # \n HAND (AP, LAT & OBLIQUE) LEFT\n Reason: fx?\n Admitting Diagnosis: DELERIUM TREMONS,ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with trauma and median nerve symptoms. going to OR in AM for\n ankle fx\n REASON FOR THIS EXAMINATION:\n fx?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 9-year-old with trauma and median nerve symptoms.\n\n A single view of the left humerus showed that the bony structures of the left\n humerus are intact with no evidence of fractures or dislocations.\n\n AP and lateral views of the left forearm showed that the bony structures of\n the radius and ulnar are intact with no evidence of fractures or bony\n destructive changes.\n\n IMPRESSION:\n\n Negative examination of the left humerus and left forearm.\n\n\n" }, { "category": "ECG", "chartdate": "2126-01-23 00:00:00.000", "description": "Report", "row_id": 192993, "text": "Sinus rhythm. Since the previous tracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-01-22 00:00:00.000", "description": "Report", "row_id": 192994, "text": "Sinus rhythm. Somewhat late R wave progression. Minor ST segment elevations in\nleads II, III and aVF in the early precordial leads of uncertain significance.\nNo previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2197-07-10 00:00:00.000", "description": "Report", "row_id": 67930, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA. Congestive Heart Failure.\nHeight: (in) 61\nWeight (lb): 112\nBSA (m2): 1.48 m2\nBP (mm Hg): 157/100\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 11:12\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement. No LA mass/thrombus (best excluded by TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild global LV\nhypokinesis. 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: Mildly thickened aortic valve leaflets (3). No AS. Trace 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. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). The estimated right atrial\npressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are\nnormal. There is mild global left ventricular hypokinesis (LVEF = 40-45 %).\nRight ventricular chamber size and free wall motion are normal. The diameters\nof aorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild to moderate (+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , there is now\nmild global left ventricular hypokinesis (may be related to atrial\nfibrillation and tachycardia). The estimated severity of pulmonary artery\nsystolic hypertension is lower.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469508, "text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n More withdrawn, follows commands partially, R. hemiparesis persist,\n weaker l.side, +facial droop. Trying to cough up sputum but unable to\n swallow due to absent gag.\n Action:\n Neuro checks q1h, Was NT suctioned to preserve the airway patent,\n Manitol q6h continues, monitoring sodium/osmo\n Response:\n Neuro exam unchanged\n Plan:\n Family meeting today , decision on Code status is pending, consider\n stopping Manitol\n Atrial fibrillation (Afib)\n Assessment:\n HR 90-100 irregular , SBO 150-170, weak pulses, hematuria with clots,\n INR 1.6\n Action:\n Sq Heparin was held,\n Lopressor q4h iv and Dilt gtt ongoing9trying to wean off)\n Response:\n Some paced spikes when hr<90, BP stable\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469510, "text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n More withdrawn, follows commands partially, R. hemiparesis persist,\n weaker l.side, +facial droop. Trying to cough up sputum but unable to\n swallow due to absent gag.\n Action:\n Neuro checks q1h, Was NT suctioned to preserve the airway patent,\n Manitol q6h continues, monitoring sodium/osmo\n Response:\n Neuro exam unchanged\n Plan:\n Family meeting today , decision on Code status is pending, consider\n stopping Manitol\n Atrial fibrillation (Afib)\n Assessment:\n HR 90-100 irregular , SBO 150-170, weak pulses, hematuria with clots,\n INR 1.6\n Action:\n Sq Heparin was held,\n Lopressor q4h iv and Dilt gtt ongoing9trying to wean off)\n Response:\n HR remains <110, Some paced spikes when hr<90, BP stable, hematuria\n transient\n Plan:\n Consider cutting Coumadin dose, wean Dilt gtt\n" }, { "category": "Physician ", "chartdate": "2197-07-09 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 469260, "text": "Chief Complaint: Stroke\n HPI:\n HPI: 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arma and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 03:55 PM\n Other medications:\n Past medical history:\n Family / Social history:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n .\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n .\n Allergies: NKDA\n Soc: The patient denies cigarette, EtOH, or illicit\n drug use. She lives with her daughter and son. She is a former\n She motivational speaker, personal life coach, and had a TV\n exercise program.\n Flowsheet Data as of 08:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.3\nC (97.4\n HR: 111 (101 - 115) bpm\n BP: 101/77(83) {101/65(77) - 125/85(111)} mmHg\n RR: 19 (13 - 20) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 559 mL\n PO:\n TF:\n IVF:\n 559 mL\n Blood products:\n Total out:\n 0 mL\n 470 mL\n Urine:\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 89 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, R end-gaze nystagmus\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): person, Movement: Purposeful, Tone: Normal, R-sided\n weakness throughout including R facial droop\n Labs / Radiology\n 138 mEq/L\n [image002.jpg]\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment And Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: NEURO: Pt has defecits consistant with a diffuse left-sided\n CVA, including a large cerebellar infarction.\n - Start mannitol\n - Elevate HOB 30 degrees\n - Keep SBP b/w 140 and 180 - hold home amlodipine.\n - Obtain CT head PRN, scheduled tomorrow.\n - ASA 325 mg PO daily (give PR if dysphagia)\n -Hold off heparin gtt for now given large size of left cerebellar\n infarct\n Neuro checks Q1hr\n Pain: Pt not in pain\n Cardiovascular: CVS: Pt is in AFib w RVR. Likely that clot is being\n showered to CNS from fibrillating heart.\n - BP control as above with metoprolol.\n - Rate control with metoprolol.\n - TTE to assess clot burden\n Pulmonary: PULM: Pt has had several episodes of apnea x30 seconds.\n - Support airway PRN.\n - Discuss code status with family.\n Gastrointestinal: Pt has poor gag reflex, failed a bedside swallow\n eval. Keep pt NPO. Place NG tube. Start tube feeds.\n Renal: Creatinine 1.3, at baseline.\n - continue maintanence fluids\n Hematology: Hct stable at 43.\n Infectious Disease: No signs of infection.\n Endocrine: RISS\n -Continue Levothyroxine\n Fluids: LR at 75\n Electrolytes:\n Nutrition: Tube feeds via NGT\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469505, "text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n More withdrawn, follows commands partially, R. hemiparesis persist,\n weaker l.side, +facial droop. Trying to cough up sputum but unable to\n swallow due to absent gag.\n Action:\n Neuro checks q1h, Was NT suctioned to preserve the airway patent,\n Manitol q6h continues\n Response:\n Plan:\n Family meeting today , decision on Code status is pending\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469645, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert and oriented x1. Pt follows commands. Pt has expressive\n aphasia but nods appropriately to some questions. Pt has no movement in\n RUE, but withdraws to pain in the RLE. Pt can lift and hold the LUE and\n LLE. Pt is on 2L NC and LS clear and diminished at bases. Pt denies\n wanting NG tube placement.\n Action:\n -Pt on mannitol, warfarin and SQ heparin\n -Neuro exam changed from q1h to q2h\n -family meeting occurred to discuss code status and plan of treatment\n Response:\n -Pt Sodium and Osmo within limits.\n -Neuro exam unchanged\n -Family said that\nMy mother said she would not want to live in a\n nursing home and that their was no quality of life\n. Son and Daughter\n ( and ) are taking 24hr to discuss and make a decision\n Plan:\n Awaiting families decision for pt\ns plan of care\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced. Pt SBP within 140-180.\n Action:\n -Diltiazem gtt titrated for HR under 100\n -metoprolol given q4hr for BP management\n -Coumadin in place\n Response:\n HR wnl and paced. SBP within goal\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep SBP 140-180\n with lopressor.\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469506, "text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n More withdrawn, follows commands partially, R. hemiparesis persist,\n weaker l.side, +facial droop. Trying to cough up sputum but unable to\n swallow due to absent gag.\n Action:\n Neuro checks q1h, Was NT suctioned to preserve the airway patent,\n Manitol q6h continues, monitoring sodium/osmo\n Response:\n Neuro exam unchanged\n Plan:\n Family meeting today , decision on Code status is pending, consider\n stopping Manitol\n Atrial fibrillation (Afib)\n Assessment:\n HR 90-100 irregular , SBO 150-170\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2197-07-10 00:00:00.000", "description": "Intensivist Note", "row_id": 469323, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arma and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n Chief complaint:\n CVA\n PMHx:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n .\n Allergies: NKDA\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Aspirin 5. Bisacodyl 6. Docusate\n Sodium 7. Famotidine 8. Heparin\n 9. Insulin 10. Levothyroxine Sodium 11. Lidocaine 1% 12. Mannitol 13.\n Mannitol 14. Metoprolol Tartrate\n 15. Metoprolol Tartrate 16. Metoprolol Tartrate 17. Ondansetron 18.\n Pneumococcal Vac Polyvalent 19. Potassium Chloride\n 20. Senna 21. Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 23. Warfarin\n 24 Hour Events:\n : Pt was tachycardic to 120s, tx'd with metoprolol. Several periods\n of apnea > 30sec. Repeat CT head showed expanding R and L cerebellar\n infarctions. Pt placed on mannitol, ASA, coumadin. Pt refused NG tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:24 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Metoprolol - 05:20 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36\nC (96.8\n HR: 112 (101 - 126) bpm\n BP: 153/109(121) {101/65(77) - 181/126(134)} mmHg\n RR: 13 (11 - 24) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 920 mL\n 601 mL\n PO:\n Tube feeding:\n IV Fluid:\n 920 mL\n 601 mL\n Blood products:\n Total out:\n 800 mL\n 610 mL\n Urine:\n 800 mL\n 610 mL\n NG:\n Stool:\n Drains:\n Balance:\n 120 mL\n -9 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n No(t) Moves all extremities, (RUE: Weakness), (RLE: Weakness)\n Labs / Radiology\n 277 K/uL\n 12.9 g/dL\n 113 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 20 mg/dL\n 100 mEq/L\n 139 mEq/L\n 38.1 %\n 6.5 K/uL\n [image002.jpg]\n 03:13 AM\n WBC\n 6.5\n Hct\n 38.1\n Plt\n 277\n Creatinine\n 1.3\n Glucose\n 113\n Other labs: PT / PTT / INR:12.3/24.7/1.0, Ca:9.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: NEURO: Pt has defecits consistant with a diffuse left-sided\n CVA, including a large cerebellar infarction.\n - Start mannitol\n - Elevate HOB 30 degrees\n - Keep SBP b/w 140 and 180 - hold home amlodipine.\n - Obtain CT head PRN, scheduled .\n - ASA 325 mg PO daily (give PR if dysphagia)\n -Hold off heparin gtt for now given large size of left cerebellar\n infarct\n Neuro checks Q1hr\n Pain: Pt not in pain\n Cardiovascular: Pt is in AFib w RVR. Likely that clot is being showered\n to CNS from fibrillating heart.\n - BP control as above with metoprolol.\n - Rate control with metoprolol.\n - TTE to assess clot burden\n Pulmonary: Pt has had several episodes of apnea x30 seconds.\n - Support airway PRN.\n - Discuss code status with family.\n Gastrointestinal / Abdomen: Pt has poor gag reflex, failed a bedside\n swallow eval. Keep pt NPO. Place NG tube. Start tube feeds.\n Nutrition: NPO, Pt refused NGT\n Renal: Creatinine 1.3, at baseline.\n - continue maintanence fluids\n Hematology: Hct stable at 43.\n Endocrine: RISS\n -Continue Levothyroxine\n Infectious Disease: No signs of infection.\n Lines / Tubes / Drains: PIV, Foley\n - place NGT\n Wounds:\n Imaging: CT scan head today\n Fluids: LR\n Consults: Neurology\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n" }, { "category": "Rehab Services", "chartdate": "2197-07-10 00:00:00.000", "description": "Cancelled Bedside Swallow Evaluation", "row_id": 469414, "text": "TITLE: CANCELLED BEDSIDE SWALLOW EVALUATION\nWe received consult and arrived to floor. Spoke with MD who\nreported patient not doing well and bedside swallow evaluation to\nbe d/c'd. RN reported plan of care pending until family meeting.\nPlease reconsult as indicated and we will be happy to return.\n_______________________________\n , MS, CCC-SLP\nPager #\n" }, { "category": "Nutrition", "chartdate": "2197-07-13 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 469984, "text": "Subjective\n patient nonverbal\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 155 cm\n 55.5 kg\n 55.8 kg ( 05:00 AM)\n 23.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 47.6 kg\n 116%\n Diagnosis: CHF\n PMH :\n Food allergies and intolerances: no known food allergies\n Pertinent medications: colace, RISS, heparin, pepcid, Dextorse 5% with\n normal saline, others noted\n Labs:\n Value\n Date\n Glucose\n 140 mg/dL\n 04:36 AM\n Glucose Finger Stick\n 152\n 08:00 AM\n BUN\n 21 mg/dL\n 04:36 AM\n Creatinine\n 1.2 mg/dL\n 04:36 AM\n Sodium\n 141 mEq/L\n 04:36 AM\n Potassium\n 3.6 mEq/L\n 04:36 AM\n Chloride\n 105 mEq/L\n 04:36 AM\n TCO2\n 24 mEq/L\n 04:36 AM\n Calcium non-ionized\n 8.8 mg/dL\n 04:36 AM\n Phosphorus\n 3.0 mg/dL\n 04:36 AM\n Magnesium\n 2.2 mg/dL\n 04:36 AM\n Triglyceride\n 124 mg/dL\n 03:13 AM\n WBC\n 8.6 K/uL\n 04:36 AM\n Hgb\n 12.6 g/dL\n 04:36 AM\n Hematocrit\n 38.3 %\n 04:36 AM\n Current diet order / nutrition support: Replete with fiber Full\n strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 40 ml/hr\n = 960 kcals/ 59 g protein\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1387-1554 (BEE x or / 25-28 cal/kg)\n Protein: 55-66 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeding\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2197-07-13 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 469985, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 155 cm\n 55.5 kg\n 55.8 kg ( 05:00 AM)\n 23.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 47.6 kg\n 116%\n Diagnosis: CHF\n PMH : Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n s/p hysterectomy in for \"uterine growth\"\n Food allergies and intolerances: no known food allergies\n Pertinent medications: colace, RISS, heparin, pepcid, Dextorse 5% with\n normal saline, others noted\n Labs:\n Value\n Date\n Glucose\n 140 mg/dL\n 04:36 AM\n Glucose Finger Stick\n 152\n 08:00 AM\n BUN\n 21 mg/dL\n 04:36 AM\n Creatinine\n 1.2 mg/dL\n 04:36 AM\n Sodium\n 141 mEq/L\n 04:36 AM\n Potassium\n 3.6 mEq/L\n 04:36 AM\n Chloride\n 105 mEq/L\n 04:36 AM\n TCO2\n 24 mEq/L\n 04:36 AM\n Calcium non-ionized\n 8.8 mg/dL\n 04:36 AM\n Phosphorus\n 3.0 mg/dL\n 04:36 AM\n Magnesium\n 2.2 mg/dL\n 04:36 AM\n Triglyceride\n 124 mg/dL\n 03:13 AM\n WBC\n 8.6 K/uL\n 04:36 AM\n Hgb\n 12.6 g/dL\n 04:36 AM\n Hematocrit\n 38.3 %\n 04:36 AM\n Current diet order / nutrition support: Replete with fiber Full\n strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 40 ml/hr\n = 960 kcals/ 59 g protein\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n GI: soft, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1387-1554 (BEE x or / 25-28 cal/kg)\n Protein: 55-66 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: unknown\n Estimation of current intake: Inadequate\n Specifics: 84 year old female admitted with CHF exacerbation with DOE x\n 2 weeks. Patient was then transferred to TSICU after CTA showed a right\n cerebellar infarct and left ICA occlusion. Patient was made CMO on \n based on patient\ns prior wishes of no tube feedings and invasive\n procedures on but then was made full code by family shortly\n afterward. Family meeting is planned today to discuss plan of care,\n ethics consulted. NGT placed and tube feedings ordered but not started\n yet. Current tube feeding underfeeds patient. Recommend changing tube\n feeding to meet 100% of nutritional needs if within plan of care.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If tube feedings are in plan of care recommend Fibersource HN\n @ 20 ml/hr advance to goal of 60 ml/hr = 1440 kcals/ 64 g protein\n 2. Multivitamin via tube feeding\n 3. Check chem. 10 daily and replete lytes prn\n 4. Will follow plan of care page with questions\n" }, { "category": "Nursing", "chartdate": "2197-07-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 470004, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert and oriented x1. Pt follows commands. Pt has expressive\n aphasia but nods appropriately to some questions. Pt has no movement in\n RUE, but withdraws to pain in the RLE. Pt can lift and hold the LUE and\n LLE. Pt is on 2L NC and LS clear and diminished at bases. Pt coughing\n up secretions but now has absent gag, so secretions need some\n suctioning.\n Action:\n -Mannitol discontinued, Neuro exam changed to q4h\n -family meeting occurred to discuss code status yesterday and family\n changed pt to , a few hr later called and made pt Full . Ethics\n now involved and daughter today found pt\ns living will, which clearly\n states no\nheroic measures\n if her mental and physical status \n return to baseline. Daughter understanding situation and wants to make\n pt , is having trouble with this decision. Social work and\n ethics involved and trying to have another family meeting to make the\n pt\ns wishes known.\n Response:\n -Neuro exam unchanged\n -Team is still trying to get in touch with son for a family meeting.\n Plan:\n Awaiting families decision for pt\ns plan of care\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced. Pt SBP within 140-180.\n Action:\n -Diltiazem gtt titrated for HR under 100\n -metoprolol given q4hr for BP management\n -Coumadin in place\n Response:\n HR wnl and paced. SBP within goal\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep SBP 140-180\n with lopressor.\n" }, { "category": "Nursing", "chartdate": "2197-07-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469246, "text": "Atrial fibrillation (Afib)\n Assessment:\n Chronic a-fib with backup pace maker.\n Presents in AF with RVR rate as high as 140\ns with stimulation.\n Action:\n Lopressor 10mg IV; then 5mg IV q4\n Response:\n HR remains 80\ns-110\ns but fewer bursts above 120.\n Plan:\n Goal SBP is 140-180 but no intervention for BP below that goal as per\n neuro and ICU teams at this time.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Presented with garbled speech, has progressed to mute / aphasia. Was\n oriented to self reliably and questionably hospital and situation, now\n unable to assess.\n Interacts appropriately by following commands, nodding yes or no to\n simple questions.\n Presented moving all extremities with right sided weakness; now\n difficult to elicit any movement of the right extremities, still able\n to lift and hold both left arm and leg.\n Obvious difficulty swallowing anything PO.\n Action:\n Q1 neuro exams, reoriented frequently\n Head CT repeated\n 25gm Mannitol given as ordered; serum osmolality and sodium sent\n PIVx2\n NPO\n Response:\n Deteriorating neuro exam as per above. Drs and present\n for much of the evening and completed their own assessments and ordered\n interventions as per above.\n Plan:\n Q1 neuro exams; repeat CT head at 0600 ; Mannitol as ordered; full\n code for now, family meeting personally about goals of care.\n" }, { "category": "Nutrition", "chartdate": "2197-07-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 469801, "text": "Ht: 61\n Wt: 55.5 kg\n IBW: 47.6 kg116%\n BMI: 23.1\n Diet Order: NPO\n Patient screened per ICU protocol. Patient has been NPO and/or on\n unsupplemented clear liquid diet for 3 days. If patient's diet is not\n able to be advanced and tolerated, for nutrition\n support.\n" }, { "category": "Physician ", "chartdate": "2197-07-13 00:00:00.000", "description": "Intensivist Note", "row_id": 469969, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arma and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Chief complaint:\n stroke\n PMHx:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n .\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n .\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:25 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:13 AM\n Other medications:\n Flowsheet Data as of 07:47 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: 35.7\nC (96.2\n HR: 77 (75 - 102) bpm\n BP: 118/71(83) {118/61(77) - 175/96(114)} mmHg\n RR: 13 (13 - 38) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 55.8 kg (admission): 55.5 kg\n Height: 61 Inch\n Total In:\n 2,371 mL\n 691 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,371 mL\n 691 mL\n Blood products:\n Total out:\n 1,075 mL\n 490 mL\n Urine:\n 1,075 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,296 mL\n 201 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 251 K/uL\n 12.6 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 104 mEq/L\n 143 mEq/L\n 38.3 %\n 8.6 K/uL\n [image002.jpg]\n 03:13 AM\n 02:00 PM\n 05:01 PM\n 02:26 AM\n 02:01 AM\n 04:36 AM\n WBC\n 6.5\n 8.9\n 8.7\n 8.6\n Hct\n 38.1\n 38.5\n 36.0\n 38.3\n Plt\n 277\n 277\n 293\n 251\n Creatinine\n 1.3\n 1.3\n 1.5\n 1.3\n Glucose\n 113\n 103\n 101\n 100\n 114\n Other labs: PT / PTT / INR:17.8/27.8/1.6, Differential-Neuts:81.5 %,\n Lymph:9.6 %, Mono:7.8 %, Eos:1.0 %, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: (1) multiple embolic strokes: evolving cerebellar\n infarction on CT , taper mannitol, keep SBP 140s-180s\n (2) pain: requiring small amt opiates\n Cardiovascular: rate controlled on diltiazem gtt + metoprolol, goal HR\n 80s-100s, if < 80 increased number of PVCs, on coumadin, likely\n embolizing from clot in fibrillating atria, TTE shows no atrial\n thrombus, no PFO (although no bubble study done)\n Pulmonary: O2 reqirements unchanged. If pt faces respiratory distress,\n family requesting intubation.\n Gastrointestinal / Abdomen: Pt has poor gag reflex, failed a bedside\n swallow eval.\n Nutrition: NPO, possible GT, she agrees to NGT and TF\n Renal: good urine output, will follow\n Hematology: Hct stable at 43.\n Endocrine: RISS, IV synthroid\n Infectious Disease: No signs of infection.\n Lines / Tubes / Drains: PIV, Foley\n Wounds:\n Imaging:\n Fluids: LR, LR at 75\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 08:05 PM\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possibly to floor\n Total time spent: 15 minutes\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469306, "text": "The patient is an 84 year old right handed woman with a history of\n chronic atrial fibrillation not on Coumadin who converted from sinus\n rhythm to atrial fibrillation 2 weeks PTA, symptomatic sinus\n bradycardia s/p PPM , and hypertension who presented to .\n Upon primary cardiology team evaluation at 7:30 am, she was noted\n to have difficulty lifting her right arm against gravity, but could\n move her right leg against gravity. The nurse reported that the patient\n has been having trouble swallowing her pills. The nurse also was the\n same one who took care of the patient the day before, and said that her\n voice was not hoarse as of at 3:00 pm. She also had nystagmus at\n right end-gaze and upgoing toes bilaterally. Head CT/CTA/CTP shows a\n right cerebellar infarct with concern for evolution from 1 am to 11 am\n today, also left ICA occlusion. Thromboembolic event in the setting of\n AF. The right cerebellar stroke is likely due to right PICA occlusion\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Unable to move R.side, complete R. hemiparesis, PERL, poor gag/cough,\n chokes on clears, no seizures noted, garbled speech, disoriented in\n place/time, combative and resistant to care\n Action:\n Mannitol q6h, neuro checks q1-2 hours, quiet environment, restrained\n according to protocol\n Response:\n No changes in neuro status since 7pm last night\n Plan:\n Family meeting, anticoagulation with Coumadin. CT head today, clearfy\n code status with the family, monitor osmo/sodium\n Atrial fibrillation (Afib)\n Assessment:\n 84 YO female with HTN, diastolic CHF, paf who over the past 9 months\n has been experiencing decrease exercise tolerance with progressively\n worsening shortness of breath that improved after pacer placement (St.\n XL DR 5816) in for sinus bradycardia with\n Wenckebach. There has been a more recent increase fatigue, shortness of\n breath, dizziness, HA, nausea, voice change. She stated that this past\n week she could only walk a few steps before becoming symptomatic.\n Today her HR 90-130 irregular with rare PVCs, BP by cuff on the r. arm.\n Weak pulses., Easily bruised skin\n SBP stay 150-170s, no pacer spikes noted\n Action:\n Lopressor q2h 4 mg\n Response:\n Slows HR down with lopressor but rebounds shortly after, requires\n lopressor q2h, keeps sbp<180\n Plan:\n Keep SBP 140-180, consider if she needs NGT for po Lopressor( after\n family meeting), consider additional IV access\n" }, { "category": "Nutrition", "chartdate": "2197-07-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 469802, "text": "Ht: 61\n Wt: 55.5 kg\n IBW: 47.6 kg116%\n BMI: 23.1\n Diet Order: NPO\n PMH: Chronic atrial fibrillation, Symptomatic sinus bradycardia with\n prolonged PR s/p St. PPM , CHF, LVEF >55%\n Hypertension, Hypothyroidism s/p resection of thyroid nodule, s/p\n hysterectomy in for \"uterine growth\"\n 84 year old female admitted with CHF exacerbation with DOE x 2 weeks.\n Patient was then transferred to TSICU after Patient screened per ICU\n protocol. Patient has been NPO and/or on unsupplemented clear liquid\n diet for 3 days. If patient's diet is not able to be advanced and\n tolerated, for nutrition support.\n" }, { "category": "Nutrition", "chartdate": "2197-07-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 469803, "text": "Ht: 61\n Wt: 55.5 kg\n IBW: 47.6 kg116%\n BMI: 23.1\n Diet Order: NPO\n PMH: Chronic atrial fibrillation, Symptomatic sinus bradycardia with\n prolonged PR s/p St. PPM , CHF, LVEF >55%\n Hypertension, Hypothyroidism s/p resection of thyroid nodule, s/p\n hysterectomy in for \"uterine growth\"\n 84 year old female admitted with CHF exacerbation with DOE x 2 weeks.\n Patient was then transferred to TSICU after CTA showed a right\n cerebellar infarct and left ICA occlusion. The patient has right sided\n facial droop, right arm and leg weakness , and profoundly dysarthric.\n Patient screened per ICU protocol. Patient has been NPO and/or on\n unsupplemented clear liquid diet for 3 days. Patient has no gag reflex\n and will need trach soon. Prior to embolic event patient refused NGT\n and would not want invasive procedures to stay alive however patient\n family is considering PEG vs CMO. Will follow plan of care and provide\n tube feeding recommendations if needed. Please page with\n questions\n" }, { "category": "Physician ", "chartdate": "2197-07-11 00:00:00.000", "description": "Intensivist Note", "row_id": 469586, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation presents with several ischemic CNS lesions, likely due\n to embolic events.\n Chief complaint:\n stroke\n PMHx:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n .\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n ULTRASOUND - At 02:04 PM\n LENI's\n EKG - At 05:04 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:23 PM\n Diltiazem - 04:36 PM\n Famotidine (Pepcid) - 10:16 PM\n Metoprolol - 04:38 AM\n Other medications:\n Flowsheet Data as of 06:07 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: 36.3\nC (97.4\n HR: 95 (74 - 126) bpm\n BP: 172/80(104) {144/70(96) - 179/122(136)} mmHg\n RR: 21 (10 - 24) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 53.2 kg (admission): 55.5 kg\n Total In:\n 2,693 mL\n 646 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,693 mL\n 646 mL\n Blood products:\n Total out:\n 2,380 mL\n 395 mL\n Urine:\n 2,380 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered rhonchi), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No movement)\n Labs / Radiology\n 277 K/uL\n 12.8 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 102 mEq/L\n 139 mEq/L\n 38.5 %\n 8.9 K/uL\n [image002.jpg]\n 03:13 AM\n 02:00 PM\n 05:01 PM\n 02:26 AM\n WBC\n 6.5\n 8.9\n Hct\n 38.1\n 38.5\n Plt\n 277\n 277\n Creatinine\n 1.3\n 1.3\n 1.5\n Glucose\n 113\n 103\n 101\n 100\n Other labs: PT / PTT / INR:17.8/27.8/1.6, Differential-Neuts:81.5 %,\n Lymph:9.6 %, Mono:7.8 %, Eos:1.0 %, Ca:9.4 mg/dL, Mg:2.3 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: (1) multiple embolic strokes: evolving cerebellar\n infarction on CT , taper off mannitol today, keep SBP 140s-180s,\n will need to clarify goals of care with family/patient at family\n meeting today (2) pain: comfortable not requiring opiates (3) Pt\n refusing procedures. Competence unclear. Family mtng scheduled for\n 13:30 today.\n Cardiovascular: Full anticoagulation, Beta-blocker, rate controlled on\n diltiazem gtt + metoprolol, goal HR 80s-100s, if < 80 increased number\n of PVCs, on coumadin, likely embolizing from clot in fibrillating\n atria, TTE shows no atrial thrombus, no PFO (although no bubble study\n done)\n Pulmonary: no active issues\n Gastrointestinal / Abdomen: no active issues\n Nutrition: Pt has poor gag reflex, failed a bedside swallow eval. Keep\n pt NPO. patient refuses NG tube\n Renal: Foley, Adequate UO, good urine output, rising creatinine, will\n follow\n Hematology: stable HCt\n Endocrine: RISS, synthroid\n Infectious Disease: No signs of infection.\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds:\n Imaging:\n Fluids: LR maintenance\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: multiple embolic events\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 08:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2197-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469893, "text": "At the beginning of the shift pt\ns son phoned and stated that he and\n his sister had spoken and changed their minds and would like to have pt\n cmo status reversed and full treatment resumed. Informed son that I\n would speak to the MD and have him phone him back. Information given\n to and he phoned back and pt was made a full code\n again and treatment resumed.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469569, "text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n More withdrawn, follows commands partially, R. hemiparesis persist,\n weaker l.side, +facial droop. Trying to cough up sputum but unable to\n swallow due to absent gag.\n Action:\n Neuro checks q1h, Was NT suctioned to preserve the airway patent,\n Manitol q6h continues, monitoring sodium/osmo\n Response:\n Neuro exam unchanged\n Plan:\n Family meeting today , decision on Code status is pending, consider\n stopping Manitol\n Atrial fibrillation (Afib)\n Assessment:\n HR 90-100 irregular , SBO 150-170, weak pulses, hematuria with clots,\n INR 1.6\n Action:\n Sq Heparin was held,\n Lopressor q4h iv and Dilt gtt ongoing9trying to wean off)\n Response:\n HR remains <110, Some paced spikes when hr<90, BP stable, hematuria\n transient\n Plan:\n Consider cutting Coumadin dose, wean Dilt gtt\n" }, { "category": "Physician ", "chartdate": "2197-07-12 00:00:00.000", "description": "Intensivist Note", "row_id": 469776, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arma and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n .\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Diltiazem - 15 mg/hour\n Other ICU medications:\n Diltiazem - 06:05 PM\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Other medications:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.6\nC (97.8\n HR: 95 (78 - 107) bpm\n BP: 152/69(91) {151/64(86) - 196/101(123)} mmHg\n RR: 22 (12 - 31) insp/min\n SPO2: 83%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 54 kg (admission): 55.5 kg\n Total In:\n 2,489 mL\n 1,046 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,489 mL\n 1,046 mL\n Blood products:\n Total out:\n 2,165 mL\n 530 mL\n Urine:\n 2,165 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 324 mL\n 516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool, Face tent\n SPO2: 83%\n ABG: ///24/\n Physical Examination\n General Appearance: tachypneic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular), paced\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n )\n Abdominal: Soft\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: No movement), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness)\n Labs / Radiology\n 293 K/uL\n 12.5 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 21 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.0 %\n 8.7 K/uL\n [image002.jpg]\n 03:13 AM\n 02:00 PM\n 05:01 PM\n 02:26 AM\n 02:01 AM\n WBC\n 6.5\n 8.9\n 8.7\n Hct\n 38.1\n 38.5\n 36.0\n Plt\n 277\n 277\n 293\n Creatinine\n 1.3\n 1.3\n 1.5\n 1.3\n Glucose\n 113\n 103\n 101\n 100\n 114\n Other labs: PT / PTT / INR:17.8/27.8/1.6, Differential-Neuts:81.5 %,\n Lymph:9.6 %, Mono:7.8 %, Eos:1.0 %, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: Neuro checks Q: 2 hr, multiple embolic strokes: evolving\n cerebellar infarction on CT \n - family still undecided on the code status\n - cont mannitol taper\n - keep SBP 140s-180s\n - pain: comfortable not requiring opiates\n Cardiovascular: -rate controlled on diltiazem gtt + metoprolol\n - goal HR 80s-100s, if < 80 increased number of PVCs\n - on coumadin\n Pulmonary: - increasing O2 requirement, awaiting family decision re:\n intubation\n Gastrointestinal / Abdomen: - refuses NGT, awaiting family decision re:\n PEG\n Nutrition: NPO\n Renal: Foley\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults: Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 08:05 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer:\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: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2197-07-13 00:00:00.000", "description": "Intensivist Note", "row_id": 469956, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arma and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Chief complaint:\n stroke\n PMHx:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n .\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n .\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:25 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:13 AM\n Other medications:\n Flowsheet Data as of 07:47 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: 35.7\nC (96.2\n HR: 77 (75 - 102) bpm\n BP: 118/71(83) {118/61(77) - 175/96(114)} mmHg\n RR: 13 (13 - 38) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 55.8 kg (admission): 55.5 kg\n Height: 61 Inch\n Total In:\n 2,371 mL\n 691 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,371 mL\n 691 mL\n Blood products:\n Total out:\n 1,075 mL\n 490 mL\n Urine:\n 1,075 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,296 mL\n 201 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 251 K/uL\n 12.6 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 104 mEq/L\n 143 mEq/L\n 38.3 %\n 8.6 K/uL\n [image002.jpg]\n 03:13 AM\n 02:00 PM\n 05:01 PM\n 02:26 AM\n 02:01 AM\n 04:36 AM\n WBC\n 6.5\n 8.9\n 8.7\n 8.6\n Hct\n 38.1\n 38.5\n 36.0\n 38.3\n Plt\n 277\n 277\n 293\n 251\n Creatinine\n 1.3\n 1.3\n 1.5\n 1.3\n Glucose\n 113\n 103\n 101\n 100\n 114\n Other labs: PT / PTT / INR:17.8/27.8/1.6, Differential-Neuts:81.5 %,\n Lymph:9.6 %, Mono:7.8 %, Eos:1.0 %, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: (1) multiple embolic strokes: evolving cerebellar\n infarction on CT , taper mannitol, keep SBP 140s-180s\n (2) pain: requiring small amt opiates\n Cardiovascular: rate controlled on diltiazem gtt + metoprolol, goal HR\n 80s-100s, if < 80 increased number of PVCs, on coumadin, likely\n embolizing from clot in fibrillating atria, TTE shows no atrial\n thrombus, no PFO (although no bubble study done)\n Pulmonary: O2 reqirements rising, awaiting family decision. If pt faces\n respiratory distress, family requesting intubation.\n Gastrointestinal / Abdomen: Pt has poor gag reflex, failed a bedside\n swallow eval.\n Nutrition: NPO, plan for GT, NGT\n Renal: good urine output, rising creatinine, will follow\n Hematology: Hct stable at 43.\n Endocrine: RISS, IV synthroid\n Infectious Disease: No signs of infection.\n Lines / Tubes / Drains: PIV, Foley\n Wounds:\n Imaging:\n Fluids: LR, LR at 75\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 08:05 PM\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2197-07-12 00:00:00.000", "description": "Intensivist Note", "row_id": 469789, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arma and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n .\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Diltiazem - 15 mg/hour\n Other ICU medications:\n Diltiazem - 06:05 PM\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Other medications:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.6\nC (97.8\n HR: 95 (78 - 107) bpm\n BP: 152/69(91) {151/64(86) - 196/101(123)} mmHg\n RR: 22 (12 - 31) insp/min\n SPO2: 83%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 54 kg (admission): 55.5 kg\n Total In:\n 2,489 mL\n 1,046 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,489 mL\n 1,046 mL\n Blood products:\n Total out:\n 2,165 mL\n 530 mL\n Urine:\n 2,165 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 324 mL\n 516 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool, Face tent\n SPO2: 83%\n ABG: ///24/\n Physical Examination\n General Appearance: tachypneic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular), paced\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n )\n Abdominal: Soft\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: No movement), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness)\n Labs / Radiology\n 293 K/uL\n 12.5 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 21 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.0 %\n 8.7 K/uL\n [image002.jpg]\n 03:13 AM\n 02:00 PM\n 05:01 PM\n 02:26 AM\n 02:01 AM\n WBC\n 6.5\n 8.9\n 8.7\n Hct\n 38.1\n 38.5\n 36.0\n Plt\n 277\n 277\n 293\n Creatinine\n 1.3\n 1.3\n 1.5\n 1.3\n Glucose\n 113\n 103\n 101\n 100\n 114\n Other labs: PT / PTT / INR:17.8/27.8/1.6, Differential-Neuts:81.5 %,\n Lymph:9.6 %, Mono:7.8 %, Eos:1.0 %, Ca:9.2 mg/dL, Mg:2.1 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: Neuro checks Q: 2 hr, multiple embolic strokes: evolving\n cerebellar infarction on CT \n - stable neurologic examination\n - family still undecided on the code status\n - cont mannitol 25 mg every 8 hours. Continue tapering.\n - keep SBP 140s-180s\n - pain: comfortable not requiring opiates\n Cardiovascular: -rate controlled on diltiazem gtt + metoprolol\n - goal HR 80s-100s, if < 80 increased number of PVCs\n - on coumadin\n Pulmonary: - increasing O2 requirement, awaiting family decision re:\n intubation\n Gastrointestinal / Abdomen: - refuses NGT, awaiting family decision re:\n PEG\n Nutrition: NPO\n Renal: Foley\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 08:05 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer:\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: 35 minutes\n Patient is critically ill\n" }, { "category": "Social Work", "chartdate": "2197-07-12 00:00:00.000", "description": "Social Work Progress Note", "row_id": 469877, "text": "Team/family meeting to confer on pt\ns son and dtr\ns decision for pt\n goals of care, in light of yesterday\ns team/family meeting. (See SW\n note from ). Present at mtg were pt\ns son , pt\ns dtr\n , Attending Neuro MD , Neuro MD , TSICU\n Resident , pt\ns RN and this writer.\n Team reported out on pt\ns current condition: that she has had some\n deterioration in the past 24 hours and that it is likely she would need\n to be intubated in the next few hours if her family\ns decision is to\n proceed w/ life-sustaining care. Pt\ns son asked several questions that\n reflected his difficulty grasping the severity of pt\ns condition. Team\n and pt\ns family processed their questions and concerns. SW assisted\n pt\ns son w/ differentiating his own needs from those of pt. Pt\ns dtr\n clearly stated she would like to make pt and believes this is c/w\n her wishes & values. After several minutes of processing, pt\ns son\n tearfully agreed that pt would not want to be trached/pegged/intubated\n and sent to a . Team reiterated primary components of making pt\n . SW offered to have a hospital Chaplain come, and team discussed\n Palliative Care\ns availability and services w/ family. At this time,\n family decline but may ask for those services at a later point.\n Provided empathic support and counseling. Reiterated SW availability.\n Plan is for pt to be transferred to the floor and be made .\n , LCSW\n Pager: \n" }, { "category": "Nursing", "chartdate": "2197-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469869, "text": "CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt remains alert, aphasic, inconsistently FCs and R sided deficit.\n Action:\n Family meeting at 1730 with Dr , Dr , SW and this RN with\n both son and daughter .\n Response:\n Pt made CMO.\n Plan:\n Contact palliative care. Transfer to private room and maintain comfort.\n" }, { "category": "Nursing", "chartdate": "2197-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469940, "text": "At the beginning of the shift pt\ns son phoned and stated that he and\n his sister had spoken and changed their minds and would like to have pt\n cmo status reversed and full treatment resumed. Informed son that I\n would speak to the MD and have him phone him back. Information given\n to and he phoned back and pt was made a full code\n again and treatment resumed.\n Atrial fibrillation (Afib)\n Assessment:\n Pt has remained in a-fib with hr in the 80 to low 100 range.\n Action:\n Lopressor 5mg iv q4 hr and dilt gtt at 15 mg.\n Response:\n Hr in the 70-90. pt is having frequent pvc\n Plan:\n Monitor hr and wean gtt as able when pt able to take po med convert to\n po dilt.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt able to squeeze with left hand and moves lower ext on bed, follows\n commands to nod head. And nodding head in response appropriately to\n questions. Pt did complain of pain in lower ext\n Action:\n Med witn dilaudid 0.5mg. on mannitol.\n Response:\n No changes in neuro status noted.\n Plan:\n Cont with mainnitol and monitor pt for any changes in weakness or\n strength.\n" }, { "category": "Social Work", "chartdate": "2197-07-11 00:00:00.000", "description": "Social Work Progress Note", "row_id": 469648, "text": "SW consulted to participate in family/team meeting to clarify pt's condition, tr\neatment options, and goals of care. Present at the meeting were pt's son \n, pt's dtr , Attending , Neuro MD , Surgica\nl Critical MD , Anesthesia MD , Anesthesia MD \n , RN , and this writer.\nTeam explained the primary medical problems pt is contending w/ at this time: \n-lateral rear cerebellum stroke, rt side paralysis, facial droop, inability to s\nwallow and no gag reflex. They explained that pt refused a feeding tube earlier\n in the hospital course, though it should be noted she did this in the setting\nof a less severe constellation of medical problems. Team explained that pt will\n likely not regain swallowing function and will likely remain paralyzed (or at l\neast very weak) on her right side indefinitely. If she leaves the hospital, she\nwill require level of care indefinitely. At present, she has been deemed inc\nompetent to make her own medical decisions. She has been intermittently oriente\nd to place and person, though at present she is not. She can communicate only th\nrough nodding at this time. It is unclear to what degree she is able to understa\nnd her present situation, though she is obviously impaired in this respect. It i\ns unclear to what extent she will regain cognitive function in so far as her abi\nlity to engage meaningfully w/ her environment, but team believes her chances ar\ne minimal.\nTeam explained her treatment options: that she could be intubated and, eventuall\ny trached/pegged and live in a long-term care facility. The other treatment opt\nion is to make pt . It was noted in the meeting that pt refused a feeding tu\nbe earlier in her hospital course. Family also noted three indicators of pt's w\nishes & values:\n1) Pt descignated her husband to be when he sufferred a brain aneurysm\n in , citing his quality of life would be inconsistent w/ his wishes &\n values. \"My mom said, 'That's no quality of life for him,'\" referring to being\nin a long-term care facility.\n2) Pt's children said pt has stated she would never want to live in a nurs\ning home\n3) son recounted that pt made her dog when faced w/ the decision\nof \"keeping him alive\" with a poor quality of life vs. \"allowing him to die peac\nefully.\"\nPt's family denied any written documentation indicating her wishes in the event\nshe become incapaciated, unable to make her own medical decisions, and face \ng-term incapacitation and level of care. They denied she has ever given any\nclear indication of what she would want in this situation; rather, she has only\nmade statements of what she would not want (i.e. ).\nAll of pt's family's questions were answered by the team. Team explained that a\ndecision of whether or not to intubate (and, therefore, whether or not pt will\nbe made ) should happen as soon as possible, preferably before tonight. SW st\nayed w/ pt's\nfamily for a few moments after the meeting to continue processing w/ them and to\n provide SW contact information.\nAt this time, it appears pt's son and dtr are struggling to integrate their prev\nious experience of pt as reasonably high-functioning, having her \"good days and\nbad days,\" with the present situation of whether or not to employ intensive, \ng-term interventions or allow her to be made . They are supporting e/o well\nand are actively exploring indicators pt has given about which decision would be\n c/w her wishes & values.\nPlan is for pt's son & dtr to inform team of their decision by tonight. SW will\n relay case information to , LICSW who covers the TSICU during the\nday.\n" }, { "category": "Nursing", "chartdate": "2197-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469751, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert, nodding head to questions ?reliability?. Pt follows commands,\n lifting Les, moves RLE on bed, no mvmtn of RUE. All sensations intact.\n Aphasic w/ some incomprehensible sounds. PERRLA. +corneals. Weak,\n nonproductive, congestive cough. Absent gag. Received on 2L NC and LS\n clear and diminished at bases.\n Action:\n mannitol, warfarin and SQ heparin administered as ordered\n Neuro exams q2hrs\n Family meeting to discuss code status and plan of\n treatment\n Response:\n Neuro exam unchanged. O2 sats dipping slightly to low 90s.\n Bilateral CPT done, NT suctioning attempted. Sodium WNL, osmolality\n pending.\n Plan:\n Awaiting families decision for pt\ns plan of care\n Cont q2hr neuro exams & administer meds as needed\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced, freqeuent PVCs. Pt SBP within\n 140-180.\n Action:\n Diltiazem gtt titrated for HR under 100\n Metoprolol given q4hr for BP management\n Coumadin administered as ordered\n K repleted\n Response:\n HR & SBP maintained w/in goal range\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep\n SBP 140-180 with lopressor.\n" }, { "category": "Nursing", "chartdate": "2197-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469757, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert, nodding head to questions ?reliability?. Pt follows commands,\n lifting Les, moves RLE on bed, no mvmtn of RUE. All sensations intact.\n Aphasic w/ some incomprehensible sounds. PERRLA. +corneals. Weak,\n nonproductive, congestive cough. Absent gag. Received on 2L NC and LS\n clear and diminished at bases.\n Action:\n mannitol, warfarin and SQ heparin administered as ordered\n Neuro exams q2hrs\n Family meeting to discuss code status and plan of\n treatment\n Response:\n Neuro exam unchanged. O2 sats dipping slightly to low 90s.\n Bilateral CPT done, NT suctioning attempted. Sodium WNL, osmolality\n pending.\n Plan:\n Awaiting families decision for pt\ns plan of care\n Cont q2hr neuro exams & administer meds as needed\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced, freqeuent PVCs. Pt SBP within\n 140-180.\n Action:\n Diltiazem gtt titrated for HR under 100\n Metoprolol given q4hr for BP management\n Coumadin administered as ordered\n K repleted\n Response:\n HR & SBP maintained w/in goal range\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep\n SBP 140-180 with lopressor.\n ------ Protected Section ------\n Pts respiratory status slowly deteriorating overnight, from high to low\n 90s. Oral suctioning attempted, pt w/ no gag & weak cough. Acute desat\n to 86%. Pt placed on 100% FiO2 humidified air face tent. HO notified.\n Pts family called prior to invasive intervention per wishes.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:35 ------\n" }, { "category": "Nursing", "chartdate": "2197-07-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 470012, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert and oriented x1. Pt follows commands. Pt has expressive\n aphasia but nods appropriately to some questions. Pt has no movement in\n RUE, but withdraws to pain in the RLE. Pt can lift and hold the LUE and\n LLE. Pt is on 2L NC and LS clear and diminished at bases. Pt coughing\n up secretions but now has absent gag, so secretions need some\n suctioning.\n Action:\n -Mannitol discontinued, Neuro exam changed to q4h\n -family meeting occurred to discuss code status yesterday and family\n changed pt to , a few hr later called and made pt Full . Ethics\n now involved and daughter today found pt\ns living will, which clearly\n states no\nheroic measures\n if her mental and physical status \n return to baseline. Daughter understanding situation and wants to make\n pt , is having trouble with this decision. Social work and\n ethics involved and trying to have another family meeting to make the\n pt\ns wishes known.\n Response:\n -Neuro exam changed and pt now able to speak fairly clearly and say her\n name and the name of her kids.\n -Team is still trying to get in touch with son for a family meeting and\n discuss new development and plan.\n Plan:\n Awaiting families decision for pt\ns plan of care, Pt transfer to\n stepdown\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced. Pt SBP within 140-180.\n Action:\n -Diltiazem gtt titrated for HR under 100\n -metoprolol given q4hr for BP management\n -Coumadin in place\n Response:\n HR wnl and paced. SBP within goal\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep SBP 140-180\n with lopressor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 55.5 kg\n Daily weight:\n 55.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: diabetes, dyslipidemia, hypertension,\n hypothyroidism, hystorectomy, cholecystectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:157\n D:76\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 84 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,393 mL\n 24h total out:\n 785 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:36 AM\n Potassium:\n 3.6 mEq/L\n 04:36 AM\n Chloride:\n 105 mEq/L\n 04:36 AM\n CO2:\n 24 mEq/L\n 04:36 AM\n BUN:\n 21 mg/dL\n 04:36 AM\n Creatinine:\n 1.2 mg/dL\n 04:36 AM\n Glucose:\n 140 mg/dL\n 04:36 AM\n Hematocrit:\n 38.3 %\n 04:36 AM\n Finger Stick Glucose:\n 130\n 02:00 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: \n Transferred to: 11\n Date & time of Transfer: 1630\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469297, "text": "The patient is an 84 year old right handed woman with a history of\n chronic atrial fibrillation not on Coumadin who converted from sinus\n rhythm to atrial fibrillation 2 weeks PTA, symptomatic sinus\n bradycardia s/p PPM , and hypertension who presented to .\n Upon primary cardiology team evaluation at 7:30 am, she was noted\n to have difficulty lifting her right arm against gravity, but could\n move her right leg against gravity. The nurse reported that the patient\n has been having trouble swallowing her pills. The nurse also was the\n same one who took care of the patient the day before, and said that her\n voice was not hoarse as of at 3:00 pm. She also had nystagmus at\n right end-gaze and upgoing toes bilaterally. Head CT/CTA/CTP shows a\n right cerebellar infarct with concern for evolution from 1 am to 11 am\n today, also left ICA occlusion. Thromboembolic event in the setting of\n AF. The right cerebellar stroke is likely due to right PICA occlusion\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Unable to move R.side, complete R. hemiparesis, PERL, poor gag/cough,\n chokes on clears, no seizures noted, garbled speech, disoriented in\n place/time, combative and resistant to care\n Action:\n Mannitol q6h, neuro checks q1-2 hours, quiet environment, restrained\n according to protocol\n Response:\n No changes in neuro status since 7pm last night\n Plan:\n Family meeting , CT head today, clearfy code status with the family,\n monitor osmo/sodium\n Atrial fibrillation (Afib)\n Assessment:\n 84 YO female with HTN, diastolic CHF, paf who over the past 9 months\n has been experiencing decrease exercise tolerance with progressively\n worsening shortness of breath that improved after pacer placement (St.\n XL DR 5816) in for sinus bradycardia with\n Wenckebach. There has been a more recent increase fatigue, shortness of\n breath, dizziness, HA, nausea, voice change. She stated that this past\n week she could only walk a few steps before becoming symptomatic. HR\n 90-130 irregular, BP by cuff on the r. arm\n Action:\n Lopressor q2h 4 mg\n Response:\n Slows HR down with lopressor but rebounds shortly after, requires\n lopressor q2h, keeps sbp<180\n Plan:\n Keep SBP 140-180, consider if she needs NGT for po Lopressor( after\n family meeting), consider additional IV access\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469302, "text": "The patient is an 84 year old right handed woman with a history of\n chronic atrial fibrillation not on Coumadin who converted from sinus\n rhythm to atrial fibrillation 2 weeks PTA, symptomatic sinus\n bradycardia s/p PPM , and hypertension who presented to .\n Upon primary cardiology team evaluation at 7:30 am, she was noted\n to have difficulty lifting her right arm against gravity, but could\n move her right leg against gravity. The nurse reported that the patient\n has been having trouble swallowing her pills. The nurse also was the\n same one who took care of the patient the day before, and said that her\n voice was not hoarse as of at 3:00 pm. She also had nystagmus at\n right end-gaze and upgoing toes bilaterally. Head CT/CTA/CTP shows a\n right cerebellar infarct with concern for evolution from 1 am to 11 am\n today, also left ICA occlusion. Thromboembolic event in the setting of\n AF. The right cerebellar stroke is likely due to right PICA occlusion\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Unable to move R.side, complete R. hemiparesis, PERL, poor gag/cough,\n chokes on clears, no seizures noted, garbled speech, disoriented in\n place/time, combative and resistant to care\n Action:\n Mannitol q6h, neuro checks q1-2 hours, quiet environment, restrained\n according to protocol\n Response:\n No changes in neuro status since 7pm last night\n Plan:\n Family meeting , CT head today, clearfy code status with the family,\n monitor osmo/sodium\n Atrial fibrillation (Afib)\n Assessment:\n 84 YO female with HTN, diastolic CHF, paf who over the past 9 months\n has been experiencing decrease exercise tolerance with progressively\n worsening shortness of breath that improved after pacer placement (St.\n XL DR 5816) in for sinus bradycardia with\n Wenckebach. There has been a more recent increase fatigue, shortness of\n breath, dizziness, HA, nausea, voice change. She stated that this past\n week she could only walk a few steps before becoming symptomatic.\n Today her HR 90-130 irregular with rare PVCs, BP by cuff on the r. arm.\n Weak pulses., Easily bruised skin\n SBP stay 150-170s, no pacer spikes noted\n Action:\n Lopressor q2h 4 mg\n Response:\n Slows HR down with lopressor but rebounds shortly after, requires\n lopressor q2h, keeps sbp<180\n Plan:\n Keep SBP 140-180, consider if she needs NGT for po Lopressor( after\n family meeting), consider additional IV access\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469287, "text": "The patient is an 84 year old right handed woman with a history of\n chronic atrial fibrillation not on Coumadin who converted from sinus\n rhythm to atrial fibrillation 2 weeks PTA, symptomatic sinus\n bradycardia s/p PPM , and hypertension who presented to \n with DOE and 2 days of hoarse voice, and was found to have nystagmus at\n right endgaze, flattening of the right NLF, and right arm>leg weakness\n called by Neurology as a CODE STROKE.\n Upon primary cardiology team evaluation at 7:30 am, she was noted\n to have difficulty lifting her right arm against gravity, but could\n move her right leg against gravity. The nurse reported that the patient\n has been having trouble swallowing her pills. The nurse also was the\n same one who took\n care of the patient the day before, and said that her voice was not\n hoarse as of at 3:00 pm. She also had nystagmus at right end-gaze\n and upgoing toes bilaterally. Head CT/CTA/CTP shows a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. To\n put this together, she most likely had a thromboembolic event in the\n setting of AF. The right cerebellar stroke is likely due to right PICA\n occlusion\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n 84 YO female with HTN, diastolic CHF, paf who\n over the past 9 months has been experiencing decrease exercise\n tolerance with progressively worsening shortness of breath that\n improved after pacer placement (St. XL DR \n 5816) in for sinus bradycardia with Wenckebach. There has\n been a more recent increase fatigue, shortness of breath,\n dizziness, HA, nausea, voice change. She stated that this past\n week she could only walk a few steps before becoming symptomatic\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469350, "text": "The patient is an 84 year old right handed woman with a history of\n chronic atrial fibrillation not on Coumadin who converted from sinus\n rhythm to atrial fibrillation 2 weeks PTA, symptomatic sinus\n bradycardia s/p PPM , and hypertension who presented to .\n Upon primary cardiology team evaluation at 7:30 am, she was noted\n to have difficulty lifting her right arm against gravity, but could\n move her right leg against gravity. The nurse reported that the patient\n has been having trouble swallowing her pills. The nurse also was the\n same one who took care of the patient the day before, and said that her\n voice was not hoarse as of at 3:00 pm. She also had nystagmus at\n right end-gaze and upgoing toes bilaterally. Head CT/CTA/CTP shows a\n right cerebellar infarct with concern for evolution from 1 am to 11 am\n today, also left ICA occlusion. Thromboembolic event in the setting of\n AF. The right cerebellar stroke is likely due to right PICA occlusion\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Unable to move R.side, complete R. hemiparesis, PERL, poor gag/cough,\n chokes on clears, no seizures noted, garbled speech, disoriented in\n place/time, combative and resistant to care\n Action:\n Mannitol q6h, neuro checks q1-2 hours, quiet environment, restrained\n according to protocol\n Response:\n No changes in neuro status since 7pm last night\n Plan:\n Family meeting, anticoagulation with Coumadin. CT head today, clearfy\n code status with the family, monitor osmo/sodium\n Atrial fibrillation (Afib)\n Assessment:\n 84 YO female with HTN, diastolic CHF, paf who over the past 9 months\n has been experiencing decrease exercise tolerance with progressively\n worsening shortness of breath that improved after pacer placement (St.\n XL DR 5816) in for sinus bradycardia with\n Wenckebach. There has been a more recent increase fatigue, shortness of\n breath, dizziness, HA, nausea, voice change. She stated that this past\n week she could only walk a few steps before becoming symptomatic.\n Today her HR 90-130 irregular with rare PVCs, BP by cuff on the r. arm.\n Weak pulses., Easily bruised skin\n SBP stay 150-170s, no pacer spikes noted\n Action:\n Lopressor q2h 4 mg\n Response:\n Slows HR down with lopressor but rebounds shortly after, requires\n lopressor q2h, keeps sbp<180\n Plan:\n Keep SBP 140-180, consider if she needs NGT for po Lopressor( after\n family meeting), consider additional IV access\n" }, { "category": "Physician ", "chartdate": "2197-07-10 00:00:00.000", "description": "Intensivist Note", "row_id": 469380, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n Chief complaint:\n CVA\n PMHx:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n .\n Allergies: NKDA\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Aspirin 5. Bisacodyl 6. Docusate\n Sodium 7. Famotidine 8. Heparin\n 9. Insulin 10. Levothyroxine Sodium 11. Lidocaine 1% 12. Mannitol 13.\n Mannitol 14. Metoprolol Tartrate\n 15. Metoprolol Tartrate 16. Metoprolol Tartrate 17. Ondansetron 18.\n Pneumococcal Vac Polyvalent 19. Potassium Chloride\n 20. Senna 21. Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 23. Warfarin\n 24 Hour Events:\n : Pt was tachycardic to 120s, tx'd with metoprolol. Several periods\n of apnea > 30sec. Repeat CT head showed expanding R and L cerebellar\n infarctions. Pt placed on mannitol, ASA, coumadin. Pt refused NG tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:24 PM\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Metoprolol - 05:20 AM\n Other medications:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36\nC (96.8\n HR: 112 (101 - 126) bpm\n BP: 153/109(121) {101/65(77) - 181/126(134)} mmHg\n RR: 13 (11 - 24) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 920 mL\n 601 mL\n PO:\n Tube feeding:\n IV Fluid:\n 920 mL\n 601 mL\n Blood products:\n Total out:\n 800 mL\n 610 mL\n Urine:\n 800 mL\n 610 mL\n NG:\n Stool:\n Drains:\n Balance:\n 120 mL\n -9 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n No(t) Moves all extremities, (RUE: Weakness), (RLE: Weakness)\n Labs / Radiology\n 277 K/uL\n 12.9 g/dL\n 113 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 20 mg/dL\n 100 mEq/L\n 139 mEq/L\n 38.1 %\n 6.5 K/uL\n [image002.jpg]\n 03:13 AM\n WBC\n 6.5\n Hct\n 38.1\n Plt\n 277\n Creatinine\n 1.3\n Glucose\n 113\n Other labs: PT / PTT / INR:12.3/24.7/1.0, Ca:9.4 mg/dL, Mg:2.1 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), embolic\n origin\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: NEURO: Pt has defecits consistant with a diffuse left-sided\n CVA, including a large cerebellar infarction.\n - Start mannitol\n - Elevate HOB 30 degrees\n - Keep SBP b/w 140 and 180 - hold home amlodipine.\n - Obtain CT head PRN, scheduled .\n - ASA 325 mg PO daily (give PR if dysphagia)\n -Hold off heparin gtt for now given large size of left cerebellar\n infarct\n Neuro checks Q1hr\n Pain: Pt not in pain\n Cardiovascular: Pt is in AFib w RVR. Likely that clot is being showered\n to CNS from fibrillating heart.\n - coumadin, SQ heparin started for anticoagulation\n - BP control as above with metoprolol.\n - Rate control with metoprolol.\n - TTE to assess clot burden\n Pulmonary: Pt has had several episodes of apnea x30 seconds.\n - Support airway PRN.\n - Discuss code status with family.\n Gastrointestinal / Abdomen: Pt has poor gag reflex, failed a bedside\n swallow eval. Keep pt NPO. Place NG tube. Start tube feeds.\n Nutrition: NPO, Pt refused NGT. Recognize issue of obtaining feeding\n site, will support family and patient wishes pending discussion with\n family\n Renal: Creatinine 1.3, at baseline.\n - continue maintanence fluids\n Hematology: Hct stable at 43.\n Endocrine: RISS\n -Continue Levothyroxine\n Infectious Disease: No signs of infection.\n Lines / Tubes / Drains: PIV, Foley\n - place NGT\n Wounds:\n Imaging: CT scan head today, LENI, TEE\n Fluids: LR\n Consults: Neurology\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2197-07-11 00:00:00.000", "description": "Intensivist Note", "row_id": 469555, "text": "TSICU\n HPI:\n 84 year old woman w a history of atrial fibrillation without\n anticoagulation presents with several ischemic CNS lesions, likely due\n to embolic events.\n Chief complaint:\n stroke\n PMHx:\n PMH/PSH:\n Chronic atrial fibrillation not on Coumadin\n Symptomatic sinus bradycardia with prolonged PR s/p St. PPM\n \n CHF, LVEF >55%\n Hypertension\n Hypothyroidism s/p resection of thyroid nodule\n PSH: s/p hysterectomy in for \"uterine growth\"\n .\n :\n Metoprolol Tartrate 12.5 mg PO Q6H\n Amlodipine 10 mg PO DAILY\n Levothyroxine Sodium 50 mcg PO DAILY\n Docusate Sodium 100 mg PO BID\n Heparin 5000 UNIT SC TID\n Senna 1 TAB PO BID:PRN constipation\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ondansetron 4 mg IV Q8H:PRN nausea\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:39 AM\n ULTRASOUND - At 02:04 PM\n LENI's\n EKG - At 05:04 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:23 PM\n Diltiazem - 04:36 PM\n Famotidine (Pepcid) - 10:16 PM\n Metoprolol - 04:38 AM\n Other medications:\n Flowsheet Data as of 06:07 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: 36.3\nC (97.4\n HR: 95 (74 - 126) bpm\n BP: 172/80(104) {144/70(96) - 179/122(136)} mmHg\n RR: 21 (10 - 24) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 53.2 kg (admission): 55.5 kg\n Total In:\n 2,693 mL\n 646 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,693 mL\n 646 mL\n Blood products:\n Total out:\n 2,380 mL\n 395 mL\n Urine:\n 2,380 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 313 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered rhonchi), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No movement)\n Labs / Radiology\n 277 K/uL\n 12.8 g/dL\n 100 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 102 mEq/L\n 139 mEq/L\n 38.5 %\n 8.9 K/uL\n [image002.jpg]\n 03:13 AM\n 02:00 PM\n 05:01 PM\n 02:26 AM\n WBC\n 6.5\n 8.9\n Hct\n 38.1\n 38.5\n Plt\n 277\n 277\n Creatinine\n 1.3\n 1.3\n 1.5\n Glucose\n 113\n 103\n 101\n 100\n Other labs: PT / PTT / INR:17.8/27.8/1.6, Differential-Neuts:81.5 %,\n Lymph:9.6 %, Mono:7.8 %, Eos:1.0 %, Ca:9.4 mg/dL, Mg:2.3 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC\n Assessment and Plan: 84 year old woman w a history of atrial\n fibrillation without anticoagulation presents with several ischemic CNS\n lesions, likely due to embolic events.\n Neurologic: (1) multiple embolic strokes: evolving cerebellar\n infarction on CT , taper off mannitol today, keep SBP 140s-180s,\n will need to clarify goals of care with family/patient at family\n meeting today (2) pain: comfortable not requiring opiates (3) Pt\n refusing procedures. Competence unclear. likely need family\n meeting today.\n Cardiovascular: Full anticoagulation, Beta-blocker, rate controlled on\n diltiazem gtt + metoprolol, goal HR 80s-100s, if < 80 increased number\n of PVCs, on coumadin, likely embolizing from clot in fibrillating\n atria, TTE shows no atrial thrombus, no PFO (although no bubble study\n done)\n Pulmonary: no active issues\n Gastrointestinal / Abdomen: no active issues\n Nutrition: Pt has poor gag reflex, failed a bedside swallow eval. Keep\n pt NPO. patient refuses NG tube\n Renal: Foley, Adequate UO, good urine output, rising creatinine, will\n follow\n Hematology: stable HCt\n Endocrine: RISS, synthroid\n Infectious Disease: No signs of infection.\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds:\n Imaging:\n Fluids: LR\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 08:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469443, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert and oriented x2/3. Pt follows commands. Pt has expressive\n aphasia but nods appropriately to questions. Pt has no movement in RUE,\n but withdraws to pain in the RLE. Pt can lift and hold the LUE and LLE.\n Pt is on room air and LS clear. Pt denies wanting NG tube placement.\n Action:\n -TEE, LENI\ns, EKG and Head CT performed today\n -Pt on mannitol, warfarin and SQ heparin\n -Q1hr neuro checks\n Response:\n -Pt Sodium and Osmo within limits.\n -Neuro exam unchanged\n -CT pending read\n Plan:\n Plan for Family meeting tomorrow with pt and team to discuss code\n status and pt\ns wants for plan of care. Plan to stop mannitol treatment\n tmr and other option is craniotomy for swelling.\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 100s to 140s afib and paced. Pt SBP within 140-180. Pt given\n q4hr metoprolol and prn Lopressor for rate and BP management. Pt unable\n to keep rate down, with betablockers\n Action:\n -Diltiazem bolus and gtt started\n -EKG performed\n -Coumadin in place\n Response:\n HR wnl and paced. SBP within goal\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100.\n" }, { "category": "Nursing", "chartdate": "2197-07-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469457, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert and oriented x2/3. Pt follows commands. Pt has expressive\n aphasia but nods appropriately to questions. Pt has no movement in RUE,\n but withdraws to pain in the RLE. Pt can lift and hold the LUE and LLE.\n Pt is on room air and LS clear. Pt denies wanting NG tube placement.\n Action:\n -TEE, LENI\ns, EKG and Head CT performed today\n -Pt on mannitol, warfarin and SQ heparin\n -Q1hr neuro checks\n Response:\n -Pt Sodium and Osmo within limits.\n -Neuro exam unchanged\n -CT pending read\n Plan:\n Plan for Family meeting tomorrow with pt and team to discuss code\n status and pt\ns wants for plan of care. Plan to stop mannitol treatment\n tmr and other option is craniotomy for swelling.\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 100s to 140s afib and paced. Pt SBP within 140-180. Pt given\n q4hr metoprolol and prn Lopressor for rate and BP management. Pt unable\n to keep rate down, with betablockers\n Action:\n -Diltiazem bolus and gtt started\n -EKG performed\n -Coumadin in place\n Response:\n HR wnl and paced. SBP within goal\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100.\n" }, { "category": "Nursing", "chartdate": "2197-07-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469679, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert and oriented x1. Pt follows commands. Pt has expressive\n aphasia but nods appropriately to some questions. Pt has no movement in\n RUE, but withdraws to pain in the RLE. Pt can lift and hold the LUE and\n LLE. Pt is on 2L NC and LS clear and diminished at bases. Pt coughing\n up secretions but now has absent gag, so secretions need some\n suctioning.\n Action:\n -Pt on mannitol, warfarin and SQ heparin\n -Neuro exam changed from q1h to q2h\n -family meeting occurred to discuss code status and plan of treatment\n Response:\n -Pt Sodium and Osmo within limits.\n -Neuro exam unchanged\n -Family said that\nMy mother said she would not want to live in a\n nursing home and that their was no quality of life\n. Son and Daughter\n ( and ) are taking 24hr to discuss and make a decision\n Plan:\n Awaiting families decision for pt\ns plan of care\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced. Pt SBP within 140-180.\n Action:\n -Diltiazem gtt titrated for HR under 100\n -metoprolol given q4hr for BP management\n -Coumadin in place\n Response:\n HR wnl and paced. SBP within goal\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep SBP 140-180\n with lopressor.\n" }, { "category": "Nursing", "chartdate": "2197-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469731, "text": "84 year old woman w a history of atrial fibrillation without\n anticoagulation and pacemaker placement for bradycardia was transferred\n to the T-SICU for multiple CNS defecits. The patient was admitted to\n cardiology on for a CHF exacerbation with DOE x2 wk. She had\n hoarseness starting on . On , the patient triggered for AMS and\n tachycardia to 140 and was treated for AFib. On at 0100, the\n patient was found to be dysarthric and weak. She recieved a CT head,\n which showed several subacute and chronic sites of infarction. At\n 7:30AM, the patient was noted to have difficulty speaking, difficulty\n swallowing, and right-sided weakness. A CTA showed a right cerebellar\n infarct with concern for evolution from 1 am to 11 am today, also left\n ICA occlusion. The patient is currently oriented x1 with R-sided facial\n droop, R arm and leg weakness (3/5 strength), and profoundly\n dysarthric.\n Injuries:\n - evolving left cerebellar infarct\n - occlusion of the left common carotid artery within a centimeter of\n its origin.\n - intraluminal thrombus of the distal right vertebral artery\n - left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification.\n - It is likely that the left vertebral artery participates in a so\n called \"subclavian steal,\" accounting for the disparate blood pressures\n noted on physical examination.\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Pt alert, nodding head to questions ?reliability?. Pt follows commands,\n lifting Les, moves RLE on bed, no mvmtn of RUE. All sensations intact.\n Aphasic w/ some incomprehensible sounds. PERRLA. +corneals. Weak,\n nonproductive, congestive cough. Absent gag. Received on 2L NC and LS\n clear and diminished at bases.\n Action:\n mannitol, warfarin and SQ heparin administered as ordered\n Neuro exams q2hrs\n Family meeting to discuss code status and plan of\n treatment\n Response:\n Neuro exam unchanged. O2 sats dipping slightly to low 90s. Bilateral\n CPT done, NT suctioning attempted.\n Plan:\n Awaiting families decision for pt\ns plan of care\n Cont q2hr neuro exams & administer meds as needed\n Atrial fibrillation (Afib)\n Assessment:\n HR in the 80s -100s afib and paced, freqeuent PVCs. Pt SBP within\n 140-180.\n Action:\n Diltiazem gtt titrated for HR under 100\n Metoprolol given q4hr for BP management\n Coumadin administered as ordered\n K repleted\n Response:\n HR & SBP maintained w/in goal range\n Plan:\n Continue Diltiazem gtt and titrate for a HR 80-100 and keep\n SBP 140-180 with lopressor.\n" }, { "category": "ECG", "chartdate": "2197-07-10 00:00:00.000", "description": "Report", "row_id": 150350, "text": "Atrial fibrillation. Predominantly ventricular pacing with occasional\nconducted complexes. Since the previous tracing the rate is slower and\nventricular pacing is now seen in most of the beats.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2197-07-09 00:00:00.000", "description": "Report", "row_id": 150351, "text": "Atrial fibrillation with a rapid ventricular response. Vertical axis.\nIntraventricular conduction delay of right bundle-branch block type. Consider\nleft posterior hemiblock. Since the previous tracing earlier the same date\nthe rate is faster. There is a single ventricular paced beat.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2197-07-09 00:00:00.000", "description": "Report", "row_id": 150352, "text": "Atrial fibrillation with variable ventricular response. Vertical axis.\nRSR' pattern in the early precordial leads. Consider right bundle-branch\nblock. ST-T wave abnormalities. Since the previous tracing of the\nrate is slower.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2197-07-08 00:00:00.000", "description": "Report", "row_id": 150353, "text": "Compared to the previous tracing ventricular fusion beats and demand\nventricular paced beats are no longer evident. The mechanism is atrial\nfibrillation with rapid ventricular response rate of approximately 115.\nThere are no significant ventricular pauses.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2197-07-08 00:00:00.000", "description": "Report", "row_id": 150354, "text": "Probable atrial fibrillation with semi-regularization of ventricular rate,\nwith dominant ventricular response rate of approximately 140. Occasional\ndemand ventricular paced beat and occasional fusion beat between spontaneous\nand demand paced beat. Right bundle-branch block/left posterior hemiblock.\nGeneralized non-specific repolarization abnormalities. Compared to the\nprevious tracing of atrio-ventricular sequential paced rhythm has given\nway to the rhythm noted above.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2197-07-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1086917, "text": " 1:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o emboli\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with afib not on coumadin\n REASON FOR THIS EXAMINATION:\n r/o emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SUN 6:39 AM\n PFI: New right cerebellar hemisphere hypodensity (2,5) which likely\n represents prior infarct, indeterminate age. Extensive chronic small vessel\n ischemic changes and prior infarcts are again identified. No shift in\n structures. Cisterns are patent. No evidence of acute hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: .\n\n HISTORY: Afib, not on Coumadin, evaluate for emboli.\n\n TECHNIQUE: MDCT axially acquired images of the brain were obtained. No IV\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: The ventricles and sulci are prominent, consistent with age-related\n atrophy. There are several low density areas within the white matter of both\n cerebral hemispheres, largest in the right occipital lobe (2,11), which is not\n significantly changed when compared to prior exam. There is no overt mass\n effect. There is increased periventricular white matter hypodensities\n consistent with chronic small vessel ischemic changes. There is no evidence\n of acute hemorrhage or shift of normally midline structures.\n\n In the right cerebellar hemisphere, (2,5) there is a new hypodensity when\n compared to prior exam from . This likely represents an infarct, subacute\n to chronic in age. Considering the infarct's size, there is relatively little\n mass effect. Atherosclerotic calcifications of the cavernous portions of both\n internal carotids are again identified, unchanged.\n\n There is no evidence of acute fracture. The visualized paranasal sinuses are\n clear except to note mild mucosal thickening of the right posterior ethmoidal\n cells.\n\n IMPRESSION: New hypodensity in the right cerebellar hemisphere, suggestive of\n infarction, subacute to to chronic in age. Multiple prior infarcts\n throughout the cerebral hemispheres, largely unchanged. No evidence of acute\n hemorrhage or shift of normally midline structures. Mild brain atrophy.\n\n\n (Over)\n\n 1:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o emboli\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2197-07-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1086835, "text": " 10:33 AM\n CHEST (PA & LAT) Clip # \n Reason: acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with DOE, CHF\n REASON FOR THIS EXAMINATION:\n acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with dyspnea on exertion and CHF. Question\n acute cardiopulmonary process.\n\n COMPARISON: Chest radiographs of .\n\n FRONTAL AND LATERAL VIEWS OF THE CHEST: A left-sided pacemaker is seen with\n leads terminating in the expected location of the right atrium and right\n ventricle. Since the prior study, the lead going to the right ventricle now\n has a slight upward curvature of the lead closer towards its distal aspect;\n however, the end of the lead terminates in approximately the same location as\n it did on the prior study. No pulmonary edema is present. Lungs are slightly\n hyperinflated, suggesting a degree of emphysema. Otherwise, the lungs are\n clear bilaterally with no focal areas of consolidation. Blunting of the\n posterior costophrenic angles is chronic. There is no sizeable pleural\n effusion or pneumothorax. The cardiomediastinal silhouette is within normal\n limits. Breast implants are again seen, calcified. A 6-mm dense nodule is seen\n projecting over a right rib, unchanged and may represent a bone island. Clips\n in the right upper quadrant suggest prior cholecystectomy.\n\n IMPRESSION: No acute cardiothoracic process.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2197-07-10 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1087097, "text": " 2:37 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: EMBOLIC CVA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p embolic stroke\n REASON FOR THIS EXAMINATION:\n r/o LE source\n ______________________________________________________________________________\n FINAL REPORT\n \n Department of Radiology\n Standard Report - Normal Venous Vascular/US Exam\n\n\n Study: Bilateral Lower Extremity Venous\n\n\n Reason: embolic CVA ? source\n\n Findings: Duplex evaluation was performed on the left lower extremity veins.\n There is normal compression and augmentation of the common femoral, proximal\n femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal\n veins. There is normal phasicity of the common femoral veins bilaterally.\n\n\n\n Impression: No evidence of bilateral lower extremity deep vein thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2197-07-08 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1086892, "text": " 5:33 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Patient admitted for increase fatigue, Nausea and vomitting.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with abd distention, n/v.\n REASON FOR THIS EXAMINATION:\n Patient admitted for increase fatigue, Nausea and vomitting.\n ______________________________________________________________________________\n WET READ: JKSd SAT 7:51 PM\n No evidence of obstruction with air and stool seen down to the level of the\n rectum. No abdominal air. Degenerative changes in visualized spine.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, TWO VIEWS, \n\n CLINICAL INFORMATION: Fatigue, nausea and vomiting.\n\n FINDINGS:\n\n Clips are present in the right upper quadrant. Radiopaque material projects\n over the right hip joint of unclear etiology. There are degenerative changes\n in the lumbar spine. There are scattered air-filled loops of small bowel and\n colon, but none demonstrate dilatation. There is no free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-07-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087110, "text": " 4:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with multiple strokes\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 7:40 PM\n Unchanged hypodensities in bilateral cerebellar hemispheres.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old woman with multiple strokes, evaluate for interval\n change.\n\n HEAD CT: Axial imaging was performed through the brain without IV contrast\n administration.\n\n COMPARISON: CT head .\n\n FINDINGS: There is a 3.5 x 4.3 cm hypodensity in the right cerebellar\n hemisphere. There is additional hypodensity in the left cerebellar\n hemisphere. Allowing for differences in head position, the size of these\n hypodensities appears unchanged. There is unchanged hypodensity in the right\n vertebral artery, which may represent intraluminal thrombus seen on prior CTA\n examination. There is no shift of normally midline structures and there is no\n evidence for herniation. There is hypodensity in the region of the left basal\n ganglia likely representing a lacunar infarct. There is periventricular white\n matter hypodensity likely the sequela of small infarction. There is no\n evidence for acute hemorrhage. The osseous structures appear intact. The\n paranasal sinuses, ethmoid and mastoid air cells are well aerated.\n Hypodensities seen in the right masticator space likely represent air and\n small venules.\n\n There is slight prominence of the ventricles and sulci likely the sequela of\n age-related parenchymal atrophy. There is no dilation of the fourth\n ventricle.\n\n IMPRESSION:\n 1. Stable appearance to hypodensities representing areas of infarction in\n bilateral cerebellar hemispheres with greater involvement of the right\n cerebellar hemisphere.\n 2. No evidence for hemorrhagic transformation, no evidence for herniation.\n 4. Stable small vessel microvascular disease and left basal ganglia lacunar\n infarct.\n\n (Over)\n\n 4:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2197-07-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087111, "text": ", C. NMED TSICU 4:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with multiple strokes\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Unchanged hypodensities in bilateral cerebellar hemispheres.\n\n" }, { "category": "Radiology", "chartdate": "2197-07-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1086918, "text": ", A. 1:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o emboli\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with afib not on coumadin\n REASON FOR THIS EXAMINATION:\n r/o emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: New right cerebellar hemisphere hypodensity (2,5) which likely\n represents prior infarct, indeterminate age. Extensive chronic small vessel\n ischemic changes and prior infarcts are again identified. No shift in\n structures. Cisterns are patent. No evidence of acute hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2197-07-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1086973, "text": " 3:46 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change, TO BE DONE AT 6:00 PM on \n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with right cerebellar infarct\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, TO BE DONE AT 6:00 PM on \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 84-year-old female with right cerebellar infarct.\n Evaluate for interval change.\n\n EXAMINATION: Non-contrast head CT scan.\n\n COMPARISONS: Comparison to head CT from performed at 10:30 a.m.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n FINDINGS: Overall, there is no significant interval change from prior\n examination from performed at 10:30 a.m. There is a persistent large\n area of hypodensity within the right cerebellum best seen on (2A:6) that is\n unchanged since examination in the a.m. In addition, there is hypodensity\n within the inferolateral aspect of the left cerebellar hemisphere, best seen\n on (2A:6). Hyperdense right vertebral artery, best seen on (2A:5) and (2A:8)\n correlates with the CTA examination performed in the a.m., which likely\n represents intraluminal thrombus. No hemorrhage, masses, or mass effect.\n There is no evidence of midline shift. The basal cisterns are patent. No\n other areas of acute infarction, periventricular hypodensity compatible with\n chronic infarction. In addition, there is old lacunar infarct involving the\n left basal ganglia. No acute fracture. The visualized portions of the\n paranasal sinuses and mastoid air cells are well aerated. The ventricles and\n sulci are prominent compatible with age-related involutional changes.\n\n IMPRESSION: Overall, no significant interval change in left of right-sided\n cerebellar hypodensity compatible with infarction and possible left-sided\n cerebellar hypodensity and hyperdensity of the right vertebral artery\n compatible with intraluminal thrombus.\n\n COMMENT AT ATTENDING REVIEW: I believe the left cerebellar hemispheric lesion\n may be slightly more hypodense than the first of the present CT\n series, suggesting it is evolving. There is no cerebellar tonsillar or upward\n herniation of the vermis noted. The right vertebral artery, noted in Dr.\n report does exhibit atherosclerotic calcification, accounting for at least\n some of its reported hyperdensity, although the clot noted on the prior CT\n angiogram may also contribute to this appearance.\n\n (Over)\n\n 3:46 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change, TO BE DONE AT 6:00 PM on \n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2197-07-09 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1086948, "text": " 10:27 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Evaluate for carotid dissection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with weakness, hoarseness, and difference in BP, right arm\n 151/111 and left arm 135/77, weaker pulses on on the left\n REASON FOR THIS EXAMINATION:\n Evaluate for carotid dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY OF THE NECK AND HEAD\n\n HISTORY: 84-year-old woman with weakness and hoarseness and difference in\n blood pressure, right arm 151/111 and left arm 135/37, weaker pulses on the\n left. Evaluate for carotid dissection.\n\n TECHNIQUE: Bolus intravenously enhanced imaging of the neck and head\n vasculature was obtained, with multiplanar reconstructions.\n\n COMPARISON STUDIES ON PACS ARCHIVE: head CT scan from 1:10 a.m.\n\n FINDINGS: The non-contrast head CT scan shows no definite interval change\n from the previous study, aside from questionably slight increase in extent of\n the right cerebellar infarct volume, which if correct, implies that this\n infarct is subacute. Interpretive difficulties in this regard arise because\n scan sections from different studies are not of comparable orientation. Also,\n when using the higher resolution post- contrast images as part of the CT\n angiogram, there does appear to be a small area of hypodensity within the\n inferolateral aspect of the left cerebellar hemisphere. This second lesion is\n consistent with an evolving left cerebellar infarct.\n\n Following the contrast infusion, the CT angiogram demonstrates occlusion of\n the left common carotid artery within a centimeter of its origin. There is\n extremely severe atherosclerotic calcification of the left common carotid\n bifurcation, and what is likely to be left external to internal carotid\n arterial flow opacifying a somewhat diminutive intracervical portion of the\n left internal carotid artery. As the internal carotid artery becomes\n intracranial, its caliber appears to increase, potentially in part due to\n collateral flow across the circle of .\n\n Upon review of the source images, there is concern for an intraluminal\n thrombus of the distal right vertebral artery, just proximal to its entrance\n intracranially, measuring slightly over 1cm in length. The vessel in this\n area is not occluded. Otherwise, the major vascular tributaries of the circle\n of appear patent.\n\n The left subclavian artery is occluded at its origin, with extensive\n surrounding atherosclerotic calcification. The occlusion extends towards the\n region of the origin of the left vertebral artery. Both vertebral arteries\n (Over)\n\n 10:27 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: Evaluate for carotid dissection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appear patent, with the right being somewhat larger. It is likely that the\n left vertebral artery participates in a so called \"subclavian steal,\"\n accounting for the disparate blood pressures noted on physical examination.\n\n Perfusion measurements were also obtained, and show protracted mean transit\n time within the large right cerebellar infarct, and likely within the smaller\n left cerebellar infarct. The blood volume within the right cerebellar infarct\n is also reduced as is blood flow.\n\n Finally, there is a left thyroid lobe mass, with heterogeneous density,\n measuring 20 x 42 mm. This lesion requires further evaluation with\n son.\n\n CONCLUSION: Multiple regions of vascular occlusion and infarctions, described\n in detail above. Left subclavian steal. Likely intraluminal thrombus in\n distal right vertebral artery.\n\n All findings discussed by me with Dr. , neurology attending, at\n 1:30PM on .\n\n" }, { "category": "Radiology", "chartdate": "2197-07-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1087950, "text": " 1:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Stroke.\n\n Portable AP chest radiograph was compared to .\n\n The NG tube tip has been exchanged by the feeding tube. The cardiomediastinal\n silhouette is stable. There is interval development of left lower lobe\n opacity consistent with atelectasis, although infection process cannot be\n excluded. The patient is in volume overload/mild pulmonary edema accompanied\n by bilateral pleural effusions. Bilateral breast prostheses, partially\n calcified, are redemonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1087599, "text": " 12:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with NGT\n REASON FOR THIS EXAMINATION:\n evaluate position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:02 PM\n PFI: NG tube in good position. Lower lung volumes and increasing\n retrocardiac opacity. The latter finding may relate to atelectasis, however,\n a developing pneumonia cannot be excluded and clinical correlation is\n recommended.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old female with NG tube placed.\n\n An AP upright portable chest radiograph is compared to . An NG tube\n terminates within the stomach, in good position. A dual-lead pacemaker is\n unchanged in position. Lung volumes are low. This may account for a\n developing retrocardiac opacity. However, the differential diagnosis includes\n developing pneumonia. A well-circumscribed granuloma in the right lower lobe\n is unchanged. Surgical clips project over the right upper quadrant. Note is\n made of calcified breast implants.\n\n" }, { "category": "Radiology", "chartdate": "2197-07-14 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1087770, "text": " 11:20 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: dysphagia\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dysphagia unable to insert NG tube\n REASON FOR THIS EXAMINATION:\n dysphagia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 84-year-old female with dysphagia with inability to\n insert nasogastric tube. For fluoroscopic nasointestinal tube placement.\n\n COMPARISONS: No prior studies available for direct comparison.\n\n FINDINGS: Under continuous fluoroscopic surveillance, -\n feeding tube was initially passed through the left nare through to a post-\n pyloric position. The patient was initially given lidocaine jelly for numbing\n of the left nare. Approximately 5 mL of Conray water-soluble contrast was\n injected through the - tube to confirm a post-pyloric position.\n There were no immediate post-procedural complications. Pacer wires are\n incompletely imaged.\n\n IMPRESSION: Successful placement of - feeding tube in a\n post-pyloric position.\n\n" }, { "category": "Radiology", "chartdate": "2197-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1087600, "text": ", C. NMED TSICU 12:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with NGT\n REASON FOR THIS EXAMINATION:\n evaluate position\n ______________________________________________________________________________\n PFI REPORT\n PFI: NG tube in good position. Lower lung volumes and increasing\n retrocardiac opacity. The latter finding may relate to atelectasis, however,\n a developing pneumonia cannot be excluded and clinical correlation is\n recommended.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2170-07-27 00:00:00.000", "description": "Report", "row_id": 1394322, "text": "RESP CARE: Pt recieved from ED intubated/on vent with settings per carevue. Lungs clear bilat. Sxd scant amt bld tinged sputum. RSBI 32. Plan is to wean pt to PS.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-27 00:00:00.000", "description": "Report", "row_id": 1394323, "text": "TSICU Nsg Admit Note\n Pt is a 21y/o male assault victim who was thrown from the of a car where he was sitting and landed on his head. Pt was noted to have + LOC and seizure actvity at the scene of the accident. He was transported to Hospital where he was initially awake yet perseverating and c/o lack of hearing in left ear, left ear draining bloody fluid. Pt's mental status decompensated and CT at the OSH showed a bleed. Pt was Medflighted to and repeat CT showed acute SAH in right parietal region, possible small SDH near tentorium, as well as facila fx's consisteng of a left zygomatic arch fx and a right maxillary sinus fx as well as fluid in the left auditory canal.\n\nNo PMHx except for asthma for which he occaisionally uses an inhaler\nNo PSHx,\nKNDA's.\n\nCurrent ROS\n\n pt sedated on 20-30mcgs of propofol per hr, when light he MAE's w/ full and purposeful strength however he does not follow specific commands or open his eyes to voice at this time, strong cough and gag, PERL from 2-5mm, corneals intact bilaterally. Some shivering noted yet no seizure activity, pt started on standing dose of dilantin and level prior to dose = 10.4 after receiving load at OSH.\n\n pt in SR 88-100's. BP stable at 98-134/ 65-76, extremities warm and dry w/ brisk pulses x's four, Hct and lytes stable.\n\n pt has no aline yet on a/c 500x's 18 and 40% and 5 PEEP, O2 sat 99-100%. Breath sounds clear bilaterally, suctioned for scant blood tinged secretions.\n\n pt NPO , NGT to LCS w/ 75cc's out grayish fluid. Abd soft nondistended, hypoactive bowel sounds. Pt started on famotidine.\n\n pt / marginal u/o from 20-40cc's hr, getting D5 NS at 120cc's hr. Urine clear, pale yellow.\n\nEndo- BS 91 this AM, no coverage required.\n\nID T max 99. 4, pt started on clinda for facil fxs.\n\n pt's Father and sister in to see patient, parents divorced and father remarried w/ two additional sons. Father choose not to notify the patients Mother at this time because they were afraid she would be too upset, will tell her today. Pt lives w/ friends in yet he is from where his father has a restaurant where he and his sister work.\n\nA/ Pt neurologically unchanged over night, plan for repeat scan this AM and possible wean and extubation, con't to monitor status closely.\n" }, { "category": "Nursing/other", "chartdate": "2170-07-27 00:00:00.000", "description": "Report", "row_id": 1394324, "text": "NPN: Review of Systems\nNeuro: Pt sleeping intermittently. Propofol off since approx. 9:15am.Pt has told me that he is in Hospital, informed me of his age, year he was born and what year and month it is now. PERRL. Restless, attempting to sit up. Repeating that he wants to \"get out of here\". Pt reminded of why he is being monitored and that he must stay flat until spine cleared. Moves all extremities. Follows commands. Spoke w/ sister on the phone. Receiving Dilantin ATC as ordered. No seizure activity observed. Repeat head CT completed.\n\nResp: Extubated approx. 9:30am. Breathing comfortably w/ RR in the low 20s. Sao2 on RA=98%. BS are CTA bilaterally. Strong nonproductive cough.\n\nCV: SR->ST. Depending on activity. HR90s-120s. No ectopy. Stable BP. Please see flowsheet for data and assessment. Skin warm. Palpbale DP/PT pulses bilaterally.\n\nGI: Abdomen is soft. Nondistended. (+) bowel sounds. No c/o nausea.\n\nEndo: Blood sugar WNL. not requirng regular insulin coverage.\n\nSkin: Skin intact w/ exception of abrasion on left side of head. Smal amt of serosanguinous fluid from left ear.\n\nSocial: Sister called and spoke w/ Pt and Nurse.\n\nA: Alert. Hemodynamics and respiratory status stable.\n\nP: F/U w/ CT results. ? have Trauma Service clear TLS. Continue to monitor as ordered. Keep bed alarm since Pt attemtpts to sit up.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-07-27 00:00:00.000", "description": "Report", "row_id": 1394325, "text": "addendum to NPN\nSitter by bedside d/t Pt attempting to get OOB independently. Wants to leave the hospital. Left shoulder x-ray obtained d/t c/o discomfort w/ movement. Awaiting results. IVF stopped. Pt drinking well, but needs encouragement. Mother at bedside at this time. Pt conversing w/ friends. OOB to chair w/ 2 assist. Pt moves well.\n" }, { "category": "Radiology", "chartdate": "2170-07-26 00:00:00.000", "description": "P TRAUMA #2 (AP CXR & PELVIS PORT) PORT", "row_id": 917135, "text": " 10:44 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) PORT Clip # \n Reason: Eval. for fx/disloc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man s/p assault\n REASON FOR THIS EXAMINATION:\n Eval. for fx/disloc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post assault, evaluate for fracture.\n\n COMPARISONS: None.\n\n AP CHEST RADIOGRAPH.\n\n Limited by underlying trauma board. Endotracheal tube is seen with tip below\n the level of the clavicle. Nasogastric tube seen coiled in the stomach.\n Cardiac and mediastinal, hilar contours appear unremarkable. No focal\n consolidation seen within the lungs. No pleural effusions. Pulmonary\n vasculature is unremarkable. No evidence of acute displaced fracture.\n\n AP PELVIS:\n\n Study is limited by underlying trauma board. No acute displaced fracture is\n identified. SI joints and pubic symphysis appear unremarkable.\n\n IMPRESSION: No evidence of acute displaced fracture.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 917170, "text": " 8:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change?\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man s/p assault w/ R SAH.\n REASON FOR THIS EXAMINATION:\n interval change?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assault and right subarachnoid hemorrhage.\n\n TECHNIQUE: Axial non-contrast CT imaging of the brain. Comparison made to\n .\n\n FINDINGS: Mild hyperdensity within the sulci of the right convexity is again\n seen representing subarachnoid hemorrhage that is slightly less apparent\n compared to . No intraparenchymal hemorrhage, mass effect, or shift\n of normally midline structures are seen. The ventricles and sulci are not\n enlarged and unchanged. No CT evidence of acute major vascular territorial\n infarction is seen.\n\n Hyperdensity in the right maxillary sinus consistent with prior hemorrhage is\n again noted. Depressed fracture of the left zygoma is again seen.\n Opacification of the left mastoid air cells is again noted.\n\n IMPRESSIONS:\n\n 1) Diffuse subarachnoid blood within the sulci of the left convexity is again\n noted, but appears slightly decreased compared to . No evidence of\n mass effect, shift of normally midline structures, or hydrocephalus.\n\n 2) Multiple facial injuries including a left zygomatic arch fracture as\n described on previous facial bone CT.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-27 00:00:00.000", "description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT", "row_id": 917255, "text": " 5:32 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: fx\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with left shoulder pain s/p assault\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left shoulder status post assault, assess for fracture.\n\n shoulder, 3 vws\n\n There is diastasis of the AC joint, which measures 11.6 mm, concerning for an\n AC joint ligament sprain/rupture. The coracoclavicular ligament interval is\n at the upper limits of normal measuring 13.4 mm. There is some surrounding\n soft tissue edema. The glenohumeral joint is congruent. No fracture is\n detected.\n\n IMPRESSION: AC joint disruption. No left shoulder fracture identified.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 917362, "text": " 3:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate left temporal bone and skull base for fracture\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with s/p assault with head trauma recent Dx of R SAH, c/o left\n sided hearing difficulty. Skull base study recommended on previous CT report\n REASON FOR THIS EXAMINATION:\n Evaluate left temporal bone and skull base for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Head trauma status post assault with left-sided hearing difficulty.\n Skull base study recommended on previous CT report. Evaluate left temporal\n bone and skull base.\n\n COMPARISON: Head, facial bone, and cervical spine CT scans of .\n\n TECHNIQUE: Axial multidetector CT images of the temporal bones were obtained\n without intravenous contrast and displayed with 2 mm slices. Coronal\n reformatted images were obtained.\n\n FINDINGS: Comminuted left zygomatic arch fracture with depressed fragments is\n again noted. No temporal bone fracture is identified. Aerosolized fluid in\n the left external auditory canal is again noted, unchanged. Fluid is again\n noted in the nasal cavity, ethmoid air cells, and right maxillary sinus,\n without significant change. Mild mucosal thickening remains present in the\n sphenoid and left maxillary sinuses.\n\n IMPRESSION: No evidence of temporal bone fracture.\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2170-07-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 917136, "text": " 10:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P ASSAULT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with head injury, intbuated\n REASON FOR THIS EXAMINATION:\n eval for ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 12:37 AM\n right parietal subarachnoid hemorrhage\n possible small subdural hematoma\n no shift of normally midline structures\n\n depressed fracture of left zygomatic arch\n likely fracture of lateral wall of left maxillay sinus\n\n aerosolized fluid seen in left internal auditory canal and subcutaneous gas\n seen just medial to angle of left mandible, concerning for occult fracture of\n skull base or left temporal bone.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head injury, intubated. Status post assault.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n FINDINGS: High density material is seen tracking along the sulci in the right\n frontovertex region, consistent with subarachnoid hemorrhage. No other extra-\n or intra-axial hemorrhage is identified. There is no shift of normally midline\n structures. There is no evidence of hydrocephalus and the cisterns\n appear patent. - white matter differentiation appears grossly preserved.\n\n High-density fluid is seen within the right maxillary sinus, likely\n representing blood. There is a likely fracture of the lateral wall of the\n right maxillary sinus. Fluid is also seen within the nasal cavity, likely\n representing blood. There is mucosal thickening, within the frontal, ethmoid\n and left maxillary sinus. Depressed, comminuted left zygomatic arch fracture\n is seen. Aerosolized fluid is seen within the left internal auditory canal\n with associated subcutaneous air seen tracking down along the soft tissue in\n the region medial to the left mandibular angle. There is also opacification of\n the left middle ear cavity and numerous mastoid air cells. These findings are\n concerning for occult left temporal bone or skull base fracture.\n\n IMPRESSION:\n 1. Acute subarachnoid hemorrhage identified in the right frontovertex region.\n 2. No shift of normally midline structures, and basal cisterns appear patent.\n 3. Depressed left zygomatic arch fracture. Likely fracture of the right\n maxillary sinus with likely blood seen in the sinus.\n 4. Opacification of left middle ear and mastoid air cells, concerning for\n temporal bone fracture (see separate report of temporal bone CT).\n (Over)\n\n 10:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P ASSAULT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Findings discussed with the surgical team following completion of the study\n and relayed to the ED dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-26 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 917137, "text": " 10:55 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P ASSAULT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with head injury, intubated\n REASON FOR THIS EXAMINATION:\n eval for facial fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 12:28 AM\n depressed fracture of left zygomatic arch\n likely fracture of lateral wall of left maxillay sinus\n\n aerosolized fluid seen in left internal auditory canal and subcutaneous gas\n seen just medial to angle of left mandible, concerning for occult fracture of\n skull base or left temporal bone.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Head injury, intubated. Evaluate for facial fractures.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial non-contrast images of the facial bones were obtained.\n Coronally reformatted images were also displayed.\n\n FINDINGS: There is a depressed fracture seen in the left zygomatic arch.\n Fluid likely representing blood is seen in the right maxillary sinus. There\n is likely small nondisplaced fracture of the lateral wall of the right\n maxillary sinus. Fluid is seen within the turbinates and ethmoid air spaces,\n also possibly representing blood. Minimal mucosal thickening noted within the\n left maxillary sinus and frontal sinuses. Again seen is evidence of\n aerosolized fluid within the left internal auditory canal and subcutaneous gas\n seen just medial to the angle of the left mandible. Findings are concerning\n for an occult fracture of the temporal bone or skull base.\n\n IMPRESSION: Depressed fracture of the left zygomatic arch. Likely fracture\n seen in the lateral wall of the maxillary sinus with resultant fluid in the\n maxillary sinus consistent with blood. Again seen is aerosolized fluid within\n the left internal auditory canal and subcutaneous gas just medial to the angle\n of the left mandible, concerning for an occult fracture in the left temporal\n bone or skull base.\n\n NOTE ADDED IN ATTENDING REVIEW: There is depressed, comminuted left zygoma\n fracture, as noted. There is no definite lateral wall or other right maxillary\n sinus fracture. Given the extensive fluid in the other paranasal sinuses, the\n hyperattenuating material within the right maxillary sinus may represent\n inspissated secretions related to chronic inflammation, as there is sclerosis\n of the walls of this sinus, and permeative changes of the ethmoid septae and\n nasal turbinates. The left temporal bone is not included in this study, and\n should be evaluated by dedicated skull base study.\n (Over)\n\n 10:55 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P ASSAULT\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2170-07-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 917138, "text": " 10:56 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P TRAUMA, ASSAULT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with head injury, intubated\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 12:43 AM\n\n no evidence of acute fracture or spondylolisthesis\n\n aerosolized fluid seen in left\n internal auditory canal and subcutaneous gas\n seen just medial to angle of left mandible, concerning for occult fracture of\n skull base or left temporal bone.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head injury, intubated, evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial non-contrast images of the cervical spine were obtained.\n Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS: There is no evidence of acute fracture or alignment abnormality.\n Evaluation of prevertebral soft tissues is limited by endotracheal and\n nasogastric tubes. CT does not provide intrathecal detail comparable to MRI,\n however there is no deformity of the thecal sac. Again seen is opacification\n of several of the included left mastoid air cells and subcutaneous gas medial\n to the angle of the left mandible and fluid in the left external auditory\n canal; the temporal bone is incompletely included in the imaging volume. Again\n seen is fluid in the right maxillary sinus.\n\n IMPRESSION:\n 1. No evidence of acute fracture or spondylolisthesis.\n 2. Opacification of the several left mastoid air cells and fluid within the\n left external auditory canal, and subcutaneous gas medial to the angle of the\n left mandible. This region is incompletely imaged, and consideration should be\n given to dedicated CT study of the left temporal bone, with reformations.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-26 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 917139, "text": " 10:57 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: S/P TRAUMA, ASSAULT\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with head injury, intubated\n REASON FOR THIS EXAMINATION:\n eval for injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 1:37 AM\n no evidence of acute traumatic injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head injury status post assault. Evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained\n with IV contrast. Multiplanar reformatted images were also displayed.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: No focal consolidations or pleural\n effusions are seen at the visualized lung bases. The liver, gallbladder,\n spleen, splenules, adrenal glands, kidneys, and pancreas appear unremarkable.\n There is no evidence of free air or free fluid within the abdomen. Visualized\n portions of bowel appear unremarkable.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, and sigmoid appear\n unremarkable. Foley catheter is noted within the bladder. There is no\n evidence of free fluid within the pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n Multiplanar reformatted images confirm the axial findings.\n\n IMPRESSION: No evidence of acute traumatic injury.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2178-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001673, "text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate NG tube placement.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with UTI and PNA s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n please evaluate NG tube placement.\n ______________________________________________________________________________\n WET READ: KYg MON 5:36 PM\n right IJ CVL terminates at the atrial SVC junction. Tip of NG is probably\n within the distal stomach. cardiomegaly and small bilateral pleural effusions\n persists. The aorta is tortuous. no pneumothorax. DJD of the thoracolumbar\n spine. \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:15 P.M. ON .\n\n HISTORY: Pneumonia. New nasogastric tube.\n\n IMPRESSION: AP chest compared to through 24:\n\n Tip of the nasogastric tube is at the level of the proximal duodenum. Right\n jugular line ends in the low SVC. No pneumothorax or mediastinal widening.\n Small bilateral pleural effusions have decreased since . Moderate\n cardiomegaly and mediastinal vascular engorgement have also improved.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001749, "text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with cardiogenic shock\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shock, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is continued\n enlargement of the cardiac silhouette. The pulmonary vessels are essentially\n within normal limits. Poor visualization of the left hemidiaphragm is\n consistent with pleural effusion and underlying atelectasis. Less marked\n changes are seen at the right base. No evidence of acute focal pneumonia.\n\n Right IJ catheter extends to the lower portion of the SVC and a nasogastric\n tube extends at least to the distal stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002081, "text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? lines/tubes, infiltrates\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with pneumonia, s/p intubation.\n REASON FOR THIS EXAMINATION:\n ? lines/tubes, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after intubation.\n\n Portable AP chest radiograph compared to and .\n\n The ET tube tip is 3 cm above the carina but note is made that the tip\n impinges the right tracheal wall, thus it should be repositioned to prevent\n stricture or malacia. The right internal jugular line tip terminates in\n distal SVC. The NG tube tip passes below the diaphragm with its tip most\n likely below the inferior margin of the film. The heart size is mildly\n enlarged but stable. The mediastinal silhouette is unremarkable. Bilateral\n pleural effusions are moderate-to-large, slightly progressed since yesterday\n although it might be contributed by slightly different position of the\n patient. No evidence of failure is present. No focal consolidations\n worrisome for pneumonia are identified although they may be obscured by\n overlying effusion.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2178-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001484, "text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate/consolidation\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with afib, altered mental status, fever\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:16 A.M. \n\n HISTORY: 87-year-old woman, atrial fibrillation, altered mental status and\n fever.\n\n IMPRESSION: AP chest compared to through 22:\n\n Bilateral pleural effusion moderate on the left, small to moderate on the\n right, has increased since . Severe cardiomegaly is longstanding,\n but increased since . Pulmonary edema is hard to exclude given the\n overlying pleural effusion but probably not present. Severe mediastinal\n vascular engorgement persists. Thoracic aorta is generally large, tortuous\n and heavily calcified but there is no good evidence of focal dilatation or\n interval change. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2178-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001951, "text": " 9:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with CAD, Afib, PNA, worsening resp status\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coronary artery disease, pneumonia, and worsening respiratory\n status.\n\n FINDINGS: In comparison with the study of , there is little change.\n Continued enlargement of the cardiac silhouette without vascular congestion.\n The left hemidiaphragm is again not well seen, though this may be a technical\n artifact. The right base is obscured by overlying cardiac monitor leads.\n\n Central catheter and nasogastric tube remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001997, "text": " 1:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for placement.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p intubation.\n REASON FOR THIS EXAMINATION:\n evaluate for placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST @ 14:20:\n\n COMPARISON: @ 9:57.\n\n INDICATION: Intubation.\n\n Endotracheal tube terminates about 2.3 cm above the carina with the neck in a\n flexed position. Allowing for greater lung volumes on the current\n examination, there is otherwise no other substantial change except for removal\n of a nasogastric tube and development of moderate gastric distention.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-26 00:00:00.000", "description": "MRA BRAIN W/O CONTRAST", "row_id": 1001046, "text": " 12:53 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please perform MRI/MRA brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman PMH afib on coumadin, right thalamic hemorrhage presents with\n with left sided weakness and mutism.\n REASON FOR THIS EXAMINATION:\n please perform MRI/MRA brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE MRI OF THE BRAIN WITHOUT GADOLINIUM. ROUTINE MRA OF THE BRAIN USING\n 3D TIME-OF-FLIGHT TECHNIQUE. ROUTINE MRV OF THE BRAIN USING 2D TIME-OF-FLIGHT\n TECHNIQUE.\n\n HISTORY: Past medical history of AFib, on Coumadin, and right thalamic\n hemorrhage; presents with left-sided weakness and mutism.\n\n Comparison is made with CT perfusion from one day prior.\n\n On the diffusion-weighted images, there is no evidence for acute ischemia.\n\n There is extensive confluent periventricular and subcortical hyperintensity\n which likely reflects small vessel ischemic sequela.\n\n There are bilateral thalamic lacunes. Small vessel ischemic sequela is also\n seen in the brain stem.\n\n There is mucosal thickening in the sphenoid sinus.\n\n On the gradient echo images, there are foci of susceptibility dropout in\n bilateral thalami which may be related to prior microhemorrhages or\n cavernomas.\n\n MRA of the circle of demonstrates patency of the major intracranial\n vessels and their proximal branches. The small aneurysm of the left PCA is\n unchanged from the recent CTA examination. Additionally, there is suggestion\n of a 3 mm aneurysm at the left PCom origin.\n\n Evaluation of the MRV demonstrates patency of the superficial venous system.\n The deep veins are not visualized, which may be related to technique.\n\n IMPRESSION:\n\n No evidence for acute ischemia.\n\n Extensive small vessel ischemic sequela.\n\n Aneurysm of the left PCA and left Posterior Communicating Artery.\n (Over)\n\n 12:53 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please perform MRI/MRA brain\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2178-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002047, "text": " 7:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? tube placement.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with pneumonia, aspiration, intubated, s/p NG tube placement.\n REASON FOR THIS EXAMINATION:\n ? tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration pneumonia, for NG tube placement.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a nasogastric tube that extends well into the stomach. Little\n change in the appearance of the heart and lungs.\n\n\n" }, { "category": "Echo", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 70137, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 194\nBSA (m2): 1.84 m2\nBP (mm Hg): 149/78\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 11:43\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Severe regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - akinetic; basal anteroseptal - akinetic; mid\nanteroseptal - akinetic; basal inferoseptal - akinetic; mid inferoseptal -\nakinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex -\nakinetic; lateral apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is severe regional left ventricular\nsystolic dysfunction with akinesis of the septum, mid- and distal anterior\nwall and distal LV segments/apex, with relative preservation of\ninferolateral/lateral wall contraction (LVEF = 25-30%). Right ventricular\nchamber size is normal. with mild global free wall hypokinesis. The number of\naortic valve leaflets cannot be determined. There is no aortic valve stenosis.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Severe regional left ventricular systolic dysfunction. Mild right\nventricular systolic dysfunction. Mild aortic regurgiation.\n\nCompared with the prior study (images reviewed) of , biventricular\nfunction has slightly improved, although the regional distribution of wall\nmotion abnormalities is similar. Severity of mitral regurgitation and\npulmonary hypertension has lessened. The other findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2178-03-26 00:00:00.000", "description": "Report", "row_id": 70138, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA.\nHeight: (in) 60\nWeight (lb): 194\nBSA (m2): 1.84 m2\nBP (mm Hg): 118/72\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 18:07\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.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Severely depressed LVEF.\nNo resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; basal anteroseptal - akinetic; mid\nanteroseptal - akinetic; basal inferoseptal - akinetic; mid inferoseptal -\nakinetic; basal inferior - hypo; mid inferior - hypo; mid inferolateral -\nhypo; anterior apex - akinetic; septal apex- akinetic; inferior apex -\nakinetic; lateral apex - akinetic; apex - akinetic;\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: Aortic valve not well seen. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate (2+) MR. LV inflow pattern c/w\nrestrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild to moderate [+] TR. Borderline PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is unusually small. Overall left\nventricular systolic function is severely depressed (LVEF= 20 %) secondary to\nakinesis of the interventricular septum, anterior free wall, and apex. Right\nventricular chamber size is normal. with focal hypokinesis of the apical free\nwall. The ascending aorta is mildly dilated. The aortic valve is not well\nseen. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests a\nrestrictive filling abnormality, with elevated left atrial pressure. The\ntricuspid valve leaflets are mildly thickened. There is borderline pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is now severely reduced, most\nlikely secondary to coronary artery disease and intercurrent myocardial\ninfarction.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-04-01 00:00:00.000", "description": "Report", "row_id": 1660311, "text": "NURSING\n VSS OVERNIGHT. BECAME SLIGHTLY HYPERTENSIVE AT 0400 WITH SBP IN THE 150'S AND HR INCREASING TO THE 130'S INTERMITTANTLY. PER MICU TEAM, EXTRA DOSE DIGOXIN GIVEN 0.125 X1. WILL MONITER FOR EFFECT. AFEBRILE OVERNIGHT. REMAINS IN AFIB.CVP 8-10.\n NEURO STATUS REMAINS UNCHANGED OVERNIGHT. SPEECH GARBLED WITH RARE WORDSPOKEN CLEARLY. ORIENTED X2. PUPILS EQUAL AND REACTIVE. MOVING EXTREMITIES IN THE BED. WRISTS REMAIN IMMOBILIZED WITH SOFT WRIST IMMOBILIZERS TO KEEP FEEDING TUBE IN PLACE.\n FOLEY IN PLACE WITH CLEAR YELLOW URINE IN ADEQUATE AMOUNTS. TUBE FEEDS CONTINUE AT GOAL. CONTINUES TO STOOL FREQUENTLY IN MODERATE TO LARGE AMOUNTS. SKIN REMAINS INTACT. FREE H2O BOULS CONTINUE FOR 400 ML/3 HOURS.\n LUNGS COARSE LOWER, COUGHING AND RAISING LARGE AMOUNTS TAN SPUTUM. UNABLE TO OBTAIN CLEAN SPUTUM SPECIMEN. O2 SATS 96-98% ON ROOM AIR.\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. SEND STOOL FOR C DIFF TODAY AND TOMORROW, FIRST SPECIMEN ALREADY SENT.\n\n" }, { "category": "Nursing/other", "chartdate": "2178-04-01 00:00:00.000", "description": "Report", "row_id": 1660312, "text": "Respiratory Care\n\n\n\n Pt intubated due to impending respiratory failure. *very difficult intubation* Pt intubated fiberopticly. B/S rhonchourous sx'd small thick yellow. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2178-04-01 00:00:00.000", "description": "Report", "row_id": 1660313, "text": "NPN 0700-1900;\nevents ;difficult intubation requiring fibroptics. pt intubated as having difficulty maintiaining airway and increased work of breathing pt is now dnr but will treat with pressorsand antibiotics. no cpr or defibrillation.\n\nneuro; pt initally alert, speech garbled perla 3mm purposeful movementsin upper arms, lower limbs move on bed. became increasingly lethargic over the course of the morning and is now sedated with fentanyl and midazolam gtt.but is rouseable to stimuli.\n\nresp; lungs diminished and coarse throughout nt suctioned for mod amounts of thick tan secretions. difficulty in maintaining o2 sats and maintaining airway with increased work of breathing decided to intubate. difficult intubation needed fibreoptics. intubated nasally. on a/c 500x12 weaned from 100-50% fio2 with alkalotic abg. suctioned for small amounts blood tinged secretions q4.diff getting good o2 sats.but po2 on abgs good,\n\ncvs; tmax 100.2 po afib poorly controlled. poor peripheral circulation fingers and toes mottled and cyanotic pos pal pulses. in all 4 limbs. initially hypertensive. nitro up to 2.5 became hypotensive to 80 nitro off on and off for most of day goal bp @ 120 sys. mixed 02 sats 58-64 post intubation.cvp 5-9.\n\ngu;u/o drifting down given 500 mls fb\n\ngi; t/f off since am for reintubation. belly soft obese pos bs passing small amounts green gelatinous stool with turns need C-DIFF\nsent bs covered on riss.\n\nskin has small red area across central back at base of fold. small circular area on coccyx. groin reddened and escoriated repositioned frequently and aloe applied.\n\nsoc; multiple family members into visit and updated with pts current condition and plan of care.by micu team.\n\na/p continue to monitor for infection follow up on cultures . wean fi2 as tolerated . monitor u/o response to fb.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 1660314, "text": "Update\nO: See carevue flowsheet for specifics.\nPt w spontaneous profound hypotension at 2015pm w systolic dwn to 60 cvp 4-7 range. Ntg gtt off 15mins prior to drop in bp, hr trending dwn from 110 range to 90's afib w no ectopics at the time. Dr in ICU at the time, made aware. Lr bolus 1 liter given and levo gtt started at 0.1mcg/kg/min, labs sent including ck w trponin.Excellent bp response w fld bolus and pressor. Levo weaned off and sbp drifted to 90,levo resumed and on very low dose continually per HO request until 5am then dc'd per Dr .Extremeties cool and cyanotic (rt hand more cyanot than lt) radials & distal pulses (+) w doppler.Afib no ectopy. Sbp goal > 100 currently sbp 150's on no levophed.Sedated on fent/midaz gtt,pserl at 2mm, responds to noxious stim, withdraws all extrems to nailbed pressure, and localizing pain.Resp - remains intubated on cmv mode fio2 40% w resp alkalosis, suct for thick tenacious tan bl tinge sputum.Gi- ngt placed by Dr and sumping bilious drng, position confirmed by pcxr, fld boluses q3h as ordered,tol well.Abd soft, hypoactive bowel snds +.\nGu-foley to gd w bdline uop cl yellow.\n\nSkin-linear reddended area across midback, no drng turned side to side q2.\n\nHeme/Id: hct dwn to 27 this am. wbc trending dwn at 16, received vanoc last pm per Dr , tmax 101.8, pan culture sent.PT 17.\n\nPsych/Soc/Family: 2 sons in to visit last pm, update given.\n\nA/P: Cont to monitor vs and assess need for levo. Doppler upper/lower extrems for pulses, keep extrems warm.Check w team re: place dht and restart tf's.Cont free h2o boluses as tol until Na+ wnl.Glucose per riss qid.Neuro checks as ordered.Pulm toilet.Provide emot support to family.\n" }, { "category": "Nursing/other", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 1660315, "text": "Respiratory Care:\nPatient continues on full vent support. Suctioned for thick, bloody secretions early in shift. Changed to active humidification with good effect and thinner secretions. BS diminshed bilat. ET tube secure 27cm at L nare and resecured. RSBI checked at 18. Plan to maintain supportive care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 1660316, "text": "respiratory care\npt on the vent changes made tol well. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 1660317, "text": "npn 0700-1900;\n\nevents ; s/b vasc for cyanotic extremeties. ? poss clot in rt radial started on argartraban .at 0.25 mcgs/kg/min ptt due at 7pm..\nplatlets down to 82 hit study sent.\ncardiac echo results pending.\nstarted on dobutamine with mixed venous sats 53-67. on 1.5 mcs/kg/min.\ns/b derm to evaluate for cholesterol emboli will return tommorrow to assess.\n\nneuro; sedated on versed .75 mgs i.v/hr and fentanyl 50 mcgs/hr pt opens eyes to voice grimaces to mouthcare and with draws to pain in all 4 limbs moves rt side more than lt.perla 3mm.\n\nresp; on cmv 40% 500x12 lungs sound clear suctioned for scant amounts thick white secretions q4,sats 98-100%.abbbbg remain alkalotic.\n\ncvs; tmax 99.9 po afib better controlled 98-100 no ectopy noted. bp less labile today 100-139/70. cvp 9-11 mixed venous o2 sats 53 dobutamine added at 1.5 mcgs/kg/min with mv02 sats to 67. pos pedal pulses by doppler feet cool cyanotic . hand continue to be cyanotic rt hand with and ulner pulses. 1st 3 digits dusky with poor cap refill. team aware s/b vasc please sees vasc note, .lt hand pos radial. and ulner,all 4 digits dusky.\n\ngu; u/o drifting down to 15 mls /hr team aware.\n\ngi; belly obese pos bs t/fs restated min residuals noted. free water boluses contine na 144. no stool nocover on riss.\n\nskin no change in areas noted please see carevue.\n\nsoc; multiple family members into visit family are meeting together to decide whether to make pt cmo. pt remains dnr.\n\na/p continue to monitor hemodynamic response to dobutamine\nfollow up on tests and cultures.\nawait family decisions offer emotional support to pt amd family.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 1660318, "text": "Update\nSee careview for details...\n: Pt made CMO by family and Dr from MICU , extubated and left on versed and Fentanyl gtt with 100mcg Fentanyl bolus given 2100: pt pronounced by MICU intern, family at bedside, MD in to speak with family.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-26 00:00:00.000", "description": "Report", "row_id": 1660298, "text": "SICU NPN\nS-Intubated.\n\nSEE CAREUVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Neuro exam as documented and unchanged. Attempting to mouth needs. Constantly biting down on OGT/ETT. Denies pain. Attempting to sedate for comfort and profound respiratory akalosis but becoming hypotensive with sedation and later discontinued. Versed times one trialed this AM while on CPAP with good affect. HR 90-120, Afib, Dilt increased with some affect and later discontinued secondary to BPs issues. Goal SBP 140-180, but accepting SBPs in the 120s. SBPs down to the 90s post sedation titration and started on Neo, since SBPs 120-140s. Heparin infusion discontinued secondary to INR of 2.9 and PTT > 150. On AC overnight, as stated above, pt with respiratory alkalosis with PCO2 in the 20s. Switched to CPAP this morning. ABG unchanged but now compensated. RSBI 99. Suctioning for minimal secretion. CXR performed this morning. UO marginal overnight, < 30cc/hr. Multiple fluid boluses. Maintenance fluid increased with some respones to fluid increase and boluses. NPO. OGT in place and clamped. Abdomen soft with (+) bowel sounds. Small brown BM times one. Tm 104.3 Tc 99.5. Given Tylenol with temps. Cooling blanket in place at that time and later discontinued. On Zosyn and Vanco. Pan cultured while febrile with results pending. Second son, calling and updated by RN. Stating he is a physcian and is mother's HCP and brother visiting is power of attorney. Also states does get along with brother and currently out of town.\n\nA/P:87 year old female s/p embolic CVA, intubated for airway protection. Overnight hypotensive, ABG with respiratory alkalosis, and low UOs. This AM on CPAP doing fair.\nMRI today\nWean to extubate as tolerated\nRate control as needed with PRN Lopressor\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-26 00:00:00.000", "description": "Report", "row_id": 1660299, "text": "condition update\nplease see carevue for specifics.\n\nPt intubated at start of shift. MAE. Following commands consistently. No c/o pain per pt. PERRL. TMAX 100.4 IVF infusing. Neo gtt infusing to keep SBP 120's-140's. OGT clamped. Foley patent and draining 20-60cc urine hourly. To MRI this am which was negative for CVA. EEG ordered. Pt received 1.5 mg versed while down in MRI. ABG's ok, Pt extubated this afternoon. Post extubation ABG unchanged. Pt w/ non productive cough. LS diminished at b/l bases.\n\nPlan: continue w/ current plan of care per sicu/ nmed teams. continue to closely monitor hemodynamics. EEG/ echo to be done. Monitor hourly uo. F/U on results of pan cx. Continue IV ABX. Aggressive pulmonary toilet.\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-27 00:00:00.000", "description": "Report", "row_id": 1660300, "text": "NPN (NOC):\n\nNEURO: PT IS AWAKE OR EASY TO AROUSE AND ORIENTED TO PERSON AND PLACE BUT NOT TIME. ABLE TO MAE TO COMMAND. PERL.\n\nCV: REMAINS IN AF W/ RATES 100-110 AND LOTS OF PVC'S. SBP'S STABLE OFF PRESSORS.\n\nRESP: RR TEENS TO 20'S, REG AND UNLABORED. BS'S CLEAR TO DIMINSIHED. + PROD COUGH, PT ABLE TO CLEAR AIRWAY. SATS HIGH 90'S ON 2 LITERS NC.\n\nGI: NPO, AWAITING SWALLOW STUDY TODAY. TOL PILLS CRUSHED IN APPLESOUCE BUT NOT A TINY AMT OF LIQ COLACE (BEGAN TO COUGH AFTER ONE LITTLE SIP.) SM BM X1.\n\nGU: UO ~ 20 CC'S PER HR. IVF CHANGED TO NS AT 75 CC'S PER HR.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-27 00:00:00.000", "description": "Report", "row_id": 1660301, "text": "ADDENDUM:\n\nINR IN THE 6'S X2. DR. (SICU) AND N-MED AWARE. PLAN IS TO D/C COUMADIN BUT NOT REVERSE AT THIS TIME. NO S/ OF BLEEDING NOTED.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-25 00:00:00.000", "description": "Report", "row_id": 1660297, "text": "condition update\nplease see carevue for specifics.\n\npt admitted from the ed this afternoon. Pt intubated on AC, + cough/gag. PERRl. MAE. Following commands consistently. LS CTA. Febrile. Tmax 104.3; cooling blk placed. Pt in AFIB w/ episodes of non sustained Vtach and occasional PVC's noted. HR 120's-130's amiodarone/ heparing gtts infusing. amio gtt off at 1800, 10 mg dilt bolus given followed by 5 mg/ hr dilt gtt started. bs 152. Integ intact. NPO, IVF infusing. NGT to LCWS and draining bilious fluid. MRI checklist completed w/ family and faxed. Unable to go to MRI d/t prob w/ vent connections. MRI rescheduled for after . Nmed team wanting to extubate pt but became very tachypneic when placed on cpap.\n\nPlan: continue w/ current plan of care per sicu team. continue to closely monitor hemodynamics. Dilt gtt for rate ctrl. NPO. IVF for hydration. RISS for bs coverage. MRI to be done tonight. IV ABX for PNA. ? extubation in the am.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-25 00:00:00.000", "description": "Report", "row_id": 1660296, "text": "Respiratory care\n\n\n Pt remains on full ventilatory support. PSV attempted on 15/5 Vt .300-.400 RR 35+ B/S sl coarse and equal Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-27 00:00:00.000", "description": "Report", "row_id": 1660302, "text": "condition update\nplease see carevue for specifics.\n\nPt more awake and alert today. she follows commands consistently. Able to MAE. PERRL. No c/o pain. Oriented x 2 (person, time) EEG done this am. No sz activity noted. AFIB w/ occasional to frequent PVC's. Dilt gtt started for rate ctrl. HR 90's-120's. Gtt currently infusing at 7mg/hr. Cardiac enzymes x 2 drawn. #3 to be drawn at 0200am. EKG done. pt afebrile. LS CTA. pt w/ non productive cough. No c/o pain per pt. foley patent and draining minimal amts of urine w/ sediment. Daily lasix started. Urine lytes drawn. Formed Bm's x 2 today. Pt failed speech and swallow study today. will be re consulted Moin or , keep NPO for now. Integ intact. FS WNL. PT/OT consulted. Pt xfered to the micu service.\n\nPlan: continue w/ current plan of care per micu service. NPO. continue IV ABX. diures w/ lasix. #3 cardiac enzymes due at 0200am. PT/ OT. Dilt gtt and lopressor for rate ctrl. Pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-28 00:00:00.000", "description": "Report", "row_id": 1660303, "text": "Nursing Progress Note:\n\nNeuro:Pt initially alert increasingly lethargic during noc. Pupils 3mm PEARL, MAE on bed and ablet to follow simple commands. Garbled speech VS aphasia. MICU team informed of worsening neuro exam.\n\nCV: Low grade temp 100.5ax. HR initially 90-100 Afib with occasional PVC's. Micu team changed Dilt gtt to esmolol gtt @ 2100 per Cardiology recommendation. Pt quickly became tachycardic 130-140's. SBP 100-110's. At 24:30 pt changed back to dilt gtt. Presenlty HR 90's and continues with occasional PVC's. INR increasing to 12.1 overnoc recieved Vit K 1mg X1, 3u FFP. Am INR 2.0? LFT gradually increasing.\n\nRESP: Lungs clear with faint crackles RLL O2 at 2l via N/C. ABG remains compensated with CO2 24. PAO2 90.\n\nGI: NPO abd soft with +BS. Small brown stool tonoc.\n\nGU: foley draining minimal yellow urine with sediment. BUN CREAT ^\n\nENDO: blood sugar WNL.\n\nPLAN: Cont to monitor cardiac status due to poor EF. Monitor for any neuro changes ? bleed. ? INR, emotional support to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2178-03-30 00:00:00.000", "description": "Report", "row_id": 1660307, "text": "Nursing Progress Note:\n\nNeuro:Pt awake and alert most of night oriented to self only. PEARL 3mm, MAE on bed and following directions. Pt denies pain.\n\nCV: Tmax 103, HR 90-100's Remains in A fib with frequent PVC's. Much improved rate control tonight since lopressor increase to 15mg q4hrs. ABP 110-140's/70-90's. Extremities warm with +PP. Lytes pending following aggressive diuresis this eve.\n\nRESP: lungs diminished, O2 at 2l via N/C. O2 sats >97%. Occasional productive cough with thick white secretions in back of throat requiring yankauer suctioning.\n\nGI: Remains NPO. abd large round and soft with + BS. No stool overnight.\n\nGU: foley draining adequate clear yellow urine.\n\nENDO: BLood sugar elevated requiring coverage per RISS.\n\nPLAN: Cont to monitor HR and neuro exam. Monitor resp status. Awaiting result from cultures. Emotional suppor.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-30 00:00:00.000", "description": "Report", "row_id": 1660308, "text": "Nursing Progress Note\nSee Carevue for specifics\n\nEvents: CVL placed at bedside, awaiting XRay to confirm placement.\n\nPt more alert today, speech remains garbled, very difficult to understand. PERRL 3mm bil. MAE, able to dangle at side of bed with assistance. PT following.\nRemains in Afib with frequent PVC's. K repleted. Repeat lytes pending. Continues on Lopressor IV. Dig x1 given with effect. Cardiology following. INR 2.3-MICU team aware, consulting Neuro to check goal INR for pt.\nAfebrile today-low-grade temps. Continues on Ceftriaxone/Vanco for E.Coli in urine and ?PNA.\nLS diminished throughout. NARD. Sats 98% 2 LNC.\nPt failed Speech and swallow x2. NGT placed at bedside. Awaiting XRay to confirm placement and start TF's. Abd soft, nontender. No Stool today.\n\nPlan: Continue neuro checks, monitor hemodyamics, PT, nutrition, follow labs and treat as necessary.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-31 00:00:00.000", "description": "Report", "row_id": 1660309, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt alert, sleeping in naps, unable to fully assess orientation due to garbled speech. Pt follows all commands answers yes/no questions appropriately, MAE, PERLA. Denies pain.\n\n Resp: Ls clear, diminished throughout. Pt C&DB with instruction. Raised small amount of thick yellow sputum x1. Maintaining O2 sat > 95% on RA. Denies SOB.\n\n CV: Remains Afib, HR 90-110, no ectopy noted. Lytes repleted prn. SBP 120-130, following , dampened, MD aware. Digoxin 0.25mg IV x1 given. Denies CP. Hands/feet cool to touch, cyanotic, MD aware. LR @ 100cc/hr x1 liter. Hct stable, coags stable.\n\n GI: Abd soft, pos bs, tol TF via NGT, no residuals. Free H2O boluses for high Na of 151. LFT's improving. BMx1.\n\n GU: Adequate amounts of clear yellow urine via foley cath\n\n Tmax 101.4 rectally. Abx as ordered.\n\nPlan: Monitor hemodynamics, monitor labs, cardiology following, continue with free water boluses, lyte repletion, provide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-31 00:00:00.000", "description": "Report", "row_id": 1660310, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt opens eyes spontaneously. PERRLA. Speech garbled and difficult to understand at times. Oriented x1-2 (to person and \"hospital\"). Pt unable to state month/year. Follows commands. Can lift/hold BUE; moves BLE in bed. +gag/cough reflex. Pt denies having any pain; no grimacing noted. Tmax 100.8. 1 set of blood culture sent (from central line). Unable to obtain peripheral blood cultures despite 3 attempts d/t poor access (Dr. aware). HR 80-110s (A.fib with rare PVCs). See CareVue for ABP. Pt on nitroglycerin gtt to keep SBP 120s, but SBP decreased to 80s. Per MICU team, stop nitroglycerin gtt. LR @ 100cc/hr infusing for total of 500cc. Pt with generalized edema. DP/PT pulses weakly palpable. Venodyne boots on BLE. Fingers and toes mottled; cool to touch (MICU team aware). Electrolytes sent this afternoon; potassium: 2.9 (20meq KCl hung at 1900; needs more repletion). Lungs diminished. O2 sat >/= 94% on room air. Pt with strong cough. Needs sputum culture. Pt placed on droplet precautions d/t being r/o for flu. Abdomen softly distended with +bowel sound. TF changed to Probalance. TF infusing via NGT at goal rate; minimal residual noted. 400cc free water boluses q3hr ordered for hypernatremia. Sodium this afternoon: 147. Pt with loose BM x4 (brown/green in color; guaiac positive). Metronidazole 500mg IV q8hr ordered. Stool sent for C.diff. FS q6hr; treated with regular insulin sliding scale. Foley intact with clear, yellow urine. UO >/= 30cc/hr; clear, yellow urine. UA/urine culture sent. Skin intact. Skin on the back (under folds) pink, but skin intact. Pt turned and repositioned q2-3hrs to maintain skin integrity. sons visited; updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Follow up results of blood culture and urine culture/UA. Follow up result of C.diff; needs 2 more stool samples. Droplet precautions; r/o flu. Continue TF at goal rate; check for residuals q4hr. 400cc free water boluses q3hr for hypernatremia. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n" }, { "category": "Radiology", "chartdate": "2178-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001299, "text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n Portable AP chest radiograph compared to .\n\n The patient was extubated in the meantime interval. The moderate cardiomegaly\n is stable but interval increase in perihilar haziness is demonstrated\n consistent with fluid overload. Bibasilar retrocardiac opacities are new\n consistent with atelectasis as well as there is new bilateral small pleural\n effusion.\n\n IMPRESSION: New volume overload with new bilateral pleural effusions. No\n overt pulmonary edema.\n\n\n DL\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2178-03-29 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1001531, "text": " 12:34 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: EVAL FOR OBS/ ACUTE PATH, HEPATITIS, ELEVATED LFTS\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with rapidly progressing LFT abnormalities\n REASON FOR THIS EXAMINATION:\n eval for obstruction/acute pathology/hepatitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old female with rapidly progressing LFT abnormalities.\n Evaluate for obstruction, acute pathology, or hepatitis.\n\n No comparison studies.\n\n LIVER/GALLBLADDER ULTRASOUND: This evaluation is limited due to lack of\n patient mobility. The liver is of normal echotexture with no gross focal\n lesions identified. There is no intra- or extra-hepatic ductal dilatation.\n The common duct measures 5 mm. The gallbladder is not visualized and likely\n absent. There is appropriate forward portal venous flow. The pancreas is not\n demonstrated due to overlying bowel gas. The spleen is incompletely\n visualized, however, appears to measure 7 cm. There is a small amount of\n perihepatic fluid.\n\n IMPRESSION:\n\n Limited examination. Small perihepatic fluid. Otherwise unremarkable liver\n gallbladder ultrasound.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1001058, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: asipration?pna?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n asipration?pna?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old female with stroke.\n\n COMPARISONS: .\n\n AP SEMI-UPRIGHT PORTABLE CHEST: The endotracheal tube terminates 3.4 cm above\n the carina and abuts the right lateral tracheal wall. The tube should be\n advanced 1 cm for optimal positioning. A nasogastric tube extends to the\n stomach with its side port just below the gastroesophageal junction. A small\n cannula paralleling the right tracheal wall terminates approximately 3 cm from\n the tip of the endotracheal tube, purpose is unknown. The cardiac silhouette\n remains enlarged with unchanged tortuosity of the aorta. There is improved\n aeration of the left upper lobe with unchanged mild bibasilar patchy\n opacities. Small bilateral pleural effusions persist. There is no\n pneumothorax. The pulmonary vasculature is normal.\n\n IMPRESSION:\n 1) Endotracheal tube abutting the right lateral tracheal wall. The tube\n should be slightly advanced for more optimal placement.\n 2) Proximal gastric tube, with the side port just below the gastroesophageal\n junction, might be edvanced 15-20 cm.\n 3) Improving left upper lobe aeration with persistent bibasilar opacities,\n likely atelectasis.\n\n\n DL\n\n" }, { "category": "Radiology", "chartdate": "2178-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1000924, "text": " 10:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with presumed intracranial bleed, now s/p ETT\n REASON FOR THIS EXAMINATION:\n tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old woman with presumed intracranial bleed, evaluate\n endotracheal tube position.\n\n COMPARISON: Chest radiograph of .\n\n SUPINE PORTABLE VIEW OF THE CHEST AT 10:10 A.M.: The endotracheal tube is\n seen extending into the left main stem bronchus and requires repositioning. An\n NG tube terminates in the stomach. Both lungs are well expanded. There is\n increased opacity of the left lung base, raising the possibility of\n aspiration. Followup radiographs are recommended.\n\n Taking into account patient rotation, the cardiomediastinal contour is notable\n for enlargement of the right atrial contour, unchanged from prior\n examinations. The pulmonary vasculature is not engorged. Again, the minor\n fissure appears slightly prominent, unchanged from prior examinations.\n\n IMPRESSION:\n 1. Endotracheal tube extending into the left main stem bronchus.\n Repositioning is required. This was discussed with the nurse caring for the\n patient, , at cell number , at approximately 10:45 a.m.\n 2. Increased opacity of the left lung base, possibly representing aspiration.\n Followup radiographs are recommended.\n 3. Stable cardiomegaly with no evidence of acute congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-25 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1000925, "text": " 10:09 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: R/o intracranial hemorrhage\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: The apparent CT perfusion abnormalities most likely are artifactual\n as they appear to have a band-like appearance over multiple images.\n\n Note is also made of approximately 3- to 4-mm outpouchings of the\n communicating segments of the internal carotid arteries bilaterally which\n given their size likely represent posterior communicating artery aneurysms.\n\n\n\n 10:09 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: R/o intracranial hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman on Coumadin, now with new onset aphasia, new left sided\n weakness, emesis. Intubated.\n REASON FOR THIS EXAMINATION:\n R/o intracranial hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe WED 11:35 AM\n CT Perfusion findings are consistent with acute ischemia in right\n MCA/watershed, left ACA territories and possibly left occipital\n territory.\n\n no intravascular thrombus identified.\n\n no intracranial hemorrhage.\n\n L PCA P2 segement 3mm aneurysm.\n\n Paged stroke fellow as could not find listed resident \" \" in pager\n database.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old woman on Coumadin with new onset aphasia, left-sided\n weakness, and emesis. Please evaluate for intracranial hemorrhage or stroke.\n\n TECHNIQUE: Multidetector CT images were obtained through the head first\n without contrast followed by CT angiogram of the neck and head. Additionally,\n CT perfusion was performed with mean transit time, relative cerebral \n volume, and relative cerebral flow map was generated on an independent\n workstation. Multiplanar MIP, curved reformats, and volume rendered\n reconstructions were obtained.\n\n NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass effect, shift\n of normally midline structures, or hydrocephalus. There is marked prominence\n of the ventricles and sulci consistent with age-related involutional change.\n There is periventricular white matter hypodensity consistent with chronic\n small vessel ischemic changes. The -white matter differentiation is\n preserved. Cataract surgical change of the globes is seen. The previously\n seen soft tissue changes of the paranasal sinuses have significantly\n improved.\n\n CT ANGIOGRAM OF THE HEAD AND NECK: Minimal atherosclerotic calcification is\n seen within the aortic arch, origins of the left subclavian and right\n brachiocephalic vessels, as well as the bilateral common carotid arteries, and\n internal carotid artery bulbs. The distal cervical ICAs measure 5.1 mm on the\n right and 4.9 mm on the left. The vertebral arteries are tortuous.\n\n There is no imaged filling defect within the intracranial vasculature. There\n (Over)\n\n 10:09 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: R/o intracranial hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is a 3 mm aneurysm of the P2 segment of the left PCA pointing laterally\n without evidence of hemorrhage.\n\n There is no evidence of vascular malformation or dural venous sinus\n thrombosis. Calcifications of the carotid siphons are seen bilaterally.\n\n Bilateral pleural effusions are noted. Degenerative changes of the\n cervical spine are noted without high grade canal stenosis. The surrounding\n osseous and soft tissue structures are otherwise unremarkable. The patient is\n intubated. A nasogastric tube is seen coursing through the imaged portion of\n the esophagus.\n\n CT PERFUSION: There is apparent increased mean transit time and decreased\n blow flow in the right MCA territory as well as the right ACA/MCA watershed\n region. Additionally, there is increased mean transit time and decreased blow\n flow in the left frontal lobe anterior cerebral artery territory. There is a\n possible small area of increased mean transit time and decreased blow flow in\n the posterior left occipital lobe in the posterior cerebral artery territory.\n The cerebral volume maps are normal. This mismatch between mean transit\n time and cerebral flow is consistent with acute ischemia.\n\n IMPRESSION:\n 1. CT perfusion findings are consistent with acute ischemia in the right MCA\n and right MCA/ACA watershed distribution as well as the left ACA distribution.\n Possible acute ischemia in the left PCA territory. No evidence for\n intravascular thrombus or intracranial hemorrhage.\n\n 2. 3-mm left PCA P2 segment aneurysm without evidence for hemorrhage.\n\n At the time of interpretation at 10:45 a.m. on , these findings were\n discussed over the telephone with the stroke fellow, Dr. .\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-28 00:00:00.000", "description": "Report", "row_id": 1660304, "text": "Events: Contact precautions initiated for MRSA/sputum, abx coverage initiated for UTI. Liver enzymes trending up.\n\nNeuro: Alert, oriented x , follows commands, attempts communication. Speach remains garbled with occ clear word, mae weakly, perrl.\n\nCV: Afib with stable bp. IV lopressor added with dilt gtt titrated to off. Recurring HR 17eens-130 this afternoon with little response to increased metoprolol dose. Please see cardiology notes.\n\nPulm: Respitory effort appears labored at times, pt denies dyspnea/sob. Lungs decreased at bases with scattered rales. 02 sat >95% on 2L nc. Expectorating thick, tenacious pale yellow sputum in moderate quantity.\n\nGU: Uo 30-100cc/hr. Lasix 80mg this afternoon followed by 160mg IVPB this evening with no change in hourly uo. Team aware.\n\nGI: Abd obese, bs hypoactive. Inc of small formed stool. Reamains npo with no GI access, aspiration precautions/npo.\n\nSkin: Grossly intact, general edema, +peripheral pulses. Tmax 100.9 ax.\n\nEndo: Ssc with regular insulin.\n\nSoc: Many family supports, children visited/phoned today.\n\nP: Follow neuro status, reorient prn. Notify team of sustained tachycardia>130's or hemodynamic instablity. Follow respitory effort, cxr/abgs as indicated. Follow response to diuretic increase with goal fluid balance 1Lneg/24hr. Follow bun/cr, lytes and replete prn. Keep NPO, repeat speech/swallow eval Monday. Repeat liver enzymes in am. Keep family up to date on pt condition/poc, validate feelings/concerns\n" }, { "category": "Nursing/other", "chartdate": "2178-03-29 00:00:00.000", "description": "Report", "row_id": 1660305, "text": "Nursing Progress Note:\nNeuro: Pt alert oriented to self. PEARL 3mm, MAE on bed and able to follow simple directions. Denies pain.\n\nCV: Temp spike 104.4 rectal. HR 110-130's Rapid afib all noc, Recieved Lopressor 5mg X1 besides 10mg Q4. LYtes WNL. Liver enzymes continue to increase. Received tylenol PR with little effect T 103.7\n\nRESP: lungs crackles O2 at 2l via N/C O2 sats 99%. CPT with little effect. weak cough with secretions in back of throat requiring yankauer suctioning.\n\nGI: NPO, Abd soft with hypoactive BS. SMall stool overnoc.\n\nGU: foley draining adequate clear yellow urine.\n\nENDO: blood sugar WNL.\n\nPLAN: Cont to monitor cardiac status, Emotional support\n" }, { "category": "Nursing/other", "chartdate": "2178-03-29 00:00:00.000", "description": "Report", "row_id": 1660306, "text": "NPN\nNEURO- CONT GARBELED SPEECH, BETTER FOLLOWING COMMANDS THIS PM, PEARL, DENIES PAIN.\n\n\nRESP-4 LITERS NASAL , CRACKLES UPPER/DIMINISHED BASES, WEAK COUGH. SAO2 95-99\n\n\nGI- CONT NPO- ? TO GET DHT IN FLURO MONDAY, PREVACID SL QD. LFT CONT TO INCREASE, MICU AWARE- HEPATITIS SCREEN SENT. DISIMPACTED LG AMOUNT SOFT FORMED STOOL.\n\n\nRENAL- CR 1.4, HUO 30-35- GIVEN LASIX 160 MG AND DIURIL 250 MG X1, UO 100-140/HR POST RX.\n\n\n\n" }, { "category": "ECG", "chartdate": "2178-03-27 00:00:00.000", "description": "Report", "row_id": 153265, "text": "Baseline artifact. Probable atrial fibrillation with intermediate\nventricular response. Intraventricular conduction delay of left bundle-branch\nblock type. Occasional ventricular premature beats. Compared to the previous\ntracing of the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2178-03-26 00:00:00.000", "description": "Report", "row_id": 153266, "text": "Compared to the previous tracing probably no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2178-03-25 00:00:00.000", "description": "Report", "row_id": 153267, "text": "Compared to the previous tracing ventricular response rate to atrial\nfibrillation is slower and ventricular ectopy is no longer evident.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2178-03-25 00:00:00.000", "description": "Report", "row_id": 153268, "text": "Atrial fibrillation, average ventricular rate 150. Intraventricular conduction\ndelay of left bundle-branch block type. Medium frequency ventricular premature\nbeats with ventricular couplets. Non-specific repolarization changes.\nCompared to the previous tracing of ventricular response rate\nto atrial fibrillation is faster and there is new ventricular ectopy.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2178-03-25 00:00:00.000", "description": "Report", "row_id": 153269, "text": "Atrial fibrillation, average ventricular rate 120. Left anterior hemiblock.\nIntraventricular conduction delay. Non-specific lateral repolarization\nchanges. Cannot exclude anterior myocardial infarction of indeterminate age\nthough unlikely. Compared to the previous tracing of ventricular\nresponse rate to atrial fibrillation is faster, ventricular ectopy is absent,\nand the late precordial R wave progression (suggesting interval anterior\nmyocardial infarction)is new.\n\n" }, { "category": "ECG", "chartdate": "2178-04-02 00:00:00.000", "description": "Report", "row_id": 153264, "text": "Atrial fibrillation with moderate ventricular response. Left axis deviation.\nPossible left ventericular hypertrophy. Intraventricular conduction\ndelay. Compared to the previous tracing of T wave inversions in the\nanterior and lateral precordial leads are no longer present. The other\nfindings are similar.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2152-01-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 613694, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:38 PM\n ARTERIAL LINE - START 09:09 PM\n PICC LINE - START 09:09 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:38 PM\n Metronidazole - 12:34 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:45 PM\n Fentanyl - 05:21 AM\n Lorazepam (Ativan) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.5\n HR: 118 (98 - 120) bpm\n BP: 106/73(86) {102/69(83) - 167/104(132)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,596 mL\n 1,089 mL\n PO:\n TF:\n IVF:\n 2,592 mL\n 1,089 mL\n Blood products:\n 1,004 mL\n Total out:\n 440 mL\n 630 mL\n Urine:\n 440 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,156 mL\n 459 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 501 (501 - 501) mL\n Vt (Spontaneous): 489 (489 - 489) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.46/33/154/22/1\n Ve: 6.3 L/min\n PaO2 / FiO2: 385\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . No JVD\n LUNGS: mild bronchial breathsounds. o/w CTAB, good air movement\n bilaterally.\n ABDOMEN: distended, dressed midline incision with serosanguinous\n discharge. hypoactive bs.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: sedated, shakes head yes/no to questions, wiggles toes on\n commands. CN 2-12 grossly intact.\n Labs / Radiology\n 247 K/uL\n 14.1 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 102 mEq/L\n 132 mEq/L\n 40.6 %\n 11.4 K/uL\n [image002.jpg]\n 07:42 PM\n 09:15 PM\n 09:24 PM\n 03:48 AM\n 04:00 AM\n WBC\n 5.5\n 11.4\n Hct\n 37\n 39.2\n 40.6\n Plt\n 223\n 247\n Cr\n 0.4\n 0.5\n TCO2\n 23\n 23\n 24\n Glucose\n 131\n 133\n 147\n Other labs: PT / PTT / INR:13.1/29.7/1.1, ALT / AST:82/72, Alk Phos / T\n Bili:89/0.8, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:6.9 mg/dL, Mg++:1.2 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 59 yo female s/p exlap for meckels with ileocolic resection c/b rebleed\n from the anastamosis and sbo, now s/p lysis of adhesions and revision\n of anastamosis.\n .\n #. GI bleed/SBP: status post revision of anastamosis, which is likely\n source of GIB, and lysis of adhesions. VSS and Hct stable after 8\n total U PRBCs. No further bloody BM.\n - trend HCT q8hours, monitor for BRBPR\n - NPO, NGT\n - follow abd exam\n - cipro/flagyl for 1-2 days post-op\n - trend LFTs//lipase (trending down)\n - continue to follow with surgery\n .\n #. s/p intubation: electively intubated for colonoscopy, then surgery.\n Remained intubated fluid resusitation and concern for volume\n overload and h/o being v. difficult intubation. Currently on PSV 5/5\n with good RSBI.\n - early morning wakeup and extubation.\n .\n #. low albumin: unclear if related to prolonged poor nutrition,\n possibly acute phase lowering. No known underlying liver disease\n (plus, coags wnl).\n - advance diet when able\n - restart TPN per recs\n .\n #. depression: resume paxil after extubated\n .\n FEN: NPO\n .\n PPX:\n -DVT ppx with pneumoboots overnight, may start SCH\n -Bowel regimen\n -famotidine\n .\n ACCESS: right PICC, left A-line, 2 18G PIVs.\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: husband \n .\n DISPOSITION: extubation and call-out\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613884, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Received pt s/p bowel resect . Hct @ 32.4, repeat @1am 32.7.\n Midline abdominal incision, drsng intact. Extubated day shift, O2\n sat 92-96% on RA. LSC, diminished at bases. Afebrile. NGT to LCS. ST\n 110s-120s, BP stable 120s. minimal UO, approx 20-30cc/hr of amber\n urine.\n Action:\n Hct q8hrs, cont w/ wall suction. LR @100cc/hr, TPN running. Encourage\n IS and PCA for pain control.\n Response:\n AM hct , no signs of bleeding. Approx cc of thick bilious outpt from\n NGT.\n Plan:\n Hct 8hrs, monitor for signs of bleed. PCA for pain control. Fluid\n bolus PRN for decreased UO or hypotension.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o constant abdominal pain of , with movement. Able to\n tolerate OOB to chair during day shift.\n Action:\n Using dilaudid PCA, 0.25mg q6mins w/ 2.5mg lockout. No basal rate.\n Response:\n Resting comfortably overnight, using PCA for turns. Lethargic, opens\n eyes to voice and answers questions appropriately.\n Plan:\n Cont PCA for pain control, OOB to chair in AM.\n" }, { "category": "Physician ", "chartdate": "2152-01-29 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 614235, "text": "TITLE:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At\n 08:31 AM\n INVASIVE VENTILATION - STOP 08:31 AM\n transferred to TICU.\n HPI: 59F s/p Ex Lap / SBR on for meckles diverticulum w/\n volvulus of the small bowel. Post op Hct 32>25 with blood bm-\n colonoscopy w blood in vault. takeback for revision of\n anastamosis and LOA with ileocolic resection and ileocolonic\n anastomosis. Revision of anasamoosis was in the setting of LGIB form\n anastamosis. Pt transferred form for further\n managment.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:08 AM\n Metronidazole - 05:29 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 02:07 PM\n Lorazepam (Ativan) - 09:00 PM\n Other medications:\n Flowsheet Data as of 01:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.1\nC (98.8\n HR: 102 (102 - 121) bpm\n BP: 126/85(106) {126/69(91) - 187/92(124)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 66 kg\n Total In:\n 4,119 mL\n 361 mL\n PO:\n TF:\n IVF:\n 2,005 mL\n Blood products:\n 945 mL\n 267 mL\n Total out:\n 3,595 mL\n 0 mL\n Urine:\n 2,895 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 524 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.47/40/72/27/4\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: No(t) Soft, Bowel sounds present, Distended, Tender:\n appropriatley, c/d/i/ incision no erythema or induration\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 239 K/uL\n 11.2 g/dL\n 139 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 11 mg/dL\n 102 mEq/L\n 132 mEq/L\n 32.0 %\n 10.5 K/uL\n [image002.jpg]\n 03:48 AM\n 04:00 AM\n 10:07 AM\n 05:35 PM\n 08:09 PM\n 01:05 AM\n 03:44 AM\n 10:34 AM\n 10:52 AM\n 08:49 PM\n WBC\n 11.4\n 10.5\n Hct\n 40.6\n 38.7\n 33.2\n 32.4\n 32.7\n 32.7\n 29.9\n 32.0\n Plt\n 247\n 239\n Cr\n 0.5\n 0.5\n 0.4\n TCO2\n 24\n 30\n Glucose\n 147\n 113\n 139\n Other labs: PT / PTT / INR:14.3/31.0/1.2, ALT / AST:108/104, Alk Phos /\n T Bili:68/0.5, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), GASTROINTESTINAL BLEED, OTHER\n (GI BLEED, GIB)\n 59F s/p Ex Lap / SBR for internal hernia takeback for\n revision of anastamosis and LOA for high-grade SBO\n NEURO: Dilaudid PCA, lorazepam prn for anxiety.\n Neuro checks Q: shift\n CVS: Tachycardic, normotensive.\n PULM: Extubated, No acute issues\n GI: Npo, TPN.\n RENAL: Stable\n HEME: recheck HCt 29 transfusing 2 units PRBC, 2units FFP\n ENDO: RISS\n ID: Enterobacter pansens on ucx.\n TLD: PIV, NGT, Foley\n IVF: HLIV\n CONSULTS: Gold\n ICU Care\n Nutrition:\n TPN without Lipids - 03:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition:Transfer to floor\n Total time spent: 45 minutes\n" }, { "category": "Respiratory ", "chartdate": "2152-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 613716, "text": "Patient self extubated placed on 3 L N/C RR 18 , HR 110,Sat 100%. Had\n plan to extubated patient this AM based on hemodynamics and RSBI of 38\n" }, { "category": "Nursing", "chartdate": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613623, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Neuro: received pt on propofol @ 50mcg, pt , 130s BP 150s.\n propofol increased to 100mcg for pt safety and weaned to 75mcg. Opens\n eyes to stimulation, ST 110s, BP 130s. Afebrile, appears comfortable\n overnight. Propofol lowered to 30mcg and a 50mcg bolus of fent given\n for SAT. Opening eyes and calm, tolerating PS. Cont w/ prop @30mcg and\n fent PRN.\n Resp: ABG on CMV @100%: 7.39/37/362. Weaned FiO2 to 40%, unable to\n tolerate PS do to high level of sedation, but becomes hyptertensive,\n tachy, and agitated with lower dose of propofol. Pt remains intubated\n overnight for fluid removal, autodiuresising approx 200cc/hr, goal is\n early extubation in AM. AM ABG: 7.46/33/154\n CV: BP stable 130s, ST 110s.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct on arrival 39.2, no obvious sign of bleeding. Midline abdominal\n drsng, dry and intact.\n Action:\n Antibiotics given overnight, monitor hct, q8hrs, NPO.\n Response:\n AM hct 40\n Plan:\n Early extubation, if hct stable probable call out to floor.\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613881, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Received pt s/p bowel resect . Hct @ 32.4, repeat @1am 32.7.\n Midline abdominal incision, drsng intact. Extubated day shift, O2\n sat 92-96% on RA. LSC, diminished at bases. Afebrile. NGT to LCS. ST\n 110s-120s, BP stable 120s.\n Action:\n Hct q8hrs, PCA for pain control, cont w/ wall suction.\n Response:\n AM hct , no signs of bleeding.\n Plan:\n Hct 8hrs, monitor for signs of bleed. PCA for pain control.\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613883, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Received pt s/p bowel resect . Hct @ 32.4, repeat @1am 32.7.\n Midline abdominal incision, drsng intact. Extubated day shift, O2\n sat 92-96% on RA. LSC, diminished at bases. Afebrile. NGT to LCS. ST\n 110s-120s, BP stable 120s. minimal UO, approx 20-30cc/hr of amber\n urine.\n Action:\n Hct q8hrs, cont w/ wall suction. LR @100cc/hr, TPN running. Encourage\n IS and PCA for pain control.\n Response:\n AM hct , no signs of bleeding. Approx cc of thick bilious outpt from\n NGT.\n Plan:\n Hct 8hrs, monitor for signs of bleed. PCA for pain control. Fluid\n bolus PRN for decreased UO or hypotension.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o constant abdominal pain of , with movement.\n Action:\n Using dilaudid PCA, 0.25mg q6mins w/ 2.5mg lockout. No basal rate.\n Response:\n Resting comfortably overnight, using PCA for turns. Lethargic, opens\n eyes to voice and answers questions appropriately.\n The pt was sleeping in naps in between PCA doses awakening easily to\n verbal stimuli and stating pain level was . She was assisted\n with PCA and encouraged to use it before activity and pain level came\n down to which pt states is acceptable.\n Plan:\n Continue as above and notify team of escalating or unrelieved pain.\n" }, { "category": "Physician ", "chartdate": "2152-01-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 614016, "text": "TITLE:\n Chief Complaint: - sinus tachycardia persisted throughout day, likely\n stress, possible hemorrhage given drop in Hct\n - serial Hct's overnight with 4 units typed and crossed\n - possible transfer to tomorrow?\n - did not start TPN today\n - deferred SC heparin as Hct unstable\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 08:31 AM\n INVASIVE VENTILATION - STOP 08:31 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 07:57 PM\n Metronidazole - 12:01 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 10:26 AM\n Famotidine (Pepcid) - 10:00 PM\n Lorazepam (Ativan) - 03:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 114 (113 - 126) bpm\n BP: 150/79(104) {96/60(66) - 151/93(111)} mmHg\n RR: 11 (9 - 24) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 66 kg\n Total In:\n 4,199 mL\n 1,261 mL\n PO:\n TF:\n IVF:\n 3,939 mL\n 905 mL\n Blood products:\n Total out:\n 1,240 mL\n 700 mL\n Urine:\n 1,040 mL\n 500 mL\n NG:\n 200 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,959 mL\n 565 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 519 (519 - 519) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n SpO2: 92%\n ABG: ///27/\n Ve: 9.5 L/min\n Physical Examination\n GENERAL: NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . No JVD\n LUNGS: mild bronchial breathsounds. o/w CTAB, good air movement\n bilaterally.\n ABDOMEN: distended, midline incision with minimal serosanguinous\n discharge, C/D/I with no dressing over staples. hypoactive bs.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert and oriented\n Labs / Radiology\n 239 K/uL\n 11.2 g/dL\n 139 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 11 mg/dL\n 102 mEq/L\n 132 mEq/L\n 32.7 %\n 10.5 K/uL\n [image002.jpg]\n 07:42 PM\n 09:15 PM\n 09:24 PM\n 03:48 AM\n 04:00 AM\n 10:07 AM\n 05:35 PM\n 08:09 PM\n 01:05 AM\n 03:44 AM\n WBC\n 5.5\n 11.4\n 10.5\n Hct\n 37\n 39.2\n 40.6\n 38.7\n 33.2\n 32.4\n 32.7\n 32.7\n Plt\n 223\n 247\n 239\n Cr\n 0.4\n 0.5\n 0.5\n 0.4\n TCO2\n 23\n 23\n 24\n Glucose\n 131\n 133\n 147\n 113\n 139\n Other labs: PT / PTT / INR:14.3/31.0/1.2, ALT / AST:108/104, Alk Phos /\n T Bili:68/0.5, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 59 yo female s/p exlap for meckels with ileocolic resection c/b rebleed\n from the anastamosis and sbo, now s/p lysis of adhesions and revision\n of anastamosis.\n .\n #. GI bleed/SBP: status post revision of anastamosis, which is likely\n source of GIB, and lysis of adhesions. No further bloody BM. Hct\n dropped yesterday 38 to 32, then remained stable without further\n transfusion, now dropped to 30. There is concern that anastamosis was\n not actual source of bleed. Pt remains hemodynamically stable with no\n BRBPR.\n - transfuse 2 U PRBC and 2 U FFP\n - trend HCT q8hours, monitor for BRBPR\n - NPO, NGT\n - follow abd exam\n - cipro/flagyl for 1-2 days post-op\n - trend LFTs//lipase (trending down)\n - continue to follow with surgery\n - PCA Dilaudid for pain control\n - transfer to surgery West\n .\n #. Tachycardia: Pt was initially tachycardic and hypertensive when\n agitated on vent, however continues to be tachycardic to 120s now\n extubated. Likely due to pain and anemia. UOP 50-80/hr.\n - cont IVF prn, transfuse as above\n - discuss with surgery\n .\n #. Fever: T 101.3 around rounds, pan-cx\n - notified surgery\n .\n #. depression: resume paxil after extubated\n .\n FEN: restart TPN today\n .\n PPX:\n -held off SCH since Hct drop\n -Bowel regimen\n -famotidine\n .\n ACCESS: right PICC, left A-line, 2 18G PIVs.\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: husband \n .\n DISPOSITION: ICU for today, discuss transfer West with surgery\n ICU Care\n Nutrition:\n TPN without Lipids - 06:22 PM 46 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to West surgery\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614079, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n RESP: bs\ns clear. Pt. had sats in low 90\ns this am on RA.\n Bs\ns were clear. Abg;s done. Ph 7.47 and po2 was 72. placed on np at 2L\n And sats have been 96-98%.\n Pt. has a weak and nonproductive cough.\n Pt. has been using her IS q1-2hrs.\n Gi: ngt patent. Irrigated this am.\n Green bilious drainage. Bs\ns hypoactive. Abd is distended.\n Given 1 dulc supp this am.\n Pt. on TPN.\n Renal: adequate u/o\ns. noted to have 1 small blood clot.\n Pt. appeared to be autodiuresing this pm. Pt. is experiencing\n spasms-states she\ns not able to urinate\n Explained to her about having spasms and that her u/o\ns were fine.\n Ivf\ns LR infusing at 100cc/hr. stopped for ffp and blood transfusions.\n Id: febrile this am to 101. pan cultured, except sputum.\n Cont. on cipro and flagyl.\n Was febrile to 101 this pm as well. No c/o chills.\n Endoc: k+ and mg+ repleted this am. No ssi required.\n Hem: hct drop this am to 29.9, from 32.7. given 2u ffp and receiving\n 1^st unit pc\ns now.\n Neuro: pt. was somewhat confused this am on awakening. Thought she was\n at hospt.\n Easily orientated. Very lethargic this am. Had been given 1mg ativan\n ivp at 4am.\n More alert and awake with family here. Ativan dose dropped to 0.5mg\n ivp. Given 1x this am.\n She doesn\nt appear as anxious as she was yesterday. (she\ns normally on\n paxel at home).\n Also for pain control PCA pump dosage was decreased.\n Pt. not c/o pain. Hasn\nt used the PCA PUMP for several hrs.\n Pt. moving well on her own.\n Oob to chair this am.\n Access: double picc and a-line. Periph line d/c\ned-infiltrated.\n Cv: pt. tachycardic and hypertensive in late am.\n Given 10mg hydralazine ivp x1.\n Action:\n Response:\n Abd appears slightly less distended then this am\n Plan:\n Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and underwent a\n Exploratory lap with an ileocolic resection.\n This was complicated by a gi bleed. Pt. returned to the or and\n underwent an revision of the anastamosis.\n Pt. also had new lysis of adhesion.\n There is a ? of the gi bleed being from the anastamosis.\n Pt. adm. To the micu/sicu on . pt. self extubated on .\n" }, { "category": "Nursing", "chartdate": "2152-01-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 614280, "text": " transferred to TICU.\n HPI: 59F s/p Ex Lap / SBR on for meckles diverticulum w/\n volvulus of the small bowel. Post op Hct 32>25 with blood bm-\n colonoscopy w blood in vault. takeback for revision of\n anastamosis and LOA with ileocolic resection and ileocolonic\n anastomosis. Revision of anastomosis was in the setting of LGIB form\n anastomosis. Pt transferred form for further\n managment.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o 0-5 incisional pain, pt on dilaudid pca, 0.12 mg dose, hr slightly\n tachy (90\ns-100\ns)nsr-st, increased hr noted even when pain free, pt\n with h/o depression/anxiety, takes paxil daily but not able to give\n while npo & can not crush pill\n Action:\n Prn iv ativan given x 1 for anxiety, using dilaudid pca well\n Response:\n Pt comfortable most of day, minimal pain with movement, pt less anxious\n after iv ativan\n Plan:\n Continue to assess pain control, resume po paxil once able to take po,\n prn iv ativan as needed for anxiety\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt with maroon liquid stool last PM, no BM today, am hct 36, tx with 2\n u pc & 2 u ffp yesterday, am hct 29 on , no c/o dizziness, SBP\n stable, HR slightly tachy, low 100\n Action:\n Hct daily, guiac all stools, VS as ordered\n Response:\n No GI bleeding noted, no stool today, am hct stable\n Plan:\n Tx to floor on tele, continue to assess for GI bleeding\n Demographics\n Attending MD:\n B.\n Admit diagnosis:\n ISCHEMIC BOWEL\n Code status:\n Full code\n Height:\n Admission weight:\n 66 kg\n Daily weight:\n 68.6 kg\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Precautions:\n PMH: Anemia, GI Bleed\n CV-PMH:\n Additional history: anxiety, difficult intubation\n Surgery / Procedure and date: csection x2, breast lumpectomy,\n ileocecotomy for strangulated bowel and \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:154\n D:92\n Temperature:\n 99.1\n Arterial BP:\n S:148\n D:92\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,262 mL\n 24h total out:\n 2,860 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:06 AM\n Potassium:\n 3.5 mEq/L\n 04:06 AM\n Chloride:\n 104 mEq/L\n 04:06 AM\n CO2:\n 25 mEq/L\n 04:06 AM\n BUN:\n 9 mg/dL\n 04:06 AM\n Creatinine:\n 0.4 mg/dL\n 04:06 AM\n Glucose:\n 146 mg/dL\n 04:06 AM\n Hematocrit:\n 36.4 %\n 04:06 AM\n Finger Stick Glucose:\n 163\n 02:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cellphone, slippers\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: 919\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2152-01-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 614277, "text": " transferred to TICU.\n HPI: 59F s/p Ex Lap / SBR on for meckles diverticulum w/\n volvulus of the small bowel. Post op Hct 32>25 with blood bm-\n colonoscopy w blood in vault. takeback for revision of\n anastamosis and LOA with ileocolic resection and ileocolonic\n anastomosis. Revision of anastomosis was in the setting of LGIB form\n anastomosis. Pt transferred form for further\n managment.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o 0-5 incisional pain, pt on dilaudid pca, 0.12 mg dose, hr slightly\n tachy (90\ns-100\ns)nsr-st, increased hr noted even when pain free, pt\n with h/o depression/anxiety, takes paxil daily but not able to give\n while npo & can not crush pill\n Action:\n Prn iv ativan given x 1 for anxiety, using dilaudid pca well\n Response:\n Pt comfortable most of day, minimal pain with movement, pt less anxious\n after iv ativan\n Plan:\n Continue to assess pain control, resume po paxil once able to take po,\n prn iv ativan as needed for anxiety\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt with maroon liquid stool last PM, no BM today, am hct\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2152-01-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 613737, "text": "Subjective\n Patient self-extubated this AM\n Objective\n Pertinent medications: flagyl, 2g CaGluc, 2gMgSO4, 40KCl, famotidine,\n propofol at 7.9ml/hr (provides 209kcal/day)\n Labs:\n Value\n Date\n Glucose\n 147 mg/dL\n 03:48 AM\n BUN\n 12 mg/dL\n 03:48 AM\n Creatinine\n 0.5 mg/dL\n 03:48 AM\n Sodium\n 132 mEq/L\n 03:48 AM\n Potassium\n 3.3 mEq/L\n 03:48 AM\n Chloride\n 102 mEq/L\n 03:48 AM\n TCO2\n 22 mEq/L\n 03:48 AM\n PO2 (arterial)\n 154 mm Hg\n 04:00 AM\n PCO2 (arterial)\n 33 mm Hg\n 04:00 AM\n pH (arterial)\n 7.46 units\n 04:00 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 04:00 AM\n Albumin\n 1.7 g/dL\n 09:15 PM\n Calcium non-ionized\n 6.9 mg/dL\n 03:48 AM\n Phosphorus\n 3.4 mg/dL\n 03:48 AM\n Magnesium\n 1.2 mg/dL\n 03:48 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen firm/distended with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 59 year old female with Meckels Diverticulum with volvulus, gangrene or\n distal ileum s/p ex-lap, LOA, resection of distal 2 feet of ileum and\n cecum with ileocolonic anastomosis c/b rebleed from the anastamosis and\n high grade SBO, now s/p lysis of adhesions and revision of anastamosis.\n Patient received TPN prior to return to OR. Noted plan to continue.\n Goal TPN is 1.7L (270g dextrose/110g protein/35g lipids) to provide\n 108kcal and 110g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n TPN as ordered\n Please start , increase insulin in TPN daily PRN\n Will follow\n 10:17 AM\n" }, { "category": "Nursing", "chartdate": "2152-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614169, "text": "Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and then underwent a\n exploratory lap with an ileocolic resection on . This was\n complicated by GIB, pt returned to OR & underwent revision of\n anastamosis & lysis of adhesions on . There is a ? of the GIB from\n the anastomosis. Pt was admitted to the MICU/SICU on . Pt self\n extubated on . TX. from to TSICU on .\n Gastrointestinal bleed, other (GI Bleed, GIB)/ s/p exp lap, lysis of\n adhesions\n Assessment:\n -to OR on for ex lap for possible GI bleed\n -Pt. OOB to commode, stool dark maroon, liquid, guiac positive\n overnight\n -Pt. tachy overnight with HR in 100\n Action:\n --Pt. received 1 unit PRBC overnight, I unit PRBC, 2 units FFP\n yesterday\n Response:\n -HCT 36 this am\n -Billious drainage from OGT\n Plan:\n -Monitor HCT and stool color and guiac\n -Monitor VS\n Pain control (acute pain, chronic pain)\n Assessment:\n -Patient had sharp incisional pain w/movement.\n Action:\n -Pt. received 0.5mg IV ativan for anxiety this am\n -Did not use Dilaudid PCA overnight\n Response:\n -Pain 0/10 without movements\n Plan:\n -?D/C PCA\n -Encourage ambulation\n" }, { "category": "Nursing", "chartdate": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613627, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Neuro: received pt on propofol @ 50mcg, pt , 130s BP 150s.\n propofol increased to 100mcg for pt safety and weaned to 75mcg. Opens\n eyes to stimulation, ST 110s, BP 130s. Afebrile, appears comfortable\n overnight. Propofol lowered to 30mcg and a 50mcg bolus of fent and 1mg\n ativan given for SAT. Opening eyes and calm, tolerating PS. Cont w/\n prop @30mcg and fent and ativan PRN.\n Resp: ABG on CMV @100%: 7.39/37/362. Weaned FiO2 to 40%, unable to\n tolerate PS do to high level of sedation, but becomes hyptertensive,\n tachy, and agitated with lower dose of propofol. Pt remains intubated\n overnight for fluid removal, autodiuresising approx 200cc/hr, goal is\n early extubation in AM. AM ABG: 7.46/33/154\n CV: BP stable 130s, ST 110s.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct on arrival 39.2, no obvious sign of bleeding. Midline abdominal\n drsng, dry and intact.\n Action:\n Antibiotics given overnight, monitor hct, q8hrs, NPO.\n Response:\n AM hct 40\n Plan:\n Early extubation, if hct stable probable call out to floor.\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614090, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n RESP: bs\ns clear. Pt. had sats in low 90\ns this am on RA.\n Bs\ns were clear. Abg;s done. Ph 7.47 and po2 was 72. placed on np at 2L\n And sats have been 96-98%.\n Pt. has a weak and nonproductive cough.\n Pt. has been using her IS q1-2hrs.\n Gi: ngt patent. Irrigated this am.\n Green bilious drainage. Bs\ns hypoactive. Abd is distended.\n Given 1 dulc supp this am.\n Pt. on TPN.\n Renal: adequate u/o\ns. noted to have 1 small blood clot.\n Pt. appeared to be autodiuresing this pm. Pt. is experiencing\n spasms-states she\ns not able to urinate\n Explained to her about having spasms and that her u/o\ns were fine.\n Ivf\ns LR infusing at 100cc/hr. stopped for ffp and blood transfusions.\n Id: febrile this am to 101. pan cultured, except sputum.\n Cont. on cipro and flagyl.\n Was febrile to 101 this pm as well. No c/o chills.\n Endoc: k+ and mg+ repleted this am. No ssi required.\n Hem: hct drop this am to 29.9, from 32.7. given 2u ffp and receiving\n 1^st unit pc\ns now.\n Neuro: pt. was somewhat confused this am on awakening. Thought she was\n at hospt.\n Easily orientated. Very lethargic this am. Had been given 1mg ativan\n ivp at 4am.\n More alert and awake with family here. Ativan dose dropped to 0.5mg\n ivp. Given 1x this am.\n She doesn\nt appear as anxious as she was yesterday. (she\ns normally on\n paxel at home).\n Also for pain control PCA pump dosage was decreased.\n Pt. not c/o pain. Hasn\nt used the PCA PUMP for several hrs.\n Pt. moving well on her own.\n Oob to chair this am.\n Access: double picc and a-line. Periph line needs to be removed.\n Cv: pt. tachycardic and hypertensive in late am.\n Given 10mg hydralazine ivp x1. bp has remained around 150\ns-160\n cont Tachycardic in 110\n c/o headache at 18pm. Given Tylenol 650mg pr x1.\n INCISION: drsg this am. staples intact. No drainage until we\n got her oob. Then only a scant amt of ss drainage. Abd pad placed.\n Social: husband and son into visit most of the day. Husband very\n supportive. Husband needs to be notified prior to transfer.\n Action:\n Response:\n Abd appears slightly less distended then this am\n Plan:\n Transfuse 2^nd u pc\ns when available. Cont. tpn. Recheck hct post\n transfusions. Ativan for anxiety. Pca for pain.\n Await blood cx results. Cxr in am. TRANSFER TO TRAUMA SICU WHEN BED\n AVAILABLE.\n Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and underwent a\n Exploratory lap with an ileocolic resection.\n This was complicated by a gi bleed. Pt. returned to the or and\n underwent an revision of the anastamosis.\n Pt. also had new lysis of adhesion.\n There is a ? of the gi bleed being from the anastamosis.\n Pt. adm. To the micu/sicu on . pt. self extubated on .\n" }, { "category": "Nursing", "chartdate": "2152-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614148, "text": "Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and then underwent a\n exploratory lap with an ileocolic resection on . This was\n complicated by GIB, pt returned to OR & underwent revision of\n anastamosis & lysis of adhesions on . There is a ? of the GIB from\n the anastomosis. Pt was admitted to the MICU/SICU on . Pt self\n extubated on . TX. from to TSICU on .\n Gastrointestinal bleed, other (GI Bleed, GIB)/ s/p exp lap, lysis of\n adhesions\n Assessment:\n -to OR on for ex lap for possible GI bleed\n -Pt. OOB to commode, stool dark maroon, liquid, guiac positive\n overnight\n -Pt. tachy overnight with HR in 100\n Action:\n --Pt. received 1 unit PRBC overnight, I unit PRBC, 2 units FFP\n yesterday\n Response:\n -HCT 36 this am\n -Billious drainage from OGT\n Plan:\n -Monitor HCT and stool color and guiac\n -Monitor VS\n Pain control (acute pain, chronic pain)\n Assessment:\n -Patient had sharp incisional pain w/movement.\n Action:\n -Pt. received 0.5mg IV ativan for anxiety this am\n -Did not use Dilaudid PCA overnight\n Response:\n -Pain 0/10 without movements\n Plan:\n -?D/C PCA\n -Encourage ambulation\n" }, { "category": "Physician ", "chartdate": "2152-01-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 613594, "text": "TITLE: PGY3 Transfer Note\n Chief Complaint: GI Bleed, SBO\n HPI:\n Most of the history is taken from notes and signout as the patient is\n intubated/sedated.\n Ms. is a 59 yo female s/p recent exlap and small bowel\n resection on for meckel's diverticulum and volvulus. She was\n a difficult intubation, but she underwent ileocolic resection with\n primary anastamosis. Her postop course was c/b ileus, but she was\n otherwise recovering well. On the night prior to transfer and the day\n of transfer, she had bloody bowel movements with a HCT drop from 32 to\n 25. She received 4 units of pRBCs. In order to assess her anastamotic\n sight, she was prepped for and underwent colonoscopy with elective\n intubation, which was significant for blood in her rectal vault. The\n rest of the colonscopy was aborted and she was sent to the OR, where\n she underwent lysis for high grade SBO and revision of her\n anastamosis. She required intra-op: LR, 4U PRBC, 1000 Hespan,\n 700cc UOP.\n .\n She was admitted to the for care until she can be extubated.\n .\n REVIEW OF SYSTEMS:\n unable to obtain sedation\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:38 PM\n Metronidazole - 12:34 AM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:45 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n takeback-anastomotic bleed\n ex-lap. ileocecectomy for internal hernia\n depression\n c section\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: drinks EtOH nights/week\n Review of systems:\n Flowsheet Data as of 01:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 112 (98 - 112) bpm\n BP: 132/80(99) {132/80(99) - 167/104(132)} mmHg\n RR: 19 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,596 mL\n 240 mL\n PO:\n TF:\n IVF:\n 2,592 mL\n 240 mL\n Blood products:\n 1,004 mL\n Total out:\n 440 mL\n 380 mL\n Urine:\n 440 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,156 mL\n -140 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 501 (501 - 501) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 99%\n ABG: 7.39/37/362/23/-1\n Ve: 9 L/min\n PaO2 / FiO2: 905\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . No JVD\n LUNGS: mild bronchial breathsounds. o/w CTAB, good air movement\n bilaterally.\n ABDOMEN: distended, dressed midline incision with serosanguinous\n discharge. hypoactive bs.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: sedated, shakes head yes/no to questions, wiggles toes on\n commands. CN 2-12 grossly intact.\n Labs / Radiology\n 223 K/uL\n 13.6 g/dL\n 133 mg/dL\n 0.4 mg/dL\n 12 mg/dL\n 23 mEq/L\n 106 mEq/L\n 3.5 mEq/L\n 134 mEq/L\n 39.2 %\n 5.5 K/uL\n [image002.jpg]\n \n 2:33 A1/6/ 07:42 PM\n \n 10:20 P1/6/ 09:15 PM\n \n 1:20 P1/6/ 09:24 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 5.5\n Hct\n 37\n 39.2\n Plt\n 223\n Cr\n 0.4\n TC02\n 23\n 23\n Glucose\n 131\n 133\n Other labs: PT / PTT / INR:13.1/29.7/1.1, ALT / AST:82/72, Alk Phos / T\n Bili:89/0.8, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:7.3 mg/dL, Mg++:1.3 mg/dL, PO4:3.0\n mg/dL\n STUDIES:\n CXR :\n IMPRESSION: PA and lateral chest reviewed in the absence of prior chest\n radiographs:\n Heterogeneous opacification of the right lower lung is probably largely\n atelectasis. Recent aspiration cannot be excluded. There is no focal\n consolidation to suggest pneumonia, no pleural effusion or indication\n of central adenopathy. Heart size is normal and there is no\n pneumothorax.\n .\n Abd film :\n IMPRESSION: Dilated loops of small bowel, which may reflect an ileus.\n However, a small bowel obstruction cannot be excluded.\n Assessment and Plan\n 59 yo female s/p exlap for meckels with ileocolic resection c/b rebleed\n from the anastamosis and sbo, now s/p lysis of adhesions and revision\n of anastamosis.\n .\n #. GI bleed/SBP: status post revision of anastamosis, which is likely\n source of GIB, and lysis of adhesions. VSS.\n - trend HCT, monitor for BRBPR\n - NPO, NGT\n - follow abd exam\n - cipro/flagyl for 1-2 days\n - trend LFTs//lipase (trending down)\n - continue to follow with surgery\n .\n #. s/p intubation: electively intubated for colonoscopy, then surgery.\n Currently on CMV with propofol for sedation.\n - wean vent\n - early morning wakeup and extubation.\n .\n #. low albumin: unclear if related to prolonged poor nutrition,\n possibly acute phase lowering. No known underlying liver disease\n (plus, coags wnl).\n - advance diet when able\n - consider TPN in the meantime\n .\n #. depression: resume paxil after extubated\n .\n FEN: NPO\n .\n PPX:\n -DVT ppx with pneumoboots tonight, SCH in am if HCT stable\n -Bowel regimen\n -famotidine\n .\n ACCESS: right PICC, left A-line, 2 18G PIVs.\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: husband \n .\n DISPOSITION: tonight, likely extubation in AM and call-out.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2152-01-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 613972, "text": "TITLE:\n Chief Complaint: - sinus tachycardia persisted throughout day, likely\n stress, possible hemorrhage given drop in Hct\n - serial Hct's overnight with 4 units typed and crossed\n - possible transfer to tomorrow?\n - did not start TPN today\n - deferred SC heparin as Hct unstable\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 08:31 AM\n INVASIVE VENTILATION - STOP 08:31 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 07:57 PM\n Metronidazole - 12:01 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 10:26 AM\n Famotidine (Pepcid) - 10:00 PM\n Lorazepam (Ativan) - 03:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 114 (113 - 126) bpm\n BP: 150/79(104) {96/60(66) - 151/93(111)} mmHg\n RR: 11 (9 - 24) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 66 kg\n Total In:\n 4,199 mL\n 1,261 mL\n PO:\n TF:\n IVF:\n 3,939 mL\n 905 mL\n Blood products:\n Total out:\n 1,240 mL\n 700 mL\n Urine:\n 1,040 mL\n 500 mL\n NG:\n 200 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,959 mL\n 565 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 519 (519 - 519) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n SpO2: 92%\n ABG: ///27/\n Ve: 9.5 L/min\n Physical Examination\n GENERAL: NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . No JVD\n LUNGS: mild bronchial breathsounds. o/w CTAB, good air movement\n bilaterally.\n ABDOMEN: distended, dressed midline incision with serosanguinous\n discharge. hypoactive bs.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: sedated, shakes head yes/no to questions, wiggles toes on\n commands. CN 2-12 grossly intact.\n Labs / Radiology\n 239 K/uL\n 11.2 g/dL\n 139 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 11 mg/dL\n 102 mEq/L\n 132 mEq/L\n 32.7 %\n 10.5 K/uL\n [image002.jpg]\n 07:42 PM\n 09:15 PM\n 09:24 PM\n 03:48 AM\n 04:00 AM\n 10:07 AM\n 05:35 PM\n 08:09 PM\n 01:05 AM\n 03:44 AM\n WBC\n 5.5\n 11.4\n 10.5\n Hct\n 37\n 39.2\n 40.6\n 38.7\n 33.2\n 32.4\n 32.7\n 32.7\n Plt\n 223\n 247\n 239\n Cr\n 0.4\n 0.5\n 0.5\n 0.4\n TCO2\n 23\n 23\n 24\n Glucose\n 131\n 133\n 147\n 113\n 139\n Other labs: PT / PTT / INR:14.3/31.0/1.2, ALT / AST:108/104, Alk Phos /\n T Bili:68/0.5, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 59 yo female s/p exlap for meckels with ileocolic resection c/b rebleed\n from the anastamosis and sbo, now s/p lysis of adhesions and revision\n of anastamosis.\n .\n #. GI bleed/SBP: status post revision of anastamosis, which is likely\n source of GIB, and lysis of adhesions. No further bloody BM. Hct\n dropped yesterday 38 to 32, then remained stable without further\n transfusion.\n - trend HCT q8hours, monitor for BRBPR\n - NPO, NGT\n - follow abd exam\n - cipro/flagyl for 1-2 days post-op\n - trend LFTs//lipase (trending down)\n - continue to follow with surgery\n - PCA Dilaudid for pain control\n .\n #. Tachycardia: Pt was initially tachycardic and hypertensive when\n agitated on vent, however continues to be tachycardic to 120s now\n extubated. Likely due to pain and anemia. UOP 50-80/hr.\n - cont IVF prn\n - discuss IVFs with surgery\n #. depression: resume paxil after extubated\n .\n FEN: restart TPN today\n .\n PPX:\n -held off SCH since Hct drop\n -Bowel regimen\n -famotidine\n .\n ACCESS: right PICC, left A-line, 2 18G PIVs.\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: husband \n .\n DISPOSITION: ICU for today, discuss transfer West with surgery\n ICU Care\n Nutrition:\n TPN without Lipids - 06:22 PM 46 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 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": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613653, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Neuro: received pt on propofol @ 50mcg, pt , 130s BP 150s.\n propofol increased to 100mcg for pt safety and weaned to 75mcg. Opens\n eyes to stimulation, ST 110s, BP 130s. Afebrile, appears comfortable\n overnight. Propofol lowered to 30mcg and a 50mcg bolus of fent and 1mg\n ativan given for SAT. Opening eyes and calm, tolerating PS. Cont w/\n prop @30mcg and fent and ativan PRN.\n Resp: ABG on CMV @100%: 7.39/37/362. Weaned FiO2 to 40%. pt becomes\n hyptertensive, tachy, and agitated with lower dose of propofol. Able to\n tolerate PS w/ propofol @30mcg and fent/ativan bolusesPRN. Pt remains\n intubated overnight for fluid removal, autodiuresising approx 200cc/hr,\n goal is early extubation in AM. AM ABG: 7.46/33/154\n CV: BP stable 130s, ST 110s.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct on arrival 39.2, no obvious sign of bleeding. Midline abdominal\n drsng, dry and intact.\n Action:\n Antibiotics given overnight, monitor hct, q8hrs, NPO.\n Response:\n AM hct 40\n Plan:\n Early extubation, if hct remains stable probable call out to floor.\n" }, { "category": "Nursing", "chartdate": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613656, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Neuro: received pt on propofol @ 50mcg, pt , 130s BP 150s.\n propofol increased to 100mcg for pt safety and weaned to 75mcg. Opens\n eyes to stimulation, ST 110s, BP 130s. Afebrile, appears comfortable\n overnight. Propofol lowered to 30mcg and a 50mcg bolus of fent and 1mg\n ativan given for SAT. Opening eyes and calm, tolerating PS. Cont w/\n prop @30mcg and fent and ativan PRN.\n Resp: ABG on CMV @100%: 7.39/37/362, weaned FiO2 to 40%. pt becomes\n hyptertensive, tachy, and agitated with lower dose of propofol. Able to\n tolerate PS w/ propofol @30mcg and fent/ativan bolusesPRN. Pt remains\n intubated overnight for fluid removal, autodiuresising approx 200cc/hr,\n goal is early extubation in AM. AM ABG: 7.46/33/154\n CV: BP stable 130s, ST 110s.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct on arrival 39.2, no obvious sign of bleeding. Midline abdominal\n drsng, dry and intact.\n Action:\n Antibiotics given overnight, monitor hct, q8hrs, NPO.\n Response:\n AM hct 40\n Plan:\n Early extubation, if hct remains stable probable call out to floor.\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613955, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Received pt s/p bowel resect . Hct @ 32.4, repeat @1am 32.7.\n Midline abdominal incision, drsng intact. Extubated day shift, O2\n sat 92-96% on RA. LSC, diminished at bases. Afebrile. NGT to LCS. ST\n 110s-120s, BP stable 120s. minimal UO, approx 20-30cc/hr of amber\n urine.\n Action:\n Hct q8hrs, cont w/ wall suction. LR @100cc/hr, TPN running. Encourage\n IS and PCA for pain control.\n Response:\n AM hct , no signs of bleeding. Approx cc of thick bilious outpt from\n NGT. UO picking up to approx 50cc/hr.\n Plan:\n Hct 8hrs, monitor for signs of bleed. PCA for pain control. Fluid\n bolus PRN for decreased UO or hypotension.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o constant abdominal pain of , with movement. Able to\n tolerate OOB to chair during day shift.\n Action:\n Using dilaudid PCA, 0.25mg q6mins w/ 2.5mg lockout. No basal rate.\n Response:\n Resting comfortably overnight, using PCA for turns. Lethargic, opens\n eyes to voice and answers questions appropriately.\n Plan:\n Cont PCA for pain control, OOB to chair in AM.\n" }, { "category": "Physician ", "chartdate": "2152-01-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 613580, "text": "Chief Complaint: Hernia Repair\n GI Bleeding\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with internal hernia and s/p repair with resection and\n anastamosis. Patient had GI bleed noted (6 units PRBC) today and with\n Colonscopy patient had evidence of blood in rectum and patient had SBO\n and required revision of anastamosis and is admitted to post\n operatively intubated.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:38 PM\n Infusions:\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:45 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pregnancy\n Occupation:\n Drugs: No abuse\n Tobacco: none\n Alcohol: Intermittent\n Other:\n Review of systems:\n Constitutional: Fatigue\n Nutritional Support: NPO\n Heme / Lymph: Anemia\n Flowsheet Data as of 11:39 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 109 (98 - 109) bpm\n BP: 134/80(100) {134/80(100) - 167/104(132)} mmHg\n RR: 18 (16 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,531 mL\n PO:\n TF:\n IVF:\n 2,527 mL\n Blood products:\n 1,004 mL\n Total out:\n 0 mL\n 440 mL\n Urine:\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,091 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 501 (501 - 501) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: 7.39/37/362/23/-1\n Ve: 10.2 L/min\n PaO2 / FiO2: 905\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: No(t) Bowel sounds present, Distended\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 223 K/uL\n 39.2 %\n 13.6 g/dL\n 133 mg/dL\n 0.4 mg/dL\n 12 mg/dL\n 23 mEq/L\n 106 mEq/L\n 3.5 mEq/L\n 134 mEq/L\n 5.5 K/uL\n [image002.jpg]\n 07:42 PM\n 09:15 PM\n 09:24 PM\n WBC\n 5.5\n Hct\n 37\n 39.2\n Plt\n 223\n Cr\n 0.4\n TC02\n 23\n 23\n Glucose\n 131\n 133\n Other labs: PT / PTT / INR:13.1/29.7/1.1, ALT / AST:82/72, Alk Phos / T\n Bili:89/0.8, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:7.3 mg/dL, Mg++:1.3 mg/dL, PO4:3.0\n mg/dL\n Imaging: CXR-ETT in good position, no focal infiltrates\n Assessment and Plan\n 52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n 1)Respiratory Failure-\n -Will move to PSV\n -Will move to wean support towards extubation in am with consultation\n with surgery\n -Good response to FIO2 and PEEP wean this PM.\n 2)GI Bleed-Likely source anastamosis\n -Follow HCT q 8 hours\n -Maintain Peripheral IV's at a minimum of 2 sites this pm\n 3)Bowel Obstruction-\n -NPO\n -Continue to follow with surgery\n -Follow abdominal exam\n -Will have to consider TPN if slow to return to bowel function\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613583, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Neuro: received pt on propofol @ 50mcg, pt , 130s BP 150s.\n propofol increased to 100mcg for pt safety and weaned to 75mcg. Opens\n eyes to stimulation, ST 110s, BP 130s. Afebrile, appears comfortable\n overnight.\n Resp: ABG on CMV @100%: 7.39/37/362. Weaned FiO2 to 40%, unable to\n tolerate PS do to high level of sedation, but becomes hyptertensive,\n tachy, and agitated with lower dose of propofol. Pt remains intubated\n overnight for fluid removal, autodiuresising approx 200cc/hr, goal is\n early extubation in AM.\n CV: BP stable 130s, ST 110s.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct on arrival 39.2, no obvious sign of bleeding. Midline abdominal\n drsng, dry and intact.\n Action:\n Antibiotics given overnight, monitor hct, q8hrs, NPO.\n Response:\n AM hct\n Plan:\n Early extubation, if hct stable probable call out to floor.\n" }, { "category": "Respiratory ", "chartdate": "2152-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 613639, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: OR\n Reason: Elective; Comments: Intubated for procedure.\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan to extubate this AM.\n Reason for continuing current ventilatory support:\n" }, { "category": "Physician ", "chartdate": "2152-01-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 613753, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:38 PM\n ARTERIAL LINE - START 09:09 PM\n PICC LINE - START 09:09 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:38 PM\n Metronidazole - 12:34 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:45 PM\n Fentanyl - 05:21 AM\n Lorazepam (Ativan) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.5\n HR: 118 (98 - 120) bpm\n BP: 106/73(86) {102/69(83) - 167/104(132)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,596 mL\n 1,089 mL\n PO:\n TF:\n IVF:\n 2,592 mL\n 1,089 mL\n Blood products:\n 1,004 mL\n Total out:\n 440 mL\n 630 mL\n Urine:\n 440 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,156 mL\n 459 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 501 (501 - 501) mL\n Vt (Spontaneous): 489 (489 - 489) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.46/33/154/22/1\n Ve: 6.3 L/min\n PaO2 / FiO2: 385\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . No JVD\n LUNGS: mild bronchial breathsounds. o/w CTAB, good air movement\n bilaterally.\n ABDOMEN: distended, dressed midline incision with serosanguinous\n discharge. hypoactive bs.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: sedated, shakes head yes/no to questions, wiggles toes on\n commands. CN 2-12 grossly intact.\n Labs / Radiology\n 247 K/uL\n 14.1 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 102 mEq/L\n 132 mEq/L\n 40.6 %\n 11.4 K/uL\n [image002.jpg]\n 07:42 PM\n 09:15 PM\n 09:24 PM\n 03:48 AM\n 04:00 AM\n WBC\n 5.5\n 11.4\n Hct\n 37\n 39.2\n 40.6\n Plt\n 223\n 247\n Cr\n 0.4\n 0.5\n TCO2\n 23\n 23\n 24\n Glucose\n 131\n 133\n 147\n Other labs: PT / PTT / INR:13.1/29.7/1.1, ALT / AST:82/72, Alk Phos / T\n Bili:89/0.8, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:6.9 mg/dL, Mg++:1.2 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 59 yo female s/p exlap for meckels with ileocolic resection c/b rebleed\n from the anastamosis and sbo, now s/p lysis of adhesions and revision\n of anastamosis.\n .\n #. GI bleed/SBP: status post revision of anastamosis, which is likely\n source of GIB, and lysis of adhesions. VSS and Hct stable after 8\n total U PRBCs. No further bloody BM.\n - trend HCT q8hours, monitor for BRBPR\n - NPO, NGT\n - follow abd exam\n - cipro/flagyl for 1-2 days post-op\n - trend LFTs//lipase (trending down)\n - continue to follow with surgery\n - PCA Dilaudid for pain control\n .\n #. Tachycardia: Pt was initially tachycardic and hypertensive when\n agitated on vent, however continues to be tachycardic to 120s now\n extubated. Is in pain but also somnolent. UOP also decreased over past\n few hours to 20cc/hr.\n - discuss IVFs with surgery and bolus\n .\n #. s/p intubation: electively intubated for colonoscopy, then surgery.\n Remained intubated fluid resusitation and concern for volume\n overload and h/o being v. difficult intubation. Self extubated this AM\n after sedation weaned. Currently stable resp status on NC.\n .\n #. low albumin: likely due to acute phase lowering. No known\n underlying liver disease (plus, coags wnl).\n - advance diet when able\n - restart TPN per recs\n .\n #. depression: resume paxil after extubated\n .\n FEN: NPO\n .\n PPX:\n -restart SCH since Hct stable\n -Bowel regimen\n -famotidine\n .\n ACCESS: right PICC, left A-line, 2 18G PIVs.\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: husband \n .\n DISPOSITION: extubation and call-out\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613847, "text": "59 year old female with Meckels Diverticulum with volvulus, gangrene or\n distal ileum s/p ex-lap, LOA, resection of distal 2 feet of ileum and\n cecum with ileocolonic anastomosis c/b rebleed from the anastamosis and\n high grade SBO, now s/p lysis of adhesions and revision of anastamosis.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n AM HCT 40.6 and 38.7 respectively and skin is warm and dry with good\n capillary refill. MAP> 60 and pt is constistently Tachycardic with\n heart rate ranging from 115-125. Rhythm is sinus with no ectopy. Serum\n K 3.3 and Mag level was 1.2. Uo has been 20-35cc/hr and is clear amber.\n Abdomen is firm and distended with hypoactive bowel sounds auscultated.\n No N/V noted or voiced. General edema noted and skin surfaces are\n grossly intact. Nutrition status is currently NPO. Fluid balance since\n MN is positive 2,064cc.\n Action:\n Fluid boluses of LR 500cc x2 and NS 500cc x1 were given over the\n course of the day, LR at 100cc/hr was maintained and magnesium and\n potassium were repleted. Pt was assisted OOB to chair and instructed on\n use of IS and splinting pillow. NGT was attached to LWS and TPN was\n initiated at 46cc/hr. Lytes and HCT were repeated at 1800.\n Response:\n Uo remains 20-35cc/hr clear amber and heart rate is currently 124 and\n soft systolic murmur now appreciated with ICU team aware of new\n finding. Lungs are clear bilaterally and 02 sat on RA is 93-955. Pt\n tolerated being OOB for several hours and transferred back to bed with\n steady gate. She is using her IS q1-2hr and achieving 750-1000cc with\n each breath. NGT return for the shift was 200cc of thick, light tan\n fluid. PM HCT 33.2 and electrolytes are pending.\n Plan:\n Continue to follow hourly urine output and respiratory status. Observe\n for n/v and follow NGT output. Aspirate and flush prn to maintain\n patency. Follow HCT q8hr and notify team of S/S GIB or hemodynamic\n instability. Repelet lytes prn.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain with activity and movement at incision site and\n abdomen.\n Action:\n PCA dilaudid initiated at 0.25mg q6min with hourly lockout of 2.5mg.\n Pt instructed on use of splinting pillow and encouraged to use her PCA\n prior to activity.\n Response:\n The pt was sleeping in naps in between PCA doses awakening easily to\n verbal stimuli and stating pain level was . She was assisted\n with PCA and encouraged to use it before activity and pain level came\n down to which pt states is acceptable.\n Plan:\n Continue as above and notify team of escalating or unrelieved pain.\n" }, { "category": "Physician ", "chartdate": "2152-01-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 613849, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:38 PM\n ARTERIAL LINE - START 09:09 PM\n PICC LINE - START 09:09 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:38 PM\n Metronidazole - 12:34 AM\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 09:45 PM\n Fentanyl - 05:21 AM\n Lorazepam (Ativan) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.5\n HR: 118 (98 - 120) bpm\n BP: 106/73(86) {102/69(83) - 167/104(132)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,596 mL\n 1,089 mL\n PO:\n TF:\n IVF:\n 2,592 mL\n 1,089 mL\n Blood products:\n 1,004 mL\n Total out:\n 440 mL\n 630 mL\n Urine:\n 440 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,156 mL\n 459 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 501 (501 - 501) mL\n Vt (Spontaneous): 489 (489 - 489) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.46/33/154/22/1\n Ve: 6.3 L/min\n PaO2 / FiO2: 385\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . No JVD\n LUNGS: mild bronchial breathsounds. o/w CTAB, good air movement\n bilaterally.\n ABDOMEN: distended, dressed midline incision with serosanguinous\n discharge. hypoactive bs.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: sedated, shakes head yes/no to questions, wiggles toes on\n commands. CN 2-12 grossly intact.\n Labs / Radiology\n 247 K/uL\n 14.1 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 102 mEq/L\n 132 mEq/L\n 40.6 %\n 11.4 K/uL\n [image002.jpg]\n 07:42 PM\n 09:15 PM\n 09:24 PM\n 03:48 AM\n 04:00 AM\n WBC\n 5.5\n 11.4\n Hct\n 37\n 39.2\n 40.6\n Plt\n 223\n 247\n Cr\n 0.4\n 0.5\n TCO2\n 23\n 23\n 24\n Glucose\n 131\n 133\n 147\n Other labs: PT / PTT / INR:13.1/29.7/1.1, ALT / AST:82/72, Alk Phos / T\n Bili:89/0.8, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:6.9 mg/dL, Mg++:1.2 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 59 yo female s/p exlap for meckels with ileocolic resection c/b rebleed\n from the anastamosis and sbo, now s/p lysis of adhesions and revision\n of anastamosis.\n .\n #. GI bleed/SBP: status post revision of anastamosis, which is likely\n source of GIB, and lysis of adhesions. VSS and Hct stable after 8\n total U PRBCs. No further bloody BM.\n - trend HCT q8hours, monitor for BRBPR\n - NPO, NGT\n - follow abd exam\n - cipro/flagyl for 1-2 days post-op\n - trend LFTs//lipase (trending down)\n - continue to follow with surgery\n - PCA Dilaudid for pain control\n .\n #. Tachycardia: Pt was initially tachycardic and hypertensive when\n agitated on vent, however continues to be tachycardic to 120s now\n extubated. Is in pain but also somnolent. UOP also decreased over past\n few hours to 20cc/hr.\n - discuss IVFs with surgery and bolus\n .\n #. s/p intubation: electively intubated for colonoscopy, then surgery.\n Remained intubated fluid resusitation and concern for volume\n overload and h/o being v. difficult intubation. Self extubated this AM\n after sedation weaned. Currently stable resp status on NC.\n .\n #. low albumin: likely due to acute phase lowering. No known\n underlying liver disease (plus, coags wnl).\n - advance diet when able\n - restart TPN per recs\n .\n #. depression: resume paxil after extubated\n .\n FEN: NPO\n .\n PPX:\n -restart SCH since Hct stable\n -Bowel regimen\n -famotidine\n .\n ACCESS: right PICC, left A-line, 2 18G PIVs.\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: husband \n .\n DISPOSITION: extubation and call-out\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n 18 Gauge - 09:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n CRITICAL CARE\n Present for key portions of resident\ns history and exam. Agree with\n assessment and plan. She is extubated successfully. Remains\n tachycardic for uncertain reasons. We have treated pain and she denies\n discomfort. Hct is stable. Given IVF bolus w/o clear effect. \n reflect stress of procedure. UO poor, however so she may still benefit\n from volume resus.\n Time spent 35 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 19:16 ------\n" }, { "category": "Nursing", "chartdate": "2152-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613821, "text": "59 year old female with Meckels Diverticulum with volvulus, gangrene or\n distal ileum s/p ex-lap, LOA, resection of distal 2 feet of ileum and\n cecum with ileocolonic anastomosis c/b rebleed from the anastamosis and\n high grade SBO, now s/p lysis of adhesions and revision of anastamosis.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614107, "text": "Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and then underwent a\n exploratory lap with an ileocolic resection on . This was\n complicated by GIB, pt returned to OR & underwent revision of\n anastamosis & lysis of adhesions on . There is a ? of the GIB from\n the anastomosis. Pt was admitted to the MICU/SICU on . Pt self\n extubated on .\n Gastrointestinal bleed, other (GI Bleed, GIB)/ s/p exp lap, lysis of\n adhesions\n Assessment:\n Patient received 2 units FFP & 1 unit PC\ns for Hct 29.9 today.\n Incision line stapled & ecchymotic. Small amt serosanguinous drainage\n from incision stained ABD pad when patient got up to chair today.\n Abdomen distended & soft. Hypoactive bowel sounds present. Patient\n c/o hunger but no flatus yet.\n Action:\n Post Hct was 32. Emptied 500cc bilious drainage, guiac trace +, from\n NGT to low wall Sx. Patient remained NPO.\n Response:\n Transferred to T SICU @ 2300.\n Plan:\n Transfuse 2^nd unit PC\ns tonight.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient had sharp incisional pain w/movement.\n Action:\n Received 0.5mg IV ativan for anxiety @ 2130. Received 0.12mg IV\n dilaudid by PCA @ 2100 & 2230 to prevent further pain during transfer\n by ambulance. This was the 1^st pain medication since noon.\n Response:\n Pain was relieved down to 3/10 w/ PCA.\n Plan:\n Evaluate need for PCA .\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614108, "text": "Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and then underwent a\n exploratory lap with an ileocolic resection on . This was\n complicated by GIB, pt returned to OR & underwent revision of\n anastamosis & lysis of adhesions on . There is a ? of the GIB from\n the anastomosis. Pt was admitted to the MICU/SICU on . Pt self\n extubated on .\n Gastrointestinal bleed, other (GI Bleed, GIB)/ s/p exp lap, lysis of\n adhesions\n Assessment:\n Patient received 2 units FFP & 1 unit PC\ns for Hct 29.9 today.\n Incision line stapled & ecchymotic. Small amt serosanguinous drainage\n from incision stained ABD pad when patient got up to chair today.\n Abdomen distended & soft. Hypoactive bowel sounds present. Patient\n c/o hunger but no flatus yet.\n Action:\n Post Hct was 32. Emptied 500cc bilious drainage, guiac trace +, from\n NGT to low wall Sx. Patient remained NPO.\n Response:\n Transferred to T SICU @ 2300.\n Plan:\n Transfuse 2^nd unit PC\ns tonight.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient had sharp incisional pain w/movement.\n Action:\n Received 0.5mg IV ativan for anxiety @ 2130. Received 0.12mg IV\n dilaudid by PCA @ 2100 & 2230 to prevent further pain during transfer\n by ambulance. This was the 1^st pain medication since noon.\n Response:\n Pain was relieved down to 3/10 w/ PCA.\n Plan:\n Evaluate need for PCA .\n" }, { "category": "Physician ", "chartdate": "2152-01-29 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 614116, "text": "TITLE:\n 24 Hour Events:\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At\n 08:31 AM\n INVASIVE VENTILATION - STOP 08:31 AM\n transferred to TICU.\n HPI: 59F s/p Ex Lap / SBR on for meckles diverticulum w/\n volvulus of the small bowel. Post op Hct 32>25 with blood bm-\n colonoscopy w blood in vault. takeback for revision of\n anastamosis and LOA with ileocolic resection and ileocolonic\n anastomosis. Revision of anasamoosis was in the setting of LGIB form\n anastamosis. Pt transferred form for further\n managment.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 10:08 AM\n Metronidazole - 05:29 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 02:07 PM\n Lorazepam (Ativan) - 09:00 PM\n Other medications:\n Flowsheet Data as of 01:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.1\nC (98.8\n HR: 102 (102 - 121) bpm\n BP: 126/85(106) {126/69(91) - 187/92(124)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 66 kg\n Total In:\n 4,119 mL\n 361 mL\n PO:\n TF:\n IVF:\n 2,005 mL\n Blood products:\n 945 mL\n 267 mL\n Total out:\n 3,595 mL\n 0 mL\n Urine:\n 2,895 mL\n NG:\n 700 mL\n Stool:\n Drains:\n Balance:\n 524 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.47/40/72/27/4\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: No(t) Soft, Bowel sounds present, Distended, Tender:\n appropriatley, c/d/i/ incision no erythema or induration\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 239 K/uL\n 11.2 g/dL\n 139 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 11 mg/dL\n 102 mEq/L\n 132 mEq/L\n 32.0 %\n 10.5 K/uL\n [image002.jpg]\n 03:48 AM\n 04:00 AM\n 10:07 AM\n 05:35 PM\n 08:09 PM\n 01:05 AM\n 03:44 AM\n 10:34 AM\n 10:52 AM\n 08:49 PM\n WBC\n 11.4\n 10.5\n Hct\n 40.6\n 38.7\n 33.2\n 32.4\n 32.7\n 32.7\n 29.9\n 32.0\n Plt\n 247\n 239\n Cr\n 0.5\n 0.5\n 0.4\n TCO2\n 24\n 30\n Glucose\n 147\n 113\n 139\n Other labs: PT / PTT / INR:14.3/31.0/1.2, ALT / AST:108/104, Alk Phos /\n T Bili:68/0.5, Amylase / Lipase:117/112, Differential-Neuts:60.6 %,\n Lymph:35.3 %, Mono:2.1 %, Eos:1.7 %, Lactic Acid:2.2 mmol/L,\n Albumin:1.7 g/dL, LDH:160 IU/L, Ca++:7.1 mg/dL, Mg++:1.6 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), GASTROINTESTINAL BLEED, OTHER\n (GI BLEED, GIB)\n 59F s/p Ex Lap / SBR for internal hernia takeback for\n revision of anastamosis and LOA for high-grade SBO\n NEURO: Dilaudid PCA, lorazepam prn for anxiety.\n Neuro checks Q: shift\n CVS: Tachycardic, normotensive.\n PULM: Extubated, No acute issues\n GI: Npo, TPN.\n RENAL: Stable\n HEME: recheck HCt 29 transfusing 2 units PRBC, 2units FFP\n ENDO: RISS\n ID: Enterobacter pansens on ucx.\n TLD: PIV, NGT, Foley\n IVF: HLIV\n CONSULTS: Gold\n ICU Care\n Nutrition:\n TPN without Lipids - 03:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:09 PM\n PICC Line - 09:09 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition:Transfer to floor\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 613891, "text": "52 yo female with initial admission for internal hernia and now with\n significant GI bleeding in the setting of recurrent SBO and now upon\n return to OR had required substantial resuscitation with colloid,\n crystalloid and PRBCS and is admitted to the ICU intubated.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Received pt s/p bowel resect . Hct @ 32.4, repeat @1am 32.7.\n Midline abdominal incision, drsng intact. Extubated day shift, O2\n sat 92-96% on RA. LSC, diminished at bases. Afebrile. NGT to LCS. ST\n 110s-120s, BP stable 120s. minimal UO, approx 20-30cc/hr of amber\n urine.\n Action:\n Hct q8hrs, cont w/ wall suction. LR @100cc/hr, TPN running. Encourage\n IS and PCA for pain control.\n Response:\n AM hct , no signs of bleeding. Approx cc of thick bilious outpt from\n NGT. UO picking up to approx 50cc/hr.\n Plan:\n Hct 8hrs, monitor for signs of bleed. PCA for pain control. Fluid\n bolus PRN for decreased UO or hypotension.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o constant abdominal pain of , with movement. Able to\n tolerate OOB to chair during day shift.\n Action:\n Using dilaudid PCA, 0.25mg q6mins w/ 2.5mg lockout. No basal rate.\n Response:\n Resting comfortably overnight, using PCA for turns. Lethargic, opens\n eyes to voice and answers questions appropriately.\n Plan:\n Cont PCA for pain control, OOB to chair in AM.\n" }, { "category": "Nursing", "chartdate": "2152-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614106, "text": "Pt. is a 59 yr old woman with hx of meckels syndrome, who underwent a\n colonoscopy and then underwent a\n exploratory lap with an ileocolic resection on . This was\n complicated by GIB, pt returned to OR & underwent revision of\n anastamosis & lysis of adhesions on . There is a ? of the GIB from\n the anastomosis. Pt was admitted to the MICU/SICU on . Pt self\n extubated on .\n Gastrointestinal bleed, other (GI Bleed, GIB)/ s/p exp lap, lysis of\n adhesions\n Assessment:\n Patient received 2 units FFP & 1 unit PC\ns for Hct 29 today. Incision\n line stapled & ecchymotic. Small amt serosanguinous drainage from\n incision stained ABD pad when patient got up to chair today. Abdomen\n distended & soft. Hypoactive bowel sounds present. Patient c/o hunger\n but no flatus yet.\n Action:\n Post Hct was 32. Emptied 500cc bilious drainage, guiac trace +, from\n NGT to low wall Sx. Patient remained NPO.\n Response:\n Transferred to T SICU @ 2300.\n Plan:\n Transfuse 2^nd unit PC\ns tonight.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient had sharp incisional pain w/movement.\n Action:\n Received 0.5mg IV ativan for anxiety @ 2130. Received 0.12mg IV\n dilaudid by PCA @ 2100 & 2230 to prevent further pain during transfer\n by ambulance. This was the 1^st pain medication since noon.\n Response:\n Pain was relieved down to 3/10 w/ PCA.\n Plan:\n Evaluate need for PCA .\n" }, { "category": "ECG", "chartdate": "2152-01-25 00:00:00.000", "description": "Report", "row_id": 268993, "text": "Sinus rhythm. Tracing is probably normal. No previous tracing available for\ncomparison.\n\n" }, { "category": "ECG", "chartdate": "2152-01-25 00:00:00.000", "description": "Report", "row_id": 268992, "text": "Sinus rhythm. Since the previous tracing of the rate is slower.\n\n" }, { "category": "Radiology", "chartdate": "2152-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115351, "text": " 9:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: ISCHEMIC BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p ex-lap and LOA\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube placement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 3 cm above the carina. The NG tube tip is projecting over\n the stomach. The stomach continues to be significantly distended.\n\n The right PICC line tip is at the level of mid low SVC.\n\n There are new bibasal opacities consistent with atelectasis that were not\n demonstrated on the prior study from . Right pleural effusion\n is minimal. There is no evidence of pneumothorax.\n\n Attention to the bibasilar opacities, in particular at the right lung base\n should be paid to exclude the possibility of pneumonia superimposed on areas\n of atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2152-01-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1115159, "text": " 2:55 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: s/p r 40cm picc\n Admitting Diagnosis: ISCHEMIC BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ischemic requiring tpn\n REASON FOR THIS EXAMINATION:\n s/p r 40cm picc\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n right subclavian PICC line that extends to the mid-to-lower portion of the\n SVC. No other change in the appearance of the heart and lungs, which are\n essentially within normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1114950, "text": " 10:13 AM\n CHEST (PA & LAT) Clip # \n Reason: R/o acute process\n Admitting Diagnosis: ISCHEMIC BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p ex lap/SBR with fever\n REASON FOR THIS EXAMINATION:\n R/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM \n\n HISTORY: Fever after surgery.\n\n IMPRESSION: PA and lateral chest reviewed in the absence of prior chest\n radiographs:\n\n Heterogeneous opacification of the right lower lung is probably largely\n atelectasis. Recent aspiration cannot be excluded. There is no focal\n consolidation to suggest pneumonia, no pleural effusion or indication of\n central adenopathy. Heart size is normal and there is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-21 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1114667, "text": " 2:57 PM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate ngt position\n Admitting Diagnosis: ISCHEMIC BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59F s/p Ex Lap / SBR for internal hernia\n REASON FOR THIS EXAMINATION:\n evaluate ngt position\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post laparotomy for reduction of internal hernia.\n Evaluate position of nasogastric tube.\n\n The nasogastric tube lies within the stomach. Dilated loops of small bowel\n are present. The gas is seen within the entire GI tract indicating more\n probable ileus rather than small-bowel obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-01-25 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1115183, "text": " 8:04 PM\n ABDOMEN (SUPINE & ERECT); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ?ileus\n Admitting Diagnosis: ISCHEMIC BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with nausea s/p internal hernia repair and small bowel\n resection\n REASON FOR THIS EXAMINATION:\n ?ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nausea status post internal hernia repair and small bowel resection,\n evaluate for ileus.\n\n COMPARISON: .\n\n SUPINE AND UPRIGHT VIEWS OF THE ABDOMEN: Midline surgical staples are noted.\n There are dilated loops of small bowel, which measure up to 5.5 cm, with\n multiple air-fluid levels noted on the upright image. Gas is also seen within\n the stomach and rectum. The degree of small bowel distention is similar to\n the prior study. No free air or pneumatosis is identified.\n\n IMPRESSION: Dilated loops of small bowel, which may reflect an ileus.\n However, a small bowel obstruction cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2152-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115602, "text": " 11:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change, r/o infiltrate\n Admitting Diagnosis: ISCHEMIC BOWEL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p lysis of adhesions and revision of anastamosis ileocolic\n resection, persistent tachycardia\n REASON FOR THIS EXAMINATION:\n please eval for interval change, r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:03 A.M. :\n\n HISTORY: Lysis of adhesions and revision of ileocolic anastomosis.\n Persistent tachycardia.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are lower. There may be a small volume of left lower lobe\n atelectasis, but there is no pulmonary edema, lobar collapse or evidence of\n pneumonia. Heart size normal. No pneumothorax. Tiny bilateral pleural\n effusion is presumed following recent abdominal surgery. Nasogastric tube\n ends in the mid stomach. No free subdiaphragmatic gas. Colonic and gastric\n distension have improved over two days.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2186-05-10 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1136582, "text": " 1:58 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: WOUND INFECTION\n Contrast: OPTIRAY Amt: 8\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with hx of chronic osteo, hx of UTI, multiple hospital\n admissions for osteo/UTI, currently in ICU for hypotension/sepsis, likely\n urosepsis. Patient has hx of poor access, needs PICC placement in IR. Venous\n team already deferred placement.\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 40-year-old man with history of chronic osteomyelitis, now\n admitted with possible urosepsis. Patient has history of poor access and a\n single lumen PICC line placement was requested.\n\n CLINICIANS: Dr. performed the procedure. Dr. ,\n the attending radiologist, reviewed the study.\n\n ANESTHESIA: Local anesthesia with 1% lidocaine.\n\n PROCEDURE AND FINDINGS: The procedure was explained to the patient and a\n verbal consent obtained. A pre-procedure timeout was performed. The right\n upper arm was prepped and draped in the usual sterile fashion. Using a\n sterile technique and local anesthesia, the right basilic vein was punctured\n under direct ultrasound guidance using a micropuncture set. Hard copies of\n ultrasound images were obtained before and immediately after establishing\n intravenous access are on file. A 0.018 guidewire was placed through the\n needle and needle exchanged for a peel-away sheath. Through the peel-away\n sheath, a single lumen PICC line was placed, but could not be advanced very\n far. Then, the inner dilator was removed and a venogram was performed through\n the peel- away sheath demonstrating patent peripheral and central veins.\n However, the basilic vein was joining the brachial veins at an acute angle.\n This junction was easily crossed with the catheter and guidewire under roadmap\n conditions. The PICC line measuring 38 cm was then easily advanced with the\n tip terminating in the SVC. The guidewire and peel-away sheath were then\n removed. Position of the catheter was confirmed by a fluoroscopic spot film of\n the chest. The catheter was easily aspirated and flushed. Catheter secured\n to skin with a StatLock device and sterile dressing applied. Patient\n tolerated the procedure well and there were no immediate complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 French\n single lumen PICC line placement via the right basilic venous approach. Final\n internal length is 38 cm with the tip positioned in SVC. The line is ready to\n use.\n (Over)\n\n 1:58 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: WOUND INFECTION\n Contrast: OPTIRAY Amt: 8\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2186-05-10 00:00:00.000", "description": "RP HIP UNILAT MIN 2 VIEWS RIGHT PORT", "row_id": 1136564, "text": " 11:57 AM\n HIP UNILAT MIN 2 VIEWS RIGHT PORT Clip # \n Reason: please evaluate for worsening osteo; request per vascular \n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with chronic osteo of the R stump after AKA with multiple\n debridements, now up to hip; here with worsening drainage and sepsis\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening osteo; request per vascular surgery to evaluate\n stump with purulent drainage\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF RIGHT HIP, AT 12:22 P.M.\n\n HISTORY: Chronic osteomyelitis post above-knee amputation and multiple\n debridements. Worsening drainage and sepsis.\n\n COMPARISON: Multiple priors, the most recent dated . Please note\n a CT of the abdomen and pelvis dated is also available for\n comparison.\n\n FINDINGS: Focused imaging over the right hemipelvis was obtained. The study\n again demonstrates a markedly dysmorphic pelvis, which, as best can be\n compared across modalities, is markedly stable relative to the CT scan. There has, however, been interval change in the appearance of\n the overlying soft tissue and skin of the stump with an apparent ulcer crater\n extending to the cortical surface of the remnant right hemipelvis. The\n severity of the underlying demineralization as such that cortical disruption\n is difficult to entirely exclude. No tracking subcutaneous gas is noted.\n\n IMPRESSION: Large apparent soft tissue ulcer extending to at least near if\n not on the cortical surface of the underlying dysmorphic right hemipelvis.\n Underlying demineralization renders evaluation for acute cortical break\n limited. No gross break or obvious osteomyelitis identified.\n\n" } ]

[ { "category": "Echo", "chartdate": "2108-09-20 00:00:00.000", "description": "Report", "row_id": 70027, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Intracardiac echo guidance provided for CABG. Myocardial infarction.\nStatus: Inpatient\nDate/Time: at 13:35\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. No\nthrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH. Mild global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nComplex (>4mm) atheroma in the aortic arch. Simple atheroma in descending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was under general anesthesia throughout the procedure. The patient\nappears to be in sinus rhythm. Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nPrebypass:\nThe left atrium is normal in size. No thrombus is seen in the left atrial\nappendage. There is mild symmetric left ventricular hypertrophy. There is mild\nglobal left ventricular systolic dysfunction with estimated Ejection Fraction\n50-55%. Right ventricular chamber size and free wall motion are normal. There\nare simple atheroma in the ascending aorta. There are complex (>4mm) atheroma\nin the aortic arch, maximum dimension 0.8 cm. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis or aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no pericardial effusion. Dr. was\nnotified in person of the results on at 1400.\n\nPostbypass:\nThe patient is AV paced on epinephrine, phenylephrine, norepinephrine &\nvasopressin infusions. There is moderate mitral regurgitation. There is mild\ntricuspid regurgitation. The remaining valves are unchanged. Biventricular\nfunction is maintained on multiple agents. There is biatrial enlargement and\nbowing of the interatrial septum L->R. The aorta is intact.\n\nPrior to chest closure, biventricular function remains intact on only\nnorepinephrine & vasopressin infusions. The tricuspid regurgitation is trace\nto mild. The mitral regurgitation is now mild to moderate.\n\n\n" }, { "category": "Echo", "chartdate": "2108-09-19 00:00:00.000", "description": "Report", "row_id": 70028, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Pre-Op CABG 3 vessel disease\nHeight: (in) 65\nWeight (lb): 138\nBSA (m2): 1.69 m2\nBP (mm Hg): 156/66\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 15:58\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. No ASD by 2D or color\nDoppler. The IVC was not visualized. The RA pressure could not be estimated.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Overall normal LVEF (>55%).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the basal-mid infero-lateral wall and inferior\nseptum. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The right\nventricular free wall is hypertrophied. The aortic valve leaflets (3) are\nmildly 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. Trivial mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is an anterior space\nwhich most likely represents a prominent fat pad.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD. No\nsignificant valvular disease.\n\n\n" }, { "category": "ECG", "chartdate": "2108-09-26 00:00:00.000", "description": "Report", "row_id": 152054, "text": "Regular supraventricular rhythm. There appear to be retrograde P waves within\nthe ST segments. Left ventricular hypertrophy with secondary repolarization\nabnormalities. Extensive ST segment changes likely due to left ventricular\nhypertrophy. Compared to the previous tracing of the rhythm is no\nlonger sinus and appears to be junctional rhythm with retrograde P waves.\nClinical correlation is suggested. There are no additional ST-T wave changes.\n\n" }, { "category": "ECG", "chartdate": "2108-09-19 00:00:00.000", "description": "Report", "row_id": 152055, "text": "Sinus rhythm. Left ventricular hypertrophy with secondary repolarization\nchanges. No previous tracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2108-09-21 00:00:00.000", "description": "Report", "row_id": 152056, "text": "Sinus rhythm. Left atrial abnormality. P-R interval prolongation. Left\nventricular hypertrophy with secondary repolarization abnormality. Compared to\nthe previous tracing of there is no significant diagnostic change.\n\n" }, { "category": "Radiology", "chartdate": "2108-09-19 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1251608, "text": " 6:41 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with 3 vessel CAD, pre op cabg\n REASON FOR THIS EXAMINATION:\n r/o acute cardiopulmonary disease\n ______________________________________________________________________________\n WET READ: EHAb WED 8:24 PM\n Hyperinflated lungs with underlying emphysema and biapical pleural thickening.\n Aortic calcification. No acute findings.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old woman with three-vessel coronary artery disease,\n preoperative CABG.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPH: The cardiac, mediastinal and hilar contours\n are normal. Lungs are clear, but hyperinflated, due to emphysema or small\n airways obstruction. There is no pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2108-09-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1251742, "text": " 6:31 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?LINE PLACEMENT, r/o\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with CAD s/p CABG. Please page at with\n abnormalities\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?LINE PLACEMENT, r/o PTX/Effusion\n ______________________________________________________________________________\n WET READ: 9:41 PM\n Right internal jugular catheter tip projects at level of mid-superior vena\n cava. Two mediastinal drains and left chest tube seen. Electrical wiring\n overlies patient; lead tips in indeterminate locations. Esophageal catheter\n tip is below the diaphragm but should be advanced further. Endotracheal tube\n tip approximately 3-cm above the carina. Sternal wires appear intact.\n Mediastinal clips seen. Heart size is mildly enlarged, increased from pre-\n operative study. Mild interstitial edema is new since pre-operative study.\n Small bilateral pleural effusions are seen. No pneumothorax is detected.\n Underlying lung hyperinflation persists. Findings reported to \n by phone at 9:35 p.m. on approximately 1.25 hours after initial\n review of the study after multiple attempts to reach , the listed\n provider caring for the patient.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation.\n\n COMPARISON: Preoperative chest x-ray from .\n\n FINDINGS: A right internal jugular catheter projects with its tip at the mid\n SVC. Two mediastinal drains and a left chest tube are seen. Electric wiring\n overlies the patient. Esophageal catheter tip is below the diaphragm and\n should be further advanced. Endotracheal tube projects with its tip 3 cm\n above the carina. The sternal wires appear intact. Multiple mediastinal\n surgical clips. The heart size is at the upper range of normal. Mild\n interstitial fluid overload. Small bilateral pleural effusions. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252101, "text": " 9:25 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for pneum s/p CT removal\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman\n REASON FOR THIS EXAMINATION:\n eval for pneum s/p CT removal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:58 A.M. ON \n\n HISTORY: 67-year-old woman, evaluate for pneumothorax after chest tube\n removal.\n\n IMPRESSION: AP chest compared to :\n\n Tiny left apical pneumothorax is new. Small left pleural effusion unchanged,\n despite the presence of the left basal pleural tube following removal of\n midline mediastinal drains. Small to moderate right pleural effusion is\n larger, even though previous pulmonary edema is resolved. Right jugular line\n ends centrally. Cardiomediastinal silhouette has a normal post-operative\n appearance. Moderate atelectasis at the left base is stable, milder\n atelectasis at the right base is new.\n\n was paged at 12:25 p.m., 2 minutes following recognition of the\n findings and we discussed them at 12:27.\n\n" }, { "category": "Radiology", "chartdate": "2108-09-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1252135, "text": " 2:10 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for ptx/effusion - please do ~ 2 PM\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for ptx/effusion - please do ~ 2 PM\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST X-RAY\n\n INDICATION: CABG, evaluation for pneumothorax, effusion.\n\n COMPARISON: at 958.\n\n Minimal left apical pneumothorax has slightly improved. There is no pulmonary\n edema. Mild to moderate pleural effusion are unchanged. Left chest tube is\n in stable position. Right jugular line ends in lower SVC. Mediastinal and\n cardiac contours are mildly enlarged and unchanged.\n\n CONCLUSION:\n\n 1. Tiny residual apical left pneumothorax has slightly improved.\n 2. Mild to moderate bilateral pleural effusions are stable.\n\n" }, { "category": "Radiology", "chartdate": "2108-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252211, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p cabg with left apical ptx\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: Patient with CABG, left apical pneumothorax, evaluation for\n pneumothorax.\n\n COMPARISON: .\n\n FINDINGS:\n\n Left apical pneumothorax has slightly improved, measuring 8 mm. There is no\n right pneumothorax. The rest of the exam is unchanged in this patient with\n recent CABG with bibasilar atelectasis, small bilateral pleural effusions.\n Mediastinal and cardiac contours are unchanged and the right jugular line ends\n in lower SVC.\n\n CONCLUSION:\n\n Left small apical pneumothorax has slightly improved.\n\n" }, { "category": "Radiology", "chartdate": "2108-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252305, "text": " 7:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p chest tube removal-evaluate L apical PTX\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal-evaluate L apical PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chest tube removal, evaluation for left apical pneumothorax.\n\n COMPARISON: , 11:23.\n\n FINDINGS: As compared to the previous radiograph, the left-sided chest tube\n has been removed. The extent of the known left apical pneumothorax is\n unchanged. Unchanged bilateral pleural effusions, unchanged size of the\n cardiac silhouette. Unchanged right internal jugular vein catheter.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1252347, "text": " 8:42 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG w/L apical PTX-pls evaluate size-?decrease\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/L apical PTX-pls evaluate size-?decrease\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: CABG. Left apical pneumothorax.\n\n IMPRESSION: PA and lateral chest compared to through 28:\n\n Small left apical pneumothorax has not increased over the past several days.\n Lateral view shows that there is a small anterior loculation of pleural air\n and fluid as well as small to moderate dependent bilateral pleural effusion\n stable since . Post-operative cardiomediastinal silhouette has been\n unremarkable and unchanged. The upper lungs are clear. Consolidation in the\n left lower lobe is usually due to atelectasis. Right jugular line ends in the\n mid to low SVC. I see no pleural drains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252176, "text": " 7:16 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : eval for ptx\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with decreased sats\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n WET READ: MDAg MON 9:57 PM\n left apical pneumothorax is slightly larger than at 2:12pm and still small.\n Possible tiny right pneumothorax versus artifact. Unchanged bilateral small\n pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: Patient with decreased saturation, evaluation for pneumothorax.\n\n COMPARISON: at 2:12 p.m.\n\n FINDINGS:\n\n Left apical pneumothorax has slightly increased from 4 mm to 10 mm. Possible\n minimal new right apical pneumothorax. The rest of the exam is unchanged with\n bilateral small pleural effusions with compressive atelectasis. The\n mediastinal and cardiac contours are slightly enlarged and unchanged. Right\n jugular line ends in lower SVC.\n\n CONCLUSION:\n\n Left small pneumothorax has slightly worsened.\n Possible new minimal right apical pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2108-09-25 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1252243, "text": " 11:20 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for interval change on water seal\n Admitting Diagnosis: R/O CORONARY ARTERY DISEASE;HEART CATHERIZATION\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with left ptx\n REASON FOR THIS EXAMINATION:\n eval for interval change on water seal\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: The patient with left pneumothorax, evaluation for change in\n water seal.\n\n COMPARISON: at 7:35 a.m.\n\n FINDINGS:\n\n Left small apical pneumothorax is unchanged. The rest of the exam is stable\n with bilateral small pleural effusions and bibasilar atelectasis. Mediastinal\n and cardiac contours are stable. Right jugular line ends in lower SVC. Left\n chest tube projects in lower hemithorax.\n\n CONCLUSION:\n\n Small left apical pneumothorax is unchanged after chest tube water seal.\n\n" } ]